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Healthcare Reform - A Special Report
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How Will It Affect You and Your Practice?


Part One
Lost in the Shuffle:

Implications of the Affordable Care Act’s 
Health Insurance Market Reforms and 
State Health Insurance Marketplaces 

First in a three-part series on the implications 
of the Affordable Care Act for clinical mental health counselors


By Joel E. Miller
AMHCA Executive Director & CEO

Over the last three years, much of the media attention to the Patient Protection and Affordable Care Act (Affordable Care Act, or ACA) has focused on Congressional attempts to repeal it, healthcare reform debates during the 2012 presidential election, and recent Supreme Court decisions related to the ACA.

Unfortunately, due to all the noise and angst surrounding the ACA, some very fundamental and sound health insurance reforms embodied in the law—and supported by large majorities of Americans—have gotten lost in the policy and media shuffle.  

This article highlights these critically important insurance reforms, how they relate to other key portions of the law such as the new State Health Insurance Marketplaces, and the implications for consumers and clinical mental health counselors.

The ACA, through
its health insurance marketplace reforms, will benefit millions
of people with
mental illness
who will
receive job-based health coverage and hold individual health insurance policies.

ACA Health Insurance 
Improves Mental Health

The ACA, through its health insurance marketplace reforms, will benefit millions of people with mental illness who will receive job-based health coverage and hold individual health insurance policies. 

An Overview of the Improvements to Health Insurance

Most Americans have access to health insurance coverage through a private health insurance plan from their employer, or through a plan they have purchased in what is called the individual health insurance market. 

Before the ACA, health insurers could refuse to sell or renew these policies based on a person’s health or mental health. In other words, they could deny or delay health insurance coverage for pre-existing conditions. And they could use a large share of premium dollars (the amount a person pays to have insurance) for high administrative fees and profits instead of for healthcare. No more.

Under the ACA:

Since 2010, under the Affordable Care Act, several noteworthy benefits have been in effect:

  • Health insurers have no longer denied children coverage for a pre-existing condition.
  • Young adults (up to age 26) also must be allowed to remain on their parents’ health insurance, if their parents so desire.
  • No health plan can have a lifetime or annual limit on certain benefits or rescind coverage if an individual gets sick.
  • Health insurance plans are now required to devote a minimum percentage of their premium income to paying for services.

These provisions are explained more fully below. 

Other ACA provisions will take effect next year, in 2014. Among those that will take effect on Jan. 1 include:

  • Insurers may not charge people with poor health more than others. Premiums may vary only by a limited amount and only on the basis of a few factors, such as tobacco use, age, geographic area, and family size.  Health insurers will have to sell and renew policies to everyone who applies (called “guaranteed issue and renewal”).
  • Health insurers are prohibited from discriminating based on a person’s mental or physical disability.
  • Financial assistance will be available to help families with lower incomes pay their premiums. Employers with 50 or more employees will have to pay the federal government a fee for every employee who receives this assistance (beginning in 2015).

Pre-Existing Conditions Are No Longer a Barrier to Coverage

One of the most important provisions in the law for children and adults with mental health needs is the ban on exclusion for a pre-existing condition. Insurers often deny coverage because a child or adult has a health condition or has been sick in the recent past, and many children and adults with mental illnesses have failed to qualify on these grounds. Some plans refuse to enroll a child or adult at all, while others delay coverage of the pre-existing condition. 

As a result, families either have faced either long periods before needed services are covered, or they have not been able to get the services at all. The ACA has prohibited insurers from denying coverage to children based on any pre-existing condition in plans sold after September 2010. This provision will also apply to adults starting in 2014. 

Young Adults Can Remain Covered

Another important provision is the option for families to keep a dependent child on a parent’s or guardian’s insurance plan until the child turns 26. Young adults often have a hard time getting and keeping insurance coverage, especially if they have emotional or behavioral disorders. Yet this is a time when access to coverage and services is critical because the first episode of a mental illness often occurs in young adulthood. 

Before 2010, coverage on the parents’ plan generally ended at age 22 or younger, and many young people with mental illnesses are unemployed or employed in part-time jobs without benefits. Ironically, these young adults would be eligible for Medicaid on their own, but when they live with parents, the parents’ income disqualifies them.

The ACA increases security for parents and young adults by ensuring coverage up to age 26.

Guaranteed Issue Means Everyone Who Applies for Coverage 
Must Be Offered Health Insurance 

The ACA addresses some of the worst abuses in the
insurance system.
In addition to banning exclusion for a pre-existing condition, health plans
will not be able
to refuse to renew
a policy because
a person or family
has needed and used significant and costly covered healthcare services.

The ACA addresses some of the worst abuses in the insurance system. In addition to banning exclusion for a pre-existing condition, health plans will not be able to refuse to renew a policy because a person or family has needed and used significant and costly covered healthcare services.

Children and adults with mental illnesses have been victims of these practices and have either lost their health coverage just when they needed it most or have been unable to purchase a policy at all. People who participate in large employer plans have not faced these difficulties, but those seeking individual policies, and some small businesses, have been affected.

Guaranteed issue does not go into effect until Jan. 1, although the ban on denial of coverage for pre-existing conditions has been in place for children since 2010. 

Health Insurance Exchanges Will Be 
a Major Marketplace for Health Insurance

To help families purchase health insurance and choose the right plan, the law creates new State Health Insurance Marketplaces (also called Exchanges). 

The Exchanges will be in place in each state by Jan. 1, 2014. They will offer families a choice of health plans that must meet certain standards for benefits and cost. However, families do not have to buy coverage through an Exchange. They can purchase or receive coverage from their employer, a state or federal program such as Medicaid or Medicare, or directly from an insurer.

Children with mental illnesses will benefit from these Exchanges in several ways. First, parents will be able to keep the coverage for their children even if they change jobs, lose their job, or move. The Exchanges will also make it easier for families to compare plans and choose one that best meets their needs.

All plans that participate in an Exchange will have to meet certain requirements, among them providing coverage of mental health and substance use disorder services, and offering insurance that maintains the consumer protections listed above. Exchanges will also have to offer a plan that is available only to children under age 22.

The Exchanges will give people with mental health conditions the opportunity to pick the health plan that best suits their needs, based on the level of out-of-pocket payments they feel able to make and the premiums they are willing to pay. This will make it much easier for people with mental illnesses to purchase insurance.

Minimum Benefits Must Be Provided in Plans

Every health insurance plan offered through the state Exchanges will have to cover at least a minimum range of services. New employer plans must also meet this standard. Included in the list of benefits is coverage for mental health and substance use disorder services, which must be available at parity with medical/surgical coverage. 

That is, there cannot be different and lower limits on the number of visits or days of care, or higher co-payments for mental health and substance abuse services than are typically required for other healthcare. 

This will greatly benefit children and adults with mental illnesses because, for the first time, families can be sure that any health plan that they purchase through the State Health Insurance Exchange covers mental health and substance abuse services on the same level as medical or surgical services.

The law also requires health plans to have an adequate network of providers to serve the people they enroll. This could be especially important for those who use mental health services and for professionals such as clinical mental health counselors, since some health plans have severely restricted the number of providers in their networks, making it hard to get timely appointments.

Therefore, the implementation of the ACA provides a significant opportunity for mental health counselors to participate in new provider networks and integrated care systems such as Accountable Care Organizations (ACA), to increase their caseloads. (In addition, clinical mental health counselors should see increased caseloads in states that opt into the New Medicaid Expansion Programs. This will be the subject of the next article in the series on healthcare reform scheduled to appear in the November issue of The Advocate.)

Health Plans Can Differ

Although every plan sold to families through the Exchanges must meet certain minimum standards for covered services, the law allows plans to differ in the premium and cost-sharing amounts they charge consumers. Plans can also be offered that provide more than just the minimum required covered services listed above.

Health plans will have to offer four levels of benefits with different amounts of cost-sharing. The law also creates a special plan for young adults under age 30, to cover only catastrophic healthcare costs. These plans will have very high deductibles, but they will protect young people from extremely high expenses for healthcare in any single year.


Coverage Will Be More Affordable

Some families who cannot afford any of the plans sold through the Exchange may still have incomes too high to qualify for Medicaid. The ACA authorizes subsidies for them. Premium subsidies will be available for people with incomes of up to 400 percent of the federal poverty level (in 2013, $45,000 for individuals and $93,000 for families).

The amount of the subsidy will vary by income, with those who have the lowest income receiving the highest subsidies. There is also an upper limit on the percentage of their income that individuals would have to spend to purchase insurance.

The ACA also limits the total out-of-pocket cost for families with incomes up to 400 percent of poverty. Those with the lowest incomes will pay no more than 6 percent of their healthcare costs. This amount rises in steps up to the point where people with incomes at 400 percent of poverty would pay no more than 30 percent of their costs.

Limiting premiums and out-of-pocket spending is critical for people with any serious illness. For individuals with mental illnesses who require regular care, co-payments mount up quickly and can present significant financial problems.

Help Will Be Available to Choose a Plan

Choosing a health insurance plan can be confusing regardless of the health insurance mechanism. 
The ACA therefore provides a way for people to get help in this process. Exchanges will provide information and assistance to help families compare plans so they can make an appropriate choice. This will include information on benefits, premiums, cost-sharing, quality, provider networks, and consumer satisfaction with each plan.

States have begun to receive funds to set up offices that will provide assistance or to operate health insurance ombudsman programs. These offices will educate health insurance consumers about their rights and responsibilities, assist them with enrollment, and help them obtain premium tax credits and file complaints and appeals. These programs will also collect and monitor problems encountered by consumers.

Plans will have to use uniform documents and terms to describe their coverage so that people can more easily understand what they offer and compare plans. These descriptions must: 

  • Be in non-technical language—easy for the average person to understand.
  • Use standard definitions of terms,
  • Include information on the dollar amounts of cost-sharing, and
  • Explain exceptions, reductions, and limitations on coverage and other important information.


Increasing Mental Health Benefits and Other Essential Services

The ACA requires the inclusion of medical benefits and mental health and substance use treatment services in the list of the 10 essential benefits that qualified health plans must offer to participate in State Health Insurance Exchange, and, as a consequence, provide through the Medicaid expansion.

Starting in 2014, the Affordable Care Act ensures that health plans offered in the individual and small group markets, both inside and outside of the Health Insurance Exchanges, offer the comprehensive essential package of items and services. 

Essential Health Benefits must include items and services within at least the following 10 categories:

  • Mental health and substance use disorder services, including behavioral health treatment;
  • Ambulatory patient services;
  • Emergency services;
  • Hospitalization;
  • Maternity and newborn care;
  • Prescription drugs;
  • Rehabilitative and habilitative services and devices;
  • Laboratory services;
  • Preventive and wellness services and chronic disease management; and
  • Pediatric services, including oral and vision care.

Final rules on the Essential Health Benefits released earlier this year ensure that consumers purchasing insurance can be confident that their health plan will provide the care they need if they get sick. 

Including mental health and substance use disorder treatment in this package means:

  • Nearly 4 million people currently covered in the individual health insurance market will gain either mental health or substance use disorder coverage or both; and
  • More than 1.2 million individuals currently in small, group insurance plans will receive mental health and substance use disorder benefits under the Affordable Care Act.

Assuring Mental Health Benefits at Parity with Medical Services

The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 prohibits financial requirements and treatment limitations for mental health and substance abuse benefits in group health plans from being more restrictive than those placed on medical and surgical benefits. 

Americans accessing coverage in the individual and small-group markets will now be able to count on mental health and substance use disorder coverage that is comparable to their general medical and surgical coverage.

Under this approach:

  • More than 7.1 million Americans currently covered in the individual market who currently have some mental health and substance use disorder benefits will have access to coverage of Essential Health Benefits that conforms to federal parity protections as provided for under the ACA and the Mental Health Parity and Addiction Equity Act; and
  • Because the application of parity to Essential Health Benefits will also apply to those currently enrolled in non-grandfathered plans in the small-group market, 24 million current enrollees in small-group planswill also receive the benefit of having mental health and substance use disorder benefits that are subject to the federal parity law.

The Affordable Care Act will expand insurance coverage to a projected 28 million previously uninsured Americans through access to private health insurance in the individual and small- group markets, the State Health Insurance Marketplaces, and Medicaid. Essential Health Benefits, including mental health and substance use disorder services subject to parity requirements, will be available to this entire newly covered population.

In total, through the Affordable Care Act, 28 million Americans 

An additional
30 million Americans who currently have some mental health and substance abuse benefits will benefit from the federal
parity protections.
By building on the structure of the
Mental Health Parity and Addiction Equity Act, the Affordable Care Act will extend federal parity protections to more than 58 million Americans.

who are uninsured with a behavioral health condition will gain access to coverage, which includes mental health and/or substance use disorder benefits that comply with federal parity requirements.

An additional 30 million Americans who currently have some mental health and substance abuse benefits will benefit from the federal parity protections. By building on the structure of the Mental Health Parity and Addiction Equity Act, the Affordable Care Act will extend federal parity protections to more than 58 million Americans. 

Practice Implications for 
Clinical Mental Health Counselors

Since the open enrollment period for the Affordable Care Act begins Oct. 1, and implementation of the law is set to begin Jan. 1 (the date on which consumers eligible for coverage can access services), mental health counselors should begin to:

  1. Gain professional competence in healthcare reform topics and on ACA eligibility and enrollment processes in your state. This is critically important in helping individuals secure the best possible health insurance coverage and mental health benefits available through your state’s Health Insurance Exchange as well as through the new Medicaid Expansion Program. 
         As a mental healthcare provider, you will be an important resource on health insurance issues. Clients are likely to want to know about insurance resources intended to address an array of unmet needs and issues, so be prepared!
  2. Plan for the influx of newly insured clients and use of behavioral health services.
  3. Identify opportunities to provide services to distinct minority populations that traditionally have had difficulty obtaining needed behavioral health services—many with complex behavioral health needs.
  4. Identify and provide unique diversity and cultural competency niche programs, and make inroads into neighborhoods and communities.
  5. Determine new staffing and equipment needs.
  6. Develop and/or upgrade new services, such as preventive services, including annual wellness services and personalized prevention plans.
  7. Identify opportunities to participate in new provider networks.
  8. Identify opportunities to participate in new care-delivery models such as health homes, accountable care organizations (ACOs) and primary-care collaborative programs, and new financing arrangements such as bundling strategies. 
  9. Anticipate system-wide behavioral health needs and participate in statewide planning to identify community behavioral health needs.
  10. Serve as navigators or consumer assisters to guide consumers in determining their health insurance needs under the ACA. 

All of these potential implications and opportunities for clinical mental health counselors will significantly increase due to new State Medicaid Expansion Programs as well as what is known as the “Woodwork Effect” or “Welcome Mat Effect.” These whimsically named effects occur when individuals eligible for coverage under the current Medicaid Program become aware of their eligibility due to the marketing and promotional programs associated with the Affordable Care Act open enrollment period.

AMHCA will also be sponsoring—at no cost to members—a series of webinars over the next six months to provide new approaches and strategies that clinical mental health counselors can adopt to be ready for the implementation of the ACA. 

Meantime, see a related article on healthcare reform in this issue on 20 steps you can take now to prepare for healthcare reform.

The ACA is a treasure trove of opportunities for mental health counselors, but readiness is required to make the most of it.

And AMHCA will help you get there.

Don’t miss Part Two ofThe Advocate’sthree-part series on Healthcare Reform.
The November issue topic is, “The ACA’s New Medicaid Expansion Program and
Its Impact on Mental Health.” Part Three will address, “New Care Delivery and Payment Models Under Healthcare Reform: Implications for Mental Health Counselors,” in the December/January issue