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Update on Mental Health Benefits and Substance Use Disorder Services Under the Affordable Care Act: Page 2 of 2

Update on Mental Health Benefits and Substance Use Disorder Services Under the Affordable Care Act: Page 2 of 2

Minimum mental health coverage in the mental health category theoretically should be affected once the HHS publishes a long-delayed final rule on the MHPAEA. That law—also known as the Wellstone-Domenici Mental Health Parity Act—says that all insurance plans must equalize access for patients with mental health issues with access for medical/surgical patients, and provide equal payment for all physicians billing the same codes (eg, evaluation and management codes).

In a letter to the HHS on March 13, 2013, the American Psychiatric Association voiced concern that states would judge network adequacy for psychiatrists included in QHP networks on the basis of the number of psychiatrists in a network, as opposed to the number of days it takes for a patient to get an appointment with a psychiatrist.

Patient access to medications is also an issue. The HHS declined to order formularies in QHPs to adhere to the Medicare Part D requirement that all drugs in 6 “protected” categories be available. Those 6 include antidepressants and antipsychotics. QHPs will have to offer at least the greater of the following:

• One drug in every United States Pharmacopeia category and class

or

• The same number of prescription drugs in each category and class as the state EHB benchmark plan

Patients who want an off-formulary drug will be able to file an appeal for it.

“It’s nice to say that people who need a drug that’s not on the formulary can appeal for it, but typically appeals are a lengthy and burdensome process, and this will be a difficult process for many mentally ill patients who seek a medically necessary but not covered drug,” responds Clements. “The drug benefit is still very limiting. Most very sick mental health patients need drugs from at least 3 different classes within the drug formulary.”

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