Mental Health Parity: How to Get Insurance to Cover Therapy and Treatment

Millions of Americans seek therapy, psychiatric care, or substance use treatment each year, yet many run into narrow networks, prior authorization hurdles, and claim denials. Federal law offers important protections. The Mental Health Parity and Addiction Equity Act (MHPAEA) generally requires health plans that cover mental health and substance use disorder benefits to do so on terms no more restrictive than those for medical and surgical care. This guide explains how the mental health parity law works and how to use it to get care covered.

What the parity law requires

MHPAEA, passed in 2008 and strengthened by the Affordable Care Act and later legislation, applies to most employer group health plans, including self-funded plans, and to individual and small group market plans. Under the ACA, mental health and substance use disorder services are also one of the ten essential health benefits that individual and small group plans must cover.

Parity applies to:

Financial requirements, such as deductibles, copays, coinsurance, and out-of-pocket maximums. A plan cannot charge a higher copay for a therapy visit than for a comparable medical office visit within the same classification.
Quantitative treatment limitations, such as visit limits or day limits. A plan cannot cap therapy at 20 visits a year if it does not impose comparable limits on medical care.
Nonquantitative treatment limitations (NQTLs), such as prior authorization, medical necessity criteria, step therapy, network admission standards, and reimbursement rates. These must be comparable as written and in operation.

Benefits are compared within six classifications: inpatient in-network, inpatient out-of-network, outpatient in-network, outpatient out-of-network, emergency care, and prescription drugs.

Recent rules

In 2024, federal agencies issued a final rule requiring plans to collect and evaluate data on how NQTLs affect access, such as network adequacy and denial rates, and to take action when disparities appear. In 2025, the agencies announced they would not enforce some of the new provisions while they reconsider the rule, although the underlying statute and earlier regulations, including the requirement to perform and provide comparative analyses of NQTLs, remain in effect.

What parity does not do

Parity does not require plans to cover mental health benefits at all if they do not offer them, although ACA-compliant individual and small group plans must. It does not apply to Medicare in the same way, although Medicare covers many mental health services. Small employer exemptions and some government plan opt-outs exist.

Finding care in network

Network shortages are one of the biggest barriers. Many therapists do not accept insurance. Strategies:

Use your insurer’s directory, then verify. Directories are often outdated. Call the therapist’s office to confirm they are in network and accepting new patients. The No Surprises Act requires plans to maintain accurate directories and, if you rely on an incorrect directory listing, to limit your cost-sharing to in-network amounts.
Ask your plan for help. Many insurers have behavioral health care coordinators who can find available providers.
Consider telehealth. Virtual therapy platforms and in-network telehealth providers can expand options.
Use employee assistance programs. EAPs often provide several free counseling sessions.
Request a network gap exception. If no in-network provider is available within a reasonable distance or time, ask your plan to cover an out-of-network provider at in-network cost-sharing.

Using out-of-network benefits

If your plan has out-of-network benefits, which many PPO plans do, you can see any licensed therapist and seek reimbursement:

Pay the therapist directly.
Ask for a superbill, an itemized receipt with diagnosis and procedure codes, the provider’s National Provider Identifier, and the dates of service.
Submit it to your insurer with a claim form.
The plan reimburses a percentage of its allowed amount after you meet the out-of-network deductible.

Check the allowed amount for common psychotherapy codes, such as 90834 for a 45-minute session or 90837 for 60 minutes, because reimbursement may be far below the therapist’s fee.

Medicare and Medicaid

Medicare Part B covers outpatient mental health services, including therapy with psychiatrists, psychologists, clinical social workers, and, since 2024, licensed marriage and family therapists and mental health counselors. You typically pay 20 percent coinsurance after the Part B deductible. Annual depression screening is covered without cost-sharing. Inpatient psychiatric hospital care is covered under Part A, with a 190-day lifetime limit in freestanding psychiatric hospitals.

Medicaid is the largest payer of mental health services in the United States and covers a broad range of services, including some community-based services not typically covered by private insurance. Medicaid managed care plans and some Medicaid benefits are also subject to parity requirements.

Common denials and how to appeal

Common reasons for denial include lack of medical necessity, missing prior authorization, exceeding a level of care criteria for residential treatment, or the provider being out of network.

Request the plan’s reasons in writing, including the medical necessity criteria used.
Ask for the NQTL comparative analysis. Under federal law, you can request documents showing how the plan applies its limitations to mental health compared with medical benefits.
Get supporting documentation from your provider, including treatment plans and clinical notes.
File an internal appeal within the deadline, usually 180 days for group plans. Request an expedited appeal for urgent situations.
Request external review by an independent reviewer if the internal appeal fails.
Contact regulators. For employer plans, the Department of Labor’s Employee Benefits Security Administration handles parity complaints. For state-regulated plans, contact your state insurance department.

Courts have also addressed parity and medical necessity. A notable federal court decision in Wit v. United Behavioral Health found that an insurer’s medical necessity guidelines were more restrictive than generally accepted standards of care, though the ruling was later partly reversed on appeal. Some states now require plans to use criteria from nonprofit professional associations.

Substance use disorder treatment

Parity applies to substance use disorder treatment as well. Plans cannot impose stricter prior authorization on addiction treatment than on comparable medical care. Medications for opioid use disorder, such as buprenorphine, methadone, and naltrexone, are covered by most plans, and federal rules have expanded access to buprenorphine prescribing.

In a crisis

If you or someone you know is in crisis, call or text 988, the Suicide and Crisis Lifeline, available 24 hours a day. Emergency mental health care is covered as emergency care, and the No Surprises Act limits surprise bills for emergency services at out-of-network facilities.

Choosing a plan with mental health in mind

During open enrollment, check:

Whether your current therapist or psychiatrist is in network.
Out-of-network benefits and reimbursement levels.
Copays for therapy and psychiatric visits.
Formulary coverage for your medications.
Telehealth options.

Levels of care and what insurers review

Mental health and addiction treatment is delivered at several levels of intensity, and insurers often authorize care one level at a time. Outpatient therapy is the most common. Intensive outpatient programs provide several hours of treatment on multiple days each week while patients live at home. Partial hospitalization programs offer day treatment close to the intensity of inpatient care. Residential treatment provides round-the-clock care in a non-hospital setting, and inpatient psychiatric hospitalization is reserved for people who need hospital-level safety and stabilization. Insurers review whether a requested level matches your symptoms and risk, often using criteria such as those published by the American Society of Addiction Medicine for substance use treatment. When authorization is time-limited, ask your provider to submit updated clinical information before the authorization ends so care is not interrupted.

Keeping costs predictable

Track your deductible and out-of-pocket totals, because weekly therapy can add up. If you have an HSA or FSA, therapy copays and many out-of-network fees are qualified expenses. Some therapists offer sliding-scale fees, and community mental health centers and university training clinics often provide lower-cost care.

Frequently Asked Questions

Can my plan limit the number of therapy sessions?

Only if it applies comparable limits to medical care in the same classification, which is uncommon.

Do I need a diagnosis for insurance to pay for therapy?

Generally yes. Insurers require a diagnosis code to establish medical necessity.

Is couples counseling covered?

Often not, unless it is part of treatment for a diagnosed condition of one partner.

This article is for general informational purposes only and is not legal, medical, tax, or financial advice. Rules vary by state and change over time; confirm details with the relevant agency or a licensed professional.