Health Insurance Exchange Regs: Mental Health Coverage and 45 CFR Parts 155-156

The NPRM for the Health Insurance Exchanges portion (45 CFR Part 155 & 45 CFR Part 156) of the Affordable Care Act came out yesterday (thanks for the tip-off, +David Harlow). I quickly scanned it for specific mentions of standards related to mental health coverage. See below for relevant sections. (I'll look at Part 153 later.)

First impressions: it does encourage specific considerations for folks with mental illnesses and other disabilities be addressed, but I am so far (just based on the above) unimpressed with provisions ensuring parity for this population -- a population that was heavily marginalized and discriminated against during the managed care cycle from the 80s and 90s. I did not find a single reference to the Mental Health Parity Act (45 CFR Part 146), either. It also mentions the need for accurate provider directories, which are notoriously inaccurate in behavioral health. It encourages input about how to hold Exchanges accountable for accuracy, including indicating whether providers are accepting new patients.

[pg 30] According to section 1311(d)(6) of the Affordable Care Act, Exchanges are required to consult with certain groups of stakeholders as they establish their programs and throughout ongoing operations. We propose that the Exchange consult on an ongoing basis with key stakeholders, including:

• a. Educated health care consumers who are enrollees in QHPs; “educated” is the term used in Section 1311(d)(6)(A) of the Affordable Care Act to describe consumers who must be consulted. We recommend that Exchanges include in these consultations individuals with disabilities;
• b. Individuals and entities with experience in facilitating enrollment in health coverage;
• c. Advocates for enrolling hard-to-reach populations, which includes individuals with a mental health or substance abuse disorder. We also encourage Exchanges to include advocates for individuals with disabilities and those who need culturally and linguistically appropriate services;

[pg 44] In paragraph (e), we propose that the Exchange conduct outreach and education activities to educate consumers about the Exchange and to encourage participation, separate from the implementation of a Navigator program described in §155.210. Exchanges should aim to maximize enrollment of eligible individuals into QHPs to increase QHP participation and competition which in turn increases consumer choice and purchasing clout. This will also reduce the number of individuals without health insurance coverage. We encourage Exchanges to conduct outreach broadly as well as in ways that are accessible to people with disabilities,

individuals with low literacy, and those with limited English proficiency. In addition, we encourage Exchanges to target specific groups including hard to reach populations and populations that experience health disparities due to low literacy, race, color, national origin, or disability, including mental illnesses and substance use disorders.

[pg 186] §155.130 Stakeholder consultation.
The Exchange must regularly consult on an ongoing basis with the following
stakeholders:

• (a) Educated health care consumers who are enrollees in QHPs;
• (b) Individuals and entities with experience in facilitating enrollment in health coverage;
• (c) Advocates for enrolling hard to reach populations, which include individuals with a mental health or substance abuse disorder;
• (d) Small businesses and self-employed individuals;
• (e) State Medicaid and CHIP agencies;
• (f) Federally-recognized Tribes, as defined in the Federally Recognized Indian Tribe List Act of 1994, 25 USC §479a, that are located within such Exchange’s geographic area;
• (g) Public health experts;
• (h) Health care providers;
• (i) Large employers;
• (j) Health insurance issuers; and
• (k) Agents and brokers.

[pg 202] §155.430 Termination of coverage.

...

(c) Termination of coverage tracking and approval. The Exchange must –

• (1) Establish mandatory procedures for issuers of QHPs to maintain records of termination of coverage;
• (2) Track number of coverage terminations and submit that information to HHS on a monthly basis;
• (3) Establish standards for termination of coverage that require issuers of QHPs to provide reasonable accommodations to individuals with mental or cognitive conditions, including mental and substance use disorders, Alzheimer’s disease, and developmental disabilities before terminating coverage for such individuals; and
• (4) Retain records in order to facilitate audit functions.

Risks & Benefits of HIE's: "Sensitive" Health Information

[cross-posted from Shrink Rap]

I participate in a committee that establishes policies for our state's health information exchange (HIE). The HIE is the electronic infrastructure that permits hospitals, physician groups, labs, imaging companies, pharmacies, and others to share information about patients. The idea behind the sharing is to make it easier for your primary care doctor to share your health data (ideally, with your permission) with your cardiologist and your dermatologist. The potential benefits to this sharing include:

• quicker exchange of information than with faxing or mailing
• less likely for papers to get misfiled or lost (eg, think Hurricane Katrina)
• better tracking of who accessed what information
• less duplication of tests ("I know you had a CAT scan at the other hospital last week but I can't wait for the results to be sent to me so I'm getting another one.")
• improved coordination of care
• fewer medical errors due to more information available
• decreased liability due to sharing of important information with other providers

The potential risks include:

• decreased privacy due to potential for data breach, identity theft
• loss of data due to technical problems (viruses, hardware failure, etc)
• failure to secure data due to inadequate authentication, authorization, encryption, etc
• more errors in health record due to automated data collection processes
• increased liability due to sharing of sensitive information with other providers

I wanted to talk briefly about this notion of "sensitive health information." Our committee has spent many hours discussing what this might mean and how to define it. One view is that all health information should be treated as "sensitive," while another is that only certain categories of health information, such as mental illness, substance abuse, HIV status, domestic violence, abortion history, and genetic data, should be treated with additional safeguards against inadvertent access or disclosure. This latter viewpoint promotes the stigma about mental illness that we have been trying to erase. It wasn't so long ago that epilepsy and cancer might have been on this list. My viewpoint is that patients should be the one to decide which elements of their health information should be treated with extra precautions and which should be considered routine.

This was ultimately agreed upon by the other committee members, but it still didn't help us much because the technology for patients to review their health information and mark which bits should be tagged as sensitive is not yet built into nearly any of the electronic health record products or the HIE systems. There is no standard for doing so nor is there even any agreement about how or whether it should be done. Groups like healthdatarights.org and speakflower.org have promoted these ideals, but we are not much closer to achieving them.

Anyway, I discussed this topic in my Shrink Rap News blog post this week over on Clinical Psychiatry News. Read more about it over there. If you are a psychiatrist, log in or register on CPN and join the discussion (my mistake -- other professionals and also consumers are allowed to register over there).