Behavioral Health Benefits: New Access and Challenges
Beginning on January 1, 2014, the estimated 11 million uninsured people with mental and substance use disorders will have access to health insurance coverage for the treatment they need to function successfully in their communities.
The Affordable Care Act requires, for the first time, that insurance plans sold through Health Insurance Exchanges cover mental health and substance use treatment. Prior to the Affordable Care Act, commercial insurance plans, both individual and employer-based, did not have to cover these vital services. According to the law, however, the U.S. Department of Health and Human Services (HHS) Secretary must issue an “essential benefits package” that all insurance plans sold through the Exchange must cover. (See Health Reform Terms below.)
The challenge now is to reach out to individuals who will benefit from the law—as well as groups who work with them—to raise awareness of the new benefits to which they may be entitled. The law not only opens up new coverage, but prohibits insurance plans from refusing to cover someone whose conditions are preexisting.
Signing up for insurance coverage will also be much easier than before. The law requires states to develop newly streamlined enrollment materials that will allow applicants to fill out a single form that will be evaluated for eligibility for Medicaid, the Children’s Health Insurance Program, or low-income assistance with premium costs for commercial plans. New Medicaid rules set one national income eligibility level at 133 percent of the federal poverty level. Prior to this, states could establish their own income eligibility levels, leading to significant variation across the country in coverage.
In preparing for 2014, SAMHSA has been working closely with states and consumer organizations to help ensure that the “qualified health plans” to be sold through the Exchanges include a range of benefits that will meet the needs of people living with mental and substance use disorders.
SAMHSA has posted resources and toolkits on its web site for states, local governments, and community organizations to use as they prepare to establish Exchanges and expand their Medicaid programs. For more information see the Health Reform Resources.
Health Reform Terms
Essential Health Benefits:
A set of health care service categories that must be covered by certain plans starting in 2014. These include doctor office visits, prescriptions, hospitalizations, and mental and substance use disorder benefits, among others. Insurance policies must cover these benefits to be certified and offered through the Exchanges, and all Medicaid state plans must also cover these benefits by 2014.
Health Insurance Exchanges:
An Exchange is a new, open, and competitive marketplace where individuals, including those who don’t have coverage or who can’t afford coverage through their employer, and small businesses can buy affordable health plans.
For more health reform term definitions, download Health Reform Common Terms Tip Sheet (PDF - 904 KB)
Health Reform Resources
Webinar Series: Together with the National Association of State Alcohol and Drug Abuse Directors and the National Association of State Mental Health Program Directors, SAMHSA developed a series of four Webinars for state policymakers on the essential health benefits (EHB) selection process and the application of the Mental Health Parity and Addiction Equity Act (MHPAEA).
- Introduction to the EHB
- Understanding and evaluating benchmark options in your state
- How to apply MHPAEA to the EHB
- Gaps between recommendations by the Coalition for Whole Health and your state’s EHB plans.
Key Fact Sheets:
Over 70 health care reform Webinar recordings and fact sheets covering a variety of health reform topics are available at www.samhsa.gov/healthreform.