What is the ACA (the Patient Protection and Affordable Care Act), what is MNsure (Minnesota’s public health insurance exchange) and why should psychologists care?

The purpose of the ACA is to curb and control runaway increases in healthcare costs, while improving overall population health. The ACA regulates private health insurance payers as well as expanding access to public health insurance, and setting standards for state-run health insurance systems.

The ACA incorporates parity rules set by the Paul Wellstone and Pete Domenici Mental Health Parity and Addictions Equity Act (passed in October, 2008 and mostly implemented by 2011). “Parity” did not require insurers to pay for mental health care; however, “parity” means that when a group health plan cannot impose treatment limitations or financial requirements for mental health benefits that are stricter than for medical or surgical benefits. The law corrects practices that had been commonplace, such as putting a limit on the number of times an insured person could see a mental health professional or capping the number of days the person could spend in a mental health or substance abuse facility (Erwin, Emmett, & Buchanan, 2012).

The ACA requires state-approved public payers to provide mental health and substance abuse coverage.  Minnesota’s state healthcare exchange, “MNsure,” provides access to insurance for any citizen who is not insured through an employer. MNsure staff help low-income individuals enroll in public assistance programs (Medicaid, Minnesota Care). In addition, MNsure staff help individuals of any income level who do not have health care through an employer. The MNsure “exchange” lists several private insurance agencies called “QHP’s” (qualified health providers) who have contracted with Minnesota to meet the standards set by healthcare reform law. People who enroll with those networks can receive state subsidies, reducing their premiums, based on their income, household size, and where they reside. The ACA says that those payer networks “must maintain a sufficient number and type of providers including those specializing in mental health and substance abuse to assure availability of all services without unreasonable delay” (MNsure, 2012).

Some of the key features of the ACA are not mandated for employer-paid healthcare plans (for instance, self-funded plans by big employers are exempt from almost all federal regulation; and small employers, with fewer than 100 employees, do not have to provide plans that meet the minimum ACA standards). MNsure, the insurance exchange that is part of Minnesota’s implementation of the ACA, significantly expanded eligibility for health care including mental health services to adults and children. Health care plans that are sold to individuals or sold via state-sponsored marketplaces must meet certain standards. For example, under MNsure/ACA rules, these insurers:

  • …must spend at least 80% of the insurance premium on health care (not on administrative costs, such as CEO salaries, or stockholder dividends).
  • …must offer a standard basic menu of preventive care, including screening for depression in adults and teens, and for behavior disorders in younger children.
  • …must offer mental health and chemical dependency coverage.
  • cannot “cherry pick” the healthiest people and exclude people with chronic illness or pre-existing conditions.
  • cannot put an annual cap, or a lifetime cap, on health care costs (including mental health and substance abuse care).
  • …must allow family coverage for dependent adult children up to age 26 years

“Medical Homes,” “Behavioral Health Homes,” and “Accountable Care Organizations” are various systems for organizing how providers get compensated for taking care of people. The ACA provided states with grant money to develop and try out different models of care. The ACA encourages states to develop models of care that integrate mental health with physical health care needs. As one example, Minnesota provided a grant to mental health providers in Ely, MN, to create a collaborative “wrap around” system involving primary care, pediatrics, social service agencies, schools, transportation options, etc., to take care of mental health needs for at-risk families in that community. Consumers and providers experienced increased satisfaction and improved health outcomes under that integrated model of care.

The ACA does not mandate one specific model of care. It is not a “one size fits all” law. It does say that new models need to be developed. In order for the insurance companies and doctors to make money, they must demonstrate that insured people are meeting specific “benchmarks” of good health. Payment is structured so that both providers and insurers will earn money by keeping people healthy, and lose money by ordering expensive tests or procedures that do not improve health outcomes.

MNsure is Minnesota’s state health insurance exchange. It includes a database that lets eligible people choose a health insurance plan, and keeps track of those insured. MNsure does not provide supplemental insurance for people who are covered by MediCare, which is America’s single-payer health care system for people 65 years of age or older, and for adults with severe disabilities. People who have access to a workplace health plan can sign up for MNsure but cannot get any premium discounts unless their total health costs exceed 9.5% of their taxable household income.

Otherwise, as of October 1, 2013, any (documented) Minnesotan can sign up for health insurance through MNsure. This includes people who work part-time or are self-employed, as well as people who are unemployed, or those whose employers do not provide affordable health care plans. Some people might save money with MNsure, as compared to their employer’s health plan, if their total health care costs or premiums are unusually high. At www.mnsure.org individuals can compare plans by costs, coverage, and rated quality. MNsure Qualified Health Plans are provided by private companies, approved and regulated by the State. In 2015, plans and providers include Blue Cross Blue Shield (Allina, Aware Network, Consumer Value); HealthPartners; Medica (Inspiration Health, North Memorial, Medica plans); and UCare (Fairview, UCare Choice).

Individuals earning less than $23,000 per year may be insured by government programs (MinnesotaCare or Medical Assistance), with low (or zero) monthly payments. Those who earn more can sign up for one of the MNsure Qualified Health Plans. Age, total household income, place of residence, whether or not the person smokes, and family size, will affect an individual’s costs and whether they qualify for government subsidies (discounts on health insurance premiums). Premium discounts are available for people with annual incomes up to about $46,000 for an individual or $94,200 for a family of four. Each MNsure plan also offers a choice of 4 payment styles. For example, “Platinum” plans have a higher monthly premium which covers 90% of medical bills (sensible for people who need frequent or expensive care). “Bronze” plans have low monthly payments but higher out-of-pocket costs for each visit (sensible for people who rarely get sick, if they set aside savings for unexpected illness). For catastrophes, all plans must cover costs above a certain point, so that neither the family nor the hospital goes bankrupt.

Individuals can use the MNsure website (www.mnsure.org) to comparison shop for insurance plans from a home computer. Or, they can get help from trained MNsure assistants at no cost. Psychologists may wish to caution patients that nobody has to PAY for assistance with MNsure registration — there are some “scams” making money from bogus MNsure enrollment schemes. Finally, psychologists who own a small business (fewer than 50 employees) can offer health care plans through MNsure, and again there is assistance for setting that up (see mnsure.org for details).

Starting in 2014, individuals will pay a tax penalty if they fail to sign up for any form of health insurance shown on the www.mnsure.org website. The amount increases each year so that by 2017 it will cost individuals about the same to refuse health insurance as it costs to get insured. Considering that either a hospital, or fellow taxpayers, or both, must pay for care when someone is injured or sick, it is fair to require everyone to contribute, particularly when the government helps cover costs for those with low incomes.  There are no tax penalties for low-income individuals and families; for those who are uninsured for less than 3 months; for members of American Indian tribes; or for people who refuse coverage on religious grounds.

The ACA is not “universal health care.”  It is a compromise. Large employers still contract with private payers for employee plans. Quality health care is still sold as a commodity, not viewed as an essential human right. The ACA and MNsure (Minnesota’s state exchange) make healthcare more accessible, better regulated, and more affordable for most people.

The ACA will require improved means of gathering and sharing data about health care outcomes. That implies the use of electronic health records. As Erwin, Emmett and Buchanan (2012) explained, “The American Recovery and Reinvestment Act of 2009 (ARRA) authorized more than $30 billion for the expansion of health information technology in this country. This expenditure is seen as a key investment in greater efficiency and improved medical care and is a cornerstone of the health reform effort now underway. For the mental health and substance abuse treatment communities, however, this initiative is a reminder of the still uncertain space they occupy in the broader health care environment, since the opportunities for HIT (Health Information Technlogy) funds in the behavioral health sphere appear limited. Advocates are dismayed that excluding behavioral health providers from ARRA funding of HIT may allow walls to rise that prevent meaningful integration of care for adults with serious mental illness and with medical complications resulting from the high rate of substance abuse among people with many chronic conditions. At the same time, many point out that the behavioral health field has long claimed a greater need than other medical sectors for the maintenance of privacy and confidentiality for patient-specific information, and some continue to fear that poorly designed HIT policy could lead to an erosion of these guarantees.”  In Minnesota, MPA’s Legislative Committee, chaired by Trisha Stark, is working with other mental/behavioral health providers and organizations to advise the legislature on guidelines for electronic health records (EHR). The MPA Health Care Reform Task Force shares information and learns from the work of the EHR group.

Karen Wills Ph.D., L.P., ABPP, co-chair of the Health Care Reform Task Force, is a clinical neuropsychologist at Children’s Hospitals and Clinics of Minnesota (Minneapolis). She specializes in assessment and treatment planning for children with conditions that affect brain function and development, such as sickle cell disease, cancer, genetic anomalies, or head injuries.

Resources

MNsure:  Website for Minnesota’s health care exchange for self-employed, uninsured or low-income individuals and families.

Mental Health Reform 2020:  The Adult Mental Health Reform 2020 Steering Committee included representatives from the major mental health organizations in Minnesota. It began in 2012, and made final recommendations in July 2013 with follow-up in November 2013, with the purpose of reviewing the mental health continuum of care and recommending potential changes to DHS for publicly funded adult programs. It had five task forces including a group focused on early onset of psychosis (in conjunction with the Children’s Mental Health Division); residential care; Adult Rehab; Peer Supports and Consumer Organization; and Behavioral Health Care Homes. A summary of those recommendations is online at http://bit.ly/1vfPgjy

National Association of State Mental Health Programs.

National Association of State Alcohol and Drug Abuse Directors.

National Conference of State Legislatures, white papers on mental health benefits.  

General APA Health Care Reform Site.

American Psychological Association Practice Organization (APAPO).   

Inter-Organizational Practice Consortium.  A coalition of the major national neuropsychological associations, working on rapid response to payer and legislative policies that affect psychological and neuropsychological testing/evaluations.

BringChange2Mind.  Advocacy organization aiming to reduce the stigma associated with mental illness.

Mental Health Association of Minnesota. Advocates with and for consumers for mental health services legislation, supporting the state and local advisory councils and organizing the Mental Health Day on the Hill with NAMI and other organizations.

National Alliance on Mental Illness (NAMI-Minnesota).

NASHP.  Summary of behavioral health services available to children and youth in Minnesota with public assistance (Medicaid).

What is a Health Home?  Describes the statute and examples of implementation in four early adopting states.

Bazelon Center for Mental Health Law.

References

Erwin, B., Emmett, B., & Buchanan, E. (2012). “Mental Health and Substance Abuse,” Ch. 11. Association for Health Care Reform.

MNsure (2012). Summary of ACA rules governing state healthcare exchanges.

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