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Fact Sheet: State Insurance Exchanges

The Affordable Care Act requires the establishment of state-based health plan "Exchanges" by January 1, 2014 through which individuals and small businesses can purchase coverage with pooled risk and thus lower premiums.

States are to create "American Health Benefit Exchanges" and "Small Business Health Options Program (SHOP) Exchanges" to be administered by a governmental agency or non-profit organization through which small businesses (up to 100 employees) and individuals can purchase insurance.

Mental health care and addiction treatment are included on the list of essential benefits that must be covered in new plans offered to the uninsured through the Exchanges. These benefits (and others on essential list including rehabilitative services, prescription drugs, preventive services, etc) will be further defined by the Secretary and Mental Health America is taking advantage of public comment opportunities to encourage the adoption of a comprehensive list of essential benefits.

The Mental Health Parity and Addiction Equity Act is expanded to apply to health insurance plans offered to small businesses and individuals in the Exchanges.

The federal government will create a floor of essential benefits that must be included in the expanded Medicaid benefits and the state health insurance exchanges. States will be allowed to provide coverage above those basic levels established by the Secretary. MHA urges its affiliates and partners to advocate on both the federal and state level for a robust essential benefit package in order to ensure that the new benefits are meaningful and address the needs of individuals with mental illnesses.

Proposed Essential Benefits

MHA proposes the below services to be included in the essential benefits in the Exchanges. State advocates are encouraged to use the below categories and services when advocating for required benefits.

Traditional Mental Health Services

  • Inpatient Services (including residential services for children, detox and other services for individuals with substance use conditions)
  • Medication Services
  • Psychotherapy Services
  • Case Management Services
  • Crisis Intervention Services
  • Screening, Assessment and Treatment Planning

Psychosocial Rehabilitation Services

  • Individual and Group Rehabilitation services
  • Supported Employment
  • Supported Education
  • Life Supports (housing, access to transportation, life skills)
  • Financial Planning/Money Management
  • Peer Support Services

Preventative Services

  • Screening and Early Intervention
  • Targeted Prevention
  • Wellness and Health Promotion Services

Ancillary Services

  • Respite care for family members
  • Consultation between health care providers

Next Steps

States are moving forward with planning for the implementation of the Exchanges. MHA encourages state and local advocates to take a leadership role with the government agencies involved in the Health Care Reform planning process and ensure that mental health and substance use concerns are being considered.

  • Identify, join or create coalitions of voluntary health organizations and provider organizations from various conditions in order to advocate for the views of mental health and substance use consumers and providers.
  • Offer consultant services to the state insurance commissioner, health department, Medicaid director, mental health and substance use authority, and governor's office to provide feedback and advice regarding the interests of the behavioral health community.
  • Advocate for the development of a committee or advisory group through statute of executive order on which mental health and substance use advocacy groups sit to inform the health establishment of the Exchanges.