Defining Essential Benefits – 12-16-11

       There is a flurry of activity as we approach the end of 2011, and I wanted to give you an update on legislative activity regarding mental health coverage which will affect LCSWs.

        DHHS just issued their formula for how "essential benefits" will be determined.  As you know, mental health/substance abuse is one of ten essential benefits that must be included in all large insurance plans by 2014.  Today DHHS Secretary Sebelius issued the criteria on which essential benefits will be based as follows:

"....Under the Affordable Care Act, consumers and small businesses can be confident that the insurance plans they choose and purchase will cover a comprehensive and affordable set of health services," said HHS Secretary Kathleen Sebelius.  "Our approach will protect consumers and give states the flexibility to design coverage options that meet their unique needs."

Under the Department's intended approach announced today, states would have the flexibility to select an existing health plan to set the 'benchmark' for the items and services included in the essential health benefits package.  States would choose one of the following health insurance plans as a benchmark:

*    One of the three largest small group plans in the state;
*    One of the three largest state employee health plans;
*    One of the three largest federal employee health plan options;
*    The largest HMO plan offered in the state's commercial market.....
  
For the complete summary of this report go to the HHS News Release, "HHS to give states more flexibility to implement health reform", at http://www.hhs.gov/news/press/2011pres/12/20111216b.html

CSWA's concern about this "benchmark" is that outpatient mental health treatment has been restricted by insurers, especially for Axis II disorders, for so long that current plans are not a valid way to determine what constitutes an adequate outpatient mental health benefit.  CSWA is preparing comments on what we see as an adequate mental health benefit and will submit them to DHHS within the next few weeks, prior to the January 31, 2012 deadline.

There is also some confusion about mental health benefits in that the 2008 Federal mental health parity law (MHPAEA) only required mental health parity if a plan includes a mental health benefit; the option of not covering mental health was allowed.  With the advent of the Affordable Care Act, mental health benefits must be included in all insurance plans, i.e., large companies, small companies, and individual plans by 2014.  However, according to DHHS, at this time "....The extent to which plans and products cover behavioral health treatment, a component of the mental health and substance use disorder EHB category, is unclear. In general, plans do not mention behavioral health treatment as a category of services in summary plan documents...."   Obviously, CSWA will be working to craft a benefit that is valid regarding outcomes, frequency, and length of coverage according to our view of adequate mental health treatment.
 
For the complete report on the current status if essential benefits go to http://cciio.cms.gov/resources/files/Files2/12162011/essential_health_benefits_bulletin.pdf

Finally, I am sure that you are all aware of the potential 29-34% cut to Medicare reimbursement for LCSWs if the Sustainable Growth Rate (SGR) is not adjusted in the next two weeks.  There is a good chance that the broad universal cut (29%) and the psychotherapy "extender" cut (5%) will be postponed as they have been for the past 5-15 years.  I will let you know as this situation becomes clearer.  
  
     Please let me know if you have any questions on these complex issues.  I hope you all have very happy holidays.