States face “decision time” on three major ACA provisions

With a sweeping review of key policies and changes affecting the future of healthcare and behavioral health, Ron Manderscheid, executive director of the National Association of County Behavioral Health and Developmental Disabilities Directors (NACBHDD), opened the first session of the Behavioral Healthcare Leadership Summit in Orlando by focusing on important healthcare decisions that states face within the next several months.

Essential health benefits

First up for the states, on Sunday, September 30, is submittal of each state’s Essential Health Benefit (EHB) to the Secretary of HHS. The EHB consists of 10 ACA-mandated categories of health services—including mental health and substance-use disorder treatment—that must be provided in the health plans that are made available to nearly all Americans in 2014. Manderscheid noted that if states fail to submit EHB’s by the deadline, the default under the ACA is to use the health benefits in the largest, small-group health plan in that state.

The content of states’ EHB requirement had been the subject of furious lobbying throughout 2011 between advocates seeking a single, strong federally defined EHB and other interests who argued that a single EHB mandate would be too costly. In the end, the Institute of Medicine (IOM) recommended an EHB approach that favored the cost-conscious concerns of small businesses, those least likely to offer significant behavioral health benefits in their health plans.   Instead of a single federal EHB, states would have latitude to choose from the benefit packages offered by existing federal employee, state employee, large-group, small-group, or HMO plans available in the state—a potential for up to 50 different variations of the EHB.

Manderscheid urged Summit participants to analyze their state’s submitted EHBs and comment on them to the HHS Secretary.  “If you don’t get the benefits you need in the EHB, nothing else will happen downstream,” he said.

Medicaid expansion

States face another major decision—whether to go ahead with Medicaid expansion—by November 30.  Manderscheid commented that half the states have decided to participate and are moving forward, 12 states are still formulating their decisions while awaiting election outcomes, while a handful are publicly maintaining opposition to the expansion.

Financially speaking, “Medicaid expansion is a ‘must-do’ deal for states,” he explained, urging advocates to “reach across to non-traditional partners, such as hospitals—whose money for charity care (disproportionate share program funds) will disappear in 2018”—and to insurance companies who want to be able to compete for $500 billion in managed care contracts, let by states as part of the Medicaid expansion.  Insurers hoping for these contracts will “do the lobbying for you” with the states, he noted.  

Insurance exchanges

“By Jan 1, 2013, the HHS Secretary must evaluate whether your state is capable of launching an affordable insurance exchange in 2014,” Manderscheid said of the third ACA requirement. As of now, half of the states have done nothing, he said, adding that “if the HHS Secretary determines that a state is not ready—it will be asked to participate in a ‘national’ exchange, or an exchange will be created for the state.”  Among the 25 percent of states who are moving forward on their own insurance exchange plans, Manderscheid said that California and Oregon are clearly leading the way, and will have exchanges ready for 2014.