Just a few short weeks ago, I wondered in an earlier piece 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 ACA 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 the 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: