Coalition for Whole Health
Webinar
STATE-BASED ADVOCACY
FOR ESSENTIAL HEALTH
BENEFIT DESIGN
FOR MENTAL HEALTH
AND SUBSTANCE USE
DISORDERS
Presenters
 Moe Keller, Vice President of Public Policy at MHA
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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.
Essential Health Benefits and
the Affordable Care Act
COALITION FOR WHOLE HEALTH
WEBINAR
APRIL 16, 2013
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
EHB Continued
 The ACA requires the Secretary of HHS to define the
benefits in each category, and requires that:
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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
How has the Secretary Defined EHB?
 In a December 2011 bulletin, HHS announced they
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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
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
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
What else do the Regulations Say?
 Provides special rules for the prescription drug
category
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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
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
Selecting a Benchmark Plan
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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.
Stakeholders included:
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Denver Health hospital
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Rose Community Foundation
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Denver Metro Chamber of Commerce
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African American Health Center
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County health departments
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Disability advocates
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Colorado Rural Development Council
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Nursing homes
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Higher education facilities
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Colorado Hospital Association
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Life and health insurance brokerages
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County governments
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Benefits-risk managers of municipalities
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Lockton Companies of Colorado
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State Commissioner of Insurance
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Governor’s Budget Office
Colorado Association of Commerce and
Industry
Qwest Communications- health and
disability benefits
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Centura Health
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Association of Family Physicians
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Colorado Center on Law and Policy
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Labor unions
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Mental health providers
Colorado’s Essential Health Benefits
Benchmark Plans Options
MENTAL HEALTH PARITY
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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
Kaiser Small Group Plan
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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.
CONFORMITY
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How to align Colorado’s two state parity mandates
with the ACA?
Colorado Division of Insurance harmonization bill:
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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.
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.
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CONCERNS
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Not ready to start in October: computer glitches, not enough navigators for
300,000 expected enrollees.
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Public outreach/explanations not sufficient.
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Plans so rich in benefits that premiums too high.
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Deadline for carriers to file products and costs is May 1, 2013.
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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.
MORE DETAILED INFORMATION
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www.Getcoveredco.org
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www.COHBE
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
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.
Ohio Exchange Status
• Unknown when Coalition began its work in late
summer
• Governor announced decision to opt for a federallyfacilitated exchange November 16, 2012.
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
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
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
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”?
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
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
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.
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)
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.
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?
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.
Coalition for Whole Health
 Thanks to presenters
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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
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William Emmet, Senior Policy Advisor, Magna Systems, Inc.
 Thanks to Mental Health America
 For more information, go to
www.coalitionforwholehealth.org