Beginning in 2014 under the Affordable Care Act (aka Obamacare) all new small group and individual market plans will be required to cover ten Essential Health Benefit categories, including mental health and substance use disorder services. Mental health and substance abuse will be covered at parity with medical and surgical benefits. Federal subsidies will help an individual making less than $46,000, or a family of four making less than $94,200 purchase insurance. The government estimates 7 million people will sign up for Obamacare in 2014 and 30 million or more over the next three to five years. So it is likely that mental health professionals will be seeing patients covered by the ACA in the next several years.
Obamacare plans are classified based on premiums and cost sharing. Bronze plans, the least expensive, will pay on average 60% of covered costs with the enrollee responsible for 40%. Silver plans will have a 70/30 split, Gold a 80/20 split and Platinum 90/10. In 2014 the Bronze plans will have a maximum out of pocket cost for health care, aside from insurance premiums, of $6,350 for singles and $12,700 for families.
Specialty care services, including mental health, will be subject to high co-pays. For Bronze plans $70 or $75 copays are likely. For Silver copays will be in the $60 to $65 range.
So, will Obamacare be a net benefit for mental health clinicians? Probably not. Studies show high co-pays are a barrier to care, especially for the sickest patients. The co-pay levels built into the most popular plans, the bronze and silver, will inhibit patients accessing care. The high deductibles will mean that insurance will only pay for a few chronically ill patients with high medical costs.
Meeting deductibles is unlikely for psychotherapy patients because most are comparatively young and likely to be healthy. According to Vessey about two-thirds of psychotherapy outpatients are female and 80% are between the ages of 21 and 50 yrs (Who seeks psychotherapy? Vessey, John T.; Howard, Kenneth I. Psychotherapy: Theory, Research, Practice, Training, Vol 30(4), 1993, 546-553.)
What changes should clinicians make in order to deal effectively with Obamacare?
First, clinicians should make more of an effort to determine what benefits patients have and whether they have met the deductible. Insurance cards will probably have the name of the insurer on the front. You will have to look closely to see if the patient has Obamacare copays and deductibles.
Second, it is in patient’s interest that clinicians file claims because it helps meet the deductible. But, since many patients will not have met their high deductibles, filing claim could be a net burden for the clinician.
Third, clinicians who reduce fees for the uninsured or underinsured may find Obamacare patients still meet their reduced fee criteria. However, using a reduced fee schedule will make it harder for the patient to meet the deductible. Standard fees that can be submitted to insurance with write-offs to reduce the burden on the patient are probably a better way to go.
Fourth, providers sometimes delaying filing claims for patients with high deductibles so the deductible can be met with claims from other providers. This might work sometimes, but timely filing will limit this option.
Overall, the the Affordable Care Act is a misnomer insofar as it concerns outpatient mental health practice.