Some supporters of the health law are dreading the possibility of talk at the Thanksgiving dinner table turning to the nation’s health law. If getting drawn into a debate over the Affordable Care Act felt rough at other years’ feasts, this year, with the law rolling out, it feels especially dicey.
The good news is we’re here to help with some great information and links you can read up on well before that turkey dinner:
- On rates in the Health Insurance Marketplace: Many people will be getting much better coverage for less than they pay now. While some people will pay more, many of these people have had a bare-bones policy that few would consider good health insurance. Stacey Pogue with the Center for Public Policy Priorities explains more here.
- On those recent health plan cancellations: Stacey also breaks down what you need to know on this score. Additionally, a new report from Families USA shows just how few people-0.5%-are both at risk of losing the coverage they had and without financial assistance to purchase a new, better plan.
- On coverage expansion: As Anne Dunkelberg points out in an Austin American-Statesman op-ed, there are also a lot fewer Texans who risk having to change plans than there are Texans who are affected by Texas’ leaders decision not to expand Medicaid in the state. Over at MomsRising, some fellow champions for health coverage help explain who the folks in the coverage gap are.
- On navigators: The people helping folks enroll in the health insurance marketplace have an important job to do and plans for them need to remember, as our blog post explains: “Insurance is difficult to understand, especially for people who haven’t had it before. Navigators provide in-person help-answering questions, deciphering plan options, and helping people enroll.”
- On other things happening in health policy beyond Obamacare: A new report from the Georgetown Center for Children and Families shows Medicaid and CHIP are huge successes. Medicaid has not only helped many more kids get covered; children also are receiving the care they need to lead healthier lives. And as Clayton Travis of Texans Care for Children explains, some new rules pertaining to mental health will help a lot of people with mental health concerns get treatment they need.
- On the big picture of whether the Affordable Care Act is working: Check out this chart posted by the Washington Post about how the nation’s health care costs are declining-even while care itself improves-thanks to the Affordable Care Act.
We wish you a wonderful Thanksgiving holiday!
Your friends at Texas Well and Healthy
P.S. We are very excited to be working with Get Covered America (a campaign of Enroll America) to connect uninsured Texans with the chance to get coverage through the Health Insurance Marketplace. Get Covered America is looking for volunteers to help spread the word. There are many different volunteer opportunities. If you hear from Get Covered America about volunteering opportunities, we hope you’ll take the time to talk with them, and learn how you can help get Texas covered.
Last Friday was a historic day in mental health policy. The final rules were issued for the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, which was passed back in October of 2008. Consumers and mental health advocates have awaited these rules because they clarify and help reinforce provisions of the law that require mental health and substance use services to be covered the same way other health services are.
This is a big deal. Treating mental illness the same as physical illness means a lot more people will be able to get the mental health services they need without today’s red tape or outright denials from insurers standing in their way. By doing away with the artificial barrier that has been separating physical and mental health, the rules will also help reduce the stigma continuing to surround mental illness.
So what exactly do the rules, which go into effect for group and individual plans in July of 2014, do and how are they different from what came before?
- The final rules removed some confusing language currently in regulations that lets plans make distinctions between medical/surgical and mental health/substance use benefits if they meet “clinically appropriate standards of care.” The Department of Health and Humans Services determined that language to be too vague, unnecessary, and subject to abuse and said there’s enough flexibility to allow for the right standards of care to be in place across the board.
- “Intermediate levels of care,” such as residential treatment or intensive outpatient treatment, fall under the final rules on parity, so if health plans cover similar levels of medical/surgical care they need to do so for mental health and substance use, too.
- The expanded definition of “non-quantitative treatment limitations” means that insurance companies must provide enrollees similar access to mental health providers, based on geographic location and facility types as physical health providers.
- Final rules clarify a participant’s right to certain information, including knowing what qualifies as a medical necessity, and, if the participant is denied services, how that determination was made.
How does all this wonky talk affect someone with a mental health concern?
For those who have been denied care, these new rules will make a world of difference. (Others whose health plans were already up to the standards in these rules won’t see much of a change.) A patient may be able to receive more comprehensive, medically appropriate care for their diagnosis, even if earlier on it was denied because it was deemed too expensive by their insurance company. Many mental health and substance use treatment supports (such as rehabilitative, residential and intensive outpatient services) will have fewer superficial limits, so people can access treatment and will be able to get the right type of care for them. Additionally, health plans are being held to higher accountability standards for mental health provider access. Finally, if you are denied a mental health or substance use service, you will have more information at your disposal to determine if it was a violation of parity.
The rule definitely doesn’t answer all questions regarding an individual’s treatment needs. There are limitations to the scope of the mental health parity law and its rules. For instance, while the law’s statutory principles apply to Medicaid managed care organizations, alternative benefit plans and the Children’s Health Insurance Program (CHIP), the final rules do not. The Center for Medicaid and Medicare Services intends to issue additional guidance to help states enforce the parity law in their Medicaid programs sometime in the future.
One thing is certain, though: we are moving in the right direction. Our health care system is being shaped by policy that improves a person’s whole health – both mind and body.
Written by: Clayton Travis, Texans Care for Children. Cross-posted from State of the Children blog.
The Countdown To Coverage series continues with a look at an essential health benefit: coverage for mental health. We also share how consumers can be sure to choose a plan in the Health Insurance Marketplace that meets their needs.
Mental health benefits and the Affordable Care Act (ACA)
Access to behavioral health care is not just a matter of having health insurance; it also requires an adequate scope of covered benefits in a health plan. For many years, benefits for Mental Health and Substance Use (MH/SU) services were not included in many health plans. In addition, when an employer did chose to offer mental health care coverage as a part of the employer-sponsored plan, MH/SU conditions were typically capped at a much lower level of coverage than that for physical conditions. As a result, people who needed MH/SU services either went without what their insurance did not cover, or were exposed to high costs if they accessed services beyond the coverage limits. To reduce this disparity, Congress passed the Wellston-Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008, that requires that group health plans (with 51+ full-time employees) that choose to provide MH/SU benefits—and all Medicaid managed care plans—must ensure that the coverage for those benefits is no more restrictive than the coverage terms for medical/surgical services.
The ACA expands those federal “parity” provisions. The essential health benefits (EHB) standard in the ACA raises the bar by requiring most health plans to cover MH/SU services, which will improve the opportunity for early intervention and continuous treatment for this vulnerable population. Individual market and small employer plans in 2014 will all be required to meet new minimum standards for the benefits they cover. Each plan must include a package of ten EHBs including mental health and substance abuse services; hospitalization; prescription drugs; rehabilitative and habilitative services; preventive and wellness services and chronic disease management; ambulatory patient services; emergency services; maternity and newborn care; laboratory services; and pediatric services, including oral and vision care.
The Marketplace plans must provide MH/SU benefits no more limited than their medical benefits, as directed by MHPAEA. Individuals and small groups in 2014 will be able to buy plans both inside and outside the Marketplace, and all coverage sold to individuals and small employers from that point forward must meet the EHB standards, whether inside or outside the exchange. In short, these plans must provide MH/SU benefits equal to medical benefits. Applying any limits to MH/SU benefits that are more restrictive than for medical benefits will be prohibited, including higher out-of-pocket financial requirements; more limited treatments; unequal use of preauthorization of services, fail-first policies, or utilization reviews; or a narrower application of “medical necessity” definitions for MH/SU treatment.
The combined effect of ACA’s standards for Essential Health Benefits and the extension of MH/SU parity to private insurance plans in 2014 should significantly increase access to adequate treatment of these conditions for all insured persons. In the process, it promises to reduce a lot of avoidable ER visits, and even some avoidable incarcerations.
Choosing a plan
Selecting a health care plan for you or your family can be intimidating, especially if this is your first time and/or you have a chronic condition such as mental illness. As we have shared with you in our blog series, Countdown to Coverage, there is a lot to understand before you select a plan and for people who suffer from mental illness and substance use disorders, there are important things to consider when selecting a plan in the Marketplace.
Prior to the ACA, many health plans did not included coverage for mental health and substance abuse services or if they did, the benefits where less than those offered for physical conditions. Also, insurance companies could flat-out deny coverage to those with pre-existing conditions like mental illness. However, under the ACA, each plan in the Marketplace will have to provide core benefits, known as the essential health benefits, including mental health and substance abuse services and insurance companies can no longer deny coverage because of pre-existing conditions.
Most individuals who are uninsured will be able to gain coverage through the Marketplace, which will offer a variety of health insurance plans. Plans will be presented in four tiers – bronze, silver, gold, and platinum – which makes it easy to compare plans.
The tier you choose affects how much your premium costs each month and your total out-of-pocket costs like copays and deductibles. Individuals with chronic conditions generally visit the doctor more frequently and take more prescription medications, which means more out-of-pocket costs within a year.
When choosing your health plan, keep this in mind:
- The bronze, silver, gold, and platinum plans do not reflect the quality or amount of care the plans provide.
- All plans in all tiers will contain essential health benefits
- In general, the lower the premium, the higher the out-of-pocket costs when you need care; the higher the premium, the lower the out-of-pocket costs when you need care. For example, the Bronze plan will generally have a lower premium but a higher out-of-pocket cost than a Silver plan.
Written by: Katharine Ligon, Center for Public Policy Priorities. Cross-posted from Better Texas blog.
Mental health has received a lot of well-deserved attention this legislative session after the recent violent tragedies in our nation. Texas legislators deserve praise for recognizing that all Texans benefit from a stronger mental health system with increased funds for prevention and better access to services. Of the more than 250 bills related to mental health filed this session, I focused on a number of bills that move the state forward in preventing and treating mental illness, assist communities in addressing their local needs and improve the outcome of individuals of all ages with mental illness. Although numerous mental-health-related bills passed, I would like to tell you about one in particular – HB 2625 by Rep. Garnet Coleman (SB 1912 by Sen. Sylvia Garcia), which was included as an amendment to two different bills that passed. This legislation revises the clinical criteria for adults to receive public mental health services at the local mental health centers.
Currently, Texas law (as the result of HB 2292 in 2003) mandates that state dollars can only fund mental health services for individuals who are medically indigent and meet the target population criteria. To receive services, an adult must have at least one of the “Big 3 diagnoses”–schizophrenia, major depression, or bipolar disorders. The door to community-based outpatient services has been closed for adults with other mental illness diagnoses (e.g., PTSD and other Anxiety Disorders). Therefore, these individuals only get services when in crisis: in the emergency rooms and through crisis services via the local mental health center. Crisis services are only temporary, do not provide continuous care, and are very costly to our local communities.
Rep. Coleman’s bill created two tiers of criteria to receive adult outpatient services in the local mental health centers. The first tier is the current law, serving those adults with the Big 3 using funds appropriated. A new second tier permits the centers to also provide clinically appropriate treatment services, with available resources, to adults with mental illnesses when their psychological, social, and occupational functioning deteriorates. The intent is to ensure that all individuals with mental illnesses, regardless of a specific diagnosis, are able to access services. This legislation opens the door to providing continuous and comprehensive outpatient behavioral health services for adults who today are cycling through the crisis system because they do not have the “right” diagnosis.
Written by Katharine Ligon, Center for Public Policy Priorities. Cross-posted from Better Texas blog.
When Texans with mental health concerns receive help, our communities, families and businesses all benefit. That’s why it has been great to see our legislature improve public investments in mental health during the 83rd Legislative Session.
Funding our public mental health system is a real step forward, but it is only part of the solution when another important opportunity exists. Our state legislature had a chance to address perhaps the biggest barrier to wellness for hundreds of thousands of Texans with mental health concerns: a lack of health insurance that keeps them from getting the treatment and services they need. Our state could have produced a plan to accept federal dollars for about 1 million uninsured Texans, so that they would have a health insurance option. Unfortunately, this never happened and politics were placed over people.
Whole communities will benefit if we develop a solution to cover more Texans with available federal dollars. Right now, unmet mental health needs cost Texas businesses an estimated $270 billion in lost revenue each year. The public spends another $13 billion addressing mental illness and substance abuse. Access to ongoing treatment and services make all the difference in whether Texans with unmet mental health needs succeed at work, in school and in the community.
Rejecting the funds altogether will only put more pressure on our state funded systems. A vast majority of uninsured Texans who use our public behavioral health system for mental health and substance abuse services would be covered if Texas were to accept these federal funds next year. It is the efficient and right choice for our state, and the governor should make sure this is addressed before the year’s end.
New research shows the key role of coverage in mental health. In Oregon, an unusual circumstance led to a lottery system where some, but not all, uninsured people could get covered through Medicaid. When researchers compared the groups with and without coverage, they found the population that had health insurance had a 30 percent lower rate of depression than the uninsured group. That real and sizable improvement followed better access to health care.
It isn’t too late for a solution, but with every month after December that we stall, lives and dollars are lost. Let’s not make Texans wait and make our public mental health system pay more. There’s a way to address the need and help more people reach their full potential from day one of the new year.
Written by Clayton Travis, Texans Care for Children
Patricia Gonzales’ story is not an uncommon one in Texas. She is a mother of three from Pasadena, Texas. Two of her children have mental health needs that require proper ongoing treatment. Her 22 year old daughter has ADHD and has been on medication since she was diagnosed at the age of 6. With proper medication she performed well in school and was able to participate in sports. Once she turned 19, she lost access to Medicaid benefits that kept her functional in her school and community. Due to the lack of medically necessary treatment she was not able to continue into higher education. The family tried working with safety net clinics in her area to continue her medication, but they only offered limited access to generic brands that weren’t as effective.
One in 5 children in the United States experiences a mental health concern and many develop a serious mental illness during their late adolescence. A disruption of medically necessary services occurs for thousands of Texas’ transition age youth (ages 14-24) each year as they age out of Medicaid. Currently, Texas’ Medicaid program serves only a small proportion of parents and aged and disabled adults. In order to qualify a transition age youth would have to have a disabling serious mental illness.
This could all change if the state decides to accept new federal dollars set aside to expand Medicaid eligibility for all low income individuals. This way, children who currently benefit from mental health services are able to continue receiving therapies and medication as a young adult until they obtain the financial stability to purchase health insurance on their own.
Patricia’s youngest son is one of these children. He is able to thrive in school and band with ADHD and an anxiety disorder. He constantly sets challenging goals for himself and hopes to attend college three years from now. But, Patricia is concerned he will not have access to affordable and comprehensive health insurance at a point in his life in which he will be going through many complex transitions such as continuing onto college, finding employment and living on his own. Expanding Medicaid will provide Patricia’s son with an assurance that his aspirations will not be disrupted by his mental health needs.
Written by Clayton Travis, Texans Care for Children
Patricia speaking with Senator Sylvia Garcia about her children and the benefits of Medicaid coverage and expansion.
The Affordable Care Act (ACA) has passed, been okayed by the Supreme Court and had many of its provisions kick in already, affecting the health and wellbeing of Texans right now. Access to affordable, comprehensive health care is a major success we can be proud of, but what about mental health care?
Well, don’t you fret. There are several areas in which the Affordable Care Act will improve the lives of those suffering from mental health disorders:
Mental Health Care as an Essential Health Benefit
The Affordable Care Act spells out a list of mandated categories of coverage that insurance plans will now be required to include in an individual’s benefit package. And guess what? Mental health care – including substance abuse and behavioral health services – is one of the ten categories. This is a big deal, because in the past mental health often wasn’t treated like other health services. Insurance companies will no longer be able to exclude mental health care benefits from their general package of benefits or offer it as a more expensive supplemental package.
Mental Health Parity
Mental health benefits must match physical health services offered under the law. This means whatever the day and visit limits, dollar limits, coinsurance, co-payments, deductibles, and out-of-pocket maximums are for physical health care, that same standard should apply to mental health. Providing mental health services at “parity” with physical health services has been required of some insurance markets since 1996, but the ACA expands parity to nearly all insurance markets.
Integrated Mental and Physical Health
The Affordable Care Act also promotes the growing trend to provide individuals with integrated care, which means meeting physical and mental health care needs in the same location. Integrated care has been shown to improve health outcomes for individuals by insuring they get all the services they need in one stop and by getting doctors to talk and work together for their patients.
Integrated care “health homes” will be set up with federal funding to build the infrastructure needed for patients to receive comprehensive care management, care coordination, health promotion, and comprehensive transitional care for inpatient to other settings, including follow-up care and individual and family support. Each of these services would greatly benefit people coping with physical and mental health disorders at the same time.
The Affordable Care Act makes some substantial jumps in access and quality of care for those with mental health disorders, but there are several ways in which Texas could utilize the ACA further:
- Make the Medicaid program available to the newly qualified ACA population.
- Enforce mental health parity laws.
- Invest in the mental health workforce.
- Take advantage of federal dollars to implement integrated health strategies.
Talk to your state legislators and advocate for taking full advantage of the Affordable Care Act so that those who struggle with mental health disorders can receive the help and assistance they need.
Written by: Clayton Travis, Texans Care for Children
