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The Patient Protection and Affordable Care Act (ACA) was enacted March 23, 2010 to expand coverage to 33 million Americans.

Expanding Coverage: New law expands access to health care coverage including mental health care and substance use treatment primarily:

  • An individual mandate will require most individuals to obtain insurance
  • Guaranteed issue- no one can be denied insurance coverage based on preexisting conditions
  • Medicaid will expand to 133% of the federal poverty level in 2014, for those states that choose to opt in to Medicaid Expansion
  • For states that opt out of expansion, there will be a gap in mental health and addiction coverage

Mental Health and Substance Use: Mental health care and substance use treatment are included in list of essential benefits (EHB) that must be covered in new plans offered to the uninsured

  • Essential benefits will be based on benefit packages already sold in the state, however they must include 10 required categories of essential health benefits
  • The state can decide to enhance the benefit package
  • Included in the EHB are preventive services:

    o For adults: alcohol misuse screening and counseling, depression screening and tobacco use screening and cessation interventions

    o For women: domestic and interpersonal violence screening and counseling, expanded tobacco use counseling for pregnant women

    o For children: behavioral assessments, depression screening for adolescents and alcohol and drug use assessments

Medicaid Expansion: 133% of the federal poverty level equals $14,404 for individuals and $29,327 for families of 4 regardless of traditional eligibility categories (this includes childless adults)

  • Those newly eligible for Medicaid through expansion will not receive regular Medicaid benefits
  • Mental health and substance use benefits that are required of plans offered through the Exchanges will apply to those newly eligible for Medicaid through the expansion
  • Federal parity requirements (MHPAEA) will also apply to those newly eligible for Medicaid
  • Benchmark coverage modeled on private insurance, but will include mental health and prescriptions as mandatory and must comply with essential package requirements

State Exchanges: ACA requires establishment of state-based health plan ‘Exchanges' or ‘Marketplaces' by January 1, 2014 through which individuals and small businesses can purchase coverage with pooled risk and lower premiums; Center for Consumer Information and Insurance Oversight (CCIIO) (CMS) will be overseeing the Marketplaces

No Wrong Door: System created to ensure that all applicants are screened for all health programs without having to complete additional forms

  • Provides outreach and enrollment and patient navigation
  • Coordinates with Medicaid

Benchmark Plans for Medicaid Expansion Population: State Chooses Best Option:

  • 1 of the 3 largest small group plans in the state by enrollment (October 1)
  • 1 of the 3 largest state employee health plans by enrollment
  • 1 of the 3 largest federal employee health plan option by enrollment
  • The largest HMO plan offered in the state's commercial market by enrollment

Private Insurance Market Reforms: Beginning in 2014:

  • Premiums will no longer be based on health/mental health status
  • Lifetime caps on the dollar value of benefits are prohibited
  • All plans are required to cover preventive services at no cost to the individual, including mental health and substance use services mentioned above
  • Minimum percentage of premiums have to go towards service

Prevention and Public Health Fund: In 2014, $2 billion will be put towards prevention and public health programs each year:

  • Community Transformation Grant Program (CDC)
  • National Prevention Strategy (CDC)
  • Public Health Workforce Development (HRSA)
  • Mental Health Training (HRSA)
  • Primary and Behavioral Health Integration (SAMHSA)
  • Suicide Prevention (SAMHSA)

This fact sheet was prepared as part of the work we do with our Regional Policy Council.