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DC Exchange Board Approves Benefit Rules for Mental Health, Substance Abuse, and Prescription Drug Services; Prohibits Substitution of Benefits in New Market

Thursday, February 14, 2013
Multi-stakeholder group reaches consensus on consumer-friendly policies.

The Executive Board of the DC Health Benefit Exchange (HBX) Authority has approved rules governing the benefits that must be included in health plans offered by insurers in the Exchange for 2014.

The Affordable Care Act, the federal health reform law, requires insurers to cover a set of “essential health benefits” in 10 major categories of care, including: hospitalizations, emergency room visits, physician care, maternity and newborn care, mental health and substance abuse services, prescription drugs, lab tests, prevention and wellness benefits, vision and dental care for children, and rehabilitation and habilitative services and devices.

The policies adopted by the Board will:

  • Prohibit limits on visits for mental health or substance abuse services, thus achieving parity with care for other conditions;
  • Require drug formularies to cover at least one product in each class of drugs offered; and
  • Prohibit the substitution of one benefit for another, thus ensuring consistent benefits across all policies sold in the DC Exchange.

“These policies will ensure that the insurance coverage offered in the Exchange will be comprehensive and meet all of the care needs of the residents of the our city,” said Mohammad Akhter, M.D., M.P.H., chairman of the Exchange Board of Directors.

The policies approved by the Board are the product of discussions by a working group comprised of more than 35 diverse stakeholders, including patient advocates, physicians and other health care providers, insurers, insurance brokers, employers, and others. (A full list of the work group’s participants is attached.) Currently more than a dozen such groups are working on issues related to the governance of the DC Exchange.

Federal law has required parity of mental health and substance abuse services with other medical care in policies sold to large employers. The Affordable Care Act extended parity to policies sold to individuals beginning in 2014. The Board vote further extends parity to people covered by small-group policies, consistent with federal guidelines.

“A major value of the benchmark package of benefits is that behavioral health services will be equivalent to other health services, thus helping us to erase the stigma often associated with health disorders such as mental illness and substance abuse.,” said Saul Levin, M.D., M.P.A., the Interim Director of the DC Department of Health, who chaired the Essential Health Benefits Working Group.

Prescription drug formularies list all of the drugs that a health plan will pay for. Patients – especially those with chronic conditions – worry that the drugs they need won’t be covered. The new policy will ensure broad coverage of needed drugs.

“Ensuring drug formularies meet the needs of people living with medical conditions and disabilities will mean insurance will be there for them when they need it,” said Kevin Dougherty of the National Multiple Sclerosis Society and Essential Health Benefits Working Group vice-chair. “The fact that insurers can’t substitute one benefit for another will also help ensure consistency across insurance choices,” he added.

Through benefit substitution, an insurer could cover fewer physical therapy visits and more occupational therapy session. While such changes could help some consumers they could hurt others.  While federal regulations permit states to allow substitution of benefits within the 10 categories, under the Board-approved policy, insurers will not be allowed to substitute one benefit for another, at least for 2014.

“Substitution of benefits can be confusing to consumers as they compare health plan options. By limiting this practice in 2014, we will create more clarity and consistency as the ACA is implemented,” said Mila Kofman, J.D., Executive Director of the Exchange Authority.

The consensus recommendation reached by the working group demonstrated efficacy of the approach established by the HBX'S new Executive Director. “I am tremendously pleased that the working group was able to reach consensus on three issues of significant importance to the residents of the District,” said Kofman.

A copy of the policies approved by the Board is on the Exchange Authority website.

For more information on the appointees, please visit www.dchbx.com


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About the DC Health Benefit Exchange Authority - The Executive Board of the Health Benefit Exchange Authority was established as a requirement of Section 6 of the Health Benefit Exchange Authority Establishment Act of 2011, effective March 2, 2012 (D.C. -Law 19-0094).


List of Members of the Essential Health Benefits Working Group

Saul Levin, M.D., M.P.H. (Chair) District of Columbia Department of Health
Kevin Dougherty (Vice Chair) National Multiple Sclerosis Society
Steve Geishecker Whitman Walker Health
Erin Loubier Whitman Walker Health
Stuart Spielman Autism Speaks
Dr. Catherine May Psychiatrist and Board Chair of the MSDC
Stephanie Laguna Kaiser Permanente
Richard McCarthy Kaiser Permanente
Dania Palanker National Women’s Law Center
Laura Meyers Planned Parenthood, Metropolitan Washington DC
Lynne Pettey Keller Benefit Services
Hannah Turner Keller Benefit Services
Aarti Subramanian The Psychiatric Institute Of Washington
Carol Desjeunes The Psychiatric Institute Of Washington
Howard Hoffman The Psychiatric Institute Of Washington
Brian Crissman The Foundation for Contemporary Mental Health
Doreen Hodges Family Voices of the District of Columbia
Jill Thorpe AFrame Digital
Luis Padilla Unity Health Care
Susan Walker DC Coalition on Long Term Care
Lida Etemad United Healthcare
Nicholas Rogers United Healthcare
Colleen Cohan United Healthcare
John Flieg United Healthcare
Carmel Colica United Healthcare
Troy Pelfrey United Healthcare
Joseph Winn Aetna
Cindy Otley CareFirst
Tonya Kinlow CareFirst
Kishan Putta Advisory Neighborhood Commission
Flora Hamilton Family and Medical Counseling Service
Peter Rosenstein The American Academy of Orthotists & Prosthetists
Lindsey Steinberg DC Behavioral Health Association
Gwen Melnick GWCSW