CMHNetwork considerations for the EHB Bulletin
Background information for the Children's Mental Health Network comments to HHS on the Essential Health Benefits Bulletin:
In a December bulletin, the U.S. Department of Health and Human Services (HHS) proposed to give states wide discretion to set their own essential health benefits (EHB) standard for health plans sold through the new exchanges. However, there are challenges ahead for children's mental health supporters in an approach that does not have a clear-cut, comprehensive federal standard to help guide the process. It is our belief that if left up solely to the states, we could see significant disparities in coverage.
1. Support the Inclusion of a Wide Array of Mental Health Benefits and an Expanded Work Force to Carry Them Out
- We risk going backward if what is required in the mental health component only includes inpatient and outpatient mental health services. The Bulletin must stress the importance of intensive community-based mental health services for children, youth and their families. Since the early 1980's the Children's Mental Health Initiative has been showcasing the value of a systems of care approach in meeting the mental health needs of children and families.
- Essential benefits must include services such as respite care, parent support providers, behavioral aides and therapeutic mentoring. The Essential Health Benefits standard should include broad coverage of home supports and related services. Ultimately, a relatively inexpensive set of home support services, along with robust coverage of rehabilitative and habilitative services, is necessary to be in compliance with both Affordable Care Act (ACA) and Americans with Disabilities (ADA) law. Robust coverage would also prevent countless unnecessary hospitalizations and maximize the functional status, independence, and quality of life of enrollees.
- The estimate is that with the Affordable Care Act an additional 37 million people will receive coverage - and that is a good thing! Expanding coverage to intensive community-based services and supports will require an expanded work force, including respite providers and parent support providers.
- The Bulletin should be strengthened to include prescriptive preventive services requirements that take the health needs of individuals with disabilities, functional limitations, and/or MH/BH/SA conditions into account.
- The EHB standard should require that medical necessity be defined to include both physical and mental illnesses, including the maintenance of maximum functional capacity.
- The Bulletin should not allow state or insurer flexibility to go below a national EHB floor or allow flexibility that will discriminate against individuals with disabilities, functional limitations, and/or MH/BH/SA conditions or otherwise undermine efforts to achieve true parity in benefits.
- When flexibility is allowed, HHS should conduct additional monitoring and enforcement to ensure that the benefit design does not discriminate against individuals with disabilities, functional limitations, and/or MH/BH/SA conditions nor promote adverse selection.
- The Bulletin should require comprehensive coverage in all ten service areas mandated by Section 1302 to ensure the EHB standard does not discriminate against individuals with disabilities, functional limitations, and/or MH/BH/SA conditions.
2. Do not allow a "Minimum Standard"
- The Bulletin should not allow state or insurer flexibility to go below a national Essential Health Benefits floor or allow flexibility that will discriminate against individuals with disabilities, functional limitations, or mental health, behavioral health and substance abuse conditions or otherwise undermine efforts to achieve true parity in benefits.
3. Support the "Plus" in the "Plus Ten" Approach
- The Affordable Care Act in its simplest form says that the Secretary must design an Essential Health Benefits package equivalent to a typical employer plan plus ten additional categories. Here is the "plus" part - A fundamental principle in the Affordable Care Act is that by investing in critical services, we will transform health care coverage and reduce long term spending. It would make no sense for the Affordable Care Act to, with regard to the Essential Health Benefits standard, list the critical services and then suggest they be covered only to the minimal extent already covered. It is no coincidence that the "plus ten" categories include critical gap services like preventive and wellness services and it is the Affordable Care Act's intent to invest in these services beyond current minimum norms. It is important to emphasize that the Affordable Care Act calls for a typical employer package "plus ten." Mental health and substance abuse services are included in the ten categories, however the rehabilitative and habilitative services necessary for intensive community-based services do not seem to be in place as they are in State Medicaid plans. For example, mental health rehabilitative and habilitative services are virtually non-existent in typical employer coverage. It would make no sense for the Affordable Care Act to create a requirement to cover a specific service "in the same scope as a typical employer" when that coverage is nearly nonexistent. For the inclusion of a service like intensive home-based servcices, wraparound, respite care or parent support provider to make any sense, each of the categories must be defined "beyond current minimum norms" and not satisfied by alignment with current employer coverage (or lack of coverage).
- The ACA in its simplest form says that the Secretary must design an EHB package equivalent to a typical employer plan plus ten additional categories. Each of the Ten Categories is a non-redundant addition to supplement typical employer coverage. Plus Ten means that provisions including services like habilitative service now take on meaning. The "plus ten" reading matches the language of the law and is the only way to give meaning to all of the provisions.
- A fundamental principle in the ACA is that by investing in critical services, we will transform health care coverage and reduce long term spending. It would make no sense for the ACA to, with regard to the EHB standard, list the critical services and then suggest they be covered only to the minimal extent already covered. It is no coincidence that the "plus ten" categories include critical gap services like preventive and wellness services and it is the ACA's intent to invest in these services beyond current minimum norms. It is important for CMHNetwork readers to understand that ACA calls for a typical employer package "plus ten." Numerous of the Ten Categories listed (for example, mental health and substance abuse disorders and rehabilitative and habilitative services) are services categories that receive virtually no coverage in typical employer coverage. It would make no sense for the ACA to create a requirement to cover a specific service "in the same scope as a typical employer" when that coverage is nearly nonexistent. For the inclusion of a service like respite care or parent support provider to make any sense, each of the categories must be defined "beyond current minimum norms" and not satisfied by alignment with current employer coverage (or lack of coverage).
- The Bulletin should be made consistent with the clear statutory language and thus amended to require that in all Ten Categories the EHB standard must provide substantial coverage, with substantial coverage defined as the level of coverage needed to meet the needs of the covered populations. This means that any benchmarks (we oppose reliance on benchmarks) should be supplemented if they offer no coverage or less than substantial coverage in one of the ten categories.
- The intent of the Affordable Care Act (ACA) is to promote health and well-being by expanding coverage to meet the needs of underserved individuals as well as fill existing gaps in the private insurance market. For followers of the Children's Mental Health Network, and especially those who have been involved in system of care development efforts for over two decades, we know that it is critical that a strong EHB standard responsive to the needs of children with mental health needs and their families be developed for application throughout the United States.
- If the decision on what benefit packages look like is left up to the states, nothing would stop states from using existing "scope of benefits" that are already woefully inadequate. For example, failure to include adequate mental health screenings will lead to expensive "crisis" treatments, hospitalizations and poor quality of life - not to mention astronomical health care costs. Those of us who have been involved in a systems of care approach know that services like respite care, family support providers, mentors can make a significant preventive difference. The EHB standard must match the needs of the populations it is designed to serve and be affordable.
- Cost is an important consideration, but not the only consideration. The ACA attempts to bend the cost curve by investing in those services which promote long-term health and well-being. The EHB package should be viewed as a tool to defray health care costs over the long term. Without a strong EHB standard designed to meet the needs of low income populations and promote long term savings, the ACA cannot be effective. A weak EHB package will do nothing to reduce long-term health spending. Think for a moment of what is at stake here. While a robust benefits package may slightly push up premiums, failure to cover necessary services drives medical debt and bankruptcies that overwhelm consumer financially. We know too well the many stories of families who have gone bankrupt in the often desperate quest to be able to pay for services that insurance plans do not cover. A weak EHB package will leave millions of individuals underinsured, generating financial hardship that will overshadow the marginal premium increases associated with a comprehensive benefit.
- The ACA was designed to ensure that people have access to the needed care. If the EHB package is defined or altered significantly due to considerations other than the health needs of the populations being served, such as up-front cost, it is likely to leave low-income and underserved individuals in worse health and lead to higher costs over the long term as individuals' conditions deteriorate and they require more expensive care.
4. Require a uniform set of national benefits
- The Bulletin suggests that HHS will allow states to benchmark to a "reference plan" that is based on a currently available healh plan in the state, modified as needed to meet the EHB requirements found in the ACA. If states are allowed to create their own variations of the EHB package it will undermine the intent of the ACA to create a comprehensive and national standard for health insurance coverage. We must make sure there are clear federal minimum EHB requirements and standards to ensure that vulnerable populations can access comprehensive care that consistently meets their needs across states.
- The Bulletin suggests that insurance issuers may have the flexibility to adjust the scope of benefits defined as "essential." If this were to take place, there should be an open and transparent comment and public involvement process.
- Another flexibility suggested in the Bulletin would allow insurers to make substitutions in benefits so long as they are "substantially equal" to the benefits of the benchmark plan as modified to meet the ten coverage categories. There are so many challenges with this approach. If the benefits are bench-marked at a level that is already minimal (at best), what is to keep insurers from eliminating vital services for those populations relying on them? The financial calculations behind such benefit designs and coverage approaches must be strictly scrutinized to ensure that the health and well-being of individuals are not being sacrificed for the sake of cost savings.
- We need strong and clear Federal EHB standards. Consider this. The HHS Action Plan to Reduce Racial and Ethnic Health Disparities requires HHS to evaluate relevant program actions within its lead agencies to determine if these activities have improved health outcomes for disparity populations. Therefore HHS must ensure that EHB standards reduce or eliminate health disparities for all impacted populations, instead of contribute.
- States should not be allowed to modify the EHB minimums, although they should be allowed to expand beyond the minimums. If HHS ultimately allows state-level implementation of the EHB standard, then that state flexibility should be tightly limited and carefully monitored and regulated.
- The Bulletin suggests that the regulatory approach will grant states and insurers extensive flexibility to reference and modify benchmarks. The general flexibility suggested to allow insurers to modify benchmark designs will lead to further increase of utilization management. The net result for the low-income individuals who will be the largest population relying on the EHB standard will be more barriers to care, which worsen their health. Why is this so? Our concern is that the majority of utilization management conducted by insurers today is used to drive down utilization, not to improve care. For vulnerable individuals, who lack the extra money to pay out-of-pocket for needed care, the result is predictable: they go without care. So, if utilization management strategies are applied to the EHB they should be limited to evidence-based criteria with the sole objective of allowing health providers to improve the quality of services offered to their patients. Utilization management criteria should be documented and publicly available to ensure that decisions are made based on sound clinical practice. The standards should be based on medical criteria (such as guidelines of the major relevant professional academies or provider associations). Ultimately, a coverage limit should only be allowed if it is based on medical evidence and is not detrimental to the health care needs of enrollees. If a health provider's clinical treatment plan is denied or limited due to utilization management criteria, the EHB standard should require a clear and easy exceptions process that will be applied in an expedited manner to determine access to the prescribed treatment.
- Utilization management techniques should be used only as a tool for providers in delivering quality health services to low-income populations, instead of cost containment or coverage limitation purposes. The Bulletin and subsequent EHB guidance should reflect this policy.
Medical necessity Requirements
- The decisions of the treating provider or the treatment team should be given great weight and deference. When decisions are reviewed, the purpose of the review should be to determine:
- Whether the treatment accords with professional standards of practice (evidence-based) and when evidence is lacking due to the condition or unique nature of a patient's needs or illness, the standards should be based on a clinician's experience in practice;
- Whether it will be delivered in the safest and least intrusive manner and least restrictive setting; and
- Whether there are equally effective treatments, services, and care that are actually available and accessible to the enrollee.
EHB Standard for Children
- We need an EHB standard for children, especially those who are lower-income and/or have special health care needs. HHS must aggressively define the EHB package for children and cannot rely on the sufficiency of the existing benchmark options outlined in the Bulletin. EHB is relevant to many low-income children who have higher prevalences of special health care needs. Private insurance plans - like the benchmark plans proposed in the Bulletin - have historically failed to cover services that are critical for children's health. A study in the New England Journal of Medicine found that children in private plans are twice as likely to be under-insured as their counterparts in public programs. This is due in large part to the overall lack of emphasis on preventive care. Additionally, private insurers commonly employ a narrow definition of medical necessity, limited to services that diagnose or treat illnesses that are needed to restore normal functioning. Only limited rehabilitative services are covered and habilitation services are not typically included at all. Such narrow definitions too often serve as a blunt tool used to draw sharp lines that deny the type of care that vulnerable children need to stay healthy and thrive.
- For these reasons, HHS should take a prescriptive, rather than flexible, approach in setting the standard for children's health care.
Coverage of Preventive Health Services
- The EHB package is specifically intended to remedy and close existing gaps in private health care coverage. For this reason, "preventive and wellness services and chronic disease management" were included in the list of ten categories of additional coverage in Section 1302 of the ACA. However, if one assigns preventive coverage in the EHB to the level of coverage already offered in a benchmark, HHS is upholding the very model that the ACA acknowledged as deficient. Failure to provide the robust and comprehensive preventive benefits that this population needs will lead to unnecessary emergency room visits, unnecessary hospitalizations, unplanned and high-risk pregnancies, and costly mismanagement of chronic illness.
- Discrimination on the bases of a mental health, behavioral health or substance abuse condition should not be allowed. We know that EHB populations will be largely low income individuals and failies and have disproportionately high incidences of mental health, behavioral health and substance abuse conditions. Further, the historic failure of health care packages to provide services for these conditions has trapped many individuals in a cycle of medical under-insurance, gaps in treatment, decreased function, socioeconomic depression, and social stigma. The historic exclusion for Mental health/behaviaoral health/sustance abuse (MH/BH/SA) services in private market health coverage means that any "benchmarking" plan would likely perpetuate that inadequate and substandard discriminatory coverage (why we oppose benchmarking). The EHB policy must require robust additional coverage of MH/BH/SA services. Anything less than a prescriptive coverage requirement is likely to discriminate against individuals with MH/BH/SA needs based on their disabilities.
Transparent and Inclusive Process for Developing EHB Standards
- HHS should issue a regulation with specific details and provide for a full opportunity for notice and comment.
- If HHS pursues a benchmarking framework, it must provide consumer stakeholders with adequate resources and analysis to evaluate the proposal.
Please send comments to EssentialHealthBenefits@cms.hhs.gov through today - so take 10 minutes (the time it takes to stand in line for a coffee or sitting in the drive-through lane picking up lunch). If you can do that today you surely can do this!