Background: “Affordable Insurance Exchanges are designed to make buying health coverage easier and more affordable. Starting in 2014, Exchanges will allow individuals and small businesses to compare health plans, get answers to questions, find out if they are eligible for tax credits for private insurance or health programs like the Children’s Health Insurance Program (CHIP), and enroll in a health plan that meets their needs.”
As a part of NY’s Coalition for Whole Health, which was formed to help shape the development of the exchanges and the ‘Essential Health Benefits’ that they offer, NYAPRS advocated in particular for strong roles for rehab and peer run services. This report includes “the EHB should include services that improve functioning and help people achieve rehabilitation and long-term recovery.”
Specifically, the Coalition for Whole Health recommends inclusion of
- “psychiatric rehabilitation skills training and all other services traditionally covered by private insurance and Medicaid including skills training…and to (help beneficiaries to) successfully transition to appropriate housing and employment settings.”
- “recovery support services, including peer wellness coaches, hospital-to-community peer bridgers and community life coaches and addiction recovery coaches”
- crisis services that include “peer crisis diversion and support services including peer crisis respite, warm line and emergency room based crisis specialists, and other services that connect persons in crisis with needed SUD and MH services.” And
- Alternative treatment and recovery services including harm reduction, targeted prevention and wellness services, care management for chronic conditions that co-occur with MH/SUD (diabetes, HIV, Hepatitis C, obesity, tobacco dependence, etc.), recovery support services, outreach services to serve hard to reach individuals, and other services that are holistic, integrated, and focused on wellness and sustained recovery. These services should be available in non-traditional settings such as recovery centers, peer run organizations, and other community settings that increase access for hard to reach individuals.”
Great thanks are due to Coalition chairs Glenn Liebman and John Coppola and to John Richter who helped pull together a lot of these recommendations.
August 17, 2012
Dear Exchange Officials,
We are writing to you on behalf of the New York Coalition for Whole Health with recommendations regarding the selection of a benchmark health insurance plan for New York State. The Coalition represents more than 30 advocacy and provider organizations committed to serving the mental health and substance use disorder needs of New Yorkers. Our primary recommendations include:
- The selection of the Empire Blue Cross-Blue Shield plan as New York’s health exchange benchmark. We believe this plan most closely resembles the content and scope of coverage needed to meet the mental health and substance use disorder needs of New Yorkers;
- The fully developed benchmark plan must comply with both New York State and federal mental health parity laws;
- The plan should include a comprehensive medication formulary that insures full access to state of the art pharmacotherapies for mental health and substance use disorders and a range of medications that will meet the needs of consumers and the medical professionals who treat them. Further, we ask that you append your submission to the federal government with a stipulation that Methadone treatment and other pharmacotherapies for substance use disorder treatment will be required in New York State as will a comprehensive array of pharmacotherapies for mental health disorders.
In addition to these recommendations, the Coalition offers more specific guidance that we hope you will consider in further developing New York’s health insurance exchange. These recommendations are contained in the attached document: Essential Health Benefits for New York State: Consensus Principles and Service Recommendations.
On behalf of the Coalition for Whole Health, thank you for considering our input at this critical juncture in developing New York’s health insurance exchange.
Glenn Liebman, CEO Mental Health Association in New York State
John Coppola, Executive Director New York Association of Alcoholism Substance Abuse Providers, Inc.
Co-Chairs, New York Coalition for Whole Health
Essential Health Benefits for New York State
Consensus Principles and Service Recommendations
The Affordable Care Act (ACA), with its inclusion of mental health (MH) and substance use disorder (SUD) benefits as essential health benefits provides an excellent foundation and framework for New York State to meet the needs of individuals with mental health and substance use disorders. New York State’s innovative Medicaid re-design efforts, with a recognition of the importance of behavioral health integration with primary care as a lynchpin for improving health care outcomes and reducing unnecessary costs, also provides some policy guidance as we begin work on the development of our health insurance exchange and the essential health benefits (EHB) that will be made available to New Yorkers.
As the federal Department of Health and Human Services develops final guidance on EHB and as New York state policy-makers move forward with ACA benefit design, the New York Coalition for Whole Health offers its recommendations for how MH and SUD services should be included in the EHB.
Substance use and mental health disorders are treatable health conditions according to the American Medical Association, all other reputable public health and medical standards, and decades of scientific research. Studies have found that nearly one-third of adults and one-fifth of children have a diagnosable substance use or mental health disorder. However, there remains an unacceptably large MH and SUD treatment services gap in this country and in New York State. It is estimated that less than half of the adults with serious mental illness received psychotherapeutic treatment or counseling for their mental health disorder and only ten percent of the people in need of care for a SUD received any specialty treatment. This lack of treatment results in the unacceptable reality that individuals with co-occurring mental illness and substance use disorders have life expectancies 35 years shorter than individuals without these illnesses. The economic impact of the failure to treat SUD and MH disorders is also unacceptable. Persons with SUD and MH disorders make up 80% of the unnecessary hospitalizations in New York State and a disproportionate share of overall healthcare expenditures.
With passage of the federal parity law in 2008, Congress attempted to eliminate the widespread discrimination experienced by persons with MH and SUD when their private insurance plans create roadblocks to care or offer inadequate treatment options. By extending the requirements of the federal parity law to all qualified health plans under the ACA, Congress has ensured significant improvement in access to the critical services necessary to treat substance use and mental health disorders. New York State, in the development of an essential health benefit for its health insurance exchange, has the opportunity to lead the country with an exchange that erases stigma, increases access to behavioral health services, drives down unnecessary hospitalizations and use of unnecessary/expensive healthcare services, and improves the health status of consumers and their families.
It is important to recognize that people have complex health needs and that those with co-occurring behavioral health and primary healthcare needs pose a particular challenge as we develop New York’s health insurance exchange. The EHB should include services that improve functioning and help people achieve rehabilitation and long-term recovery. It should cover a comprehensive continuum of behavioral health and primary care prevention, treatment, and recovery support services that meet each person’s multiple needs, recognizing that no single treatment for mental illness and substance use disorders is effective for all individuals. A comprehensive continuum of SUD and mental illness prevention, treatment and recovery support services must be included in the essential health benefit offered in New York’s health insurance exchange. Research shows that prevention and early interventions reduce the incidence of mental illness and substance use disorders, and other costly co-occurring chronic illnesses such as diabetes, hypertension, heart disease and certain cancers. Substance use disorders and serious mental illnesses are often chronic diseases that need to be managed over a lifetime. Like other chronic conditions, there are varying degrees of severity for MH and SUD and a continuum of care is necessary to ensure that people can receive the appropriate level and type of care, including all evidence-based acute care, behavioral health services, medications, care coordination, and recovery support services.
Individuals should have choices regarding their health, mental health, and substance use disorder care that foster recovery and wellness through individualized community-based services and supports. All services, including residential and hospital-based services, should be rehabilitation-focused and recovery-directed. As with all medical care practices, behavioral health services, integrated with primary care, should be person-centered, whole health-oriented, and based in the person’s community of residence.
The following New York Coalition for Whole Health recommendations are based on a review of how MH and SUD services have typically been offered through employer plans and on evidence-based practices that are effective and necessary to ensure that the MH and SUD needs of children, youth, adults, and elderly persons are well met:
Levels of Care
- Outpatient treatment including all services traditionally covered by private insurance and Medicaid (i.e. screening, intervention, referral, assessment, treatment planning, laboratory services, individual, group and family psychotherapy/treatment services, medication and medication monitoring, ambulatory detoxification, and all other services that are part of the service continuum outlined in OMH/OASAS regulations). Outpatient services should be made available in a variety of settings including but not limited to mental health and substance use disorder clinics, primary care practices, community health centers, hospital clinics, patient centered medical homes, and other accessible entities. Outpatient services should be provided by a range of qualified health professionals such as psychologists, social workers, physicians of various specialties such as psychiatrists, credentialed addiction professionals, recovery coaches, peers, primary care physicians, and others fitting the OASAS/OMH definition as qualified health professionals.
- Inpatient hospital services including all services traditionally covered by private insurance and Medicaid. Hospital-based detoxification and psychiatric stabilization services should be covered and readily accessible. It is vital that hospital-based behavioral health services are available to meet the acute behavioral and physical health needs of persons across New York State, especially those with co-occurring, chronic conditions.
- Intensive outpatient and partial hospital services for persons with MH and SUD whose assessment and level of care determination indicates the need for intensive services but does not indicate the need for hospitalization. All intensive outpatient behavioral health services traditionally covered by private insurance and Medicaid should be included in the essential health benefit offered by New York State’s health insurance exchange.
- Intensive home-based treatment including all services traditionally covered by private insurance and Medicaid for children and adults with serious mental illness and/or substance use disorders, such as counseling, behavior management, and medication management. These services could include use of technologies such as telemedicine and would be particularly helpful in the development of a service continuum that is practical and cost effective in rural communities.
- Crisis services including emergency room crisis intervention, psychiatric stabilization, mobile crisis services, community-based detox, SBIRT (Screening, Brief Intervention, and Referral to Treatment), care management, peer crisis diversion and support services including peer crisis respite, warm line and emergency room based crisis specialists, and other services that connect persons in crisis with needed SUD and MH services.
- Residential Treatment including the full range of residential services provided in the context of OASAS and OMH regulation (those that correspond to the American Society of Addiction Medicine’s level III of care; detoxification as described in Part 816 of NYSMHL, rehabilitation as described in Part 818 of NYSMHL, and other residential services). The essential benefit should include coverage for all treatment services offered in residential settings, i.e. SUD treatment groups, counseling, etc.
- Alternative treatment and recovery services including harm reduction, targeted prevention and wellness services, care management for chronic conditions that co-occur with MH/SUD (diabetes, HIV, Hepatitis C, obesity, tobacco dependence, etc.), recovery support services, outreach services to serve hard to reach individuals, and other services that are holistic, integrated, and focused on wellness and sustained recovery. These services should be available in non-traditional settings such as recovery centers, peer run organizations, and other community settings that increase access for hard to reach individuals. Regulatory relief should provide opportunity for service integration and reimbursement in multiple settings. Services should be culturally competent and trauma informed with special emphasis on multi-lingual services, LGBT sensitive, and address the needs of under-served populations.
- Out-of-network benefits should be available, accessible, and paid for to ensure that consumers have choice in the context of a comprehensive continuum of integrated health and behavioral health services.
Medication Assisted Treatment and Recovery
New York State’s essential benefit should include a comprehensive array of medications appropriate for the treatment and recovery of persons with MH and SUD. New York State’s health insurance exchange should require all insurance plans to cover FDA approved medications that consumers and medical professionals deem appropriate and helpful for MH and SUD. The approved formulary should be developed with input from consumers and medical professionals. New medications introduced in the last decade represent a major advance in the effective treatment of mental illnesses and addiction. Many newer medications have proven effective at treating various disorders (particularly schizophrenia, major depression, and substance use disorders), with a noticeable reduction in, or absence of, the adverse side effects often associated with older generation medications and should be included in the formulary. Timely access to the most effective pharmacotherapies can reduce the need for inpatient treatment or hospital detox, minimize the disabling effects of severe mental health crisis, and help to prevent relapse for persons with SUD.
The Coalition for Whole Health recommends the following to ensure a strong pharmacotherapy component in the behavioral health benefit required by the New York Health Insurance Exchange:
- A comprehensive medication formulary that includes new, state of the art pharmacotherapies for MH and SUD and a range of medications that will meet the needs of consumers and the medical professionals who treat them.
- Coverage of medication dispensing and medication management services including all services rendered in OASAS licensed Opioid Treatment Programs, OMH/OASAS treatment settings, and in a variety of healthcare settings (primary care practices, hospitals, health clinics, community health centers, etc.).
- Medical necessity and off-label prescribing guidelines that incorporate a relatively “wide birth” in practice standards when applied to non-FDA approved prescribing.
- Physician directed and patient-centered medication selection as required elements of the health insurance exchange’s pharmacotherapy benefit. Physician prevails language should be in place ensuring that the final determination of a medication is the responsibility of the physician and not relegated to a health plan. Consumers should know with absolute certainty that, when their physician prescribes a medication after consultation with the consumer, that medication, whether or not it is on a formulary, should be accepted by the health plan. Physician prevails language will address cost concerns and consumer need simultaneously by preventing the use of step therapy, where a person has to go through a series of medications, generally based on cost, before they are approved for the medication that is clinically appropriate to their need. Subjecting patients to sequential trials of medications in a step therapy fashion can unnecessarily post-pone recovery. Physician prevails language will ensure that, when a particular medication is indicated as the first line of treatment, the needs of the consumer will be met and the needless expense of “step therapy” will be avoided.
- Clear communication about the pharmacy benefit and available pharmacotherapies from DOH to consumers. Communications should emphasize how consumers can access the help line and help them to understand their rights relative to the appeals process they can utilize when they have any concerns regarding access to appropriate medications.
- Periodic analysis of physician prescribing practices and insurance/managed care responsiveness to pharmacotherapy needs of consumers. Using PSYCKES and other data sets, analysis of pharmacotherapy practices will help to assess consumer satisfaction, achievement of health outcome goals, progress with SUD/MH recovery etc. It will also be invaluable in healthcare planning, ensuring access to needed care, and strengthening recovery-oriented systems of care.
Rehabilitative and Habilitative Services and Devices
The essential health benefit package required by the health insurance exchange should include habilitative services for persons with chronic SUD and MH conditions with particular emphasis on integrated services for persons with co-occurring disorders. A comprehensive continuum of rehabilitative services should also be included to support ongoing recovery. Specifically, the Coalition for Whole Health recommends inclusion of
- Life skills training and other habilitation services that will facilitate independent living or capacity to thrive in supportive services settings.
- Psychiatric rehabilitation skills training and all other services traditionally covered by private insurance and Medicaid including skills training to address functional impairments and rehabilitation services designed to avoid institutional placement for children and adults with severe mental illness (i.e. therapeutic foster care) and to successfully transition to appropriate housing and employment settings.
- Services that strengthen family environments such as services meeting the needs of women with children and services co-located in child protective services offices. These services strengthen parenting and ensure better child rearing environments while providing needed SUD and MH treatment services.
- A comprehensive continuum of treatments for eating disorders
- A comprehensive continuum of treatment services addressing problem gambling disorders
- Recovery support services, including peer wellness coaches, hospital-to-community peer bridgers and community life coaches and addiction recovery coaches.
A comprehensive continuum of services for children should be incorporated into the essential benefit package required by the health insurance exchange.
- An array of age appropriate and evidence-based prevention, early identification, early intervention, treatment, and recovery services should be required targeting infancy through late adolescence/early adulthood
- Services should be easily accessible and include an array of settings and a range of qualified health professionals on par with those recommended above for adults.
- A comprehensive continuum of alternative rehabilitation for transitional age youth between the ages of 16 to 24.
- Access to state of the art clinical interventions including cognitive behavioral therapy and motivational interviewing.
Prevention and Wellness Services
A comprehensive continuum of primary, secondary, and tertiary prevention services that incorporates behavioral and primary care concerns using an integrated approach should be available through the exchange including but not limited to:
- School and community-based primary prevention services using evidence-based strategies to address wellness, health promotion, and specific disease/health disorder prevention
- Home visiting programs using evidence-based tools targeting caregivers, infants, and children of all ages
- Wellness services for SUD and MH consumers and their families that include education on maintaining healthy weight, good nutrition, substance use prevention, suicide prevention, emotional/psychological wellness, and other health promoting activities
- All prevention and wellness services required by the ACA
- Education and skills training about preventing, treating, and recovering from substance use and/or mental disorders targeting individuals and families across the lifespan
Chronic Disease Management
The essential benefit should include coverage for;
- Comprehensive care management including intensive case management for persons with severe mental illness and substance use disorders
- Care coordination and health promotion specifically designed for children, young adults, adults, and elderly persons with mental illness and substance use disorders
- Patient and family support including education and self-management assistance for persons with severe mental illness and substance use disorders
- Recovery coaching, peer wellness coaches and recovery center services supporting persons throughout their recovery process
- Appropriate referral to community and social support services
Meeting the ACA’s Requirements for Mental Health and Substance Use Disorder Care
The EHB must comply with the requirements of the ACA regarding parity and non-discrimination. Under the Mental Health Parity and Addiction Equity Act of 2008, coverage of mental health and substance use disorders may not be more restrictive than coverage of other medical/surgical benefits by the plans.
In addition, the requirement in the ACA that the Secretary shall ensure that health benefits established as essential not be subject to denial based on age, expected length of life, present or predicted disability, or quality of life has very significant implications for individuals with MH and/or SUD. This means that none of the categories of essential health benefits may result in discrimination with respect to children, adults, or elderly persons with severe mental illness or substance use disorders. This language is particularly relevant with respect to rehabilitation services and chronic disease management. Enforcement of these protections must be included among the highest priorities for implementation and ongoing administration of the ACA and in the development of New York State’s health insurance exchange.
MH and SUD services that reflect the latest and best available evidence-based or consensus-based practice should be included in the essential health benefit. Certain newer interventions and those that have not yet been fully researched show tremendous promise in helping people avoid disease, better comply with treatment, and sustain long-term recovery. The health insurance exchange and Medicaid benchmark plans should employ appropriate quality measures for MH and SUD services aimed at producing the best possible outcome for each individual. These measures should be used in performance-based payment plans.
Medical necessity must be defined using nationally accepted models to support parity and enforce the oversight of the benchmark options. Using nationally accepted tools to assess the need for services and to determine the appropriate level of care will increase the likelihood that service providers and payers are acting in the best interests of service consumers and their families.
The Coalition for Whole Health’s benefit recommendations are intended for implementation by all plans participating in New York’s health insurance exchange. Particularly for those individuals with serious chronic mental illness and substance use disorders, a comprehensive continuum of services is needed ranging from primary prevention, through early intervention and treatment, to recovery support services. The essential health benefit must include a continuum that ensures the complex web of health needs of these individuals will be addressed successfully. As recommended by the IOM, there should be a formal mechanism to ensure that individuals with substance use and/or mental health disorders and their family members are partners with care providers in designing and implementing service plans. Policies should be in place to implement informed, patient-centered participation and shared decision-making in prevention, treatment, illness self-management and recovery plans and strategies. Individuals and their families should be educated participants in the design, administration and delivery of prevention, treatment, rehabilitation, and recovery support services.
The ACA requires that the EHB package reflect balance among the ten broad benefit categories. While there is currently an unacceptably large treatment gap limiting access to behavioral healthcare in New York State, the NY Coalition for Whole Health is also concerned that people with MH and SUD also lack good coverage in all of the other ACA benefit categories. The EHB package as a whole should reflect an appropriate balance of services that ensures enrollees can access medically necessary primary and behavioral healthcare to avoid disease, become well, and maintain long-term wellness.
The EHB should be designed so that it can be updated at regular intervals to reflect new treatments and medications shown to be effective. Technology is changing and new drugs and treatment interventions are being introduced as new tools for MH and SUD care.
National healthcare reform presents us with a tremendous opportunity to improve public health, reduce costs, and ensure coverage and access to necessary care for all New Yorkers. With full implementation of the ACA in the health insurance exchange, New Yorkers with limited or no access to MH and/or SUD services will have coverage for these services, many for the first time. Inclusion of the range of effective MH and SUD prevention, treatment, rehabilitation, and recovery support services recommended by the Coalition for Whole Health will result in significant cost-savings to the healthcare system and ensure that New Yorkers lead healthy lives.