What to Check in Mental Health Benefits Before Open Enrollment

Open enrollment is the one time a year most people look closely at their health plan, and mental health coverage is usually the part they check least. You compare premiums, glance at the deductible, maybe confirm your doctor is still in network. Then in March you try to find a therapist and discover what the plan actually offers.

I spent years helping employers set up and renew benefits, and the questions below are the ones I wish more employees and HR teams asked before the enrollment window closed rather than after. The list works for both audiences. Employees can use it to compare plan options. HR and benefits teams can use it to pressure-test what they are about to offer. One note before starting: this is general information about how benefits tend to work, not legal or medical advice. Plan terms vary, and your plan documents control.

Where the answers live

Most of what you need is in documents you already have, though it is spread across several of them.

Source	What it tells you	Watch out for
Summary of Benefits and Coverage (SBC)	Copays, coinsurance and deductibles for outpatient and inpatient mental health and substance use care	Standard categories can hide details such as prior authorization
Summary plan description or certificate of coverage	Full rules: limits, exclusions, authorization requirements, appeals	Long; search for "behavioral health," "mental health" and "substance use"
Provider directory	Who is in network, by location and specialty	Often out of date; rarely shows who is accepting new patients
Carrier member services	Live answers, help finding providers, network exceptions	Ask for answers in writing and note the date and reference number
EAP materials or vendor	Free session count, services, how to reach a counselor	Usually a separate network from the health plan
Formulary (drug list)	Which medications are covered and at what tier	Can change during the plan year

HR teams have a few more sources: the carrier's or administrator's network reports, claims and utilization data, and, for parity, the plan's documentation of how it applies treatment limits. More on that below.

The checklist

1. Can you actually get an appointment?

A plan with a large behavioral health network on paper can still leave people stuck. Directories often list providers who have retired, moved, stopped taking the plan or closed their practice to new patients. These are sometimes called ghost networks, and they are among the most common complaints about mental health coverage.

Employees: Before choosing a plan, pick three or four in-network therapists or psychiatrists near you from the directory and call them. Ask whether they take the specific plan, not just the carrier, and whether they are accepting new patients. If you have children, check for child and adolescent providers specifically; they are often scarcer.

HR: Ask the carrier how many in-network behavioral health providers are accepting new patients in the zip codes where employees live, and what the average wait is for a first appointment. If they can't answer, that tells you something. Some employers run their own test calls, which is tedious and usually eye-opening.

2. What will a year of visits cost?

Weekly therapy adds up. A $30 copay is very different from 30% coinsurance on a $150 session, and different again on a high-deductible plan, where you pay the full negotiated rate until the deductible is met.

Employees: Find the cost of an outpatient mental health office visit in the SBC for each option. Then estimate a year of weekly or biweekly sessions under each plan, not just a single visit. On a high-deductible plan, check when therapy starts being shared with the plan and whether an HSA or FSA can cover the gap.

HR: Compare the cost of a therapy visit with the cost of a primary care visit in each plan option. If behavioral health is noticeably more expensive, find out why. It may be a parity question.

3. Are mental health benefits on equal footing with medical?

The Mental Health Parity and Addiction Equity Act, usually just called the federal parity law, applies to most employer group health plans that offer mental health or substance use disorder benefits. At a general level, it says those benefits can't carry financial requirements or treatment limitations that are more restrictive than the ones applied to comparable medical and surgical benefits. That covers obvious things like copays and visit caps, and less obvious ones like prior authorization rules, how providers are admitted to the network and how medical necessity is decided.

Rules differ for some smaller employers and certain plan types, so ask your broker or plan administrator how the law applies to your specific plan.

Two practical points are worth knowing. Plans covered by the law must make their medical necessity criteria for mental health and substance use benefits available on request, and must give the reason for any denial. And since 2021, plans have been required to document comparative analyses of how they apply those less obvious limits to mental health care versus medical care.

The federal rules have also moved. A final rule issued in 2024 added further requirements, and both those requirements and how they are enforced have shifted since. Rather than rely on a summary that may already be dated, check the Department of Labor's mental health parity page for the current position.

Employees: If something in your mental health coverage looks more restrictive than the equivalent medical coverage, ask the plan to explain it in writing.

HR: If you are self-funded, the plan is yours, and so is the compliance responsibility. Ask your administrator for the comparative analysis and review it with counsel. Fully insured employers should still ask the carrier how it addresses parity.

4. Is there a limit on sessions?

Hard caps on outpatient therapy visits are less common than they used to be, partly because of parity. But limits can still appear in other forms, such as a clinical review after a set number of sessions, or a requirement that the provider submit a treatment plan before care continues.

Employees: Search the plan document for visit limits and for phrases like "concurrent review" or "treatment plan." Ask member services what happens after, say, the twentieth session.

HR: Ask whether any behavioral health benefits carry visit or day limits, and how ongoing review of therapy compares with review of physical therapy or other long-running medical care.

5. What needs prior authorization?

Routine outpatient therapy often doesn't need prior authorization, though some plans require it. Authorization is more common for intensive outpatient programs, partial hospitalization, residential treatment, psychological testing, transcranial magnetic stimulation and some medications.

Employees: Ask which mental health and substance use services need prior authorization, who is responsible for getting it (usually the provider, but not always), and how long decisions take. If you are planning care that might need it, weigh that when choosing between plans.

HR: Put the list of behavioral health services requiring authorization next to the medical list. A noticeably longer list on the behavioral side deserves a question.

6. How does telehealth work in this plan?

Video therapy is now an ordinary part of care, but plans handle it in different ways. Some cover any in-network provider by video at the same cost as an office visit. Others route virtual care through a separate vendor with its own network, cost sharing and session rules.

Employees: Check whether you can see your own in-network therapist by video, or only providers on a particular platform. Therapists generally need to be licensed in the state where you are located during the session, which matters if you travel for work or live near a state line.

HR: If the plan uses a separate virtual behavioral health vendor, make sure employees understand how it relates to the main network, and whether they can move from the vendor's counselor to a local provider without starting from scratch.

7. Where does the EAP stop and the plan start?

The EAP is usually a separate benefit that offers a small number of free counseling sessions per issue, with no claims or copays. After that, ongoing care moves to the health plan, with its own network and costs.

Employees: Know how many EAP sessions you get and what happens when they run out. Ask whether the EAP counselor is also in your plan's network, so you can keep seeing the same person if you need more help.

HR: Walk through the handoff from EAP to plan as an employee would experience it. Is there a warm referral, or a list of names? Do EAP counselors overlap with the plan network? Our piece on why employees don't use the EAP covers the access problems that tend to cluster at this point.

8. What about out-of-network care and medications?

Many therapists don't take insurance at all. If you already see one, or want to, out-of-network benefits matter. Check whether the plan has them, whether there is a separate deductible, and how reimbursement is calculated. For medications, look up anything you take now in the formulary, note its tier, and check for step therapy rules that require trying a cheaper drug first.

HR: Ask whether the plan will grant a network exception, covering an out-of-network provider at in-network cost, when no in-network provider is reasonably available. Get the process in writing so you can share it with employees.

9. Is there coverage for higher levels of care and crises?

Most people never need intensive treatment, but families who do find out very quickly what the plan covers. Look at intensive outpatient, partial hospitalization and residential programs; substance use treatment, including medication for opioid use disorder; and emergency and crisis services.

Whatever plan someone chooses, they should also know that the 988 Suicide & Crisis Lifeline is available by call or text anywhere in the US.

Before the window closes: a note for HR

If you are on the employer side, the most useful thing you can do this season is put the answers in one place. Employees won't read four documents. A single page that shows, for each plan option, what a therapy visit costs, how the EAP handoff works, what telehealth looks like and how to request a network exception will do more than another wellness email.

Then use the year ahead to work on the gaps you found. The access section of the four key areas lists recommended actions, and our workplace mental health self-check can show whether access to care is your weakest area or one of several. For free benefits communication and plan-comparison guides, see the resources library.

Frequently asked questions

The directory lists plenty of therapists, but nobody is taking new patients. What now?

Call member services, ask for help finding an available in-network provider, and keep a record of every call. If no one is available within a reasonable distance or wait, ask about a network exception. Some plans also offer a concierge or care-finding service that will make calls for you.

Does parity mean therapy has to cost the same as any doctor's visit?

Not exactly. The law compares mental health benefits with medical benefits within broad categories of care, such as outpatient or inpatient, rather than matching one specific visit to another. If the gap looks large, ask the plan to explain how it complies.

My claim or authorization was denied. What can I do?

Ask for the reason and the criteria used, in writing. Employer plans have an internal appeals process, and in many cases you can request an independent external review if the internal appeal fails. Your provider's office can often help with the paperwork.

Is the EAP part of my health insurance?

Usually not. It is typically a separate benefit with its own counselors and session limit, and because the sessions are free, using them generally has no effect on your deductible.