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.