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Presentation on theme: "STATE-BASED ADVOCACY FOR ESSENTIAL HEALTH BENEFIT DESIGN FOR MENTAL HEALTH AND SUBSTANCE USE DISORDERS Coalition for Whole Health Webinar."— Presentation transcript:


2 Presenters Moe Keller, Vice President of Public Policy at MHA Colorado and former Colorado State Senator Donna J. Conley, Chief Executive Officer, Ohio Citizen Advocates for Chemical Dependency Prevention and Treatment Kathleen Gmeiner, Project Director, UHCAN Ohio Moderator William Emmet, Senior Policy Advisor, Magna Systems, Inc.

3 COALITION FOR WHOLE HEALTH WEBINAR APRIL 16, 2013 Essential Health Benefits and the Affordable Care Act

4 Overview of Essential Health Benefits Ten categories of benefits that all plans in the health insurance exchanges, all small group and individual market plans outside the exchanges, and certain Medicaid coverage must include beginning in 2014 Includes mental health and substance use disorder services, prescription drugs, preventive and wellness services, and other categories Mental health and substance use disorder services must be covered at parity with other services

5 EHB Continued The ACA requires the Secretary of HHS to define the benefits in each category, and requires that:  The scope of the EHB is equal to benefits under a typical provider plan;  The EHB does not discriminate based on age, expected length of life, disability, degree of medical dependency, or quality of life;  The EHB takes into account the health needs of diverse segments of the population;  The EHB reflects appropriate balance among categories. ACA says states are responsible for costs of benefit mandates that go beyond EHB requirements

6 How has the Secretary Defined EHB? In a December 2011 bulletin, HHS announced they would allow states to define their own EHB based on a “benchmark plan” Benchmark plan options include any of the three largest small group plans in the state, any of the three largest state employee plans, any of the largest federal employee plans, or the largest HMO in the state HHS has provided a framework to ensure coverage of all ten benefit categories For states that do not choose, default is largest small group plan The EHB will include all state benefit mandates that were in place in December 2011

7 What do the Regulations Say? EHB regulations were finalized in February 2013 Very similar to December 2011 bulletin  Allows state flexibility  Largest small group plan is default  Provides the framework for substituting missing EHB categories Restates the requirement that MH/SUD be included in EHB Reiterates MH/SUD parity, and says that if parity requirements aren’t met, EHB is not being provided

8 What else do the Regulations Say? Explicitly tells states that they must supplement the EHB as needed to meet parity requirements, and clarifies that states will not have to defray costs for parity compliance Says states have primary EHB enforcement responsibilities, but feds will step in if needed Gives states the flexibility to allow, limit, or prohibit plans’ ability to substitute benefits within EHB categories, and says any substitution must be actuarially equivalent

9 What else do the Regulations Say? Provides special rules for the prescription drug category  Require all categories and classes to be covered,  Allows plans to cover more drugs if they choose, without exceeding the EHB,  Requires plans to allow access to clinically appropriate drugs that aren’t on the drug list. Restates that HHS will consider revisiting the benchmarking approach to defining EHB for the year 2016. Provides the list of EHB benchmarks for all the states, DC, and the territories

10 COLORADO’S BENCHMARK PLAN Mental Health Parity Public Outreach Efforts Underway Moe Keller Vice President of Public Policy & Strategic Initiatives Mental Health America of Colorado

11 Selecting a Benchmark Plan  Public hearings  MHAC comments with NAMI  Division of insurance picked from nine suggested plans.  Benchmark plan chosen; MHAC’s first choice.  Chronic Care Collaborative and Colorado Consumer Health Initiative non profit groups worked together to choose a common preferred benchmark plan from their memberships.

12 Stakeholders included:  Rose Community Foundation  African American Health Center  Disability advocates  Nursing homes  Colorado Hospital Association  County governments  Lockton Companies of Colorado  Colorado Association of Commerce and Industry  Centura Health  Association of Family Physicians  Denver Health hospital  Denver Metro Chamber of Commerce  County health departments  Colorado Rural Development Council  Higher education facilities  Life and health insurance brokerages  Benefits-risk managers of municipalities  State Commissioner of Insurance  Governor’s Budget Office  Qwest Communications- health and disability benefits  Colorado Center on Law and Policy  Labor unions  Mental health providers

13 Colorado’s Essential Health Benefits Benchmark Plans Options

14 MENTAL HEALTH PARITY  1997 – Six biologically based mental illness in the small group and large group markets.  2007 – Expanded parity to include PTSD, eating disorders, specific anxiety disorders and substance use disorders. Large group market only.  2009 – Mental Health Parity and Addiction Equality Act passes.  2010 – ACA passes; includes the MHPAE

15 Kaiser Small Group Plan  Colorado chose the Kaiser small group plan for the exchange.  Included mental health parity for schizophrenia, schizo-affective disorder, bi polar, anxiety disorder, panic attacks and clinical depression.  Did not include a second mental health/substance use disorder mandate.

16 CONFORMITY  How to align Colorado’s two state parity mandates with the ACA?  Colorado Division of Insurance harmonization bill:  Both state mental health parity bills will apply to the individual and small group markets  The director of the division of insurance will have rule making authority for further conforming language to comply with the ACA.

17 Federal Rules  No uniform national standard of coverage.  States can set their own specific requirements.  Enforcing standards is a state responsibility.  Federal government will step in if it is felt the state is not enforcing insurance standards of coverage.

18 CONCERNS  Not ready to start in October: computer glitches, not enough navigators for 300,000 expected enrollees.  Public outreach/explanations not sufficient.  Plans so rich in benefits that premiums too high.  Deadline for carriers to file products and costs is May 1, 2013.  Colorado has already placed in statute many of the huge cost drivers: mental health mandates, underwriting prohibitions, zero copays for preventative coverage, and gender prohibitions. Also, Colorado chose the Kaiser plan. This should keep possible higher rates lower than many other states.


20 Ohio Process Ohio Health Benefits Coalition (OHBC) convened August, 2012 MH and SUD state advocacy organizations MH and SUD treatment provider associations State prevention association Community MH and SUD board association Recovery Community representatives Universal Health Care Action Network Ohio (UHCAN) Ohio Consumers for Health Coverage Legal Action Center - Technical assistance partner

21 Coalition Goals Ohio ’ s implementation of the Affordable Care Act will include strong mental health and substance use disorder benefits. Barriers to enrollment and access to benefits are minimized.

22 Ohio Exchange Status Unknown when Coalition began its work in late summer Governor announced decision to opt for a federally- facilitated exchange November 16, 2012.

23 Coalition Workplan Based on political environment, work proceeded based on political environment and assumption of a federally-facilitated Exchange Decision to focus on analysis of the default plan (Ohio’s largest small group plan) Completed a high level review of MH & SUD services – “covered, not covered, could not determine, excluded” Drilled-down to determine scope of each service

24 Workplan (con’t.) Reviewed plan for ACA ’ s required compliance using tool developed by Coalition for Whole Health: o Mental Health Parity and Addiction Equity Act o Non discrimination Challenges: Obtaining default plan documents Lack of federal guidance on compliance standards

25 Workplan (con’t.) Identified gaps in compliance and parallel coverage for other populations: Parity examples Preventative care & screenings SUD & MH screenings Chronic disease management Recovery support services Discrimination/Exclusions examples Hospitalization Residential treatment Prescription drugs (onsite injectables) Methadone

26 Challenges: Plan benefits not defined Complexity of plan documents Uncertainty of Ohio Exchange status In FFE, how do we get a “ seat at the table ” ?

27 Advocacy Submitted 16 pages of comments on EHB to CMS December, 2012 and copied Governor Submitted letter to Governor and all legislators urging expansion of Medicaid January, 2013 Actively involved in Medicaid expansion advocacy with legislators, e.g., letters, phone calls, webinars, rallies

28 Planned Advocacy Medicaid expansion advocacy through June Review Qualified Health Plan application documents due to state by 4/30/13 Explore federal funding opportunities for peers as Navigators Consumer outreach and education

29 What Ohio’s Health Benefits Coalition and Ohio Consumers for Health Coverage Are Doing Now Getting Ready for April 30, 2013 Ohio insurers who want to sell in the Marketplace (Exchange) will submit their qualified health plan bids. They will use the online SERFF System (System for Electronic Rate and Form Filing). Ohio functioning as a plan management state even though referred to as a Federally Facilitated Exchange. Ohio will decide whether plans meet minimum Qualified Health Plan requirements.

30 What We Are Looking For in Plan Review Parity – Is there parity between mental health/substance use disorder and other key benefits (hospitalization, visits, etc)

31 What We Are Looking for (continued) Premium Affordability Are plans structured so that persons who use tobacco will be able to avoid the premium “surcharge” as soon as they enter into cessation treatment? Cost Sharing Affordability—What is the cost sharing in the plan? Will certain plans be “magnets” for people with chronic illness and result in adverse selection.

32 What We Are Looking For (Continued) Adequate provider networks Do the networks include the providers who will be essential for persons with Substance Use Disorder and Mental Illness? Will in-patient treatment be provided by the providers who are most likely to be recommended? Are community health centers in the network? Will travel be a problem, particularly in rural areas?

33 Getting Input to the Reviewer Some states have very good web sites with means to learn about plans and comment on plans. See Oregon, Connecticut, New Mexico and Colorado. In other states it will be more difficult to get copies of plan documents or summaries. In FFE states plans need to be submitted through the HIOS system. Suggestion: Talk to the CCIIO contact with your state to get ideas on how to get access to the plan data.

34 Coalition for Whole Health Thanks to presenters  Moe Keller, Vice President of Public Policy at MHA Colorado and former Colorado State Senator  Donna J. Conley, Chief Executive Officer, Ohio Citizen Advocates for Chemical Dependency Prevention and Treatment  Kathleen Gmeiner, Project Director, UHCAN Ohio Moderator  William Emmet, Senior Policy Advisor, Magna Systems, Inc. Thanks to Mental Health America For more information, go to


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