Taking essential actions on core features of the ACA on the eve of implementation

As we approach the eve of Affordable Care Act (ACA) implementation, it is exceptionally important for us to take stock, assess where we actually stand, and then act. Three core ACA features deserve specific action—the Essential Health Benefit (EHB), the State Medicaid Expansion, and the State Marketplace. These mechanisms will determine how many persons will become newly enrolled in health insurance, and what insurance benefits will actually be available to them.

The ACA is expected to provide new insurance coverage for about 32 million persons; half will be covered through the Medicaid Expansion, and half will be covered through the State Marketplaces. We estimate that as many as 11 million of these persons will have a behavioral health condition at the time of enrollment, and that the majority of these persons will have a primary substance use condition (see https://www.acmha.org/content/events/national/WHC_Universal_Coverage.pdf).

The Essential Health Benefit

The EHB must cover 10 specific types of benefits including mental illness and substance use disorder services. For both of these services, the benefit must be at parity with that for the medical/surgical benefit. This means that the specific insurance benefits for each of these conditions cannot be more restrictive than those for the medical/surgical benefit. The EHB also is exceptionally important because it will determine the amount of federal funds a state will receive for its optional Medicaid Expansion, as well as the size of the federal tax subsidy available to those insured under the State Marketplace.

In 2012, each state was given the opportunity to define its EHB from a benchmark health insurance plan. It could choose from among 10 options defined by the U.S. Secretary of Health and Human Services. These 10 options included the three largest federal employee health benefit plans, the three largest state employee health benefit plans, the three largest small group plans in the state, and the largest health maintenance organization in the state. If a state elected not to choose any plan, then the largest small group plan in that state became its default plan.

A total of 19 states and the District of Columbia have chosen a small group plan for their EHB; 3, a state employee plan; and 4, an HMO plan. The remaining 24 states have defaulted to a small group plan. You can learn about the specific situation in your state at:   https://www.kff.org/healthreform/quicktake_essential_health_benefits.cfm, and you can find more detailed information at: https://www.ncsl.org/issues-research/health/state-ins-mandates-and-aca-essential-benefits.aspx#Appendix%203. As a key point of comparison, you can access the model Coalition for Whole Health benefit at   https://www.coalitionforwholehealth.org/2012/01/ehb-consensus-principles-and-service-recommendations/.

Actions You Can Take: You need to understand your state’s EHB and its mental health and substance use benefit. If the benefit is not adequate to provide for appropriate care, you need to advocate with state representatives for a better benefit. If the benefit is not at parity, you need to write to the Secretary of the US Department of Health and Human Services (hereafter, the Secretary) to alert her to this critical deficiency. Time is of the essence for these actions.

State Medicaid Expansion

The Medicaid Expansion is at state option as a result of the Supreme Court decision sustaining the ACA. However, the financial benefit to states is so considerable that most are ultimately expected to take advantage of this opportunity. Fully 100 percent of the cost of the Medicaid Expansion will be paid by the federal government in 2014, 2015, and 2016, after which time the federal contribution will gradually decline to 90 percent by 2020, and then remain at that level permanently. An estimate of the minimum financial benefit for each state is available at https://www.kff.org/medicaid/upload/8384.pdf.

For those states that do opt to undertake the Medicaid Expansion in 2014, enrollment is slated to begin on October 1, 2013, and the system is intended to become fully operational on January 1, 2014. The Medicaid Expansion is designed to extend health insurance coverage to all adult persons in a state at or below 133% of the federal poverty level, who are not already eligible for another Medicaid program. Currently, 133% of the federal poverty level is equal to an annual income of $15,282 for a person or $25,975 for a family of 3. Because the ACA ignores the first 5% of income, this actually means that the Medicaid Expansion will extend up to 138% of the federal poverty level.

The Medicaid Expansion and the State Marketplace will employ a single streamlined application. You can see the draft form athttps://files.www.enrollamerica.org/best-practices-institute/federal-guidance/508_CMS-10440_Appendix_C_FA_Paper_Application.pdf .

To date, a total of 22 states and the District of Columbia have chosen to do the Medicaid Expansion in 2014, and 5 are leaning toward doing the Medicaid Expansion. The remaining 19 states are leaning against doing the Medicaid Expansion. You can learn about the specific situation in your state at: https://www.advisory.com/Daily-Briefing/2012/11/09/MedicaidMap, and further information about your state isavailable athttps://www.statereforum.org/medicaid-expansion-decisions.

Actions You Can Take: If your state has opted to do the Medicaid Expansion, you need to support its implementation and help to enroll persons with a mental health or substance use condition. If your state has not yet opted to take this action, you need to advocate with your governor, state legislature, and state health insurance commissioner about the essential nature of the Medicaid Expansion. Frequently, a decision not to implement is based on faulty information. If so, you need to bring the correct information to light. 

The State Marketplace

The State Marketplace (formerly called the State Insurance Exchange and the Affordable Insurance Exchange) will operate as an online site where uninsured persons can go to shop for and purchase health insurance. It will offer good, comparative information on a range of health insurance products at different levels based upon one’s needs for health insurance. These products will be classified from bronze (least expensive) to platinum (most expensive). Persons below 400 percent of the federal poverty level insured through this mechanism will receive a sliding scale federal tax subsidy to assist them with the purchase of health insurance.

The State Marketplace is designed to extend health insurance coverage to all adult persons in a state above 133% of the federal poverty level. Because the ACA ignores the first 5% of income, this means that the actual threshold for the State Marketplace is 139% of the federal poverty level. If a state does not elect to do the Medicaid Expansion, the State Marketplace can provide health insurance down to 100% of the federal poverty level.

Since the State Marketplaces are mandatory, every state will have one. If a state has already chosen to develop a State Marketplace, implementation work is now underway. If a state has decided against doing its own State Marketplace, or has not made a decision either way, the Secretary will implement its State Marketplace. That may take the form of a Partnership Marketplace with one or more other states or participation in a Federal Marketplace, depending on which a state has elected to do. At any time in the future, a state may apply to operate its own State Marketplace.

For all states, enrollment is slated to begin on October 1, 2013, and health insurance through the State Marketplaces will become effective on January 1, 2014 Enrollment in health insurance will be mandatory, and a tax will be levied on persons who do not enroll.

A total of 17 states and the District of Columbia are planning to develop their own State Marketplaces; 7 are planning Partnership Marketplaces and 26 have defaulted to the Federal Marketplace. The current status of State Marketplace development in your state is available at https://statehealthfacts.kff.org/comparemaptable.jsp?ind=962&cat=17, and further details about your state are available athttps://healthreform.kff.org/en/state-exchange-profiles-page.aspx.

Actions You Can Take: Sinceevery state will have one, you need to find out about the specific operational details of your State Marketplace. How it will operate, including the insurance plans it will encompass, will determine how effective it will be in enrolling persons with mental health and substance use conditions. If you identify problems, then you need to advocate for improvements with appropriate state representatives, and you need to inform the Secretary about these deficiencies.

Conclusion

The eve of ACA implementation is approaching very rapidly. In less than 9 months, enrollment will begin in all of the State Marketplaces and in the state Medicaid programs undertaking the Medicaid Expansion in 2014. Hence, inadequacies in the EHB and operational deficiencies in the State Marketplaces and the state Medicaid programs need to be identified and addressed immediately. The national Coalition for Whole Health (www.coalitionforwholehealth.org) can help you with these issues. Please reach out if you require assistance.