Most Americans with health insurance will be guaranteed access to mental health services, including for depression and alcoholism, equal to medical and surgical treatment under long-delayed rules issued on Friday by the Obama administration. But the protections do not apply to tens of millions of people, including the elderly.

The rules implement the 2008 Mental Health Parity and Addiction Equity Act, which took on greater urgency with the administration’s vow to address gun violence after a series of mass shootings across the United States in the past few years.

Health and Human Services Secretary Kathleen Sebelius estimated that 90 percent of Americans with substance-use disorders do not receive the care they need.

“For way too long, health plans openly discriminated against” Americans with mental illness, she said in a call with reporters on Friday. Labor Secretary Thomas Perez said mental illnesses “the stepchildren of the healthcare system.”

In any given year, about one-quarter of American adults have a mental illness that meets diagnostic criteria, says the National Institute of Mental Health.

Under the final rules, health plans must not have different co-pays, deductibles or visit limits for mental disorders and substance abuse than they do for other illnesses.

If they allow people to receive treatment out-of-state for, say, heart disease, then they must do so for mental illness as well. If an insurance plan uses particular clinical guidelines in determining what medical conditions and treatments to cover, it must use comparable ones for mental disorders.

Covered health plans are also prohibited from imposing a separate deductible for mental health treatment. And they cannot limit patients to receiving mental health treatment only from, say, licensed social workers rather than physicians and psychologists, as some plans have in an effort to limit spending.

The rules had been so long in coming that, on Thursday, former Congressman Patrick Kennedy, who was instrumental in passing the 2008 law, told a Senate panel that it had “entered a kind of twilight zone.” The five-year wait was a “particularly bad example” of how laws can languish without being implemented, said Kennedy, who has discussed his battles with bipolar disorder and addiction to prescription drugs.

After passage of the 2008 mental health parity law, more than 30 states passed laws of their own implementing its requirements. But the largest plans, since they are regulated at the federal level, were not affected by state laws.

President Barack Obama’s healthcare reform law requires that all individual and employer-based health insurance policies, including those sold on the state-based insurance exchanges, cover mental health and substance abuse as one of 10 “essential health benefits.” The only exceptions are those few plans that have been unchanged since the law was signed in March 2010.

As a result, the final rules on mental health parity have already been largely incorporated into plans sold since October 1 on the online exchanges set up under the Patient Protection and Affordable Care Act, also known as Obamacare. They are also part of most employer-based plans, according to the administration, which estimates that mental health treatments make up 5 percent of the benefits that plans pay for.

There are still loopholes, however.

The parity rules do not apply to standard Medicaid plans, the joint federal-state program for poor Americans. If states require Medicaid beneficiaries to enroll in managed care plans, however, those plans must cover mental health treatment.

A bigger loophole is that the rules do not apply to Medicare, the government-run healthcare program for the elderly. The 2008 parity law had that exemption “because it was a cost issue,” said Andrew Sperling, director of legislative advocacy for the National Alliance on Mental Illness (NAMI). “They would have had to make up the additional costs elsewhere” by cutting other benefits, “and Congress didn’t want to do that.”

Depression alone affects more than 6.5 million of the 35 million Americans old enough for Medicare, NAMI estimates.

“Medicare,” said Kennedy, “still has a distance to cover in its journey to parity.”

Large employer-based plans also have an escape hatch. If mental-health parity causes their costs to increase at least 2 percent in the first year it’s in place, or 1 percent any subsequent year, the plan may apply for an exemption. NAMI’s Sperling believes the exemption will be onerous enough to apply and qualify for that few employers will request it, however.

The mental-health parity law does not apply at all to group insurance plans at private companies that cover 50 or fewer employees.

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By Sharon Begley