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Questions & Answers about the Affordable Care Act (ACA) - October 2013

Welcome

Welcome to this month's edition of “Ask the Expert.” This month's questions relate to the Affordable Care Act (ACA), which will move into enrollment phase in October of this year.

We are pleased to have Dr. Ron Manderscheid, Executive Director of the National Association of County Behavioral Health and Developmental Disability Directors (NACBHDD), to provide his insights on the implications of the ACA, both in general and specific to FASD prevention and intervention.

To make this information as easy to access as possible, we have included some general, background information on the ACA, and then divided this column into four sections, each intended for a different audience (though there may be some overlap):


General Information about Implementation of the ACA

Implementation of the ACA presents an exceptional opportunity to extend health insurance and additional services, including FASD prevention, to additional female populations, especially to poor and near-poor female individuals who do not currently have health insurance.

On October 1, State Health Insurance Marketplaces in all states will begin enrolling uninsured persons who have incomes at or above $15,282 who are above 133 percent of the Federal Poverty Level (FPL), now about $15,282 (In states not undertaking the Medicaid Expansion, Marketplace coverage will begin at $11,490.)

Although the original ACA intent was to provide new health insurance coverage to 19 million adult citizens with incomes up to 133 percent of the Federal Poverty Level (FPL), only 25 states and the District of Columbia have thus far elected to implement the 2014 Medicaid Expansion. States that elect the Expansion will be required to choose coverage for the new enrollees that meet the EHB requirements. Because federal financial incentives are very strong (100 percent federal payment for 2014, 2015, and 2016, decreasing to 90 percent by 2020 and remaining at 90 percent thereafter), we expect that most states ultimately will elect Medicaid Expansion. This expansion is particularly important to the substance use prevention and treatment community, since most persons with substance use disorders have been excluded from Medicaid coverage since the late 1990s.

If a state is undertaking the optional Medicaid Expansion, that new program will cover all uninsured persons up to 133 percent FPL. For more information on enrollment, go to who are at or above $15,282.

The initial enrollment period for the Marketplaces will be from October 1, 2013 to March 31, 2014. Medicaid enrollment will be continuous.

Initial insurance coverage for newly covered individuals will become effective on January 1, 2014.


Information for Consumers

Question:

Will I be able to get the coverage I need?

Answer:

ACA Medicaid coverage will offer a defined substance use benefit to all new enrollees, which will be helpful to women who cannot stop drinking on their own. Similarly, new enrollees through the State Health Insurance Marketplaces will have a defined substance use benefit. That means people enrolled in a health care plan through a marketplace or through Medicaid will have access to substance abuse treatment services. These benefits will vary from state to state, and the Center is currently analyzing state by state differences. Check back for updates on this information in the near future.

Question:

Will my coverage pay for things like brief interventions in primary care settings?

Answer:

Individuals covered by the ACA Medicaid plan as well as those who find a plan using their State’s Health Insurance Market Place will have access to treatment and preventive interventions.

In fact, for those already insured through private or public insurance programs, coverage of FASD treatment and prevention interventions will improve as well. For example, the ACA removes co-pays and deductibles for prevention interventions, including FASD prevention interventions.

Question:

Does the ACA do anything about the ban on paying for the treatment of preexisting conditions found in many health care plans?

Answer:

Yes. The ACA removes preexisting condition clauses in all health insurance plans.

How this affects individuals varies:

  • If you are under the age of 19, insurances plans have not been able to deny coverage for preexisting conditions since September 23, 2010.
  • If you are over the age of 19, insurers will no longer be able to deny benefits for preexisting conditions beginning on January 1, 2014.

Question:

Does the ACA cover diagnostic services for cognitive disabilities, including FASD?

Answer:

All children will be eligible for an initial health assessment before age 2. Beyond this, covered services will vary from state to state.

Question:

Does the ACA change how long my child can remain on my insurance?

Answer:

Yes. The ACA extends family insurance coverage up to age 26 for all young adults, including offspring who are pregnant women.

Question:

Can the benefits afforded by ACA vary from state to state?

Answer:

Yes. Benefits will vary from state to state; the Center is conducting an analysis regarding these differences and will provide more information on these details in the near future.


Information for Providers who Serve Women

Question:

Is there anything under the ACA that might help me to serve women at risk of an alcohol exposed pregnancy?

Answer:

Yes. The ACA is designed to give more women access to prenatal care, without co-payment. That means women have a greater potential to hear prevention messages and experience interventions earlier in their pregnancies.

As noted above, individuals covered by the ACA Medicaid plan as well as those who find a plan using their State’s Health Insurance Market Place will have access to treatment and preventive interventions. What’s more, the ACA removes co-pays and deductibles for prevention interventions, including FASD prevention interventions.


Information for Providers who Serve Children and Families

Question:

Some of the families I serve have children affected by an FASD. Can the ACA help with reimbursements for diagnostic services?

Answer:

Under ACA, the expectation is that an additional 8 million uninsured children in the United States will be covered by 2018. This insurance expansion should offer a significant opportunity to extend treatment to children with an FASD who previously have been without care.

In addition, the ACA ensures that a variety of preventive health services will be available to infants and children, without co-pays or cost sharing. Under the new regulations, all infants and children have access to physical exams, including measurements, vision and hearing screening, and developmental assessments.

Clearly one of the challenges of addressing FASD and preventing or reducing the behavioral health issues associated with FASD is that children are often not identified and do not receive appropriate interventions early enough in their development. However, the new ACA regulations make it much more likely that children will be seen in a setting where the signs and symptoms of FASD can be identified early, since the ACA provides for all children under age 2 to have a complete health assessment.

Question:

Does the ACA do anything about annual or lifetime limits on health coverage?

Answer:

Yes. The ACA removes annual and lifetime limits to health insurance coverage, which will be critical for ensuring that people with an FASD get the services they need over the course of a year or over the course of a lifetime.


Answers for State Agency Representatives who Coordinate FASD Prevention and Treatment Services

Question:

What should we do in anticipation of reaching out to newly covered individuals?

Answer:

State agencies will be in a unique position to develop an effective outreach strategy on FASD for those will be newly insured as a result of the ACA. Appropriate messaging and outreach will need to be designed to inform individuals about the FASD-related benefits that are now available to them. Each state office will need to analyze the benefits available through the state Marketplace and through the state Medicaid Expansion in order to inform people of these benefits.

Question:

I keep hearing about the Essential Health Benefit. What is that?

Answer:

In essence, the Essential Health Benefit (EHB) is the types of coverage that will be required in the ACA State Medicaid Expansion and in plans offered by the ACA State Health Insurance Marketplace.

While each state will determine its own EHB, that EHB must include mental health and substance use prevention and treatment benefits. In addition, coverage for mental health and substance abuse must be equal to the plan’s coverage of primary care.

Since each state will determine its own EBH, considerable analysis will be required to determine state-by-state coverage of FASD prevention and treatment interventions for new insurance enrollees.



About the Expert

Dr. Ron Manderscheid is the Executive Director of the National Association of County Behavioral Health and Developmental Disability Directors (NACBHDD). The NACBHDD represents county and local authorities in Washington, D.C., and provides a national program of technical assistance and support. He is also Adjunct Professor at the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, and Immediate Past President of ACMHA—The College for Behavioral Health Leadership. Dr. Manderscheid serves on the boards of the Employee Assistance Research Foundation, the Danya Institute, the FrameWorks Institute, the Council on Quality and Leadership, the National Research Institute, and the International Credentialing and Reciprocity Consortium. He is also Co-Chair of the national Coalition for Whole Health.


DISCLAIMER: The views, opinions, and content of this column are those of the authors/experts and do not necessarily reflect the views, opinions, or policies of SAMHSA or HHS.