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Update on Mental Health Benefits and Substance Use Disorder Services Under the Affordable Care Act

Update on Mental Health Benefits and Substance Use Disorder Services Under the Affordable Care Act

Affordable Care ActCome next year, psychiatrists will start seeing patients who have purchased new individual and small-group health plans on the state exchanges mandated by the Affordable Care Act. But mental health benefits will differ from state to state, and it is hard to know whether they will meet the requirements of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). Moreover, important issues such as network adequacy as far as psychiatrist coverage is concerned and physician payment rates are also up in the air.

Julie Clements, JD, MPP, Deputy Director of Regulatory Affairs at the American Psychiatric Association, recently conducted a webinar for psychiatrists. She told Psychiatric Times, “A lot of them don’t yet realize how big an issue this is. They are just beginning to understand that the state exchanges will offer private plans and subsidies for individuals of up to 400% of the poverty rate. So this could mean 60 million to 70 million people impacted.”

The Department of Health and Human Services (HHS) issued a final rule on February 25, 2013, that outlines the essential health benefits (EHBs) that all qualified health plans (QHPs) on each state exchange must cover. Those EHBs fall into 10 categories. Two are of prime importance to psychiatric patients: mental health and substance use disorder services, including behavioral health treatment, and prescription drugs.

Almost all 50 states and the District of Columbia have chosen “benchmark plans,” which set minimum levels of benefits for QHPs in each of the 10 EHB categories. The EHB rule is very general with regard to the mental health category and does not address how the MHPAEA affects those minimums.

Clements explains that most states have chosen the largest small-group plan in their state as their benchmark. These typically have less generous mental health benefits than private employer plans. California, for example, has chosen the Kaiser Small Group HMO 30 plan as its benchmark. “Many stakeholders in California have grave concerns over Kaiser’s minimal mental health services,” reports Jane Adcock, Executive Officer, California Mental Health Planning Council. “Recently, Kaiser was found to be out of compliance with access and availability rules and is in a corrective action plan mode.”

States do have the option of supplementing mental health or any other category of benefits within the benchmark plans. But they will not get federal financial assistance to do so, which decreases the likelihood that supplementation will occur, according to Clements. “NASMHPD is learning that states’ approaches to supplementing benefits or substitution are diverse,” explains, Joel E. Miller, Senior Director of Policy and Healthcare Reform, National Association of State Mental Health Program Directors (NASMHPD). “NASMHPD is concerned that this flexibility could affect mental health consumers’ ability to make apples-to-apples comparisons among plans and allow plans to use benefit design to cherry-pick healthier enrollees.”


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