# What should a good plan cover for mental health?

Source: https://www.getprescience.com/guides/mental-health-benefits
Author: Aditya Jain, MD, Cofounder and COO, Prescience
Published: 2026-11-11
Updated: 2026-11-11
Cite as: Aditya Jain, MD. "What should a good plan cover for mental health?." Prescience, November 11, 2026. https://www.getprescience.com/guides/mental-health-benefits

A good plan makes therapy and psychiatry reachable and affordable, with clinicians who are accepting patients. I would review access, cost-sharing, substance use treatment and the handoff from an employee assistance program. Federal parity requirements remain important, although the agencies announced nonenforcement of the 2024 final rule while reconsidering it. That announcement did not suspend the underlying statute or the earlier rules.

- **Check access:** Available appointments, not directory size
- **Parity law:** MHPAEA
- **EAP:** Check session limits and referrals
- **Compare:** Annual costs and treatment access

## How many people on your plan need mental health care

SAMHSA’s national survey documents substantial mental health and substance use needs. But a national prevalence estimate does not establish how many people on a particular team need care. I would plan for confidential access without asking managers to identify who might use it.

Review employees and dependents separately. A network that serves adults may not include a clinician accepting children, and a telehealth service may not offer every level of treatment. Ask the administrator to demonstrate the route from an initial request to an appointment and, if necessary, a higher level of care.

## What good coverage looks like

**Mental health coverage checklist for an employer plan**

| Service | What good looks like | Common gap |
| --- | --- | --- |
| Outpatient therapy | Low copay from the first session, no visit cap | Full cost until a high deductible is met |
| Psychiatry and medication management | In-network psychiatrists or psychiatric nurse practitioners with openings within weeks | Long waits, many psychiatrists out of network |
| Telehealth | Video therapy and psychiatry covered like in-person visits | Telehealth limited to one vendor's network |
| Intensive outpatient and partial hospitalization | Covered with the same rules as comparable medical care | Stricter prior authorization than medical |
| Inpatient and residential treatment | Covered for mental health and substance use, with clear medical necessity criteria | Blanket exclusions of residential care |
| Substance use treatment | Medications for opioid use disorder, outpatient and inpatient care | Fail-first rules not used for medical drugs |
| Crisis care | Emergency and crisis services covered like any emergency | Ask how emergency billing protections and the policy apply to the particular facility |

An employee assistance program (EAP) is a useful front door: a few free, confidential sessions and referrals. It is not a substitute for therapy coverage in the health plan. Many people need more sessions than an EAP provides, and the handoff is where they drop out.

## The real problem is the network

A provider directory is a starting point, not proof of access. For each location where employees live, ask the administrator to confirm participation in the exact plan, acceptance of new patients, appointment availability and the types of patients treated. Repeat the check for therapy, medication management and substance use services. Let employees make private checks for their own clinicians rather than collecting treatment histories at work.

When people can't find in-network care, they pay cash, rely on out-of-network reimbursement, or give up. Ask any carrier or vendor for the share of in-network therapists accepting new patients and the median wait for a first appointment, not just the size of the directory.

## What a year of weekly therapy costs an employee

**40 therapy sessions under three situations**

Illustrative. An employee sees a therapist 40 times in a year. Assumes an in-network allowed amount of $150 per session and an out-of-network cash price of $200. Plan A: $3,000 deductible, then 20% coinsurance. Plan B: $30 copay from the first visit. Situation C: no in-network therapist available, so the employee pays cash and the plan reimburses nothing under the hypothetical policy’s out-of-network terms. All prices and terms are hypothetical, not vendor quotes; assume no other claims, premiums excluded, and an in-network maximum above $3,600.

- Allowed cost in network (40 × $150): $6,000
- Plan A: deductible + 20% of the remaining $3,000: $3,000 + $600 = $3,600
- Plan B: 40 × $30 copay: $1,200
- Situation C: 40 × $200 cash: $8,000

The assumed annual employee costs are $1,200, $3,600 and $8,000 before premiums. The calculation does not predict whether anyone will stop treatment. It shows why an employer should compare a continuing course of care and verify actual network access before choosing a plan.

## What parity law requires

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires group health plans that cover mental health and substance use disorder benefits to do so on terms no more restrictive than medical and surgical benefits. That covers financial rules (copays, deductibles, coinsurance), numeric limits (visit or day caps), and non-numeric rules called nonquantitative treatment limitations or NQTLs: prior authorization, medical necessity criteria, step therapy, network admission standards and how out-of-network rates are set. Financial requirements and quantitative limits are tested within benefit classifications using substantially-all and predominant-level rules. Comparing one therapy visit with one medical visit is not a complete compliance analysis.

**Examples of what parity does and doesn't allow**

| Plan rule | Allowed? |
| --- | --- |
| $30 copay for therapy when primary care visits cost $30 | Not enough information: the financial requirement must satisfy the applicable classification test, not simply match a primary care copay |
| 20 therapy visits a year when medical office visits are unlimited | No: a numeric limit applied only to mental health |
| Prior authorization for every therapy visit but not for comparable medical visits | Likely no: a stricter NQTL |
| Excluding residential treatment for addiction while covering skilled nursing for medical conditions | Regulators treat blanket exclusions like this as an enforcement priority |
| Not covering mental health at all | Only for plans not required to cover it (see below) |

**Which plans it applies to.** Insured small group and individual plans must cover mental health and substance use services as an [essential health benefit](https://www.getprescience.com/guides/what-are-essential-health-benefits), and HHS rules require that coverage to meet parity. Large group plans that cover these services must follow parity. MHPAEA has a small employer exemption for employers with 50 or fewer employees, which in practice matters mostly for small self-funded plans; insured small group plans are pulled back in through the EHB rules. Since 2021, the Consolidated Appropriations Act has required plans to document a written comparative analysis showing their NQTLs meet parity and to produce it on request.

## The 2024 parity rule: where enforcement stands in 2026

The Departments’ May 15, 2025 statement says they will not enforce the 2024 final rule for failures occurring before a final decision in the litigation, plus 18 months. It also says the agencies will reconsider the rule. I would not treat an anticipated replacement rule or an unverified timeline as an obligation already in force.

The statement preserves the statutory MHPAEA obligations, the 2013 regulations and the comparative-analysis requirements added by the Consolidated Appropriations Act, 2021. For a plan subject to those requirements, ask who prepares the analysis, how it is updated and how the administrator will respond to a participant or regulator request. Hiring an administrator does not remove the sponsor’s applicable duties.

DOL’s September 8, 2026 Field Assistance Bulletin 2026-03 confirms the continuing nonenforcement of provisions new in the 2024 rule and identifies three NQTL priorities: separate treatment limitations and exclusions, medical-necessity review, and network standards including admission and reimbursement methods. This is an enforcement policy, not a repeal of statutory parity duties.

## Loneliness is a health issue

The Surgeon General’s 2023 advisory identifies social connection as a public health concern. The associations it summarizes do not prove that an employer social event prevents a specific illness. My practical suggestion is to make participation in workplace activities optional, respect different needs, and keep social support separate from access to clinical treatment.

## What an employer can do this year

1. Price therapy under your plan the way the example above does. If a year of weekly sessions costs more than a couple of thousand dollars in network, fix plan design first.
2. Test the network: ask for the number of in-network therapists and psychiatrists near your team who are accepting new patients, and the typical wait.
3. Make telehealth therapy and psychiatry part of the plan, not only an add-on.
4. Tell employees how to get care in plain language: who to call, what it costs, and how clinical information is protected. Put the 988 Suicide and Crisis Lifeline in your benefits guide; call 911 for immediate physical danger or a medical emergency.
5. Ask your carrier or administrator for the parity comparative analysis, especially if you're level-funded.
6. Train managers to point people to resources, not to diagnose.

## Check the handoff when short-term support ends

I would ask the EAP and medical plan to describe one ordinary handoff: a member completes the sessions included in the EAP and needs continuing therapy. Who finds the next clinician? Can the employee keep the same therapist under the medical benefit? Is a new authorization needed, and what will the next visit cost? Request a written explanation that employees can use without telling a manager why they need it.

For children and adolescents, confirm age eligibility and the availability of appropriate clinicians. A platform offering adult video visits does not necessarily provide pediatric psychiatry or family therapy. For substance use care, ask how members locate the needed level of treatment and how the plan handles a transition between inpatient and outpatient services. These are access questions, not an instruction for managers to choose treatment.

If the directory fails, ask the administrator to help locate an available provider and explain any network-exception process. Keep records of the access problem without circulating clinical information at work. The plan’s denial and appeal procedures should be easy to find.

## How Prescience helps

At Prescience, we design and run your company's health plan, from setup and enrollment to claims, compliance and COBRA. What your team gets:

- **An effective $0 deductible,** so the plan helps from the first visit.
- **Simple copays** shown before a visit, capped by a low out-of-pocket maximum.
- **A broad national PPO network,** plus providers we contract with directly.
- **24/7 physician-led care navigation:** a care team that finds the right provider, books appointments and explains costs up front.

What your company gets: one monthly cost set in your quote, usually 10–20% below comparable fully insured coverage and fixed before the plan starts, with no admin fees. You keep your payroll provider, and the plan can start mid-year.

> **Prescience Diamond: A company health plan with an effective $0 deductible.** When the directory fails, our 24/7 physician-led care team helps members find a therapist or psychiatrist who is accepting patients, and explains the cost before the first session.
> - **An effective $0 deductible** and simple copays shown before a visit
> - **A broad national PPO network,** plus providers we contract with directly
> - **24/7 physician-led care navigation** that books visits and explains costs
> - **Usually 10–20% below comparable fully insured coverage,** fixed in your quote, with no admin fees
> Best for teams of about 15 or more that want one great group plan. [Get a Diamond quote](https://www.getprescience.com/get-started?p=Employer&product=diamond)

**Put access and employee costs into the plan comparison**

Use the employee census for pricing, and review the actual network and support process in the written proposal. A benefits label alone does not establish whether a clinician is available.

[Compare benefits for my team](https://www.getprescience.com/quote)

[Use the full employer plan scorecard](https://www.getprescience.com/guides/best-health-insurance-for-small-business)

## Frequently asked questions

**Are employers required to cover mental health?**

Non-grandfathered insured small-group and individual plans cover mental health and substance use services as essential health benefits. Large and self-funded plans are not subject to that entire EHB package mandate, although other laws and plan commitments matter. MHPAEA has exceptions, including a small-employer exception that mainly matters for small self-funded plans.

**What is mental health parity?**

A federal requirement under MHPAEA that mental health and substance use benefits be no more restrictive than medical and surgical benefits, including copays, visit limits, prior authorization and network rules.

**Is the 2024 mental health parity rule being enforced?**

The agencies’ May 15, 2025 statement announced nonenforcement of the 2024 final rule during the specified litigation period and 18 months after a final decision. It did not suspend MHPAEA, the 2013 rules or the 2021 comparative-analysis requirement. Check current agency guidance for your plan year.

**What is an NQTL comparative analysis?**

A written analysis a group health plan must keep, since the Consolidated Appropriations Act of 2021, showing that rules like prior authorization and network standards are applied no more strictly to mental health and substance use care than to medical care. Regulators can request it.

**Does MHPAEA apply to small employers?**

MHPAEA itself exempts employers with 50 or fewer employees, but insured small group plans must meet parity anyway through the ACA's essential health benefit rules. The exemption mainly matters for small self-funded plans.

**Is an EAP enough mental health coverage?**

No. An EAP usually offers a few free sessions and referrals. People who need ongoing therapy or psychiatry need coverage in the health plan itself.

**Can an HSA plan cover therapy before the deductible?**

Qualifying telehealth can be covered before the deductible under the permanent statutory safe harbor. Ordinary in-person treatment generally remains subject to HDHP requirements unless an exception applies. Notice 2019-45 permits pre-deductible SSRI coverage for people with depression. Other HSA eligibility requirements still apply.

**Why is it so hard to find an in-network therapist?**

Availability depends on the exact network, location, clinician type and capacity. Ask the administrator for available appointments, not just a list of names, and request help or a network exception when the listed providers cannot see the member.

**How much are behavioral health costs rising?**

Costs vary by plan and population. Ask the administrator to separate changes in use, negotiated rates and treatment intensity. A national projection is not a prediction for a small team or evidence that a particular treatment should be restricted.

## Sources

- [DOL, FAQs about Affordable Care Act implementation Part XVII and MHPAEA (small employer exemption and EHB)](https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs17.html)
- [SAMHSA, 2024 National Survey on Drug Use and Health (released July 2025)](https://www.samhsa.gov/newsroom/press-announcements/20250728/samhsa-releases-annual-national-survey-on-drug-use-and-health)
- [IRS Notice 2019-45, Additional preventive care benefits permitted to be provided by an HDHP](https://www.irs.gov/pub/irs-drop/n-19-45.pdf)
- [U.S. Surgeon General, Our Epidemic of Loneliness and Isolation (2023)](https://www.govinfo.gov/app/details/GOVPUB-HE20-PURL-gpo212387)
- [DOL, May 15, 2025 parity enforcement statement](https://www.dol.gov/sites/dolgov/files/ebsa/laws-and-regulations/laws/mental-health-parity/statement-regarding-enforcement-of-the-final-rule-on-requirements-related-to-mhpaea.pdf)
- [IRS Notice 2026-5, HSA eligibility, bronze plans, telehealth and direct primary care](https://www.irs.gov/pub/irs-drop/n-26-05.pdf)
- [DOL, MHPAEA self-compliance tool](https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/mental-health-parity/mhpaea-self-compliance-tool.pdf)
- [SAMHSA, 988 Suicide and Crisis Lifeline](https://www.samhsa.gov/find-support/in-crisis)
- [DOL, Field Assistance Bulletin 2026-03, September 8, 2026](https://beta.dol.gov/system/files/media/policy-regulations/guidance-search/ebsa-field-assistance-bulletin-no-2026-03.pdf)