The essential health benefit: will minimal become vanishing? Reliance on small-business plans as the EHB standard could lead to reductions in treatment.
Subject: Small business (United States)
Health insurance (Usage)
Author: Manderscheid, Ron
Pub Date: 03/01/2012
Publication: Name: Behavioral Healthcare Publisher: Vendome Group LLC Audience: Academic; Trade Format: Magazine/Journal Subject: Health; Health care industry; Psychology and mental health Copyright: COPYRIGHT 2012 Vendome Group LLC ISSN: 1931-7093
Issue: Date: March-April, 2012 Source Volume: 32 Source Issue: 2
Topic: Computer Subject: Small business; SOHO
Product: Product Code: 9970000 Small Business; 6322000 Medical Care Insurance; 6320000 Accident & Health Insurance; 9108144 Small Business Aid Programs NAICS Code: 524114 Direct Health and Medical Insurance Carriers; 5241 Insurance Carriers; 92611 Administration of General Economic Programs SIC Code: 6321 Accident and health insurance
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 287392625
Full Text: Just a few short weeks ago, I wondered whether the essential health benefit might in fact become a "minimal" health benefit. At that time, I was very concerned about the recent Institute of Medicine report to HHS, which recommended that the Department use a typical small-business health insurance benefit plan as the standard for defining the Essential Health Benefit (EHB) required by the Affordable Care Act (ACA).

While the AC A requires the EHB to include benefits for mental health and substance use care, and these benefits must be at parity, small business plans often do not include behavioral health benefits and when they do, they are almost never at parity. Hence, small business plans are inadequate as a standard for the EHB.

The EHB is important because it will be used not only as the "floor" health insurance plan for the state Medicaid expansion (providing health coverage for those with incomes up to 133% of the Federal Poverty Limit), but also as the "floor" plan for plans offered in each state's health insurance exchange (providing coverage with subsidies for those with incomes from 134 to 400% of FPL).

And, of those who will be newly eligible for coverage, we know that 10.5 million have an existing mental health or substance use condition, and of these:

* virtually all to be covered in the state Medicaid expansion will require services equal to those currently provided to consumers in the public mental health/ substance use care systems,

* most covered by the state health insurance exchanges will need that same level of care as well.

With the December 15 release of the Essential Health Benefit recommendation from HHS, I became even more concerned because HHS did not develop a standard for die Essential Health Benefit. Instead, HHS recommended that each state establish its own EHB by choosing among four existing plans:

* the Federal Employee Health Benefit Plan (FEHBP)

* the state employee health benefit plan

* the health benefit plan of the three largest small businesses in the state

* or the health benefit plan from the largest Health Maintenance Organization in the state.

In making its EHB decision, each of the 50 states will have to face conflict between its own financial interests--and the public health interest of its citizens, and the financial interests of its own business community. Here's why:

* The amount of federal money a state will receive will be defined by the value of the floor EHB. (Note: Value in this case is "actuarial value," calculated as the total dollar cost of care for a "standard" individual or population that is covered by the plan, versus paid for by the individual through deductibles, co-pays, etc.)

* The value of the EHB selected will define the costs of the state's own contribution to its Medicaid expansion after the period 2014- 2018 when the federal match covers the full cost of the expansion, And, the value of the EHB will also determine the value of the personal subsidy for each individual who participates in the state's insurance exchange, which is available to all individuals with incomes up to 400% of FPL,

* Yet, a higher value EHB could raise the ire of a state's business community, since it will require those employers and employees who participate in the state exchange to pay more for the more valuable EHB coverage selected by the state.

While the HHS EHB recommendation may be politically expedient, since it blunts criticism of the ACA, it does nothing to promote adequate or uniform mental health or substance use care benefits. In an era when improved science and more evidence-based practices should move standards of care toward greater uniformity and quality, the HHS approach promotes disparity. This approach makes it likely that a person in one state will be covered to receive a required, evidence-based practice, while a person in an adjacent state with the same condition will not receive coverage for that practice. To me, this disparity makes very little sense.

And, although states may be confronted with the dilemma of deciding between more federal funding and more complaints from their local business community, I suspect that they will take action to avoid the ire of their local business community. This will result in a choice among the permitted standards that minimizes the financial value of the floor EHB in most states. As a consequence, mental health and substance use care benefits will likely be minimized, or may vanish altogether, in those states.

I, together with many in the field of behavioral health, hope that HHS will pause to reconsider, then to expand, its definition of the essential health benefit on which so many will depend, now and in the future.



Ron Manderscheid, PHD, is Executive Director of the National Association of County Behavioral Disability Directors (

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