Health Care Reform

The implementation of the Affordable Care Act holds the promise of providing critical behavioral health care to many previously uninsured or under insured individuals. If you are having trouble understanding the effectiveness of the ACA, check out this video from the Henry J. Kaiser Family Foundation or discover useful tools in our Resources section.

Wins for Mental Health and Substance Use Disorder Consumers

  • As a part of the , all individual and small group plans must include mental health and substance use disorder benefits at as of 2014.
  • The Federal Parity Law, addressing financial requirements and other quantitative and nonquantitative limitations, applies to all non-grandfathered individual and small group plans as of 2014.
  • All must meet certification standards, which include a requirement that the insurer have an adequate network of providers, including a sufficient number of mental health and substance use disorder providers so that individuals may access treatment without unreasonable delay.
  • The Affordable Care Act provides funding for behavioral health homes- improved health care models that provide for better integration and coordination of primary and behavioral health care for individuals with serious mental illnesses.
  • Individuals cannot be denied health insurance for pre-existing conditions, including mental health and substance use disorders, and in 2014 plans will no longer have annual or lifetime dollar limits.

Maryland Successes

  • Maryland’s Essential Health Benefit Plan that must be included in all includes the robust package of mental health and substance use disorder benefits provided by the Federal Employee GEHA plan. These benefits include a full complement of services: inpatient, outpatient, partial hospitalization, intensive outpatient, and residential treatment for mental health and substance use disorders.
  •  As of 2015 all insurers in Maryland are required to provide continuity of care provisions for individuals who are transitioning from one plan or MCO to another. These 90-day provisions will enable individuals to carry a prior authorization for a current course of treatment with them to the new plan, as well as, allow an individual to continue to see their current provider at in-network cost-sharing even if that provider does not participate with the new insurance plan.
(1) ambulatory patient services; (2) emergency services;(3) hospitalization; (4) maternity and newborn care;(5) mental health and substance use disorder services including behavioral health treatment; (6) prescription drugs; (7) rehabilitative and habilitative services and devices;(8) laboratory services;(9) preventive and wellness services and chronic disease management; and (10) pediatric services, including oral and vision care
The law does NOT ALLOW limits for your mental health or addiction treatment benefits that are separate from your medical or surgical treatment. It also does NOT ALLOW any limits on mental health/addiction treatment that are more restrictive than for medical/surgical treatment.
Insurance plans certified by the Maryland Health Benefit Exchange that they cover the 10 essential health benefits and comply with robust certification standards, including network adequacy requirements and limits on cost-sharing.
Insurance plans certified by the Maryland Health Benefit Exchange that they cover the 10 essential health benefits and comply with robust certification standards, including network adequacy requirements and limits on cost-sharing.
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Maryland’s Health Care Reform Efforts

  • Maryland has passed laws in three subsequent General Assembly Sessions to implement the provisions of the Affordable Care Act. HB 166 of 2011 conformed MD state laws to the ACA provisions and established the Maryland Health Benefit Exchange. HB 443 of 2012 created the navigator program of the Health Benefit Exchange and established certification standards for HB 228 of 2013 authorized Maryland Medicaid Expansion and established continuity of care protections to start in 2015.
  • Maryland Health Connection, the consumer face of the Health Benefit Exchange, will go live in October of 2013, enabling individuals and small employers to purchase health insurance plans for plan years 2014 and beyond.
  • Maryland Health Connection awarded grants 6 regional navigator entities, who will perform education and outreach about and Medicaid and assist individuals in enrolling.
  • Maryland will expand Medicaid eligibility to adults at or below Individuals who were receiving benefits through the Primary Adult Care Program were transitioned to the full Medicaid benefit in January of 2014.
  • This new Medicaid Expansion population will receive the current Medicaid benefit package and will choose a managed care organization as current enrollees do today.
  • In 2012, Maryland selected the largest small group plan as its Essential Health Benefit Benchmark, but in order to meet the federal parity requirements chose instead to supplement the mental health and substance use disorder benefit with the Federal GEHA plan, which provides a more robust, parity compliant benefit package.
  • Maryland has established standards for that require that they contract with as well as have adequate networks of primary and specialty care providers. The Maryland Health Benefit Exchange will be collecting quarterly data on these requirements to ensure that consumers have access to quality care.
  • In 2015 all health plans in Maryland will be required to provide for individuals who are transitioning between plans or managed care organizations.

There are many ways to get involved in Maryland’s health care reform efforts. Consider attending a meeting, joining a committee or coalition, or simply providing feedback or asking a question.

Insurance plans certified by the Maryland Health Benefit Exchange that they cover the 10 essential health benefits and comply with robust certification standards, including network adequacy requirements and limits on cost-sharing.
Insurance plans certified by the Maryland Health Benefit Exchange that they cover the 10 essential health benefits and comply with robust certification standards, including network adequacy requirements and limits on cost-sharing.
$15,415 for an individual; $26,344 for a family of three in 2012
Insurance plans certified by the Maryland Health Benefit Exchange that they cover the 10 essential health benefits and comply with robust certification standards, including network adequacy requirements and limits on cost-sharing.
ECPs serve predominantly low-income, medically underserved populations and include, but are not limited to, safety net providers who are eligible to participate in the 340B drug purchase program in these six categories: Federally Qualified Health Centers (FQHCs), Ryan White providers, family planning providers, Indian providers, specified hospitals, and others.
Receiving plans must honor existing prior authorizations for lesser of current course of treatment or 90 days, as well as allowing individual to see their current provider for lesser of current course of treatment or 90 days at in-network cost-sharing.
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ACA Fast Facts

  • Medicaid Expansion will cover adults up to
  • Individuals and families between 139-400% of federal poverty will qualify for advanced tax credits which will help pay for premiums for insurance plans purchased through the exchanges (marketplaces).
  • States or Federal Government will establish Health Exchanges or marketplaces where individuals and families may purchase affordable, comprehensive insurance plans. Open enrollment for these plans will begin October 2013- March 2014. Assistance will be available to help with enrollment in these plans.
  • All Qualified Health Plans (QHP) will cover the and will be certified by state or federal regulators that they have complied with robust certification standards.
  • In 2014 Insurers may no longer deny coverage for individuals who may have a pre-existing condition.
  • Dependent children under the age of 26 will be allowed to stay on their parents’ health plans.
  • Insurance companies must spend 80% of every premium dollar on health care claims and not administration.
  • In January of 2014 all individuals must have health insurance or face a tax penalty. This health insurance may be from an employer, Medicare, Medicaid, or may be purchased inside or outside the health insurance exchange (marketplace).
$15,415 for an individual; $26,344 for a family of three in 2012
(1) ambulatory patient services; (2) emergency services;(3) hospitalization; (4) maternity and newborn care;(5) mental health and substance use disorder services including behavioral health treatment; (6) prescription drugs; (7) rehabilitative and habilitative services and devices;(8) laboratory services;(9) preventive and wellness services and chronic disease management; and (10) pediatric services, including oral and vision care
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