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Behavioral health benefits shift with GOP plan

March 14, 2017

While Congress presses forward with the American Health Care Act (AHCA), many treatment center executives continue to wonder how the proposed legislation will ultimately affect their patients. Apart from the total number of patients who could lose or opt out of their coverage, those who remain enrolled in health plans might see their benefits for behavioral health reduced, experts say.

Medicaid benefits

For Medicaid, AHCA removes the essential health benefit categories for the expansion population, allowing states to create plans that cover fewer services, Kevin Malone, associate with Epstein Becker Green, tells Behavioral Healthcare Executive. In theory, states could choose to stop covering behavioral health for about 14 million Medicaid expansion enrollees.

Malone also says AHCA’s cap on how much the federal government chips in on Medicaid will likely result in states bearing more of the total program costs. Many states will look at shrinking the number of people eligible—in the traditional and expansion groups—as a cost-cutting measure.

“You can see in the long term over the next three years, a reduction in who will be eligible for Medicaid at all,” he says. “And a lot of people in the expansion population have behavioral health conditions, especially substance use disorder, where you don’t have a pathway to a disability determination under Social Security. For that population, the Medicaid expansion was important. And as that goes away, you have a real reduction in benefits.”

Traditional Medicaid plans are not obligated to cover behavioral health services, so community-based services are often delivered through waivers.

“Those are optional programs that many states use because they have access to federal matching dollars to support those investments,” he says. “In the future with the cap on federal matching dollars, it will put downward pressure on state’s willingness to finance those optional behavioral health services.”

The combined effect will be significant reductions in access, he says.

Experts note the estimates of the total financial impact on Medicaid vary. Georgetown University estimates $560 billion in Medicaid costs would be shifted to states over a decade, meanwhile the Congressional Budget Office report indicates a cut of $880 billion.

Commercial benefits

Beyond Medicaid, the commercially insured population will also see impact on behavioral health benefits under AHCA.

 “Essential health benefits are still in place in the current versions of the proposed legislation on the commercial side,” says Helaine Fingold, senior counsel with Epstein Becker Green. “However, what will go away and undermine mental health and other services is the actuarial value requirements.”

The prevailing Affordable Care Act (ACA) rules require commercial policies—those that are not employer-based—to have specified coverage values starting at a minimum of 60%. The figure approximates the average percentage of medical costs the insurance company will pay overall, with the consumer paying the rest. A higher number means more coverage.

Fingold says with the actuarial-value requirements sunsetting in December 2019, health insurers will likely create plans with values below 60%. The bottom line is that while they would have behavioral health benefits, consumers would pay a greater percentage of the bills.

Authors of the AHCA anticipate the new plans would have lower base premiums and thus be more affordable. It’s important to note that many consumers buying plans on the exchanges under ACA are not paying sticker price for premiums now, and a small percentage of those buyers are also receiving subsidies for copays and deductibles.

“As the subsidies phase out, obviously coverage will be more expensive for people, so it will ultimately end up with few people being able to afford coverage,” Fingold says. “It would hit the product from multiple ends.”

Malone also notes that it’s uncertain at this point how managed care Medicaid will change with healthcare policy changes.

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