Paying for care & your rights

Words you’ll see

• Premium: what you pay each month to have insurance
• Deductible: what you pay yourself each year before your plan starts to share costs
• Copay: a set amount you pay per visit, like $20
• Coinsurance: a percentage you pay per visit, like 20%
• In network: providers who have a deal with your plan, so you pay less
• Out of network: providers without a deal, so you usually pay more (sometimes your plan pays part back)
• Prior authorization: when your plan has to approve care before you start

The number for mental health or “behavioral health” is usually on the back of your insurance card. Ask what you will pay per visit, whether you have a deductible to meet first, and whether you need a referral or approval before you start.

Write down

• The date, and the name of the person you spoke to
• A reference number for the call, if they give one
• What they said you will pay
• Whether video or phone sessions are covered

If you aren’t using health insurance to pay for care, providers generally must give you a “good faith estimate” of what it will cost. You should get one if you book at least 3 business days ahead, and you can ask for one before you book.

Keep a copy. If your final bill is at least $400 more than the estimate, you may be able to dispute it. You need the estimate to do that.

Since January 2022, the No Surprises Act has protected people from many unexpected out-of-network bills. This includes emergency room care, and some care from out-of-network staff during a visit to an in-network hospital or surgery center.

Questions, or think a bill breaks the rules? The No Surprises Help Desk is at 1-800-985-3059, with help in more than 350 languages.

“Parity” means fairness. The Mental Health Parity and Addiction Equity Act is a federal law. It says many group health plans and insurers must cover mental health and substance use care in a way that is similar to how they cover medical and surgical care.

What parity generally means for you

• Copays and deductibles for mental health should be similar to those for physical health
• Limits on the number of visits generally can’t be stricter than for medical visits
• If a plan covers out-of-network or inpatient medical care, it should also cover these for mental health
• Most plans can’t require pre-approval for all mental health care
• You have a right to information about your job-based plan

If a claim is denied, you can appeal. For free help with job-based plans, the U.S. Department of Labor’s benefits advisors can be reached at 1-866-444-3272 (help in Spanish and translation are available).

All Marketplace plans cover mental health and substance use services as “essential health benefits.” That includes therapy and counseling, inpatient mental health care, and substance use treatment. The exact benefits vary by state and plan.

Also good to know

• Coverage for a mental health condition starts when your plan starts
• Plans can’t put yearly or lifetime dollar limits on essential health benefits
• Plans can’t turn you down or charge you more because of a mental health condition you already have

Medicare Part B covers individual and group therapy, family counseling when it’s part of your treatment, psychiatric evaluation, and partial hospitalization and intensive outpatient programs. It also covers safety planning if you are at risk of suicide, and a follow-up call after an emergency room visit for a mental health crisis.

Who you can see

• Clinical psychologists
• Clinical social workers
• Marriage and family therapists
• Mental health counselors
• Nurse practitioners, clinical nurse specialists and physician assistants
• Psychiatrists and other doctors

A yearly depression screening in primary care costs $0 if your provider accepts assignment. For most other visits, you pay 20% of the Medicare-approved amount after your Part B deductible.

Medicaid is health coverage for people and families with lower incomes, and for some people with disabilities. It is the single largest payer for mental health services in the United States. Each state runs its own program, so what’s covered and who qualifies varies by state.

Things Medicaid may cover, depending on your state

• Counseling and therapy
• Peer support services
• Mobile crisis services
• Care from community behavioral health clinics
• Extra screening and services for children and teens

Medicaid and the Children’s Health Insurance Program (CHIP) offer free or low-cost health coverage for eligible kids and teens up to age 19. Mental health services are covered, along with check-ups, doctor visits and more.

Income limits vary by state, and families who were turned down before may qualify now. You can apply any time of year. Visit InsureKidsNow.gov or call 1-877-543-7669 (1-877-KIDS-NOW).

Many therapists and clinics offer a “sliding scale,” which means you pay according to your income. NIMH suggests asking about this when you are choosing a therapist.

How to ask

• “Do you offer a sliding scale or reduced fee?”
• “What would a session cost for someone with my income?”
• “Do you keep any lower-cost spots for people without insurance?”

Certified Community Behavioral Health Clinics (CCBHCs) must serve anyone who asks for mental health or substance use care, regardless of their ability to pay, where they live or their age. They offer crisis services 24 hours a day, 7 days a week.

Services they provide

• Care coordination and case management
• Crisis services
• Mental health and substance use care
• Peer and family support
• Primary care screening
• Support for veterans

Community mental health centers and community health centers also offer counseling, often on a sliding fee. The SAMHSA Helpline can point you to places that use sliding fees or accept Medicaid or Medicare.

Every state runs public mental health programs. If you have no insurance or limited coverage, the SAMHSA National Helpline (1-800-662-4357) can refer you to your state office, which is in charge of state-funded treatment.

Places to look

• Your EAP at work: often a few free counseling sessions
• Community mental health centers and health centers
• College and university counseling centers (for students)
• Support groups and peer support, often free
• State-funded programs: the SAMHSA Helpline can refer you to your state office if you have no insurance or limited coverage
• Faith communities and local nonprofits

“Informed consent” means you get clear information about a treatment, you understand it, and you choose freely whether to agree. Your provider should explain why it’s recommended, what it involves, the risks and benefits, other options, and what might happen if you wait.

Your part

• Ask questions until it makes sense
• Ask them to explain it a different way if needed
• Take time to think, when it’s not an emergency
• You can say no to a treatment you don’t want, if you understand your options

Conversations with your provider are private and generally can’t be shared without your permission. That’s what makes therapy a safe place to be honest.

Confidentiality does have limits, and they can vary by state and situation. NIMH suggests asking your therapist how confidentiality works and what its limits are. Good questions are: “When would you have to share something?” and “What happens if you’re worried about my safety?”

HIPAA is a federal law about health privacy. Its Privacy Rule gives you the right to see and get a copy of your health record from health plans and most providers. You can get it on paper or electronically, and you’re entitled to it even if you owe money on your bills.

Good to know

• You can share your record with anyone you choose, like another doctor or a family member
• If you see several providers, each may have its own process for requests
• If you spot a mistake, you can ask for it to be corrected
• State laws can add extra protections, especially for teens

One exception: a therapist’s private “psychotherapy notes”, kept separately from your main record, are not covered by the right to see your records. These notes have extra protection, and generally can’t be shared with others without your written permission.

You can ask for more information about any diagnosis or treatment. If a suggestion makes you uncomfortable or is unfamiliar, say so and ask about other options. A second opinion is always okay.

The Americans with Disabilities Act (ADA) is a civil rights law that protects people with disabilities from discrimination in many areas of public life. Many mental health conditions can count as a disability under the law.

At work, it is illegal for an employer to discriminate against you simply because you have a mental health condition. You can usually keep your condition private, and you can ask for “reasonable accommodations.”

Examples

• A changed schedule or breaks to fit in therapy
• A quieter workspace
• Written instructions from your supervisor
• Working from home
• In some cases, unpaid leave

You can ask at any time, and you don’t need to have a specific idea in mind. Your employer may ask for a note from your provider. If you think your rights were broken, you generally must file a charge with the EEOC within 180 days (300 days in some states). The EEOC can be reached at 1-800-669-4000.

See the Work & mental health guide for much more on this.

The ADA protects people with disabilities from discrimination in many areas of public life, including many places that offer services to the public. That means care should be accessible: in a building you can get into, in a format you can use, and with communication that works for you.

Things you can ask for

• A sign language interpreter or captioning
• A step-free or accessible office, or telehealth instead
• Longer appointments, or breaks during sessions
• Text or email instead of phone calls
• Written information in large print or plain language

Employers can only ask medical questions in limited situations, such as when you ask for an accommodation. They must keep what you share confidential, even from coworkers. You can describe your condition in general terms if you don’t want to name a diagnosis.

It is also illegal to punish you for asking for an accommodation or for contacting the EEOC. The EEOC can be reached at 1-800-669-4000.

Inpatient units are usually locked or secured for safety. Stays are often short, from a few days to a few weeks. The goal is to help someone through a crisis, understand what is going on, and build a plan for continuing care outside the hospital.

What a day may look like

• A daily schedule with set times for meals, groups and rest
• Meetings with members of the care team, such as a psychiatrist, psychologist, social worker and nurses
• Group sessions on coping skills, emotions and wellness
• Time for rest, reading, art or quiet activities
• Visiting hours and phone times, depending on the unit

Things people find helpful to know

• Belongings may be checked, and items like cords, belts or sharp objects held for safety
• Write down the names and roles of your care team, so you know who to ask about what
• Ask early who is in charge of your discharge planning
• It’s okay to ask questions about anything you don’t understand

A voluntary stay is when a person agrees to be admitted. An involuntary stay (sometimes called a hold or commitment) is when the law allows a hospital to keep someone for a limited time without their agreement, usually because there is a serious risk to their safety or someone else’s. Each state sets its own rules about when this can happen, for how long, and how decisions are reviewed.

If you are admitted involuntarily, you can usually…

• Ask for a written explanation of why you are being held and for how long
• Ask about a hearing or review, and how to request one
• Ask to speak with a patient advocate or patients’ rights office
• Ask for help contacting a lawyer or legal aid

Patients’ rights differ by state and hospital, but hospitals are generally expected to tell you your rights, often in writing, when you arrive. If no one gives you a copy, ask for one.

Rights many patients have

• To be treated with dignity and respect, and to be safe from abuse
• To be told about your care and to take part in planning it
• To privacy about your health information. You decide who the team can talk to, by signing a release form
• To communicate with family, friends and a lawyer, within the unit’s rules
• To make a complaint without being punished for it
• To an interpreter and disability accommodations

Some people make a psychiatric advance directive while they are well. It is a written plan saying what care they prefer and who should help make decisions if they are in crisis. Ask your provider whether this is available in your state.

A discharge plan explains what will happen when someone leaves the hospital: where they will go, which services they will follow up with, the warning signs of a new crisis, and what they will do to stay well. It is developed by the treatment team, the person, and ideally family members. Often one nurse or social worker coordinates it.

A discharge plan usually includes

• The reason for the hospital stay
• Referrals for follow-up care, often a “step down” to a less intensive level such as a partial hospitalization program or outpatient care
• Follow-up appointments, typically scheduled within 7 days of leaving
• A crisis plan: warning signs, coping skills, people to contact, and services like 988 or the nearest emergency department
• Links to community resources, such as housing, supported employment, support groups and clubhouses
• Everyday self-care, like movement, food and sleep

Going home can bring relief, but also tiredness, worry, embarrassment or a sense of being “behind” on life. Research shows that the weeks and first months after leaving a psychiatric hospital are a time of higher risk for suicide, especially for people who were admitted because of suicidal thoughts. That is why follow-up care and support matter so much.

What can help

• Go to the first follow-up appointment, even if you feel better
• Keep your crisis plan somewhere easy to find, like your phone
• Return to work or school gradually if you can, and ask about accommodations
• Plan simple, gentle days with regular sleep and meals
• Stay in touch with at least one supportive person every day
• Decide ahead of time what you want to tell others about your stay. “I was in hospital to get well” is enough

1. Say clearly what you need: “I’d like a referral to a therapist.”
2. Describe your symptoms, how long, how often, and how they affect daily life
3. Ask questions until you understand
4. Write down names, dates and what was agreed
5. Follow up if you don’t hear back

Family and friends can help a lot: encouraging someone to see a provider, helping them get to appointments, and offering practical support. Partners and family are often the first to notice that something is wrong.

Tips

• Ask what kind of help they want, rather than taking over
• Ask your loved one to give written permission for their provider to talk with you
• Share what you have noticed with their provider; you can always give information, even when they can’t share back
• Look after yourself too (see the Caregiver stress & burnout guide)

If a mental health claim is denied, you can file an appeal. For job-based plans, the U.S. Department of Labor has benefits advisors who help for free at 1-866-444-3272.

1. Ask your plan for the denial in writing, and the reason
2. Ask your provider for a letter explaining why the care is needed
3. Send your appeal before the deadline, and keep copies
4. Ask whether mental health parity rules apply to your plan

1. Ask for an itemized bill and compare it with your insurer’s statement
2. Call the billing office and ask them to explain anything that doesn’t match
3. If you paid without insurance, compare the bill with your good faith estimate
4. If you think a bill breaks federal billing rules, call the No Surprises Help Desk at 1-800-985-3059

Every state and territory has a Protection and Advocacy (P&A) system. Their mental health program protects adults with serious mental health conditions and children with serious emotional challenges. They investigate abuse, neglect and rights violations, and offer legal-based advocacy.

There are 57 of them, covering all 50 states, Washington, D.C., five territories and a Native American consortium.

National groups like the National Alliance on Mental Illness (NAMI) have local chapters, support for families, and a HelpLine (1-800-950-6264, or text “NAMI” to 62640) that can help you find resources. Many groups also campaign for better mental health laws and services.

Joining a group can turn a lonely struggle into shared action. You can share your story, connect with others, and help change things for the next person.

• Help them call their insurer and fill in the worksheet “My insurance & costs check”
• Keep a folder (paper or digital) for bills, letters and estimates
• Offer to sit in on calls, with their permission
• Help them check whether Medicaid, CHIP or a sliding fee might apply

Ask your loved one to give written permission for their provider or insurer to talk with you. Without it, they may not be able to share details with you.

Consider asking your loved one to sign a release of information early in their stay, so you can take part in treatment and discharge planning. Tell the team what support they already have at home, and any concerns you have, so the discharge plan can address them.

Other ways to help

• Visit or call during allowed times, and keep conversations gentle
• Bring approved comfort items, like clothes, books or photos
• Take care of their pets, plants, mail or bills while they’re away
• Keep their stay private unless they say it’s okay to share

The weeks after a hospital stay can be fragile. Help with follow-up appointments, keep in regular contact, and learn the warning signs in their crisis plan so you can act early.

• Treat them as the same person you know and love
• Help with practical things like meals, rides and errands
• Don’t watch them every second, but do check in kindly
• Ask: “What would be most helpful from me this week?”

• Children’s coverage (Medicaid and CHIP): InsureKidsNow.gov or 1-877-543-7669
• Job-based health plans: U.S. Department of Labor benefits advisors, 1-866-444-3272
• Low-cost and state-funded care: SAMHSA National Helpline, 1-800-662-4357 (24/7)
• Surprise bills and good faith estimates: No Surprises Help Desk, 1-800-985-3059

• At work: the EEOC, 1-800-669-4000
• In a hospital or facility: ask for the patient advocate or patients’ rights office, or contact your state’s Protection and Advocacy system
• For legal help: a local legal aid office
• For information and support: the NAMI HelpLine, 1-800-950-6264 (not a crisis line)

Worldwide, most people living with mental health conditions do not have access to effective care. Ask a local doctor, community health worker or your country’s health ministry website what public services exist where you live.

For free, confidential emotional support, Find A Helpline (findahelpline.com) lists checked helplines in many countries. The International Association for Suicide Prevention points people to it.