Elements of Essential Benefits: Impact on Those with Mental Health and Substance Use Conditions


The Department of Health and Human Services (HHS) has finalized its regulations on a key element of health reform, the essential health benefits package. These regulations are an important step forward for expanding access to mental-health and addictions treatment in the U.S., because they require a broad range of plans to cover behavioral health services and to do so at parity with medical/surgical services.  According to a new report, this means that over 62 million Americans will gain access to insurance coverage that meets parity standards. This includes 27 million uninsured Americans plus 35.5 million who have coverage that either does not cover MH/SUD or is not required to cover them at parity. Beginning in 2014, the essential benefits package will become the minimum standard of coverage that most insurance plans must meet, including plans sold on the exchanges, individual and small group plans, and Medicaid expansion plans.

Other highlights of the regulation are:

  • The proposed rule includes language to assure non-discrimination in plan design, a major issue for people with chronic conditions. The rule prohibits cost-sharing structures, utilization management techniques and benefit designs that discriminate against beneficiaries based on race, age, disability status, health status, quality of life, having high health-care needs, or other characteristics. States must monitor and identify discriminatory benefit designs.
  • The definition of essential benefits includes both the required preventive services outlined in the ACA as well as any state-mandated benefits (for example, autism coverage mandates) that were in effect prior to December 31, 2011.

However, HHS also left up to states’ discretion several other important decisions, including the definition of habilitative (= rehabilitation) benefits, establishment of non-discrimination standards in plan design, and the enforcement of benefit substitutions within categories. It also adopted a prescription drug policy that requires plans to cover at least one drug in every category and class of the U.S. Pharmacopoeia, an approach that could allow states to offer coverage that does not include the full range of psychiatric medications.

Given the recent report of  blatant patient dumping by Southern Nevada Adult Mental Health Services, I for one am not sure leaving it up to “State” discretion to expand on and flesh out the remaining standards is all that good of an idea.

Other Available Substance Abuse & Mental Health Services Admin Reports at HHS

  • OAS Methodology Reports – “[These reports address] various methodological issues concerning OAS data collection systems including:  statistical techniques and theories, survey methods, sample design, survey instrument design, and objective evaluations of the reliability of collected data.”
  • NSDUH Reports on Substance Abuse and Mental Health – “SAMHSA’s National Survey on Drug Use and Health (NSDUH) is the primary source of information on the prevalence, patterns, and consequences of drug and alcohol use and abuse in the general U.S. civilian non institutionalized population, age 12 and older.”
  • Youth and Substance Use  – These NSDUH reports discuss youth substance abuse.
  • Parental, Peer and School Influences – These reports analyze information regarding parental, peer and school influences on drug abuse from the National Surveys on Drug Use & Health by SAMHSA.
  • Analytic Series and Other Special Reports – “The Analytic Series addresses special topics relating to alcohol, tobacco, drug abuse, and mental health.”
  • Mental Health Reports – These reports analyze information regarding mental health issues as related to drug abuse from the National Surveys on Drug Use & Health by SAMHSA.
  • Violence, Suicide, & Risky Behaviors Reports – These reports provide data on suicide attempts, suicides, violence and risky behaviors as related to and influenced by drug use; data was provided by SAMHSA’s National Survey on Drug Use and Health and SAMHSA’s Drug Abuse Warning Network (DAWN).
  • Reports on Depression – These reports provide information regarding depression, or related activity, and its connection to substance abuse as reported by NSDUH.
  • Mental Health by Racial & Ethnic Group – These reports discuss mental health as it relates to racial and ethnic groupings.
  • Homeless Reports – These reports, provided by DASIS, have information regarding homelessness admissions and substance abuse treatment.
  • Katrina/Rita Areas:  Substance Use and Mental Health – “[These reports present data] on substance use and mental health problems before and after Hurricanes Katrina and Rita”
  • Youth & Mental Health Issues Reports – These reports provide information on mental health and substance use among youths.
  • Serious Psychological Distress – These reports provide information about people suffering from serious psychological distress, its affects on mental illness and the connections that it has to substance abuse.
  • Cities/Counties/Metropolitan Areas – These reports provide information regarding substance use in specific geographic areas.
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