Frequent readers of this blog will know that we’ve written previously on Essential Health Benefits (EHB), a minimum set of core benefits the Affordable Care Act (ACA) requires most plans to cover starting in 2014. States are in the process of choosing a benchmark plan, and many advocates have provided input to support plans that have the most robust benefits for consumers. But advocates face a new challenge on EHB: Many benchmark plans selected by states will fall short on mental health and substance use disorders services.

Some plans might not have the benefits consumers should expect from their coverage. Others will not meet requirements in the parity law, which bars most health plans from having different treatment limits and cost sharing for mental health and substance use disorders services than for coverage for physical health services. Many EHB benchmarks will be based on small group plans that previously didn’t have to meet the parity rules, but now must be modified to comply.

By September 30, 2012, all states must choose their benchmark plan or have it chosen for them by the federal government. With the benchmarks set, a second phase of important work begins for consumer advocates. At this stage, advocates must ask if the benefits are sufficiently robust, and if the treatment limits and cost sharing are at parity compared to physical health benefits. This work is of particular importance to advocates working on mental health and substance use disorders.

Two Community Catalyst resources will be helpful to advocates working on EHB. The first brief describes strategies for advocates, which include outreach to mental health/substance use disorders groups to bring them into EHB coalitions and gain their insight, assessing benchmarks for strength in these areas as well as parity compliance, and working with state officials to ensure a transparent process. The second brief lists what services should be included as Essential Health Benefits.

The federal government has said twice that it expects many benchmarks to fall short of compliance for treatment limits and cost sharing for mental health and substance use disorders. Although this is certainly a problem, advocates should use the next phase of EHB implementation to improve the benchmark. The federal government will oversee states as they “supplement” and “adjust” the benchmarks after September 30 to meet the threshold laid out by the ACA, and in some states federal officials will even perform this duty. Advocates will need to track the work of the state and federal governments to ensure consumers have access to the benefits promised by health reform.

Advocates must continue to stay engaged into 2013, because with Essential Health Benefits, like most of health reform, the devil is in the details.

— Tom Emswiler, Policy Analyst