No Clarity on “Essential Benefits” for Mental Illness & Addiction

Written by crchealthgroup   // November 14, 2011   // Comments Off


As seen in Open Minds.

The much-awaited release of the Institute of Medicine’s (IOM) Essential Health Benefits: Balancing Coverage and Cost, didn’t provide quite the clarity that consumers, professionals, and provider organization managers expected for what is considered ‘essential’ coverage of behavioral health treatment.

Since the passage of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAE) and its incorporation into The Patient Protection and Affordable Care Act of 2010 (PPACA) (see Health Reform Legislation Extends Behavioral Health Treatment Parity to All Health Plans), health care analysts expected the incorporation of a more expansive array of benefits for treatment of mental illnesses and addictions in the ‘essential benefit’ package. As a contribution to the IOM on this issue, a group of advocacy organizations submitted recommendations about this essential benefit package – Letter to HHS Recommending Essential Behavioral Health Benefits.

This letter is a joint recommendation submitted by a coalition of behavioral health industry advocacy groups to the federal government proposing the essential behavioral health benefits (EHB) to be included in commercial health insurance benchmark plans available through affordable health insurance exchanges as of 2014.

The IOM report took a different path, writing “The committee concluded that it was best to begin simply by defining the EHB package as reflecting the scope and design of packages offered by small employers today, modified to include the ten required categories. This package would then be assessed by criteria and a defined cost target recommended by the committee. The committee considered how four policy domains – economics, ethics, population-based heath, and evidence-based practice – could guide the Secretary in determining the EHB package in general. From these policy foundations, the committee recommends: criteria to guide the aggregate EHB package; criteria to guide specific EHB inclusions and exclusions; and criteria to guide methods for defining and updating the EHB.”

The concern, as explained in The New England Journal of Medicine’s Defining Essential Health Benefits – The View from the IOM Committee, has arisen from the recommendation “that the initial EHB package be equivalent in scope to what could be purchased by the average premium that a small business would pay on behalf of an employee.”

That may be fine for other areas of health care, but packages “offered by small employers today” are most often discriminatory to citizens with mental illnesses and addictive disorders. This non-recommendation certainly flies in the face of the parity legislation and, hopefully, will be resolved in future applications of the IOM recommendations.

by Kristen Hayes

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