With the insurance and benefit requirements of the Affordable Care Act going into full effect in just 2 months there is a lot of confusion about benefits that are available, what coverage is required, and how it affects you, especially as it relates to substance abuse and mental health treatment. This FAQ question and answer session with Morningside Recovery’s Director of Billing and Insurance aims to clear up some of the confusion. We welcome you to continue the discussion with us on Facebook, Google+, or Twitter as our industry continues to navigate substance abuse and mental health coverage into the new year.
What is the health insurance Marketplace?
Health Insurance Marketplaces (also known as Exchanges) are new organizations that will be set up to create more organized and competitive markets for buying health insurance. They will offer a choice of different health plans, certifying plans that participate and providing information to help consumers better understand their options. Through the Marketplace, individuals and families will be able to shop for coverage if they need to buy health insurance on their own. Premium and cost sharing subsidies will be available through the Marketplace to reduce the cost of coverage for individuals and families, based on their income.
here will be a health insurance Marketplace in every state for individuals and families and for small businesses. Some Marketplaces will be operated by the State and have a special state name (such as CoveredCalifornia) and some will be run by the federal government.
Who should I talk to first?
Links to all state healthcare marketplaces can be found at www.healthcare.gov
What are essential health benefits?
These are a set of health care service categories that must be covered by certain plans, starting in 2014.
The Affordable Care Act ensures health plans offered in the individual and small group markets, both inside and outside of the Health Insurance Marketplace, offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include items and services within at least 10 categories including mental health and substance use disorder services.
Insurance policies must cover these benefits in order to be certified and offered in the Health Insurance Marketplace.
Does the ACA guarantee coverage for mental health and substance abuse services?
Building upon the federal mental health parity act passed in 2008, mandating comparable coverage for medical and substance abuse services because insurance coverage for substance abuse treatment can be more restrictive in terms of cost sharing and treatment limitations, the ACA is another important stepping stone to ensuring that Americans who need psychiatric and substance abuse treatment can have access to it.
While the ACA (in conjunction with the mental health parity legislation) includes coverage for the treatment of both mental and substance abuse disorders at equal levels to treatment for physical concerns, limits can and still are placed on such treatments. The limits are more lax than they were perhaps under the older system, but people still do not have access to “unlimited” psychotherapy treatments. Insurance companies still require therapists to obtain authorization for additional treatments after a certain number of sessions has been reached (which varies from insurance company to company).
Will the ACA improve the quality or level of care covered for mental health and substance abuse services?
The law was originally designed to help increase incentives to physicians and other health and mental health professionals to look after people across the entire continuum of care. It’s also focused on preventative care.
However, the U.S. Department of Health and Human Services, the agency in charge of implementing and regulating the ACA, has left the specific definitions of these essential health benefit categories up to individual states. Therefore, each state’s definition is going to be different. What this means is that coverage of things like mental health screening in primary care, mental health prevention services, crisis services, and other non-traditional services for the treatment or care of mental health and substance abuse concerns may not be covered. Under some plans, if it’s not straight inpatient or outpatient care, it may not be included. This will all largely depend upon the state you live in.
Do restrictions on pre-existing conditions disappear after 2014?
Yes. Starting in 2014, as insurance policies are sold or renewed, health plans are not allowed to deny coverage or charge you more based on your health status or pre-existing condition.
I have a patient at my treatment center and they need insurance, will they be denied?
The new law says that you can’t discriminate against a person because of a pre-existing condition. This means that more people will be approved for the coverage they need, likely even if they are already in a treatment program at the time they enroll.
It also means when verifying benefits for new plans effective after 2014, you will no longer be concerned with pre-existing waiting periods.
2. The Henry J. Kaiser Family Foundation, Health Reform: Frequently Asked Questions (2013), available at http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/?search-global=premiums
3. Parity Laws for Substance Abuse Disorder Linked to Increased Treatment, Medical News Today, available at http://www.medicalnewstoday.com/releases/267781.php
4. John M. Grohol, Psy.D., An Update on How the U.S. Affordable Care Act Impacts Mental Health Care, PsychCentral (Nov 1, 2013), http://psychcentral.com/blog/archives/2013/11/01/an-update-on-how-the-u-s-affordable-care-act-impacts-mental-health-care