Supreme Court upholds Affordable Care Act: What psychologists need to know

Most provisions of the Affordable Care Act will continue to move forward, with many portions fully implemented in 2014

By Government Relations and Legal & Regulatory Affairs staff

July 16, 2012—On Thursday June 28, the Supreme Court voted to uphold the Patient Protection and Affordable Care Act (ACA) by a 5-4 decision. In an opinion written by Chief Justice Roberts, the Court held that the individual mandate requiring people to buy health insurance or face a penalty on their income taxes after 2014 is constitutional under Congress’s power to tax.

The opinion also clarified that the ACA provision to expand state Medicaid programs to cover roughly 16 million Americans who are currently uninsured is optional. For the states that choose to expand their Medicaid program, the federal government will pay 100 percent of the costs for this expansion for three years starting in 2014 and then the federal share gradually decreases to a minimum of 90 percent. It is not known just how many of the states will choose to expand their programs.

Overall, the Supreme Court ruling means that most provisions of the Affordable Care Act, including an array benefitting mental health patients and the psychologists who serve them, will continue to move forward, with many portions fully implemented in 2014.

What you need to know

What does the affirmation of ACA mean for your practice?

More people with insurance coverage. Prior to the Supreme Court decision, 32 million people were projected to become insured under ACA, mainly through new state-established health insurance exchanges (HIEs) and Medicaid expansion. Making Medicaid expansion optional for states may reduce that number.

More access to mental health and substance use services at parity. ACA mandates that, beginning January 1, 2014, mental health and substance use disorder services are part of the essential benefits packages that all qualified health plans will offer through state HIEs. While the law does not specify benefits requirements, states will establish “benchmark” and “benchmark equivalent” plans with benefits levels that qualified health plans must meet.

All qualified health plans must comply with the federal parity law, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA). This means that mental health and substance use benefits must be provided at parity with medical/surgical benefits in these plans.

An influx of people into the health insurance market (private and Medicaid) as well as the requirement that mental health services be offered at parity has great potential to increase consumer utilization of mental health and substance use treatment services.

Psychologist relationship with HIE health plans. Psychologists will provide services to enrollees in HIE-qualified health plans much in the same way they provide services in the employer-based system. For example, psychologists will negotiate payments rates with exchange plans, as well as with plans in the private market. Depending on how a state implements its HIE, psychologists may have new opportunities to provide preventive services, as incentivized by ACA, and to participate in integrated care systems.

New opportunities for psychologists in integrated care. The APA Practice Organization (APAPO) continues to work to ensure that psychologists have the opportunity to participate in new integrated care initiatives, which are fast developing in federal health programs and in the private market. In implementing ACA and establishing HIEs, states may take a lead from the major federal integrated care initiative, the expanded Medicare Accountable Care Organization (ACO) model.

Under this model, providers will coordinate services to specified groups of Medicare beneficiaries, and share any savings from such coordinated efforts. Psychologists may fully participate in these Medicare ACOs.

Additionally, psychologists are included in a number of ACA initiatives that promote integrated care. Psychologists may participate in community interdisciplinary, interprofessional health teams that promote primary care practices, work within a consortium of health providers to deliver comprehensive and integrated care services for low-income populations and participate in health homes as part of health teams. Additionally, health plans may no longer discriminate against psychologists and other health providers with respect to plan participation.

What happens next?

If the White House and Congress change parties following the November 2012 election, legislative or regulatory changes to ACA could occur. However, overturning the law seems highly unlikely because rules of the Senate require 60 votes to do so – a number the Republican Party is currently not predicted to attain in the November elections.

Regardless, states will need to begin moving forward on implementation of ACA provisions. They need to decide: whether to implement an insurance exchange or default to a federally run alternative; whether to expand their Medicaid programs; and how quickly and effectively they can implement enrollee eligibility systems.

The federal government will need to continue drafting regulations implementing ACA as well as respond to potential legislative or legal challenges to ACA. This information will continue to be released on a regular basis as we head toward the potential full implementation of ACA in 2014.

Many of ACA’s fundamental provisions do not take effect until January 2014 – such as state establishment of HIEs. ACA is not slated for full implementation until 2015. But several insurance market reforms, which APAPO fought for in the law and that benefit patients, are already in effect, including the elimination of lifetime and annual visit limits, prohibitions against retroactive cancellation of insurance coverage and denying coverage for children with pre-existing conditions, and benefit appeal rights.

Working for our members

The APA Practice Directorate and APA Practice Organization (APAPO) continue to work for our members to ensure that professional psychology is well represented as ACA and state regulations related to health care reform are developed and implemented, and that psychologists are well positioned to participate fully in the evolving health care system.

Our Government Relations department is closely monitoring any federal legislation and regulations related to health care reform, and continuing to look for opportunities to protect and promote the interests of our members. A brief summary of key advocacy efforts can be found online.

APA and APAPO serve on the executive committee of the Patient Centered Primary Care Collaborative (PCPCC), an extraordinarily large coalition dedicated to fostering movement toward patient-centered medical homes. We face great challenges to ensuring that psychologists are able to fully participate in and integrate mental and behavioral health services into medical homes. This coalition allows psychology’s voice to be heard in the medical home dialogue.

In fall 2011, a team of senior APA Practice staff members was assembled to address the aspects of ACA that are most relevant to the practice of psychology and implementation of health-care reform. The Legal and Regulatory Affairs department is researching the state Medicaid programs to identify opportunities for and barriers to psychologist participation, examine utilization of health and behavior (H&B) codes and assess concerns about reimbursement rates.

APA Practice Directorate and APA Practice Organization staff are also working with state associations to address issues related to the state implementation of ACA, including Medicaid expansion. As issues related to ACA unfold, we will continue to provide our members with information about the impact on practitioners in all settings.