Additionally, these plans must comply with mental health and substance use parity requirements, as set forth in MHPAEA, meaning coverage for mental health and substance abuse services generally cannot be more restrictive than coverage for medical and surgical services. Answer: In general, for those in large employer plans, if mental health or substance use disorder services are offered, they are subject to the parity protections required under MHPAEA. And, as of , for most small employer and individual plans, mental health and substance use disorder services must meet MHPAEA requirements.
Because of the Affordable Care Act, health insurers are required to provide you with an easy-to-understand summary about your benefits including mental health benefits, which should make it easier to see what your coverage is. Additional, helpful information on what you can do to better understand the parity protections you have is available in Know your Rights: Parity for Mental Health and Substance Use Disorder Benefits. These services often include counseling, therapy, medication management, social work services, peer supports, and substance use disorder treatment.
While states determine which of these services to cover for adults, Medicaid and CHIP requires that children enrolled in Medicaid receive a wide range of medically necessary services, including mental health services.
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In addition, coverage for the new Medicaid adult expansion populations is required to include essential health benefits, including mental health and substance use disorder benefits, and must meet mental health and substance abuse parity requirements under MHPAEA in the same manner as health plans. Find additional information on Medicaid and mental health and substance use disorder services.
Medicare Part A Hospital Insurance covers inpatient mental health care services you get in a hospital. Part A covers your room, meals, nursing care, and other related services and supplies. Medicare Part B Medical Insurance helps cover mental health services that you would generally get outside of a hospital, including visits with a psychiatrist or other doctor, visits with a clinical psychologist or clinical social worker, and lab tests ordered by your doctor. Medicare Part D Prescription Drug helps cover drugs you may need to treat a mental health condition.
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Each Part D plan has its own list of covered drugs, known as formulary. Most of this decrease occurred between and , coinciding with the availability of Marketplace coverage. Within the nonelderly population, nonelderly adults adults aged saw a large decrease in their uninsured rate, reflecting that changes in coverage under the ACA were implemented to increase coverage for this population. Compared to Medicaid expansion states as a whole, a higher share of uninsured Pennsylvanians remain eligible for coverage as of early , reflecting that Pennsylvania implemented the Medicaid expansion a year after most other states.
As part of the ACA, all states are required to implement new, simplified eligibility and enrollment processes, and Pennsylvania has made progress in implementing some of these changes. As of January , individuals in Pennsylvania can apply for both Medicaid and Health Insurance Marketplace coverage through multiple pathways, including in-person, over the phone, by mail, and online.
Pennsylvanians are able to shop for health plans through HealthCare. Pennsylvania is one of 34 states in which the federal government has established and is running the Health Insurance Marketplace. Focus group participants with Marketplace coverage in Pennsylvania were positive about their ACA coverage and grateful for health insurance.
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However, they had difficulty weighing plan options, including the impact of tiered insurance networks, with many reporting having to switch plans every year. Marketplace participants also reported that they struggled with out-of-pocket costs and the financial impacts of medical bills. Support for outreach and enrollment in Pennsylvania is being provided by the federal government and private organizations.
Pennsylvania is one of 32 states currently adopting the ACA Medicaid expansion.
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Coverage under the waiver became effective January 1, The transition from Healthy Pennsylvania to Health Choices was completed in the summer of With the adoption of the Medicaid expansion, eligibility levels for parents and childless adults have increased Figure Focus group participants in March reported positive experiences with their Medicaid coverage. Specifically, they reported being able to find doctors and access needed care and noted that costs were minimal with Medicaid, which was important to them because they felt they had no capacity to take on new costs.
Pennsylvania is in the process of reforming its payment and delivery system to promote new care delivery models focused on multi-payer approaches with patient, provider and payer interest. By creating a Healthcare Transformation Support Center that will provide training courses, including medical home training, and disseminate best practices to providers throughout the state, the state plans to strengthen the workforce. It also plans to use the enhanced telemedicine infrastructure to create the Pennsylvania Health Learning Network, which will provide primary care physicians with access to trainings and consulting services with specialists on complex patients.
Pennsylvania’s own insurance exchange coming next year
Large provider organizations play important roles in both insuring patients and delivering care to Pennsylvanians. Geisinger Health System in northeast and central Pennsylvania and the University of Pittsburgh Medical Center UPMC in western Pennsylvania are both health care systems that expanded into providing insurance, including Medicaid managed care plans, in their respective geographic locations.
Geisinger Health System is a physician-led fully integrated health services organization that serves over 3 million residents across 48 counties in Pennsylvania and insures almost , people through Geisinger Health Plan. Most Medicaid beneficiaries are enrolled in managed care plans for physical health.
These offices serve as a referral source, and most services are delivered by plans and local providers that contract with the county. In July , after releasing a request for information RFI , Pennsylvania received public comments and responses to help the state develop new procurements for the provision of Medicaid managed care for physical health.
As a result, the state plans to incorporate ways to improve coordination between physical and behavioral health services, expand value-based purchasing and team-based approaches to care delivery, and promote community-based public health initiatives into the managed care contracts. Pennsylvania is home to 40 federally qualified health centers FQHCs , which operate sites throughout the state. Following national trends, Pennsylvania continues to shift toward community, rather than institutional, long term services and supports LTSS. There are unmet needs for care in Pennsylvania.
As of , Pennsylvania ranked 4 th in the country for the ratio of medical students to , population Pennsylvania is one of 17 states with licensure laws that limit the autonomy of nurse practitioners in at least one area of practice. With Individuals who have gained coverage in the Marketplace and through Medicaid are continuing to interact with their new health plans and seek care.
Meanwhile, the health care system in Pennsylvania, like all states, is evolving and changing to meet new demands as providers adapt to the changing health coverage landscape. Grande noted that such clinics are particularly vital in immigrant neighborhoods — Northeast Philadelphia is one example — where many residents are ineligible for insurance as a result of a legislative compromise that excluded undocumented immigrants from ACA eligibility.
Ultimately, bringing more patients into the system — whatever their health or legal status — is among the most critical near-term challenges facing the ACA. From the standpoint of public health, covering more people is a no-brainer; from a fiscal perspective, a larger, more diverse patient pool spreads risk more evenly across insurers, which could theoretically stabilize costs.
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The ACA will inevitably need more young, healthy consumers to offset costly new enrollees like Barbara White of Wilkinsburg. So White quit her job in medical billing and — as a newly unemployed person — was eligible to sign up mid-year for a marketplace plan. A few months later, she had her hip replaced; two knee replacement surgeries followed, all of it made possible by the new healthcare law. And in order to qualify initially, she had to quit her job — a move that ultimately damaged her career, sending her onto the Medicaid rolls as she starts her own business from scratch.
For now, they are grateful for a program that, for all its drawbacks, offers indisputable advantages. Sign up for our must-read roundup of the top political news, editorials, schedules and more — all in your inbox by a. Having trouble subscribing?
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