The Affordable Care Act (ACA), signed into law in 2010, has provided millions of individuals with new health insurance coverage, including thousands of people with HIV. To explore what new ACA era coverage opportunities have meant for this population, we examined the coverage and enrollment experiences of people with HIV, by conducting focus groups with HIV positive individuals in five states (California, Florida, Georgia, New York, and Texas).¹  These focus groups were conducted after the end of the first open enrollment period and consisted of participants who enrolled in or attempted to enroll in private coverage through the marketplaces, those who enrolled in Medicaid as part of the expansion population, and those who remained uninsured, largely because they lived in a state that elected not to expand its Medicaid program.

In this brief, we report on findings from follow-up, one-on-one interviews conducted with a subset of twelve individuals from the focus groups to provide an in-depth look at how the ACA has affected them. The interviews that inform these profiles took place after the second round of open-enrollment, which ended in February 2015, to see how participants were faring with respect to their health and insurance coverage after two enrollment periods. Participants came from both states expanding their Medicaid programs and from states that have elected not to expand. Similarly, participants were from states relying on the federally facilitated marketplace as well as those running their own marketplaces. During the interviews, which lasted about one hour each, participants were asked to discuss their enrollment and coverage experiences, including whether they got new coverage, and how their HIV care was affected. Participants were also asked to describe the role that the Ryan White HIV/AIDS Program, the nation’s safety net for people with HIV who are uninsured and underinsured, played in their care.

While the experiences of each of the twelve individuals profiled in this report are unique, several key themes related to their health care and coverage in the ACA era emerge:

• First, the Ryan White HIV/AIDS Program is a linchpin in their lives, without which many feel their HIV care would be compromised. Most of those profiled had been uninsured for years before the ACA and were only able to get their HIV care through Ryan White, including accessing medications through its AIDS Drug Assistance Program. Today, for those in states that have not expanded Medicaid, Ryan White remains their primary vehicle for accessing HIV care and treatment. Ryan White also continues to support many who gained new coverage under the ACA, including by providing premium support to make insurance more affordable for those in private marketplace plans, through the provision of wrap-around services such as case management, and by offering assistance during gaps in coverage. Almost all talked about the critical role Ryan White plays in their HIV care.
• Second, among those who were able to get new coverage, either through Medicaid or in the marketplace, most said they were satisfied with their insurance but many faced enrollment or reenrollment/recertification challenges and delays. In some cases, these challenges caused individuals to fall temporarily out of care. In addition, some individuals had trouble selecting a plan that met their needs and chose coverage without fully understanding benefit designs- for instance not knowing whether a provider was in network. One individual chose a bronze plan because of the low premium but knew that he would not be able to use it unless he had an emergency because of the very high deductible.
• Third, knowledge of ACA coverage increased over time and systems got better. Several of those profiled reported improved experiences in the second open enrollment period compared with the first. A few individuals changed plans, finding new coverage that would work better for them and a couple of those profiled gained Ryan White premium support that they had not had in the past, making coverage more affordable.
• Finally, those with new coverage reported a tremendous sense of relief and feeling much more secure. In particular, some of the people profiled have complex and serious, non-HIV health complications and were able to meet these needs with either Medicaid or private coverage under the ACA, including getting physical therapy and pain management for a back injury and receiving mental health and substance use services. Conversely, those profiled who did not gain coverage, largely because they lived in non-expansion states and fell into the coverage gap, were left without coverage options under the ACA. While they were still able to meet their HIV care needs through the Ryan White Program, they were unable to address other health problems, which in some cases were very significant, including cancer and heart disease, issues that could potentially impact their HIV disease.  

The below table details the state and insurance coverage status (marketplace enrollee, Medicaid expansion enrollee, or uninsured) of the twelve individuals profiled in this report.

When taken regularly, antiretroviral therapy not only improves the health and longevity of people with HIV, it has also been shown to significantly reduce the risk of HIV transmission.²  For these reasons, current federal HIV treatment guidelines recommend initiation of ART as soon as one is diagnosed alongside regular care and monitoring.³  However, less than one third of people with HIV in the U.S. have an undetectable viral load and many more are not yet engaged or retained in care and treatment.⁴  Therefore, improving access to insurance coverage under the ACA could play an important role in bringing more HIV positive individuals into care and treatment and is one key component to further addressing the domestic epidemic.

While many provisions of the ACA have implications for people with HIV, two are expected to have the most far reaching effects on coverage – the expansion of Medicaid, in states that choose to expand, and the creation of health insurance marketplaces in each state where individuals can purchase private coverage, subsidized for those with low and moderate incomes. In addition, key insurance reforms in the private market, including the prohibition on rate setting tied to health status, elimination of preexisting condition exclusions, and end to life time and annual caps means that those with HIV and other chronic conditions have more equitable access to coverage.

While these reforms could have a profound impact on those who enroll in new coverage opportunities, not all people with HIV will gain insurance. Many with HIV live on both limited incomes and in states that have not elected to expand their Medicaid programs. Individuals in non-expansion states below the threshold to gain subsidies on the exchanges (100% of the federal poverty level) will find themselves in the coverage gap- ineligible for Medicaid as well as subsidies to help to purchase coverage in the marketplace. There are many other reasons why individuals may not have engaged with new coverage opportunities as well. For one, having public or private coverage may be new to some and enrollment and ability to navigate insurance may take time. Others, such as undocumented immigrants, are not eligible for coverage at all. In addition, even those who gain new coverage may still face barriers to paying for that coverage or may find that some HIV-related services they need are not covered.

It is for these reasons that the Ryan White HIV/AIDS Program has played and will continue to play a critical role in the lives of many with HIV. In addition to providing HIV care and treatment to those ineligible or unenrolled in coverage, including those in the coverage gap, the Ryan White Program, along with other- often industry lead- programs, is helping some clients with affordability by assisting with the cost of health insurance premiums and other out-of-pocket costs.⁵  In addition, the Ryan White Program may support those who have gained insurance access with certain types of services that are important for HIV care but remain unreimbursed under traditional coverage (e.g. Medicaid or private insurance), such as transportation and case management. The program can also provide consistency for those experiencing gaps in coverage and will continue to be the primary payer of care and treatment for those who have been left out of new coverage opportunities.

HIV Profiles: Valentine

New York, NY: Marketplace Enrollee

“I was saying that with the Obamacare I originally thought it was going to be something where it was going to be affordable, like for what I made, I was going to be able to afford it…like it wasn’t going to disrupt my life so to speak… And that wasn’t the case…At the end of the month, I literally probably have like $75 or $100 to get by with three kids until the next paycheck. So it’s hard. But what can you do?”

Valentine is a 34 year old African American woman living with her female partner. She works as an administrative assistant and is the mother to three children. She is living with HIV, the Epstein Barr Virus, rheumatoid arthritis, anemia and has battled cancer twice. In addition, her eldest son needs treatment for chronic asthma. Before the ACA, Valentine had coverage through an employer but lost that coverage and was uninsured for 8 months before finding out about new coverage available to her in the New York state marketplace. She learned about marketplace coverage after seeing a click advertisement in her e-mail during the first open enrollment period. However, she had a difficult time with the enrollment process which took her several months because her social security number was showing up as belonging to someone else and she felt the representatives at the call center were not helpful. Eventually, she worked through these challenges and qualified for a subsidy. She pays $672 a month for herself and her three children which she says is “doable” but challenging.

Valentine has been able to get her HIV treatment, which is in generic form, through her plan without a problem. She says that she knew her HIV drugs would be covered but not what the cost to her would be and she only learned her doctor was out-of-network when she called to make an appointment after enrolling and so had to change providers unexpectedly. She has faced the greatest difficulty meeting non-HIV care needs in the plan. Since enrolling she has faced several issues with her coverage and with unforeseen out-of-pocket costs, including being unable to fill two non-HIV prescriptions and overall, says she is not happy with her health insurance. She says her plan seemed like a good choice for her family and for her situation, but once she started to use her insurance for more than just basic check-ups, she encountered problems. She says her medical issues are “more than just a common cold” and feels her plan does not adequately cover her family’s health care needs and that her out-of-pocket expenses are more than they should be. She is currently dealing with medical debt, including bills for an EKG, medication, and blood work. In order to cope with these expenses, she talks about cutting back on things for herself so she can pay her bills and so her children do not go without.

“Certain things can be just patched up with $60, $70 you get medication and you’re good. But then when you have to have like chemotherapy or radiation where it’s thousands and thousands of dollars…And you’re fighting to live, but in order to fight to live, you also have to be able to afford to live. It sucks.”

Valentine says making her health a priority is important because her children depend on her and she knows she is living with a health condition that could kill her if she does not take care of herself. She feels like her life and her health depend on her keeping her insurance and says she would probably die without it. When she first heard about the Affordable Care Act, Valentine says she was excited, but now she feels let down – she thought health insurance was going to be more affordable and she now still feels coverage is lacking. She had not spoken to anyone about the possibility of receiving assistance from Ryan White to help with premiums and only learned of this possibility during the focus groups but plans to look into this program.

HIV Profiles: Jorge

Miami, FL: Marketplace Enrollee

“I talked to my case manager and he recommend me to change to [a new plan] because it was better for me and my doctors take that insurance. It was a little difficult to do the changes, but I’m now enrolled and I saw my doctor last week without a problem.”

Jorge is a nearly 50 year old Latino man who has been HIV positive since 2001. He lives with his husband in Miami. He is currently doing cleaning work; while he has a license to work security, he has been unable to find work in that field. Prior to the ACA, he received his HIV care through the Ryan White Program. In January 2014, Jorge enrolled in a marketplace plan through HealthCare.gov. He did this on his own which he says was a “difficult and traumatic experience” because of problems getting through the enrollment process and repeatedly having to provide additional verification documents. As a native Spanish speaker, he found it helpful to be able to seek assistance from the marketplace call center in that language. He selected a bronze level plan⁶  based on its low premium, $1.85 per month, knowing it had a $6,000 deductible. He knew that he would not be able to afford the full cost of routine HIV drug and medical care that would be required under the plan before hitting that deductible and viewed the policy as more of a safety net in case he had a real emergency. He hoped he would not have to use it and planned to continue getting his HIV care and treatment through Ryan White where he was comfortable. He also said that he enrolled in this plan to avoid paying the fine.

Because Jorge could not afford to use his plan, he received his HIV medications through the Ryan White AIDS Drug Assistance Program (ADAP) throughout 2014. In January 2015, Jorge’s case manager, who he has seen for the past six years at a local AIDS Service Organization, suggested he switch to a different health plan with a more affordable benefit design. Jorge says the process of switching plans was difficult – he had to cancel appointments with his doctor twice and called the new issuer several times before his new plan became active. Under his new plan his $600 a month premium is cut in half through subsidies and Jorge’s case manager helped him enroll in premium assistance through the state Ryan White Program which covers the remaining $300. He says enrolling in premium support was a little slow and required that he bring paperwork to his case manager who sent it on to another location in Miami. However, that seems to be sorted out and he has since seen his doctor of seven years, who was also in-network in his new plan, without a problem. He is now paying nothing out of pocket toward his monthly premium and pays $10 to see his primary care physician and $35 to see a specialist. He feels these costs are affordable and knew what they would be when he enrolled.

“I feel good with this [plan]. I think it’s a very good thing; Ryan White can help people with HIV like me. Because medication is very expensive. That premium is very expensive.”

Jorge has not yet used his new plan to fill a prescription because he is taking the medication he had previously received through ADAP. He says he has a few months left of medicine and has been told Ryan White will cover any out-of-pocket costs associated with his HIV medicine in the future. He hopes this will be a smooth process as he will begin accessing his medication through his new plan in the near future. Under his new plan he is excited to be switching from a three pill regimen to a once daily singlet-tablet-regimen. He will have to change pharmacies and use a mail-order service but he is pleased with this change and thinks it will work well for him.

For the most part, Jorge says he is in good health and generally able to get the care that he needs. However, he is currently putting off treatment for chronic migraines because in the past he could not afford the care. He says now that he has a plan with more manageable costs, he will look into finding a neurologist. He says having coverage makes him feel good and that the assistance he receives through Ryan White to cover his premiums is essential.

HIV Profiles: Eric

Los Angeles, CA: Marketplace Enrollee

“Getting my monthly premium paid by OA-HIPP is absolutely integral to my life at this point. My premium is over 300 dollars and without their help my finances would be dramatically affected in a negative way. What OA-HIPP is doing in their help is amazing.”

Eric is a gay Latino man living in Long Beach. He is in his late 20s working in the art and design industry and has been receiving HIV care at the same clinic for two years now. His preference is to see the nurse practitioner rather than the physician as he has a better relationship with her and feels as though “she really cares.” Prior to enrolling in ACA era coverage Eric relied on the Ryan White Program and ADAP for his HIV care and treatment but knew he would be out-of-pocket if he were to have an unforeseen emergency and end up in the hospital. In December 2013, he enrolled in a plan with platinum level coverage through Covered California (California’s health insurance marketplace) with the help of his case manager and was able to stay with his same clinic. He tried to educate himself on his coverage options under the law in advance and purposefully waited until the end of the open-enrollment hoping that any system bugs would be worked out when he enrolled.

His case manager helped him enroll in premium assistance through the state ADAP program’s Office of AIDS-Health Insurance Purchasing Program (OA-HIPP) which covers the cost of his insurance premiums in the marketplace. At first he had issues with payment delays and as a result his plan was not activated until March, three months after he first enrolled. During this time he was dis-enrolled and he had to re-enroll with OA-HIPP eventually overnighting payment after he received a warning from his plan in the mail. He describes the OA-HIPP premium payment process as frustrating and like “walking in the dark and really not knowing.” However, once his premium payments were sorted out, he says the rest of the year went smoothly.

“I’m thinking about changing pharmacies, but I’ll be quite honest, there is such a fear in me …I’m afraid that something could go wrong and just how I was stuck in the middle between two insurances, I could be stuck in the middle of two pharmacies where neither one is providing medications.”

During the second open enrollment period, Eric changed to a new plan because he was unhappy with his original coverage compared to insurance he had experience with in the past. During this second enrollment process he faced issues relating to payments again. He discovered that OA-HIPP had pre-paid his plan from the first enrollment period through the first three months of 2015 and could not send payments to his new plan until they were reimbursed the balance. He was told the fastest way to handle this would be to get reimbursed directly from the old plan and pay the new plan’s premiums himself with the rebate and that OA-HIPP premium payments would start when those funds were used up. He did this but Eric went without insurance for about a month during the transition to the new plan. Eric says going without insurance when he was between plans was not disruptive to his health because he did not need to go to his doctor during that time and ADAP covered his medications. This was a relief as he says his greatest fear is not having his medications paid for and describes ADAP as the “backbone” of his care. At the time of the interview, Eric was on his last month of insurance paid for with the rebate and was in the process of confirming whether OA-HIPP would be ready to pick up the premium bill going forward. Despite the hurdles he faced managing his premium payments, Eric says receiving assistance through OA-HIPP is essential to his life and his health and he is very grateful for it.

While Eric wishes that his cost-sharing for provider visits was lower, he says it is a relief to know that if he were to get sick or injured, he would be covered. He would also like to change pharmacies but is worried, based on his experience of trying to change health plans, that something in the process might go wrong and he would not be able to stay on treatment during the transition.

HIV Profiles: Maria

Atlanta, GA: Marketplace Enrollee

“When I signed up the first time I didn’t really ask the questions that I needed to ask. Like is my doctor going to be in network and all that because my doctor wasn’t in network. And then when I did try to change doctors the copay was so high that I couldn’t go see the doctor.”

Maria is a 36 year old African American woman who has been HIV positive for nearly 20 years. She has been uninsured and receiving care from a county health department clinic, since moving to Atlanta in 2004. She left work in social services last year to pursue an internship as a pre-requisite before beginning graduate school this fall. Maria enrolled in a silver level plan at the end of the first open enrollment period in April 2014. While Maria knew she would need to find a new doctor that accepted private insurance, she was surprised to learn that ADAP would no longer cover the cost of her medications. Soon after enrolling, Maria made an appointment with a new provider but found that the $60 office visit copay was too high. She had not thoroughly looked at the costs associated with accessing services when she selected the plan. As a result, she was hesitant to use her new coverage and put off going to the doctor. She also struggled to get her medications after she lost ADAP eligibility. While she had some medication to hold her over for a bit, she went without HIV medications for almost two months – she would have gone longer but was able to get two additional months’ worth of medication from her old doctor at the county clinic. Going without medication for that period had an immediate impact on her health – she went from having an undetectable viral load to having a significant amount of virus in her body and her T cell count fell by more than one third.

“It didn’t really feel good to not be able to go to the doctor when I needed to or not be able to get my medication…I can only imagine if I would have [gone] without meds for any longer what would have been the outcome. So you know it’s just a good feeling to be able to take care of myself.”

During the second enrollment period, Maria called the Marketplace to switch to a plan that was more affordable for her. She says she felt more informed her second time enrolling and knew what questions she should be asking, which allowed her to choose a plan that better suited her needs. She says, “I knew that I needed to be able to go to the doctor, I needed to pay the copay, I know I need my medications.” Under her new plan, Maria’s copay to see her doctor is $5 and her monthly premium is $52 with a subsidy. Since enrolling in this plan, Maria has started seeing a new HIV doctor at general care practice with an infectious disease sub-specialty and says she has established a strong relationship with both her doctor and the practice. She says that she knew the plan she selected had a narrow network but that she was okay with that so long as she could get the care that she needed. In addition, Maria’s case manager connected her with the Patient Access Network (PAN) Foundation, through which she receives financial assistance to cover the out-of-pocket costs associated with her HIV treatment. She says the second enrollment period and new plan has been a “much better experience.”

This summer Maria is moving to Tennessee to pursue her Master’s in Social Work. She says she plans to commute the couple of hours to see her current doctor until she enrolls in coverage in Tennessee. Staying insured is very important to Maria – she says that the Ryan White Program was wonderful for her when she was uninsured, but she feels better knowing that she can now also take care of non-HIV related health care needs.

HIV Profiles: Al

Dallas, TX: Marketplace Enrollee

“… I was in a horrible plan too. My deductible was like $6,600 to meet. And so I had to have like so many promotional discounts before I was able to get my first pill. So I literally sat in the pharmacy office for my first 30 day prescription for almost four hours just to get the 30 day pill selected just for HIV alone, for them to cover that because my deductible was so high.”

Al is a gay African American man and a recent college graduate in his late 20s. He learned he was HIV positive in April 2014 – one month after he first enrolled in new coverage in the marketplace. When Al first enrolled he chose a plan with a high deductible because he was unemployed at the time and thought it would best fit his budget. He says that the plan he chose did not meet the needs of someone with HIV given the very high deductible but he selected it because the premium seemed manageable. After learning his HIV status, Al worked with the county health services to sign up for a county based insurance assistance program that leverages Ryan White funds to help him with the costs associated with his HIV care. Al received $750 a month, which he put towards his monthly premiums and copays for doctor’s visits. He was also enrolled with a manufacturer’s copay assistance program that provided $5,000 a year to help with HIV medication costs. Al says the process of signing up for financial assistance took several months during which time he went without HIV medication. He also believes it was a slow process because he was the first client health services had helped with premium assistance. However, he was grateful to have the support and help navigating different assistance programs and once everything was in place, Al had no out of pocket expenses towards his health care.

“…I chose like five plans …and then I went to Health Care Services and asked them if there’s a preference on insurance that a lot of other HIV clients have…and they helped me narrow down…And so every company that I chose that had a book that told how much the medicine was going to be every month… So, that was very helpful.”

Then, in July 2014, Al got a job as an accountant and had the option of either getting health insurance through his employer or selecting a Marketplace plan for which his employer would cover a certain amount of the costs. Al did not want his employer to know his HIV status and was more comfortable with marketplace coverage. He had to wait until the end of the year to enroll but in the interim, he was able to remain covered with premium assistance through the county. In selecting a new plan, he wanted coverage that would best meet his HIV needs and after consulting with different enrollment workers selected a new plan in January 2015. His monthly premium is $153, but with his employer’s assistance, Al is responsible for just $1.50 a month. While his employer covers most of his monthly premium, health services continues to assist with office visit co-pays, which Al says would be manageable at $30, if he did not have the help. Under his new plan, Al’s HIV medication costs $2,000 a month which must be paid in full until he reaches his $3,400 deductible, but with help from the copay assistance program he does not have to pay anything out of pocket.

Tax time was a bit confusing for Al. He completed his taxes, including information about his coverage, and received notice that he was owed a refund related to his insurance but he was not sure what it meant or what he had to do. Al has tried to be in communication with the IRS without luck and is waiting on further follow-up.

Speaking broadly about insurance literacy, Al worries that young people graduate from college without knowing how to navigate the insurance world and wishes there was more education around this issue for them. As a recent grad himself, he notes that without the assistance from the county he would not have known how to get his own health care needs met.

HIV Profiles: John

Dallas, TX: Marketplace Enrollee

“[The non-profit where I get some assistance] told me, oh well if you want to keep the program where you’re reimbursed or Ryan White pays your insurance, you have to go back and change your coverage because you’re on the gold level and Ryan White will only cover individuals on a silver level…for the first year I elected no, I’ll pay my own insurance.”

John is a gay man who has been living with HIV since 2004. He is self-employed and had private insurance for several years prior to enrolling in a health plan through the marketplace. Before marketplace coverage became available, he received help paying his monthly premiums from a community based organization (CBO) using Ryan White funding for this purpose. He signed-up for a plan in the marketplace in February of 2014 through the same issuer with which he had previous coverage, leaving his off marketplace plan behind.⁷  Once gaining marketplace coverage, however, he lost Ryan White premium assistance because he signed up for a gold metal level plan with the aim of enrolling in more robust coverage. He was told that in order to continue receiving premium assistance, he had to change to a silver level plan but elected not to go through the “long fiasco” of having to reapply. In addition, he wanted to retain what he believed was more comprehensive coverage. For the first year he forwent premium assistance but paying the $400 a month premium out-of-pocket was sometimes a struggle for him.

When the time came for him to renew his plan during the second open enrollment period, John stuck with the gold level plan because he liked having a lower deductible and more comprehensive coverage. The CBO, however, had changed their policy and John was able to get premium assistance once again. Now, John is paying a total of about $65 out of pocket each month for his doctor’s visits and non-HIV medication copays and does not pay monthly premiums. John gets his HIV medication without having to pay anything out-of-pocket because his pharmacist helped him enroll in a copay assistance program with the drug maker. He paid his first month’s premium himself which he says helps ensure that the third party payments (from the CBO) get to the plan on time, and says that even if they are late, he is effectively paid a month in advance. This is important to him as he found getting his premium paid on time a challenge when he was receiving pre-ACA era premium assistance. John says access to premium assistance is very “significant” and allows him to use the money he saves to help pay down his debt.

“[It’s] worthwhile to have private insurance. Just because you feel like a normal [person], you get normal medical care where you walk in, you have a doctor’s appointment, you see your doctor, you’re doing what you’re supposed to do and then you leave.”

Without premium assistance John believes his coinsurance would be over $300 a month. He also was able to get his non-HIV prescription at a discounted rate negotiated through a website which he also learned about at his pharmacy, rather than directly through his plan. John goes to his psychiatrist twice a year to renew his non-HIV prescription and pays a $10 copay for each visit. He says he will probably look at different plans during the next open enrollment period, but that he is comfortable with his current plan and does not plan on switching.

When John filed his taxes this year he gave his accountant a 1095-A form detailing his policy and subsidy information that he received in the mail. He learned that because his income had gone up a few thousand dollars from what he had projected, he owed some money back to the IRS related to his subsidy which was a bit surprising to him but says dealing with the tax issues around marketplace coverage was not a problem.

HIV Profiles: Patrick (CA)

Los Angeles, CA: Medicaid Enrollee

“I was expected to renew in January because that’s when my year had ended, but not at the center where I had [initially enrolled in Medi-Cal], but at the Department of Social Services. I had no idea, I mean, why would I think that? And they didn’t really get proactive about communicating that and boom, people were dropping left and right from Medi-Cal.”

Patrick is a white man in his late 40s and has been living with HIV for over a decade. He was able to enroll in Medi-Cal (California’s Medicaid program) because the state expanded Medicaid eligibility as part of the ACA. Prior to enrolling in Medi-Cal, he had been enrolled in Healthy Way LA, Los Angeles’ pre-curser to the Medicaid expansion. As the program intended, he explained that this allowed him to easily transition into Medi-Cal in December 2013 (for 2014 coverage) with the help of his case manager.

He has faced some technical issues with the Medi-Cal program around renewals and has been dropped out of coverage twice since enrolling. On the first occasion, Patrick was briefly dropped from Medi-Cal in May 2014 because he did not know he had to renew on his birthday, but he was able to quickly reenroll after talking to someone at his clinic. After that, he did not experience interruptions in care until January 2015, when he was dropped from coverage a second time because he again failed to renew his plan. He says that he, along with many others at his clinic, were not aware they had to renew through the Department of Social Services. Many assumed renewals would be handled by the clinic where they receive care and case management and where they had initially enrolled in Medi-Cal. Patrick feels there was a lack of communication about renewals from both Medi-Cal and the clinic.

“I can go [into the doctor’s office] and tell them that I have a problem and they’ll get me a referral and I have to follow-through on it, but it’s all pretty amazing. Because it wasn’t always that way, the pain was pretty much there for a long time and, you know, I was lucky to get [Medi-Cal].”

Patrick also missed the re-enrollment deadline to continue with case management in early 2015 and he was kicked out of the clinic’s case management program. He was very frustrated and felt neglected by his case manager, especially because he felt these services would have been particularly helpful during the period when he lost coverage.

Patrick spent all of January without coverage, causing him to go without his HIV medications and without doctor’s visits. He found it worrying that the clinic did not seem to be able to help with his medications while he was uninsured. Without case management services he decided to re-enroll on his own. He explains that it took a lot effort to navigate the system but ultimately he was able to make an online appointment and go in person where he was re-enrolled with his plan after a 20-day activation period. He describes the month as “exhausting” and “overwhelming” and says he spent much of February recovering after getting sick and going almost a month without care.

Despite the issues he has faced around renewing and lapse in coverage, Patrick says having Medi-Cal has changed his life. He has been able to seek care for health issues that he had been putting off for years, including physical therapy and pain management for a back injury from being hit by a car two years ago. Patrick also receives mental health care through Medi-Cal from a nonprofit organization focused on the mental health and wellness of people living with HIV and AIDS. Additionally, he has been able to see an eye doctor and a dentist who specifically works with people with HIV. He says his future looks good and his experience having coverage through Medi-Cal has been “amazing” overall, despite the administrative challenges.

HIV Profiles: Nick (NY)

New York, NY: Medicaid Enrollee

“[Having Medicaid] feels good because I know that if I needed to do something or if there was an emergency that I have a plan that can cover it.”

Nick is an African American gay man in his mid-20s working as an actor and earning a limited income. He was first diagnosed with HIV in February of 2013. When first diagnosed he had insurance through his mother which he lost that summer upon turning 26. Nick first engaged in HIV care and started treatment 6 months after his diagnosis when he had become uninsured and had to rely on ADAP and Ryan White more generally. After urging from a social worker at his clinic, Nick signed up for a Medicaid managed care plan in March of 2014, which she helped him to select, pointing out that he could stay with them in-network, if he chose to. He signed up online at the LGBT Center with a counselor who was knowledgeable about his HIV status, which he says was helpful. The whole process only took him 15 minutes, and he faced no difficulties enrolling. His priority when choosing a plan was to be able to stay with his Ryan White funded clinic. Since gaining Medicaid coverage, Nick has been able to continue to receive care from his same provider and has been able to continue with his HIV medication at no cost. In addition, Nick receives substance use harm reduction services and attends support groups through a community-based organization that provides assistance for LGBT youth, services which are new to him since gaining coverage through Medicaid.

“Well my social worker explained to me that ADAP is basically like a Band-Aid. It doesn’t really cover all of the things but with Medicaid I’m able to cover support groups and other things like that that I couldn’t get [before].”

Nick says he has not had to pay anything out of pocket for care, including check-ups, dental visits, and HIV medication co-pays (he previously had a $3 copay but that has now been waived). The only issue he has faced since gaining coverage was a short delay in getting his medication when he switched to a mail order pharmacy service, which he opted to do for the convenience. At first the pharmacy was unable to fill his prescription because their system listed his Medicaid plan as inactive but he was able to rectify the situation over the course of two days with the help of his case manager and only went one day without his HIV medication. When this occurred his case manager reassured him that if there was going to be any significant gap, ADAP could step in to assist to ensure he was able to stay on treatment.

He says having Medicaid makes him feel more secure knowing that he has coverage in case something happens to him. He feels Medicaid offers him access to more comprehensive health care and he is more aware of the health care services that are available to him. He also says he is more mindful of his health needs now that he knows those services are available to him, if needed.

HIV Profiles: Patrick

New York, NY: Medicaid Enrollee

“Well now, I’m able to get my meds I’m able to see the doctor and it makes you feel good about yourself now. It makes you feel like you’re doing self-care and you’re taking care of yourself.”

Patrick is a gay 32 year old African American man living with his partner and working in criminal justice social services. He has been living with HIV for several years. In June of 2014, Patrick enrolled in New York state’s Medicaid expansion program, with the assistance of an enrollment specialist at New York City Human Resources Administration/ Department of Social Services who helped him select a Medicaid Managed Care plan. Prior to enrolling in Medicaid, Patrick was not regularly seeking out care and treatment; though when he did seek out HIV care, he received it from a community health center that specialized in providing care to New York’s LGBT population. With Medicaid, his main priority in selecting a plan was to ensure he had options for and flexibility in where he could go to receive care. He also wanted to ensure he could stay with his doctor at the community health center. Patrick says the clinic has a philosophy of the doctor staying with a patient and describes his doctor as the best thing in his life.

“… I went to the case manager and I’m not gonna sit here and lie to you; that’s complicated when you have to go through a book and have to look at different health insurances and different you know and it’s like okay; wait, wait, wait, wait, wait I just need health insurance.”

Overall, Patrick has had a positive experience with the care he receives under Medicaid, but he faced challenges with enrollment. He wishes that the process for enrolling were simpler and more straightforward; he also found plan selection complicated. He says it took him forty-five days to get coverage, during which time he went without his HIV medication and doctor’s visits. Patrick says he is very happy with his Medicaid plan and the care and treatment he receives related to his HIV needs, particularly not having to pay out-of-pocket for care. He says he is able to make doctor’s appointments when he needs them. Patrick had been paying a co-payment for his HIV medication at the pharmacy at his clinic, but he recently switched to another mainstream pharmacy, which is closer to home, and where his copay is waived. Additionally, the new pharmacy has a pharmacist with whom Patrick has developed a good relationship and who he describes as a counselor, explaining he can go to him with general questions about health and nutrition. He says the pharmacy makes “life easier for you” and appreciates that they will call to remind him when his medication is running low and will get refills approved on his behalf. Patrick has also been able to take care of non-HIV care needs through Medicaid and recently went to the podiatrist – he needs foot surgery and was pleased when his plan approved it right away.

Despite his overall satisfaction, Patrick faced an issue recertifying for Medicaid coverage. In October, when he went to an appointment at his clinic, the billing department told him that his card was showing he was no longer enrolled in Medicaid when it was scanned. They followed-up for him and learned that he had been terminated as he had not recertified. In order to resolve this he had to go through a fair hearing process, waiting until December for a hearing date. At the hearing he learned that he had been marked as homeless when he first enrolled in Medicaid (despite the fact that he was not and as a result he never received a recertification letter). He was able to demonstrate that he had resided in the same place for the past three years and that the error must have occurred at the agency end. After explaining his situation at the hearing, he was quickly reinstated but leading up to that time, he went without care.

HIV Profiles: Zena

Miami, FL: Uninsured

“[Being uninsured] is very stressful because you know when it comes down to going to the doctor or trying to get medication, that’s a really hard thing to do because if you don’t have insurance you can’t get medicine, and that’s driving me crazy because it’s stuff that I need and I sit and I cry because I can’t get it.”

Zena is a 47 year old African American woman, a mother and a grandmother. She has been uninsured for most of her life. While her HIV disease is well managed due to care she receives through the Ryan White program, she currently is not working due to her many non-HIV health problems and stress level. During the first open-enrollment period case managers encouraged Zena to enroll in marketplace coverage. She was frustrated by the process and ultimately did not enroll because she found it confusing and knew she would not be able to afford coverage. Nobody explained to her that she fell into the coverage gap because she lived in a non-expansion state.

Zena receives her HIV health care through Ryan White, including her medications and visits to an HIV specialist. She says without Ryan White she would not be able to afford her $800 a month medication and says that “It would go bad, it would really go bad. I probably would be so sick I’d die, just honestly I would die because if you don’t have your medication, your T cells, your viral loads, everything drops and if you get sick, you’re in the hospital with pneumonia or whatever else and you die.” Despite this, when it comes time to recertifying her Ryan White eligibility, she sometimes struggles to wade through the “red tape” and recertify on-time and keep up with her medication consistently. She says that sometimes there is a delay and she ends up stretching out dosing while she waits for her new prescription; she worries about the impact that this could have on her viral load and her health. Still, while meeting her other healthcare needs presents very real challenges, Zena says that it is a relief to know that at the very least she will have her HIV needs met.

“I’m back and forth in the emergency room, you know … they’ll give you a little medicine and you take that, and then you come back home and you still sick, you know not leaving the house, not getting out of my bed, just sick. I mean it wasn’t nothing I could do about it because I don’t have any insurance, I don’t have money, so I just do without.”

Zena says she is unable to take care of her non-HIV health care needs and is living in pain. She has been trying to manage her worsening health without insurance, which she says has adversely affected her health and by extension her ability to find work. She says being uninsured is very stressful and that she is often sick with her various health issues, sometimes ending up in the ER where care and treatment is short-lived.

She is putting off surgery on her knee, treatment for chronic back pain, getting a machine to assist with her breathing difficulties, as well as regular blood pressure treatment, and dental and vision care because of the costs involved. In addition, she is a breast cancer survivor and in February, Zena had a surgery for cervical cancer, and is now receiving bills she cannot pay, adding to her existing medical debt of over $10,000. She has been putting off follow-up care, including radiation and chemotherapy, and gets an over the counter treatment rather than the costly prescription drug she is prescribed. She is only sometimes able to get her medications filled for pain management and blood pressure because she hates to ask her children for help and finds it difficult to pay on her own.

Zena filed a disability application over a year ago but is told only that it is in process when she follows-up and her case manager tells her she must continue to wait. She is hopeful that once approved, she will be able to gain public insurance. She says getting insurance would “mean the world to her.” Zena wants to have control over which doctor she goes to and be seen by the doctor right away, rather than sitting for hours in the waiting room as she does now. She wants to get the care and treatment she needs. She feels the ACA was first conceived for people like her, but now feels left out and forgotten.

HIV Profiles: Shandora

Atlanta, GA: Uninsured

“Certain areas of my health I’m neglecting because I’m not insured… I may need a knee replacement, and financially I don’t have the ends to do that right now, because I’m not insured, Ryan White does not cover orthopedic care.”

Shandora is a 50 year old African American woman who has was diagnosed with HIV more than 25 years ago, in 1989. She has been uninsured for thirty years. She explains that, in part, she has been uninsured due to a battle with drug and alcohol addiction that made seeking coverage in the past impossible. She started receiving HIV treatment in 1996 but was in and out of care as she battled substance use. Today, she has been in recovery for more than seven years and for the last six has been in HIV care consistently since moving to Atlanta. She says she is in “an extremely good place” right now. Still, she has been unable to get coverage, primarily because she earns only a limited income as a server in a restaurant and she can’t afford it.

To obtain her HIV care, Shandora has been using a city university hospital’s Infectious Disease Program supported by Ryan White and gets her HIV medication at no cost through ADAP. The Ryan White Program covers the cost of her healthcare costs related to HIV, including visits with her primary doctor – who is an HIV specialist. She says she has a good relationship with her doctor, which is important to her because her doctor can make personalized recommendations for her. She now takes just two pills a day – her HIV medication and a water pill for high blood pressure – which is down from more than twenty pills she was previously taking daily.

In addition, for the past eighteen months, Shandora has been in a residential living program that provides housing to HIV positive low-income people who are at risk of becoming homeless. She describes this program as “the best thing that could ever happen to [her].”                                                                                    

“[Getting insurance] would give me a sense of relief because I wouldn’t be hesitant about going to the doctor if there’s anything that I need to have checked out, because I know I’m covered. And now, just with Ryan White I feel limited because I can’t afford just to go to a doctor when I feel like something is going wrong, other than dealing with my HIV.”

Shandora tried to get coverage through the Marketplace last spring, with the help of a case manager at her residential program but later, at her clinic, learned her income was too low to receive assistance– she fell into the coverage gap, so she did not apply for coverage. She was relieved to learn that she would not have to pay the penalty, but wants the security that having insurance would offer. However, she also admits that she is afraid of what getting coverage would mean for the assistance she receives through Ryan White which she has come to rely on and she says that it is keeping her alive.

While she is managing without insurance, Shandora says being uninsured makes her feel limited and afraid – there is care that she needs but is not seeking because of costs, including dental and vision care, which are important for helping to manage HIV disease. She also needs orthopedic surgery. She has also been putting off a knee replacement for over a year, describing the pain as “unbearable” and tells of several falls at work when her knee has given out, yet she is not pursuing treatment because she is without insurance coverage and fears large medical bills. She has an outstanding bill of a few hundred dollars from a sonogram that she is unable to pay and worries about the impact on her credit, which she is trying to restore.

HIV Profiles: Darin

Dallas, TX: Uninsured

“They told me I had to make a certain amount and that I didn’t qualify because of the amount that I was making. So it was a little confusing because I really didn’t understand what the whole health care plan was…I thought it was supposed to be for lower income, but it wasn’t …because they said I didn’t make enough.”

Darin, who is 50 years old, has been mostly uninsured since 2009 when he relocated to Texas from another state and lost employer coverage, an experience which he describes as stressful. He briefly signed up for a health plan through HealthCare.gov in March 2014 before learning that he fell into the coverage gap and that, as a result, he would not be able to receive subsidized premiums through the marketplace or help paying his premiums from an AIDS Service Organization (ASO). Darin could not afford his premiums without assistance so let his plan lapse after just two months. He described the enrollment process and loss of coverage as frustrating and confusing and he remains unsure as to why he does not qualify for assistance, because the eligibility requirements were not explained to him. He says he feels like he has limited options to access health care without insurance. He feels aggravated since he will sometimes be denied care at county hospitals because his income is too high but makes too little to qualify for subsidies in the marketplace. He says, “one place is telling me I don’t make enough and another is saying I make too much.”

In the meantime, Darin is receiving assistance for his HIV needs through the Ryan White Program at an ASO, including medications, lab work, and doctors’ visits. He describes his physical health, including being HIV positive, as “very strong” and says the providers he sees are extremely knowledgeable about HIV. He says without Ryan White “my health would definitely diminish because that would cut off my medications and if I can’t get my medications then my systems, the HIV would take over because I need those medications to keep my system up.” With the assistance he receives, he says he never misses taking his HIV medicine.

While his HIV care needs are met through Ryan White, Darin says he is putting off a visit to the cardiologist for his heart condition which is a problem because he recently ran out of medication and cannot get a new prescription without seeing this provider. He says the heart medication itself is affordable, at just $20 a month, but is inaccessible because he cannot afford the $200 office fee to see his cardiologist to get a prescription refill. He says he is trying to manage without his heart medicine by eating right, exercising, and taking fish oil and aspirin, but is afraid of what might happen if he goes too long without it. Darin had a heart attack in 2013 and now has $15,000 in medical bills that he has no way of paying. Aside from his physical health, he says his mental health has been a “little rocky” but he is able to get mental health services and medications through a publically funded program providing these services to low-income Texans.

“[Being insured] would take away a lot of stress because I do stress over it and I worry about if I get sick what’s gonna happen. And so it would have a sense of relief for me where I didn’t have to worry about if I get sick or if something came up that…or, if heaven forbid, I had another heart attack or something. So it would be a major relief. Because if I get sick, I can just go in and give them my insurance card and be done with it.”

In November 2014 Darin enrolled in Supplemental Security Income (SSI) benefits but, at the time of this interview, had not heard from his case manager about how this might impact his eligibility for public insurance. He had thought, based on hearsay, that he may have a two year waiting period.⁸  He plans to follow-up on his eligibility.

Having insurance would give Darin a sense of relief and take away a lot of the stress in his life. He says he feels uneasy being uninsured because of the uncertainty of what might happen to him if he gets sick. He says he would be “ecstatic” if Texas expanded its Medicaid program and he was able to get coverage. He wants to be able to take better care of himself and get the care that he needs.

1. Kates, J, Dawson, L., Undem, T., and Perry, K. Kaiser Family Foundation. Under the Affordable Care Act: Experiences in Five States. 2014. Available at: https://modern.kff.org/hivaids/issue-brief/health-insurance-coverage-for-people-with-hiv-under-the-affordable-care-act-experiences-in-five-states/ ↩︎
2. Myron S. Cohen, et al. “Prevention of HIV-1 Infection with Early Antiretroviral Therapy.” New England Journal of Medicine. 365(2011):493-505. ↩︎
3. Department of Health and Human Services, Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in HIV-1-infected Adults and Adolescents. April 8, 2015;. Accessed 5/4/15. at: http://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/0. ↩︎
4. Heather Bradley, et al. Centers for Disease Control and Prevention. “Vital Signs: HIV Diagnosis, Care, and Treatment Among Persons Living with HIV — United States, 2011.” Morbidity and Mortality Weekly Report.63(47);1113-1117. November 28, 2014. ↩︎
5. For a discussion of the role The Ryan White Program plays in insurance purchasing see: Cite insurance purchasing brief ↩︎
6. Marketplace plans are grouped into different metal levels- platinum, gold, silver and bronze- each is associated with an actuarial value (a percentage representing the share of costs a plan would cover for a typical enrollee). Typically platinum offer the most generous coverage and bronze the least, with gold and silver plans falling in between. ↩︎
7. Marketplace plans are those health plans sold on the health insurance marketplaces set up by the federal government and some states. Most individual non-marketplace plans now have the same protections as marketplace plans but only those plans selected through the marketplaces afford access to the health insurance subsidies available to those 100-400% of the federal poverty level. ↩︎
8. There is no waiting period for enrolling in Medicaid through an SSI pathway but there is two year waiting period for those enrolling in Medicare based on SSDI eligibility. This information was provided to the respondent after the interview. ↩︎

Medicaid plays a key role in financing behavioral health care, including mental health and substance use disorder services. As of 2014, many previously uninsured adults are newly eligible for Medicaid in states that choose to implement the Affordable Care Act’s (ACA) coverage expansion or for subsidized coverage through a Marketplace qualified health plan (QHP). People with behavioral health diagnoses will need clear information about which services specifically are and are not covered to make meaningful comparisons among plans when shopping for coverage.

This issue brief analyzes specific specialty behavioral health services covered by state Medicaid programs and Marketplace QHPs in four states: Arizona, Colorado, Connecticut, and Michigan. We analyzed a total of 8 Medicaid program benefit packages and 105 Marketplace QHPs. We identify similarities and differences in Medicaid and Marketplace coverage of behavioral health services across the four study states as well as similarities and differences in behavioral health coverage between Medicaid and Marketplace QHPs generally within each state and between different QHPs within each state.

Key findings are summarized in Executive Summary Table 1 and include the following:

• While a large portion of the behavioral health services in this analysis are covered by both state Medicaid programs and Marketplace QHPs, Medicaid coverage of these services is generally more comprehensive than QHPs. Overall, Medicaid coverage of specialty behavioral health services in the four study states is very comprehensive, even though particular services may not be covered by every state’s Medicaid program. For example, all four states’ Medicaid programs covered psychiatric hospital visits, case management, day treatment, psychosocial rehabilitation, psychiatric evaluation, psychiatric testing, medication management, individual therapy, group therapy, family therapy, inpatient detoxification, methadone maintenance, and smoking and tobacco cessation services. By contrast, the only services covered by all Marketplace QHPs in the 4 study states were psychiatric hospital visits and smoking and tobacco cessation services. No QHPs covered psychosocial rehabilitation or adult group home services (the latter are covered by 2 states’ Medicaid programs).
• Medicaid coverage of behavioral health services for newly eligible adults in the four study states generally aligns with coverage for other Medicaid beneficiaries. Behavioral health coverage is comparable – mostly by state design – for beneficiaries eligible for traditional Medicaid and those newly eligible under the ACA’s Medicaid expansion.
• Marketplace QHPs in the four study states provide behavioral health coverage but are generally less clear about the specific services covered as compared to Medicaid. Across the four study states, Marketplaces QHPs explicitly cover many specialty behavioral health services, but QHPs provide general coverage statements rather than an exhaustive list of covered services. In addition, QHPs are silent about coverage for a number of specialty behavioral health services, and several QHPs exclude or limit important behavioral health services, such as residential treatment, treatment of chronic conditions, and substance use disorder medication management.
• Coverage of behavioral health services in Marketplace QHPs in the four study states varies by insurer, but this coverage does not vary by metal tier in QHPs offered by a given insurer within a state’s Marketplace.

Looking Ahead

The information presented in this analysis can help insurance shoppers, particularly those eligible for Marketplace QHPs and those transitioning between Medicaid and Marketplace coverage, and policymakers to better understand the scope of coverage and information available when choosing plans. It will be important to monitor coverage of specialty behavioral health services in QHP plan documents and in the actual experience of plan enrollees seeking services as well as the impact on consumers who move from Medicaid to Marketplace coverage as their income increases in terms of their ability to access necessary specialty behavioral health services and any gaps in access to needed services on which beneficiaries rely to support their recovery and ability to work. The relative newness of the Marketplace QHP coverage option, coupled with a lack of information in QHP documents about coverage of specific services, increases the potential for confusion or misunderstanding about the scope of benefits available for adults with behavioral health needs. This may be especially important as this population needs certain specialty behavioral health services that historically have not been covered by typical private insurance plans. More QHPs than noted in our analysis may in fact cover certain services, but the lack of explicit coverage statements in publicly available plan documents in many cases made it difficult to determine whether a specific service was or was not covered. As policymakers and beneficiaries gain more experience with the new ACA coverage options, further study in this area could examine questions such as the extent of behavioral health needs among newly eligible Medicaid adults and QHP enrollees, which behavioral health services are used by these populations, and the impact of cost-sharing obligations on access to necessary services.

Behavioral health encompasses both mental illnesses and substance use disorders. In 2013, an estimated 10 million adults (or 4.2 percent of all adults) had a mental illness that seriously impaired their functioning (serious mental illness, SMI),¹  and an estimated 20.3 million adults (8.5 percent) had a substance use disorder involving alcohol or illicit drugs in the past year.²  There is some overlap between these groups, with 2.3 million adults (23.1 percent of adults with SMI in the past year) experiencing SMI co-occurring with a substance use disorder.³  SMI includes a range of conditions, such as anxiety disorders, bipolar disorder, major depression, schizophrenia, and post-traumatic stress disorder.

Medicaid plays a key role in financing behavioral health services, accounting for 26% of spending on behavioral health care nationally.⁴  Examples of behavioral health services include psychotherapy, prescription drugs, day treatment, case management, crisis intervention, peer support, assertive community treatment, and supported employment. Prior to the implementation of the Affordable Care Act’s (ACA) coverage expansion, in 2009, 35 percent of non-elderly adult Medicaid beneficiaries had a chronic behavioral health condition, likely reflecting Medicaid eligibility rules that extend coverage to people with substantial health needs.⁵ 

However, not all adults with behavioral health diagnoses receive treatment services. In 2013, 11 million adults (4.6 percent of all adults) reported an unmet need for mental health care in the past year, with 5.1 million of these adults receiving no mental health services during that time. Of these 5.1 million adults, the most common reason cited for foregoing services was the inability to afford the cost.⁶  Also in 2013, 22.7 million persons aged 12 or older needed treatment for an illicit drug or alcohol use problem (8.6 percent of persons aged 12 or older). Of these individuals, 20.2 million persons (7.7 percent of the population aged 12 or older) needed treatment for an illicit drug or alcohol use problem but did not receive treatment in the past year. The most common reason cited for not receiving substance use treatment was no health care coverage and inability to afford cost of the treatment.⁷ 

People may be unable to afford the cost of health care because they are uninsured. While lower than the prevalence among Medicaid beneficiaries, a sizeable share — 13 percent — of low-income non-elderly uninsured adults had a chronic behavioral health condition in 2009.⁸  The actual rate of behavioral health conditions among uninsured adults may be even higher, as this population is more likely than those with coverage to have undiagnosed chronic illnesses.⁹ 

As of 2014, many previously uninsured adults may be newly eligible for Medicaid in states that choose to implement the ACA’s coverage expansion or for subsidized coverage through a qualified health plan (QHP) in the Marketplace.¹⁰  As additional people become insured under the ACA, policymakers and other stakeholders can be helped by a better understanding of the benefits and challenges that adults with behavioral health needs are likely to experience when applying for coverage through Medicaid, selecting an individual plan on the Marketplace, or moving between Medicaid and Marketplace coverage as their income changes. People with behavioral health diagnoses will need clear information about which services specifically are and are not covered to make meaningful comparisons among plans when shopping for coverage.

This issue brief analyzes specific specialty behavioral health services covered by state Medicaid programs (including the benefit packages for adults newly eligible for Medicaid under the ACA’s expansion) and Marketplace QHPs in four states: Arizona, Colorado, Connecticut, and Michigan. We identify similarities and differences in Medicaid and QHP coverage of behavioral health services across these states as well as similarities and differences in behavioral health coverage between Medicaid and QHPs generally and between different QHPs within each state. Detailed coverage information for all plans analyzed in each study state is included in Appendix A, and Appendix B provides brief background about each state’s Medicaid program.

Medicaid Behavioral Health Services

Behavioral health benefits are not a specifically enumerated service required to be provided by states to adult¹¹  Medicaid beneficiaries under the state plan benefit package.¹²  Nevertheless, states can and do cover behavioral health services under various mandatory and optional Medicaid state plan benefit categories, such as inpatient, outpatient, physician, other licensed practitioner, federally qualified health center, pharmacy, clinic, case management, and health home services.¹³  (Due to a long-standing payment exclusion in federal law, Medicaid reimbursement is unavailable for inpatient services provided in “institutions for mental disease” (IMD) for adults ages 22-64.¹⁴ ) Medicaid’s rehabilitation services option is a major source of behavioral health coverage, with all states offering some amount of behavioral health services through this state plan category as of 2013.¹⁵  In FY 2011, 78% of beneficiaries receiving Medicaid rehabilitation services had a mental health diagnosis, and 76% of spending for Medicaid rehabilitation services was devoted to those with a mental health diagnosis.¹⁶ 

Adults newly eligible for Medicaid under the ACA’s expansion must receive an alternative benefit plan (ABP), which, at state option, may or may not include all of the services covered by the traditional Medicaid state plan benefit package.¹⁷  ABP coverage is based on a commercial health insurance plan or otherwise approved by the Health and Human Services Secretary. Unlike Medicaid state plan benefit packages, ABPs must cover all of the ACA’s essential health benefits, including behavioral health services.¹⁸  Beneficiaries who are “medically frail,” including newly eligible adults, are exempt from mandatory ABP enrollment and instead must have access to the full Medicaid state plan benefit package, to the extent that it differs from the new adult ABP; however, medically frail beneficiaries may choose to enroll in the ABP.¹⁹  The federal definition of “medically frail” includes “individuals with disabling mental disorders (including. . . adults with serious mental illness) [and] individuals with chronic substance use disorders.”²⁰  Many states are offering their traditional Medicaid state plan benefit package to newly eligible adults to avoid having to determine which new adults qualify as medically frail.²¹ 

States provide behavioral health services either through a fee-for-service (FFS) or managed care delivery system. If beneficiaries are required to enroll in capitated managed care, they generally must have a choice of at least two managed care organizations (MCOs). States also may carve-out behavioral health services (beyond simple physician services) to a specialty behavioral health managed care entity. For example, in our analysis, Arizona, Colorado, and Michigan use pre-paid inpatient health plans (PIHPs) to deliver specialty behavioral health services on a capitated basis (see Appendix B for additional detail).

The ACA requires that Medicaid ABPs provide behavioral health services in parity with physical health services, consistent with the Mental Health Parity and Addiction Equity Act.²²  Specifically, quantitative treatment limitations, cost-sharing obligations, medical necessity criteria, and out-of-network coverage standards for behavioral health benefits must be no more restrictive than those for medical/surgical benefits when both types of services are covered by a health plan. Current federal mental health parity requirements apply to Medicaid MCOs and to Medicaid ABPs but not to other Medicaid services delivered on a FFS basis. Previously, CMS had encouraged, but not required, states to apply mental health parity to PIHPs and PAHPs.²³  In proposed regulations issued in April 2015, CMS would require parity for state Medicaid programs’ MCO enrollees, across all delivery systems that provide services to MCO enrollees, including PIHPs, PAHPs, and FFS. CMS also proposed regulations to implement parity for ABP enrollees, regardless of delivery system.²⁴  CMS continues to encourage, but not require, parity in FFS benefits that are not delivered to MCO or ABP enrollees. Consequently, there may be different utilization limits or other restrictions on services that affect parity depending on the type of delivery system through which services are provided.

Marketplace Behavioral Health Services

The ACA provided for the creation of Marketplaces to facilitate the purchase of QHPs by individuals and small businesses. The Marketplace in each state may be operated by the state or the federal government or in partnership between the state and federal government. Marketplaces allow consumers to compare and shop for health plans and are the mechanism through which premium tax credits (for people with income from 100-400% of the federal poverty level (FPL), $11,770-$47,080 per year for an individual in 2015) and cost-sharing reductions (for people with income from 100-250% FPL, $11,770-29,425 per year for an individual in 2015) (for silver-level plans) are administered. (People with income between 100-138% FPL ($11,770-$16,243 per year for an individual in 2015) who qualify for Medicaid are ineligible for Marketplace subsidies.)

Behavioral health services are one of the ACA’s 10 categories of essential health benefits and thus must be included in QHP benefit packages.²⁵  (EHB requirements also apply to health plans sold in the individual and small group markets outside the Marketplace.) Federal regulations require the selection of a benchmark plan to define EHBs in each state and to which a QHP’s covered benefits must be substantially equivalent.²⁶  States had the option to select a benchmark plan from among the largest small-group plan by enrollment, one of the three largest health plans offered to state employees, one of the three largest federal employee health plans, or the health maintenance organization with the largest commercial non-Medicaid enrollment in the state.²⁷  If states did not make a selection, the benchmark plan defaulted to the largest small group plan. States have broad leeway to further define the scope of services required to be covered by QHPs. In addition, federal mental health parity requirements (described above) apply to all QHPs.²⁸ 

 

This project analyzed specific specialty behavioral health services available in state Medicaid programs and Marketplace QHPs in the individual market in four states: Arizona, Colorado, Connecticut, and Michigan. (Our analysis excludes small-group policies available on the Marketplaces.) These four states represent various geographic regions of the country and span the variety of Marketplace models, including State-based Marketplaces (Colorado and Connecticut), Federally-facilitated Marketplace (Arizona), and state Partnership Marketplace (Michigan). All four states have expanded Medicaid to newly eligible adults under the ACA (with Michigan’s expansion effective in April 2014). Additional detail about the methodology is provided at the end of this brief.

We examined particular specialty behavioral health services in the four study states as these are the services that adults with behavioral health needs are most likely to require, and these services may vary by coverage type (Medicaid vs. Marketplace) and among QHPs, may differ by plan or insurer. They include services that are specifically designed to treat behavioral health conditions; providers in this sector include physicians, such as psychiatrists, and non-physician mental health providers, such as psychologists, social workers, counselors, and psychiatric nurses.²⁹  We did not focus on general service categories that have overlap between physical and behavioral health care (e.g., physician services, prescription drugs, home health services) and that may be provided by non-mental health providers, such as primary care physicians. We analyzed each state’s Medicaid program and 105 Marketplace QHPs. We examined benefits information to determine similarities and differences in behavioral health services coverage in Medicaid and the Marketplace across the four states. We also identified similarities and differences in specialty behavioral health services within a given state, both between Medicaid and Marketplace QHPs generally and between different QHPs offered in a given state’s Marketplace. Our findings are illustrative of the similarities and differences in behavioral health coverage across and within states, and specifics in other states will vary. Our analysis does not focus on any utilization limitations on coverage of specific services or on any required cost-sharing, which particularly for QHPs, may limit access to services even if services are covered.

The four states in this analysis all provide behavioral health services to all Medicaid beneficiaries (including newly eligible adults), although the particular services offered differed across the states. In states that have not opted to align their new adult ABP with their Medicaid state plan benefit package, there may be differences in specific services covered depending on the beneficiary’s Medicaid coverage pathway.³⁰ 

Our analysis classifies adult specialty behavioral health services into four categories: institutional and intensive services, outpatient facility services, outpatient provider services, and substance use disorder treatment services. Numerous discrete behavioral health services are mapped to these four categories, as listed in Table 1.

 

Medicaid Coverage of Behavioral Health Services

Overall, Medicaid coverage of specialty behavioral health services in the four study states is very comprehensive, even though particular services may not be covered by every state. (This observation refers to a state’s overall Medicaid program, without distinguishing the particular delivery system in which one system for part of a state’s Medicaid population, such as a PIHP, may cover one service listed here, while another system for another segment of the population, such as FFS, may not.) Medicaid benefits are largely determined by state policy choices as outlined in the state’s Medicaid plan, within the minimum requirements provided in federal law. In the institutional care and intensive services category, all four states covered psychiatric inpatient hospital visits (in non-IMD settings for most adults), and three states (all but Michigan) covered psychiatric residential services. Connecticut and Michigan allowed for 23-hour observation, and Arizona and Connecticut covered adult group home services. Most states covered the majority of outpatient facility services (e.g., case management, day treatment, psychosocial rehabilitation, partial hospitalization), although it appears that Arizona does not cover two particular relatively common services in this category: partial hospitalization and intensive outpatient mental health services. All four states covered all of the outpatient provider services (e.g., individual and family therapy, psychiatric testing) in our analysis. In the substance use disorder treatment category, all four states covered inpatient detoxification, methadone maintenance, and smoking and tobacco cessation services. However, Arizona did not explicitly cover outpatient detoxification or Suboxone treatment, and Colorado did not explicitly cover residential rehabilitation or chemical dependency intensive outpatient services.

All four states covered the following services in their Medicaid programs:

• Psychiatric hospital visits
• Case management services
• Day treatment (community behavioral health program)
• Psychosocial rehabilitation
• Psychiatric services – evaluation and testing
• Medication evaluation, prescription and management
• Psychological testing
• Individual, group and family therapy
• Inpatient detoxification
• Methadone maintenance
• Smoking and tobacco use cessation counseling.

These findings are summarized in Table 2 below and state-specific coverage details are included in the tables in Appendix A.

Behavioral health coverage is comparable – mostly by state design – for beneficiaries eligible for traditional Medicaid and those newly eligible under the ACA’s Medicaid expansion. The four study states chose to align their traditional Medicaid state plan behavioral health benefits and their new adult ABP behavioral health coverage, often intentionally to reduce the effects of churning between different Medicaid coverage groups.

Marketplace Coverage of Behavioral Health Services

Across the four study states, Marketplaces QHPs explicitly cover many specialty behavioral health services. In the four study states, all QHPs analyzed provide inpatient psychiatric hospital services and inpatient substance use services. Most plans explicitly cover individual and group therapy. Many of the plans specifically cover intensive outpatient services, partial hospitalization, residential treatment, and substance use disorder residential rehabilitation services.

However, QHPs provide general coverage statements rather than an exhaustive list of covered services. The QHPs in all four study states include general coverage statements in their plan documents. For example, the documents for a given plan generally state that the QHP covers inpatient and outpatient mental health and substance use disorder services. As plan documents are the most detailed publicly available information about which services will or will not be covered, these general coverage statements make it difficult to determine whether specific services are covered without submission and disposition of an actual claim. Although the QHPs in our analysis mention some specific services, such as partial hospitalization (Arizona, Colorado) and intensive outpatient (Connecticut, Michigan), the plans lack an exhaustive list of covered services, which could prove especially problematic for adults with behavioral health needs seeking to compare QHPs, as it is important for these individuals to know whether their chronic health needs will be met by a given plan.

QHPs are silent about coverage for a number of specific specialty behavioral health services. For example, in Arizona, Colorado, and Connecticut, none of the QHPs explicitly covers or excludes from coverage the following mental health services: 23-hour observation, group home services, mental health rehabilitation, and individual testing. In addition, QHPs in Arizona and Colorado are silent about coverage for inpatient rehabilitation for substance use disorder treatment. In Michigan, QHPs are silent about coverage for psychosocial rehabilitation. Without an explicit coverage statement, it is difficult to determine whether specific services necessary for adults with behavioral health needs will or will not be covered.

Across the four study states, several QHPs exclude or limit important behavioral health services, such as residential treatment, treatment of chronic conditions, and substance use disorder medication management. Four of thirty QHPs in Arizona explicitly exclude coverage for residential treatment and treatment of chronic conditions not subject to favorable modification for those with mental illness. In Colorado, a few plans exclude counseling for those who do not respond to “therapeutic treatment” as stated, but not defined, in the plan document. The determination about whether a beneficiary will respond to therapeutic treatment is left to the discretion of the plan physician. In addition, multiple plans in Colorado exclude coverage of residential treatment, and one plan explicitly excludes coverage of substance use disorder residential treatment including rehabilitative services. In Michigan, two of twenty-eight plans cover residential treatment only for mental health conditions that are likely to show improvement during the admission. Five plans also exclude from coverage treatment for antisocial personality disorder. Further, two plans do not cover treatment for chronic substance abuse conditions. Across the study states, a number of plans limit substance use medication management services. For example, these services only are available during an inpatient stay or for the treatment of withdrawal symptoms. Excluding and/or limiting these important behavioral health services reduces access to care and is likely to negatively impact plan enrollees who need these services.

QHP coverage for behavioral health services varies by insurer; however, coverage does not vary by metal tier in plans offered by a given insurer within the Marketplace. In all four study states, behavioral health coverage and exclusions, as described in the plan documents, for a given insurer often were the same across all plans offered within the state’s Marketplace. Coverage of specific services did, however, vary by insurer, as expected due to rules permitting substitution of actuarially equivalent services within EHB categories. Our findings about QHP coverage of behavioral health services are summarized in Table 3.

Medicaid and Marketplace Coverage of Behavioral Health Services Compared

In general, a large portion of the four categories of behavioral health benefits identified in this analysis are covered through both Medicaid programs and at least some Marketplace QHPs; however, across the four study states, Medicaid coverage of behavioral health services is generally more comprehensive than in QHPs. For example, all four states’ Medicaid programs covered psychiatric hospital visits, case management, day treatment, psychosocial rehabilitation, psychiatric evaluation, psychiatric testing, medication management, individual therapy, group therapy, family therapy, inpatient detoxification, methadone maintenance, and smoking and tobacco cessation services. By contrast, the only services covered by all Marketplace QHPs in the 4 study states were psychiatric hospital visits and smoking and tobacco cessation services. No QHPs covered psychosocial rehabilitation or adult group home services (the latter are covered by 2 states’ Medicaid programs).

Medicaid benefit packages are more specific about which benefits are covered, while QHPs tend to provide general coverage statements instead of a list of specific covered services. Consequently, it appears that state Medicaid programs offer more comprehensive behavioral health coverage. However, there are a few exceptions. For example, some QHPs in Arizona specify substance use disorder treatment coverage for partial hospitalization, outpatient detoxification, and residential rehabilitation services whereas the state Medicaid program does not. Therefore, it seems that Arizona QHP coverage for substance use services is more comprehensive than Arizona’s Medicaid program. Further, some Michigan QHPs specify coverage of more services than the state Medicaid program (e.g., residential treatment facility, intensive outpatient, individual testing, family therapy).

As noted above, QHP behavioral health coverage is generally less clear about which specific services are covered than that available in Medicaid, with QHPs generally lacking an exhaustive list of covered services. While QHPs cover many general categories of specialty behavioral health services, it is difficult to determine definitively which specific services are covered. General coverage statements, silence about coverage of certain services, and the lack of an exhaustive benefit coverage list make it almost impossible to determine whether specific services are covered by a given QHP without submission and disposition of an actual claim.

Moving forward, the information presented in this analysis can help insurance shoppers, particularly those eligible for Marketplace QHPs and those transitioning between Medicaid and Marketplace coverage, and policymakers to better understand the scope of coverage and information available when choosing plans. As the state Medicaid plan benefit packages in this analysis seem to be more comprehensive in their coverage of specialty behavioral health services than QHPs, it will be important to monitor the impact on consumers who move from Medicaid to Marketplace coverage as their income increases in terms of their ability to access necessary specialty behavioral health services and any gaps in access to services on which beneficiaries rely to support their recovery and ability to work.

In addition, it will be important to monitor coverage of specialty behavioral health services in QHP plan documents and in the actual experience of plan enrollees seeking services. The relative newness of the Marketplace QHP coverage option, coupled with a lack of information in QHP documents about coverage of specific services, increases the potential for confusion or misunderstanding about the scope of benefits available for adults with behavioral health needs. This may be especially important as this population needs certain services that historically have not been covered by typical private insurance plans. More QHPs than noted in our analysis may in fact cover certain services, but the lack of explicit coverage statements in publicly available plan documents in many cases made it difficult to determine whether a specific service was or was not covered.

The lack of transparency about QHP coverage of specialty behavioral health services also may be reflected in QHP coverage of other specialty health care services, which could impact enrollees with other chronic diseases that may require specialized treatment (e.g., Parkinson’s disease, kidney disease and cancer). Marketplace navigators and application counselors/assistors in particular may receive questions from consumers about whether certain services are covered by a QHP or Medicaid, which they may not be able to answer.

As policymakers and beneficiaries gain more experience with the new ACA coverage options, it will be important to study this area further, examining questions such as the extent of behavioral health needs among newly eligible Medicaid adults and QHP enrollees, which behavioral health services are used by these populations, and the impact of cost-sharing obligations on access to necessary services.

To determine which services were covered in each state’s Medicaid program, five primary sources were reviewed: each state Medicaid agency’s website, each state’s Medicaid plan (where available electronically), state plan amendments, applicable waiver documentation available on Medicaid.gov and state Medicaid department websites, state Medicaid policy and provider manuals, and provider covered procedure codes (e.g., CPT and HCPCS), where available by state.

To determine the available QHPs in a state, three primary sources were reviewed: the healthcare.gov website, the respective insurer’s website, and each state’s System for Electronic Rate and Form Filing (SERFF) portal (where available). A representative sample of plans was then selected based on their Marketplace premium. Platinum and gold plans with the highest actuarial values of 90 and 80 percent, respectively; silver plans with 70 percent actuarial value;³¹  and bronze plans with 60 percent actuarial value were selected for review. The health insurance plan documents and summary of benefits were analyzed for behavioral health (including mental health and substance use) benefit coverage for adults ages 21-64. Each plan was examined for both inpatient and outpatient behavioral health service coverage.

ARIZONA

Colorado

CONNECTICUT

MICHIGAN

Arizona

Most Medicaid beneficiaries in Arizona receive acute care services through a capitated managed care organization (MCO). (One exception is for those who receive services through a long-term care contractor for seniors and people with developmental or physical disabilities.) MCO primary care providers may prescribe psychotropic medications and provide medication adjustment and monitoring services for MCO enrollees with depressive, anxiety, or attention deficit hyperactivity disorders.³²  Otherwise, Medicaid beneficiaries must receive behavioral health services through regional behavioral health authorities, which carve out these services from the acute care MCOs and are the primary delivery system for Medicaid behavioral health care in Arizona.³³ 

Overall, minimum coverage of behavioral health benefits in Arizona’s Medicaid program is very specific. State documents detail coverage by provider type (e.g., hospital, provider office) and by procedure code.

Arizona intentionally provides its newly eligible adults with the same Medicaid benefit package that other categorically eligible Medicaid beneficiaries receive to minimize disruptions for individuals moving among different Medicaid coverage groups.³⁴  The benchmark plan for purposes of essential health benefits (EHBs) in both the Marketplace and the Arizona Medicaid ABP for newly eligible adults is the State’s employee health benefit plan.

Colorado

With few exceptions, all Colorado Medicaid beneficiaries must obtain behavioral health services through their assigned behavioral health organization (except for Medicare-covered mental health services and emergency care), which is a capitated prepaid inpatient health plan.³⁵ 

Colorado’s ABP includes the same services as those available in traditional Medicaid, plus additional preventive services and habilitative services.³⁶  Colorado uses the same base benchmark plan (i.e., Kaiser Deductible/Coinsurance HMO 1200D) to determine EHBs in its new adult ABP and in the Marketplace, to ease transitions between Medicaid and Marketplace coverage.³⁷ 

Connecticut

Connecticut’s Medicaid program provides all behavioral health services on a fee-for-service basis and contracts with an administrative services organization (ASO) to oversee and coordinate these services. All Medicaid coverage groups receive essentially the same services.³⁸  Broadly categorized, these include inpatient mental health, inpatient substance use disorder treatment, institutional treatment, outpatient mental health, and outpatient substance use disorder treatment. Overall, behavioral health coverage in Connecticut’s Medicaid program is quite thorough and detailed by treatment setting (e.g., hospital, provider office) and by procedure code.³⁹  Some services require prior authorization from the ASO.

In addition, Connecticut was awarded a five year grant under the CMS Medicaid Incentives for Prevention of Chronic Diseases program to provide tobacco cessation services and participation incentives to beneficiaries who smoke and have SMI (among other target groups).⁴⁰  Connecticut is the only study state participating in this grant program, although other states outside our analysis are participating in the program and targeting beneficiaries with SMI and another chronic condition.

Connecticut chose Secretary-approved coverage as the basis for its new adult ABP and used duplication and substitution to align the new adult ABP with the state plan benefit package.⁴¹  For purposes of EHBs in the Marketplace, Connecticut used the Blue Cross and Blue Shield Service Benefit Plan—Basic Option as its benchmark, a Federal Employee Health Benefit Plan option.⁴² 

Michigan

Michigan provides behavioral health services through its traditional FFS program, Medicaid managed care organizations (MCOs), and PIHPs. Generally speaking, the delivery system through which a beneficiary accesses services depends on the severity of behavioral health condition. The MCOs and FFS program provide outpatient services to treat mild and moderate conditions.⁴³  MCOs are required to cover up to 30 outpatient mental health visits per calendar year, although they may contract with PIHPs to provide these services.⁴⁴  MCOs are not required to provide inpatient or outpatient primary diagnosis substance use disorder services; instead, these services are provided FFS or through PIHPs.⁴⁵  Medicaid beneficiaries with SMI who require benefits exceeding those provided by the FFS or MCOs receive specialty services delivered by PIHPs.⁴⁶ 

Michigan’s Medicaid behavioral health benefits are outlined in the state’s Medicaid provider manual, which lists covered services and types of providers allowed to bill for specified services. The covered services are essentially equivalent for new adults and traditional Medicaid populations.⁴⁷  For purposes of determining EHBs, Michigan chose the largest small group insurance plan in the State, the Priority Health HMO, for both its new adult ABP and Marketplace benchmark.

1. Substance Abuse and Mental Health Services Administration (SAMHSA), Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings at 12 (2013), available at http://www.samhsa.gov/data/sites/default/files/NSDUHmhfr2013/NSDUHmhfr2013.pdf. ↩︎
2. Id. at 50. ↩︎
3. Id. ↩︎
4. Mark TL, Levit KR, Yee T, and Chow CM, “Spending on mental and substance use disorders projected to grow more slowly than all health spending through 2020.” 33 Health Affairs 1407-15 (Aug. 2014), available at http://content.healthaffairs.org/content/33/8/1407.abstract?sid=1e1a3e1e-7024-4836-bfab-bc68f1f32277. ↩︎
5. Kaiser Commission on Medicaid and the Uninsured, The Role of Medicaid for People with Behavioral Health Conditions at 2 (Nov. 2012), available at https://modern.kff.org/health-reform/fact-sheet/the-role-of-medicaid-for-adults-with/. ↩︎
6. Substance Abuse and Mental Health Services Administration (SAMHSA), Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings at 24 (2013), available at http://www.samhsa.gov/data/sites/default/files/NSDUHmhfr2013/NSDUHmhfr2013.pdf. ↩︎
7. Substance Abuse and Mental Health Services Administration (SAMHSA), Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings at 93 (2013), available at http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf. ↩︎
8. Kaiser Commission on Medicaid and the Uninsured, The Role of Medicaid for People with Behavioral Health Conditions at 2 (Nov. 2012), available at at https://modern.kff.org/health-reform/fact-sheet/the-role-of-medicaid-for-adults-with/. ↩︎
9. Id. (internal citation omitted). ↩︎
10. One study predicted that Medicaid enrollment for non-elderly adults with SMI would nearly double with implementation of the ACA’s expansion (estimated 24.5% of Medicaid beneficiaries in 2019, compared to 12.8% in 2006), with 31% of previously uninsured adults with SMI becoming newly eligible for Medicaid. However, this study pre-dates the Supreme Court’s ruling on the ACA’s constitutionality, which effectively made implementation of the Medicaid expansion a state option (Kaiser Commission on Medicaid and the Uninsured, A Guide to the Supreme Court’s Decision on the ACA’s Medicaid Expansion (Aug. 1, 2012), available at https://modern.kff.org/health-reform/issue-brief/a-guide-to-the-supreme-courts-decision/).   To date, 30 states (including DC) have implemented the ACA’s Medicaid expansion (Kaiser Commission on Medicaid and the Uninsured, Status of State Action on the Medicaid Expansion Decision (April 29, 2015), available at https://modern.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/). The same study predicted that 28% of previously uninsured adults with SMI would become eligible for private insurance under the ACA. Rachel Garfield, Judith Lave, and Julie Donohue, Health Reform and the Scope of Benefits for Mental Health and Substance Use Disorder Services, 61 Psychiatric Services, 1081-1086 (Nov. 2010). ↩︎
11. Medicaid beneficiaries from birth through age 21 qualify for comprehensive coverage, including behavioral health services, under the mandatory Early Periodic Screening Diagnosis and Treatment benefit. 42. U.S.C. § § 1396a(a)(43), 1396d(r)(5). ↩︎
12. Cf. 42 C.F.R. § § 440.210, 440.220. ↩︎
13. 42 U.S.C. § 1396a(a)(1); 1396d(a); see generally Kaiser Commission on Medicaid and the Uninsured, Medicaid Enrollment and Expenditures by Federal Core Requirements and State Options (Jan. 2012), available at https://modern.kff.org/medicaid/issue-brief/medicaid-enrollment-and-expenditures-by-federal-core/. States also may provide behavioral health services through § 1915(c) home and community-based services waivers, which are outside the scope of this analysis. ↩︎
14. CMS recently proposed that states may make capitation payments to MCOs and PIHPs for enrollees receiving services of no more than 15 days per month in an IMD that is an inpatient hospital facility or sub-acute facility providing crisis residential services. Proposed 42 C.F.R. § 438.3(u). CMS proposes this change in the capitated managed care context to address difficulties with beneficiary access to short-term inpatient behavioral health treatment and to recognize managed care plans’ flexibility in providing care in alternate settings in lieu of those covered by statute. 80 Fed. Reg. _____ (June 1, 2015), available at https://federalregister.gov/a/2015-12965. ↩︎
15. See, e.g., SAMHSA, Medicaid Handbook: Interface with Behavioral Health Services at 3-5 (2013), available at http://store.samhsa.gov/shin/content/SMA13-4773/SMA13-4773_Mod1.pdf. ↩︎
16. Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY 2011 MSIS and CMS-64 reports. 2010 data was used for FL, KS, ME, MD, MT, NM, NJ, OK, TX, and UT and then adjusted to 2011 spending levels. ↩︎
17. 42 U.S.C. § 1396a(k)(1). The statute uses the former terminology, “benchmark benefits.” In its July 2013 final rule, CMS began using the term “ABP.” 78 Fed. Reg. 42160 (July 15, 2013); see generally 42 U.S.C. § 1396u-7; 42 C.F.R. § § 440.300-440.390. ↩︎
18. 42 C.F.R. § 440.345(d). ↩︎
19. 42 U.S.C. § 1396a(k)(1); 42 C.F.R. § 440.320. Technically, beneficiaries in the new adult expansion group who meet an ABP exemption “must be given the option of an Alternative Benefit Plan that includes all benefits available under the approved State plan” instead of being required to receive the ABP that the state has selected for the expansion group. 42 C.F.R. § 440.315. ↩︎
20. 42 C.F.R. § 440.315(f). ↩︎
21. HHS, Office of the Assistance Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy, How the Affordable Care Act Can Support Employment for People with Mental Illness at 3 (May 2014), available at http://www.aspe.hhs.gov/daltcp/reports/2014/ACAmiesIB.cfm. ↩︎
22. 42 C.F.R. § 440.345(c); see also CMS, State Health Official Letter re: Application of the Mental Health Parity and Addiction Equity Act to Medicaid MCOs, CHIP, and Alternative Benefit (Benchmark) Plans (Jan. 16, 2013), available at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-001.pdf. ↩︎
23. CMS, State Health Official Letter re: Application of the Mental Health Parity and Addiction Equity Act to Medicaid MCOs, CHIP, and Alternative Benefit (Benchmark) Plans (Jan. 16, 2013), available at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-001.pdf. ↩︎
24. 80 Fed. Reg. 19420 (April 10, 2015), available at. https://www.federalregister.gov/articles/2015/04/10/2015-08135/medicaid-and-childrens-health-insurance-programs-mental-health-parity-and-addiction-equity-act-of; see also Kaiser Commission on Medicaid and the Uninsured, Behavioral Health Parity and Medicaid (forthcoming, 2015). ↩︎
25. 45 C.F.R. § 147.150(a); see also 42 U.S.C. § 18022(b). ↩︎
26. 45 C.F.R. § 156.100. ↩︎
27. 45 C.F.R. § 156.100(a). ↩︎
28. 45 C.F.R. § 147.160; see also ACA § 1311(j). ↩︎
29. See Kaiser Commission on Medicaid and the Uninsured, Mental Health Financing in the United States: A Primer at 3 (April 2011), available at https://modern.kff.org/medicaid/report/mental-health-financing-in-the-united-states/. ↩︎
30. See, e.g., Kaiser Commission on Medicaid and the Uninsured, Benefits and Cost-Sharing for Working People with Disabilities in Medicaid and the Marketplace (Oct. 2014), available at https://modern.kff.org/medicaid/issue-brief/benefits-and-cost-sharing-for-working-people-with-disabilities-in-medicaid-and-the-marketplace/. ↩︎
31. This measure was selected due to the availability of subsidies. ↩︎
32. Arizona Health Care Cost Containment System, Medical Policy Manual, ch. 300, Policy 310, p. 310-2. ↩︎
33. CMS, Special Terms and Conditions, Arizona Health Care Cost Containment System Section 1115 Demonstration at 11, available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/az/Health-Care-Cost-Containment-System/az-hccc-stc-10012011-09302016-amended-042013.pdf. ↩︎
34. CMS, Letter to Tom Betlach, Director, AHCCCS (April 1, 2014) and State Plan Amendment AZ-14-0006, available at www.medicaid.gov. ↩︎
35. Colorado Dep’t of Health Care Pol’y & Financing, Community Behavioral Health Services Program, available at http://www.colorado.gov/cs/Satellite?c=Page&cid=1212398231156&pagename=HCPR%2FHCPFLayout; Colorado Medical Assistance Program, Colorado 1500 Specialty Manuals at p. 5, available at http://www.colorado.gov/cs/Satellite?c=Document_C&childpagename=HCPF%2FDcoument_C%2FHCPFAddLink&cid-1210237704667&pagename=HCPFWrapper. ↩︎
36. CMS, Colorado SPA CO-13-0055, (February 10, 2014), available at medicaid.gov. ↩︎
37. CMS, Letter to Susan E. Birch, Executive Director, Dep’t of Health Care Pol’y and Financing (Feb. 10, 2014) and SPA CO-13-0055, available at www.medicaid.gov. ↩︎
38. See http://www.ctbhp.com/about.htm. ↩︎
39. See, e.g., http://www.ctbhp.com/providers/covrdsrvcs/CTBHP_Covered_Services.pdf. ↩︎
40. See http://innovation.cms.gov/initiatives/MIPCD/MIPDC-The-States-Awarded.html. ↩︎
41. Connecticut SPA 14-008, available at www.medicaid.gov. ↩︎
42. Id. at 7. ↩︎
43. Michigan Dep’t of Comm’y Health, Medicaid Provider Manual: Mental Health/Substance Abuse, p. 3-4 (April 1, 2014), available at http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf. ↩︎
44. Michigan Dep’t of Comm’y Health Medicaid Provider Manual: Medicaid Health Plans, p. 7 (April 1, 2014), available at http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf.). Medicaid health plans are required to cover inpatient hospitalization due to complications of a substance use disorder, where substance use is a secondary diagnosis. Id. at 8. ↩︎
45. Id. at 8. ↩︎
46. Id. at 1. ↩︎
47. CMS, Michigan SPA 14-0001 (April 30, 2014), available at www.medicaid.gov. ↩︎