Doctors navigating their way through the Affordable Care Act's final minimum coverage requirements for 2014 face a complex environment in which more people are obtaining access to mental health care and other services, but doing so through benefits that can vary significantly by insurer and by state.
On Feb. 20, the Dept. of Health and Human Services issued a final rule mandating a core package of 10 “essential health benefits” categories that qualified plans on health insurance exchanges — and some plans outside of those marketplaces — will need to cover. Each state has been asked to choose a benchmark plan from a selection of popular existing plans to determine more precisely what benefits must be covered under the categories.
Although the affected plans now have a benefits floor that will ensure more uniformity, plans will retain some flexibility, not only in benefits design but also in cost sharing and utilization management, said Sonya Schwartz, program director for the National Academy for State Health Policy. “One plan may allow some to get access to some sort of service or drug right away. Another may require pre-authorization,” she said.
Most states have chosen for their benchmark plans the most popular small-group plan in their jurisdictions, which also serves as the default option for states that don't actively choose a benchmark.
In the final rule, HHS placed a special emphasis on how essential benefits standards starting in 2014 would strengthen and expand coverage of mental health and substance abuse disorder services, one of the 10 broad categories of care.
The rule states that the federal mental health and substance abuse parity law will apply to new plans sold on the exchanges, as well as to non-grandfathered small-group and individual plans sold outside of the marketplaces, said Mark Covall, president and CEO of the National Assn. of Psychiatric Health Systems. That means insurers will not be able to cover those services under different limitations than the ones that apply to other medical care.
These policy changes will help close gaps that have existed in mental health coverage in the insurance market, HHS officials stated in a report released in tandem with the final health benefits rule. The department estimated that 20% of those who have individual market insurance have no mental health services coverage, while a third can't get coverage for substance abuse disorders.
“For far too long we have had a two-tiered insurance system, with those who had brain disorders getting less coverage than those who had heart disease. Finally, this practice is coming to an end,” Covall said.
It's encouraging that the ACA required mental health and substance abuse coverage as one of the 10 categories of care and mandates parity for those benefits, said Julie A. Clements, deputy director of regulatory affairs with the American Psychiatric Assn. The rule also clarified that if a benchmark plan is missing the category, it must supplement it from another approved state plan, she said.
But the APA didn't get everything it wanted in the final rule. Of particular concern is the scope of mental health/substance abuse services that plans under the law must offer within the category. “The way it currently is, you can have a lot of variation from state to state,” Clements said.
For the most part, HHS gives states a great deal of leeway in the design of essential health benefits above the floor. “How substantive a state's mental health and substance abuse benefits may be is really going to reflect the interaction between federal EHB guidelines and existing state law,” she said. Only some states require that care for certain mental health diagnoses be covered by all insurers.
There's also going to be variability in how mental health parity is defined among individual plans, making it difficult for doctors and patients to compare plan offerings, said Barry Perlman, MD. He's director of the Dept. of Psychiatry at St. Joseph's Medical Center in Yonkers, N.Y., and the past president of the New York State Psychiatric Assn. Mental health must be covered at the same level as other medical benefits, but he said that doesn't guarantee strong coverage.
Jim Smith, senior vice president of the Camden Group, a national health care consulting firm, recommended that physicians familiarize themselves with the list of 10 broad benefit categories but remain cognizant of the fact that there will be differences by state, as well as by plan.
Despite the gains in mental health coverage, some physician organizations said there were other parts of the final rule that fell short, including the prescription drug category.
The final rule retains the proposed rule's provision that affected health plans must cover the same number of drugs in a particular class as does the state benchmark plan. Plans must cover at least one drug in a class in cases where the benchmark doesn't cover any.
But these conditions still are limiting, the APA's Clements said. HHS allows a plan appeals process for those seeking coverage for a “clinically appropriate” drug not on the formulary. But she noted that such appeals happen now, “and thus far it doesn't usually work out for patients.”
Chris Hansen, president of the American Cancer Society Cancer Action Network, said he was encouraged, however, that the rule recognized the importance of covering new drugs under the essential benefits as those medications become available.
In the final rule, HHS did not adopt advice by the American Medical Association and the American Academy of Pediatrics to use Medicaid's Early and Periodic Screening, Diagnostic and Treatment program as the model for defining pediatric essential health benefits. Medicaid covers more robust benefit options for children than many of the private plans listed as state benchmarks, the groups said.
NASHP's Schwartz observed that the final rule opened the door to some pediatric benefits that wouldn't necessarily be covered by commercial plans, such as habilitative, dental and vision services.
But pediatric medical organizations contended that the rule offers no guarantee of these benefits. States “may choose to effectively eliminate dental coverage, even though dental caries are the most preventable health condition in the pediatric population. Durable medical equipment may be substituted for habilitation, even though a child with spina bifida or a congenital defect may need both,” the AAP and other groups wrote in a Feb. 25 letter to HHS.
Access to pediatric drugs and mental and behavioral health services for kids also may be excluded or weakened, they stated.
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