Saving Mental Health Reform Samuel Dotson, 2016 UNC School of Medicine Class of 2017 samuel_dotson@med.unc.edu Saving Mental Health Reform Getting Up to Speed Before Advocating for Key Mental Health Provisions in the ACA

Food for Thought “As the President and Vice President have made clear, mental illness should no longer be treated by our society – or covered by insurance companies – differently from other illnesses.” - DHHS Press Release on the Final Rule on Parity Implementation November 8, 2013

Definitions Mental Health Parity: The equal treatment of psychiatric, medical, and surgical benefits in insurance plans. Entails equivalent cost-sharing and network adequacy It does not entail “good” coverage, just “equal” coverage It does not necessarily entail a requirement for coverage LG, SG, and NG: Large group (>50), Small group, and Non-group (individual) insurance plans

Definitions ACA (the Affordable Care Act): “Obamacare” Formally the Patient Protection and Affordable Care Act (PPACA) The Marketplace: Collectively refers to a group of formal, online markets established by the ACA where consumers can purchase private insurance with federal subsidies. Formally the Health Insurance Marketplace or Exchange EHB (Essential Health Benefit): A list of 10 health care categories that must be offered at no annual or lifetime limit on every SG and NG plan under the ACA. Applies to plans on and off the Marketplace Does not apply to LG plans, but most already include them

Definitions The 10 EHBs Ambulatory patient services (outpatient services) Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services Prescription drugs Rehabilitative and habilitative services Laboratory services Preventive and wellness services Pediatric services, including oral and vision care

Timeline 1996 MHPA (President Clinton) 2008 MHPAEA (President Bush) Mental Health Parity Act Parity in lifetime/annual limits for LG plans 2008 MHPAEA (President Bush) Mental Health Parity and Addiction Equity Act Extended parity to cost sharing, treatment limits, and network adequacy for LG plans, Medicaid/Medicare managed care plans Also includes substance abuse treatment for the first time Neither applied to SG or NG plans Neither mandated coverage, just parity if offered MHPAEA also applies to CHIP

Timeline 2010 ACA (President Obama) 2013 HHS Final Rule Parity extended to all marketplace plans (SG and NG) EHB requires MH and substance abuse treatment on all non- grandfathered SG and NG plans (on and off the marketplace) 2013 HHS Final Rule Defines parity as intrinsic to the mental health EHB Effectively extends parity to SG and NG plans off the marketplace Prohibits discriminatory reimbursement rates as a way of discouraging mental health providers from participating in a network Requires plans to disclose their medical necessity criteria and the reasons for denial of a MH claim upon request Medicaid application is complex, but managed care is included in parity extensions 2013 Final rule includes Depts of Labor and Treasury

What the ACA adds to MH MDD, EtOH and Tob misuse all USPSTF A/B EHBs Requires MH coverage Abolishes annual and lifetime limits Parity Extensions to the MHPAEA To all SG and NG plans Prohibits Underwriting and Exclusions for Preexisting Conditions Dependent Coverage until age 26 Free USPSTF Grade A and B Screening Guidelines Expands Coverage via the Marketplace and Medicaid Expansion Promotes Integrated and Coordinated Mental Health Care And Various Other Provisions MDD, EtOH and Tob misuse all USPSTF A/B Underwriting by age, geography, and tobacco use only Theoretically prohibitions on underwriting and exclusions for preexisting conditions must be pared with mandates Medicaid expansion to 138% FPL (about 40% of potential insurance growth)

What the ACA adds to MH 62.5 million Americans gain MH coverage 30.4 million by parity extensions to existing MH coverage 32.1 million by EHB requirements 27 million previously uninsured gain a policy with MH as an EHB 5.1 million previously insured on a policy without MH now must have MH added to their policies Latest CBO projections in 2014 revised down uninsured gain from 27 to 25 million. The uninsured benefit is likely to drastically change with the new administration and is completely unreliable at this point. The 30.4 + 5.1 is what we would be most likely to save. That is still >10% of the US population. Projections from the DHHS Assistant Secretary for Planning and Evaluation 2013 research brief

March to Parity MHPA MHPAEA ACA Final Rule The 21st Century Cures Act 1996 2008 2010 2013 2016 Partial LG Full LG Some Marketplace All SG, NG EHB Enforcement

Sources and Further Reading Parity Implementation Coalition, https://parityispersonal.org Robert Wood Johnson Foundation, Mental Health Parity Factsheet, 2014, http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf 412062 Beronio, Kirsten, Sherry Glied, and Richard Frank. "How the Affordable Care Act and Mental Health Parity and Addiction Equity Act greatly expand coverage of behavioral health care." The journal of behavioral health services & research 41.4 (2014): 410-428. Beronio, Kirsten, et al. "Affordable Care Act will expand mental health and substance use disorder benefits and parity protections for 62 million Americans." Mental Health 2 (2014). Koyanagi, Chris, and A. W. Allison Siegwarth. "How will health reform help people with mental illnesses." Retrieved from http://www. bazelon. org./linkClick. aspx (2010).