State health insurance marketplaces provide us unparalleled opportunity

This week, fewer than 90 days remain until the launch of the state Health Insurance Marketplaces. These insurance bazaars will represent an essential Affordable Care Act (ACA) tool for providing insurance coverage to an estimated 20 million Americans, including about 5 million persons with behavioral health conditions. Hence, we need to have a clear understanding of their structure and operation. A federal site is available to keep you informed about these Marketplaces: www.marketplace.cms.gov.

Health Insurance Marketplaces

Types of Marketplaces. Under the ACA, each state is mandated to have a Health Insurance Marketplace. A state can choose to have a State Operated Marketplace, a State Partnership Marketplace operated jointly with the US Department of Health and Human Services (HHS), or a Federally Facilitated Marketplace operated entirely by HHS. If a state does not choose one of these options, it then defaults to a Federally Facilitated Marketplace. You can learn more about what your state has elected by going to: https://statehealthfacts.kff.org/comparemaptable.jsp?ind=962&cat=17.

Marketplace Functions. The Marketplaces have several core functions: to operate a health insurance bazaar for prospective insurance enrollees; to organize and monitor the Qualified Health Plans that will be offered through the bazaar; and to engage in Consumer Outreach so that all state citizens are aware of the opportunity being provided. The type of Marketplace chosen by a state will determine whether the state or HHS will be undertaking these specific functions.

Qualified Health Plans. The Qualified Health Plans offered through the Marketplace must include ten Essential Health Benefits. One of these benefits is mental health and substance use care, which must be offered at parity with medical and surgical benefits. Four levels of health insurance must be made available: bronze, silver, gold, and platinum. These insurance levels will be equivalent to 60, 70, 80, or 90 %, respectively, of the actuarial value of the ten Essential Health Benefits. To learn more about the Essential Health Benefit in your state go to: https://kff.org/health-reform/state-indicator/ehb-benchmark-plans/

Eligible Persons and Federal Subsidies.  The Marketplaces will offer insurance to persons at or above 133 % of the Federal Poverty Level (FPL), currently about $15,200 for a single person. All persons between 133 and 400 % FPL will receive a federal tax subsidy on a decreasing sliding scale. On average, the federal tax subsidy is estimated to be slightly more than $5,500 in 2014. Those between 133 and 250 % FPL also will receive reduced co-pays and deductibles. The federal tax subsidy will be based on the silver level of insurance and will be paid directly to the Qualified Health Plan in which a person is enrolled.

For those states that have opted-in to the Medicaid Expansion, persons below 133 % FPL will be offered insurance through the state Medicaid Program. Fully 100 % of the cost of the Medicaid Expansion will be borne by the Federal Government for 2014, 2015, and 2016, after which the amount will decrease gradually to 90 % by 2020, and remain permanently at that level. For these opt-in states, persons seeking insurance can go to the state Marketplace and then be linked to the state Medicaid Program if their income is at or below 133 % FPL.

Initial Enrollment Period. The state Marketplaces will begin enrolling clients in Qualified Health Plans on October 1 of this year, and their health insurance will become effective on January 1, 2014. The initial enrollment period will extend from October 1 to March 31, and then be closed until October of 2014. Currently, HHS is engaged in the initial phases of a very extensive insurance enrollment campaign. Materials from this campaign will become available to you very soon.

Enrollment Process. The intent is to make it very easy to enroll from anywhere at anytime. Hence, one will be able to enroll online, over the phone, or in-person. Health Insurance Navigators and Enrollment Assisters will be available to facilitate this process. Much more information on this process is available from www.enrollamerica.org.

Important Related Opportunities for Behavioral Healthcare

Medicaid Expansion Opt-Out States. For states that have opted-out of the Medicaid Expansion, the Marketplaces will extend down to 100 % FPL rather than 133 % FPL. Thus, potentially, up to a third of the persons eligible for the Medicaid Expansion in opt-out states can actually be insured through the Marketplaces. We estimate that up to 40 percent of these persons will have a prior behavioral health condition. Many of those who are eligible will lack knowledge of this opportunity. We have a major mission to get the word out to these people in our own communities.

Further, opt-out states have current Medicaid programs that make provision for covering persons who are medically frail. Hence, it will be very important to develop an understanding of this feature of a state’s Medicaid Program, including income limits. Uninsured persons who are medically frail can be referred for Medicaid coverage rather than receive health insurance through the state Marketplace when they meet state criteria.

Finally, in opt-out states, we have an obligation to advocate strongly for health insurance coverage for those persons who will not be eligible for any ACA program. These people will “fall through the cracks’ and will include a significant number with behavioral health and ID/DD conditions. 

Federally Qualified Health Center (FQHC) Enrollment Sites. FQHCs have received more than $150 million to help people enroll in health insurance. Many uninsured persons with behavioral health and ID/DD conditions use FQHCs as their care sites. Hence, we need to help the FQHCs be very successful in reaching out and enrolling this population.

County and City Enrollment Sites. County and city governments operate many programs that will be very useful sites to engage and enroll uninsured persons. These include county and city hospital emergency departments, jails, behavioral health and ID/DD programs, health departments, and public health departments. Many persons with behavioral health conditions will be seen in one or more of these sites. Now is the time to prepare to enroll these uninsured persons as they are encountered in these sites after October 1.

Health Insurance Navigators and Enrollment Assisters. Federal grants from HHS will be made to entities in states with Federally Facilitated and State Partnership Marketplaces to fund Health Insurance Navigators. These Navigators will help people enroll in health insurance. States with State Operated Marketplaces will fund Enrollment Assisters to perform a similar function. It will be exceptionally important for us to work with the navigators and assisters so that uninsured persons with behavioral health and ID/DD conditions are not overlooked in the outreach process. Peers should play a very large and important role in this process.

Our Next Steps

Without doubt, the state Marketplaces provide a once-in-ever opportunity for a very large segment of the uninsured population. We must and will take full advantage of this opportunity for uninsured persons with behavioral health and ID/DD conditions.