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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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)

9. 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 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

10. 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

11. Sources and Further Reading
Parity Implementation Coalition,
Robert Wood Johnson Foundation, Mental Health Parity Factsheet, 2014,
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):
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 bazelon. org./linkClick. aspx (2010).