Shrink Rap News

Health Benefit Exchanges


You’ve probably read something about the Health Benefit Exchange (HBE) system that comes out of the Accountable Care Act (ACA). At the time I’m writing this, the Supreme Court has yet to render its opinion about the ACA’s constitutionality. But the Health Benefit Exchange is intended to be a marketplace for insurance plans that meet certain rules and have certain minimal essential health benefits, referred to as Qualified Health Plans or QHPs.

Every state is deciding whether or not to implement an HBE; most of them are, especially given the fact that the federal government will fund 90% of the cost for the first 2 years – seed money, if you will, for the states to get this up and running. Afterward, the cost-sharing reverts back to what it is for all Medicaid recipients, with the feds paying around 40-50% of the Medicaid costs.

I am on one of the advisory committees for Maryland’s HBE, and we just had our first meeting. This is the Plan Management Committee, whose purpose is to collect state-specific perspectives from key stakeholders to inform policy decisions to ensure that the Exchange meets the needs of Maryland residents.

Specifically, we are being asked to be sure that we have sufficient rules in place to ensure that the plans meet federal and state requirements for “qualified plans.” We are also being asked to comment on the following areas and questions:

  • Plan Certification, Recertification & Decertification Standards What certification, recertification and decertification rules should be adopted? Should the Exchange require a standardized plan to be offered at each metal level?
  • Health Disparity Reduction How can certification standards be used to reduce disparities?
  • Pricing of Dental & Vision Plans How should dental and vision plan pricing be presented to consumers to balance accessibility and affordability?
  • Plan Choice Architecture How can plan information be presented to best assist consumers to choose a plan on criteria other than price?

Should Maryland limit the number of qualified plans issuers can submit to the Exchange?

If you have not stopped reading this column yet, you are probably asking what any of this has to do with psychiatry. Everything.

These plans need to be in place by 2014, but the rules about what they need to look like and what services they offer need to be developed now. Qualified plans will need to satisfy the Mental Health Parity and Addiction Equity Act, but there is still a lot of confusion about what that means.

Despite this Act becoming law in 2008, there are still no final regulations about how plans can ensure compliance. And, it is starting to look like we won’t see final regulations until after 2014. So, it is important to have stakeholders at these meetings to ensure that they get it right. I attend the meetings, holding my mental health stake, hoping that I can get it right.

That first bullet, about Certification, means the group of 20 or so stakeholders at this meeting must learn about the federal and state law about what the certification standards are, and be sure that we make recommendations to ensure that HBE plans are compliant. I know this includes compliance with the parity law and will come prepared to explain that when the time comes.

There is one other mental health advocate on the committee, Adrienne Ellis, and she knows even more about parity compliance than I do. She is the one person in Maryland who receives complaints from patients and providers about possible parity act violations. Working for the Mental Health Association of Maryland, she investigates complaints and takes action be passing them on to the state Insurance Commissioner, to the U.S. Department of Labor, and to the U.S. Department of Health and Human Services.


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