Peter, age 41, has bipolar disorder, HIV, and a history of substance use disorder. He also has begun to exhibit symptoms of cardiac disease and needs to undergo additional testing for a final diagnosis and potential treatment plan. Peter has information technology and systems software expertise and works periodically as a consultant when he feels able to do so. He has not historically qualified for Medicaid due to his income levels and existing asset. In the past he has paid out-of-pocket for expensive private insurance, but since 2012 he has subscribed to the Pre-Existing Condition Insurance Plan (PCIP). Peter wants to know if he is eligible for subsidies in the Marketplace or under Medicaid expansion. He is especially concerned about difficulties he has experienced getting sufficient mental health coverage through private insurance, keeping his current mental health professionals, maintaining his ongoing treatment regimen for HIV, and having access to cardiac specialists who either have expertise in HIV/AIDS or who are willing and able to work with providers who do have such expertise. Peter also wants to know how he could deal with potential “churn” between successive periods of eligibility for public healthcare and private Marketplace health insurance.
What are key issues for Peter in selecting healthcare insurance coverage?
- Is Peter eligible for Medicaid?
Possibly. If Peter’s state is participating in the Medicaid expansion and his income is below about $15,282 per year he will be eligible for the Medicaid Alternative Benefit Plan. Since Peter has complex medical conditions, he should be advised that the federal definition for “medically frail” individuals in the Medicaid expansion population has recently been expanded and includes “individuals with disabling mental disorders” in addition to “individuals with serious and complex medical conditions.” (42 C.F.R. 440.315.) This is an important fact for Peter to weigh as “medically frail” individuals will have the option to enroll in standard Medicaid and potentially have access to greater services and supports than those available under the Alternative Benefit Plan benefit package developed by his state. While the Alternative Benefit Plan benefit packages must include all ten categories of Essential Health Benefits, specific benefits that are important to Peter could still fall short of the scope, duration and amount of benefits included in the state’s standard Medicaid coverage. Navigators should assist Peter to understand and weigh his various Medicaid options, beyond simply whether his income level makes him eligible for enrollment.
- Is Peter eligible for lower costs on private health coverage?
Possibly. If Peter’s income is less than about $45,960 annually, and he is not eligible for Medicaid coverage, he likely will be eligible for lower costs on his health insurance coverage through the Marketplace. The variation in Peter’s income, both within a year and over multiple years means that Navigators need to take particular care to inform Peter of both the likely consequences of under- or over-estimating his income for the upcoming year, and the fact that the Federal Government can adjust his premium subsidies over the course of a year if he informs them of how his actual income does or does not meet the forecast that he provided. Since continuity of care in both treatments, prescription drugs, and providers is particularly important to Peter, he has a vested interest in maintaining a stable relationship with his health plan to the maximum extent possible. Furthermore, individuals with chronic conditions almost invariably have numerous out-of-pocket health-related expenses and costs that can arise unexpectedly and monopolize available resources. If Peter attempts to maintain a reasonable liquid “emergency fund,” he needs to be advised that when he files his next income tax return, the Federal Government is likely to ask him to refund any excess Marketplace subsidies that have been provided.
- Will Peter be able to get the mental health coverage that he needs through the Marketplace or under the Medicaid expansion?
Probably. Peter is justifiably anxious though, as historically many health plans and insurers offered no or little coverage of mental health services or substance use disorder treatments. However, the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) required group health plans and group health insurance coverage (both public and private) that offered mental health and substance use disorder treatments to offer coverage that is “generally comparable” to the medical and surgical care offered in the plan. In 2010 the ACA extended the reach of the MHPAEA by including “mental health and substance use disorder services, including behavioral health treatment” as one of the ten categories of Essential Health Benefits (EHB) that must be covered as of January 1, 2014 by non-grandfathered plans* in individual and small group markets, both inside and outside of the Marketplace. In addition, HHS enacted regulations under the ACA that extend MHPAEA’s parity requirements to the EHB mental health and substance use disorder category.
- Could Peter still face any special limitations on his mental health benefits?
Probably not. Since Peter has been most recently enrolled in a PCIP plan, he was not in a “grandfathered” plan. MHPAEA and the EHB requirements of the ACA both apply to any plan that he purchases through the Marketplace, and also to the Alternative Benefit Plans that will be offered to the Medicaid expansion. This means that whether Peter obtains coverage through an individual Marketplace plan or through the Medicaid expansion, he should obtain mental health or substance use disorders service coverage that is no more restrictive than the coverage for medical/surgical conditions. This requirement applies to treatment limitations such as limits on office visits or inpatient days, financial requirements such as copayments, coinsurance, and deductibles, and the use of care management tools such as a plan’s policy requiring that lower cost therapies be proven ineffective before higher cost therapies are approved.
However, Peter could still possibly encounter some historical limitations in mental health treatment. This is because the ACA allowed individual states to choose a “benchmark” for Marketplace coverage among existing plans. If the benchmark plan did not cover an EHB category, then the state had to supplement the benchmark and establish standards for the coverage of the missing EHB category. If the chosen benchmark plan contained existing historical limitations on specific categories of coverage, for example an annual monetary cap or limit on office visits that applied to mental health treatments overall or to specific types of treatment, it is unclear whether those restrictions can be “imported” into the standards that all plans in the Marketplace must meet. For this reason, Navigators should assist Peter to check into the specific mental health coverage offered by plans in the Marketplace to choose a product that will come closest to meeting his mental health treatment needs. Navigators should also help Peter to determine the overall cost of his healthcare if he chooses a plan with higher premiums because it offers access to more visits and/or the cost of co-payments for each visit is lower as compared with other plans.
- Will Peter be able to continue seeing his longtime mental health providers, including a psychiatrist and psychologist?
Possibly. Peter needs to ask his providers if they contract with or are in the provider networks of any of the plans that he is considering in the Marketplace. Alternatively, if Peter qualifies for the Medicaid expansion, he should ask his mental health providers if they accept Medicaid. If he is in a state where Medicaid is offered through mandatory managed care, he needs to check if his providers contract with the Medicaid plans that are available to him. Navigators can also help Peter to get information from plans concerning their mental health provider networks, and if he can continue to see his providers as a new plan member. Some providers can be administratively unavailable to new plan members, regardless of the fact that the new member may be an “old” fee-for-service patient of that provider.
Since Peter’s variable income could place him in a position of being alternately eligible for Medicaid expansion coverage and Marketplace coverage, with or without federal credits, Navigators should assist Peter to look for any plans that may offer a range of products to both Marketplace consumers and Medicaid beneficiaries. Peter’s purchase of health coverage through such a plan will not guarantee that he can retain his health care providers since the plan could conceivably choose to make some providers exclusively available through certain products. However, in light of Peter’s need to retain certain long-time therapists and a treatment professional who understands the potential interactions among his bipolar medications, HIV treatment regimen, and a potential new chronic cardiac condition, Navigators should take extra steps to provide Peter with as much in-depth information about plans’ provider networks as possible. This should include information about an individual plan’s continuity of care policies, any relevant continuity of care rights that the state gives Peter, and potential grievance and appeal procedures than can apply to out-of-network continuity of care requests.
*“Grandfathered” plans are plans that existed when the Affordable Care Act was enacted (i.e., March 23, 2010) that have not been changed in certain specified ways