What to Know When Assisting a Consumer with Mental Illness
This fact sheet is intended to help Navigators identify issues that are unique to consumers with mental health conditions to assist them in making decisions related to their healthcare coverage.
Click here for a pdf version of this Fact Sheet
Q1. What do I need to know about mental illness?
A. Mental illnesses are medical conditions affecting the brain that disrupt a person’s mood, feelings, thinking and ability to relate to others. Although the exact causes are unknown, research shows that mental illness results from biological, psychological and environmental factors. Mental health conditions affect people of all ages, ethnicities, genders, and income levels. With appropriate treatment and support, people with mental illness can lead full, contributing lives.
Q2. What type of health care providers does someone with mental health conditions need to have access to?
A. Primary care providers often provide routine mental health care, including diagnosis, prescriptions and referral. However, people with serious or ongoing mental health needs may need to see a mental health provider. Types of mental health specialists include:
- Psychiatrist: Psychiatrists are Medical Doctors (M.D.) or Doctors of Osteopathy (D.O.) who receive an additional four years of training in psychiatry. Psychiatrists may conduct psychiatric and medical evaluations, provide psychotherapy, and prescribe and monitor medications.
- Psychologist: Licensed psychologists with doctoral degrees (Ph.D., Psy.D, or Ed.D.) perform a number of services including psychological testing, evaluation and psychotherapy.
- Psychiatric or Mental Health Nurse Practitioner (PMHNP): PMNHPs have either a Master’s of Science in Nursing (MSN) or a Doctor of Nursing Practice (DNP). PMHNPs provide assessment and diagnosis, may prescribe and monitor medication, and provide psychotherapy for people with mental health conditions. In some states, PMHNPs must practice under the supervision of a psychiatrist.
- Mental Health Nurse (MHN): Mental Health Nurses may have degrees that range from an associate’s degree to a doctoral degree. Depending on education and experience, the MHN may assess a mental health condition, administer medication, and provide case management or psychotherapy. In some states, MHNs may prescribe or monitor medication.
- Social Workers: Social workers may have degrees from a Bachelor of Social Work (BSW) to a Master of Social Work (MSW) or a Doctor of Social Work (DSW). Depending on their licensure and level of education, social workers provide a range of services, including case management, inpatient discharge planning, placement and planning services, assessment and treatment of mental health conditions, and psychotherapy.
- Licensed Professional Counselors (LPCs): LPCs have a master’s degree in counseling, therapy or another mental health field. LPCs may provide evaluation, assessment and diagnosis of mental health conditions. LPCs generally provide individual, group, or family counseling.
- Peer Specialists: Peer specialists have lived experience of mental health conditions and have been trained and credentialed to assist others in their recovery. Peer specialists provide emotional support, coaching and service linkage.
Q3. What are some of the prescription needs that someone with a mental health condition may have?
A. A broad selection of medications can treat mental health conditions. Medications do not cure mental health conditions but can help reduce symptoms. Often medications are used in combination with other types of treatment such as psychotherapy. There are five classes of commonly prescribed psychiatric medications: 1) antidepressants to treat depression and anxiety; 2) anti-anxiety medications to treat anxiety and panic disorders; 3) mood stabilizers to treat bipolar disorder or as an added treatment for some types of depression; 4) antipsychotic medications to treat disorders such as schizophrenia and bipolar disorder; and 5) stimulant medications to treat conditions such as Attention Deficit Hyperactivity Disorder (ADHD).
Individual response to mental health medications vary widely. Doctors make medication decisions based on effectiveness, side effects, duration of use, individual history and patient preference. Psychiatric medications are highly specific and are not therapeutically interchangeable. Therefore, it is important that a person check the health plan’s drug formulary to ensure that the medications they use are available at a reasonable cost.
For more information on prescription medication benefits, please see Fact Sheet #5.
Q4. What type of therapies (physical, occupational, speech, etc.) and/or devices (durable, disposable, etc.) would someone with mental illness potentially require?
A. Many types of evidence-based therapeutic interventions have proven effective for people living with mental health conditions. These include, but are not limited to, cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), cognitive enhancement therapy (CET) and psychodynamic therapy. People with mental health conditions may participate in individual psychotherapy, group therapy, or family therapy. Treatment settings vary, but therapy is often conducted by a mental health professional in an office setting. Learn more about these types of treatments here. Also keep in mind that someone with a mental illness may have co-occurring physical disabilities and chronic conditions (see Q6). It is a good idea to check in with the individual about the range of their therapeutic and equipment health care needs while they are making coverage decisions.
Q5. What other services and supports, which are not generally medically arranged therapies and devices, are typically required by persons with mental illness? Are these arranged and financed in some private health insurance plans or in some Medicaid programs?
A. Individuals with mental health conditions can benefit from a range of services, supports and therapies that are not traditional health services.
- Case management includes the coordination of services and supports that help a person move toward recovery.
- Peer support can include peer support groups, peer run services in traditional mental health agencies, and service coordination by peer support specialists. Peer services are coordinated by people who have lived experience of mental illness.
- Supported employment helps individuals find and maintain employment as part of their recovery plan. Individual Placement and Support (IPS) and Clubhouses are two evidence-based supported employment programs for people with mental illness.
- Supportive housing services help people locate and maintain safe, quality and affordable housing as part of their recovery plan.
- Assertive Community Treatment (ACT) is an evidence-based program that provides intensive support to individuals with serious mental illness in community-based settings 24 hours a day, 7 days a week. ACT provides services directly to individuals in the community where they live and work.
- Family support and education can include information on mental illness and treatment, problem-solving and coping skills for family members of individuals with mental illness. It can also include a wide array of supports such as respite services and in-home support.
Medicaid traditionally covers most of these types of services. Unfortunately, traditional private health insurance plans may place limits or restrictions on these services.
Q6. Are there any other unique medical needs that someone with a mental health condition should consider when evaluating a health plan?
A. Some individuals with mental health conditions have co-occurring chronic illnesses like diabetes, heart disease, or hypertension. In addition, there is a high overlap between substance use disorders and mental illness. It is very important that people with mental health conditions receive coordinated care to address all of these concerns. It is also imperative that people with mental health condition have access to quality crisis support, emergency and hospital care as well as residential treatment, partial hospitalization or intensive outpatient treatment (IOP).
Q7. Are there any type of accommodations I should consider when I’m planning to meet with someone with mental health condition?
A. People with mental health conditions may need additional assistance in the application process. Many people with mental health conditions have experienced stigma and discrimination. As a result, they may be more sensitive about sharing information about their condition. Educate yourself about mental health conditions, do not stereotype and be sure to treat people with respect. Most are quite capable of making their own health care decisions. Some may request help from a family member or friend. However, always ensure that you address the person shopping for insurance directly. If a person is experiencing psychosis or intense anxiety, it is important to speak calmly and ensure they understand the decisions they are making. People with mental health conditions may need you to explain things step-by-step or may require extra follow-up to ensure they have been enrolled. In case of a mental health crisis, keep a list of the appropriate contacts in your local area.
Q8. Are there any resources you would recommend to obtain additional information about mental health conditions?
A. To learn more about mental illness, check out:
- NAMI (National Alliance on Mental Illness)
- Substance Abuse and Mental Health Services Administration (SAMHSA)
- National Institute of Mental Health (NIMH)
- Fact Sheet #7 – Mental Health and Substance Use Disorder Parity
* This Fact Sheet written by NAMI (National Alliance on Mental Illness)