Summary of the Patient Protection and Affordable Care Act and Impact on Psychiatry and Patients

Thu June 28, 2012

Summary of the Patient Protection and Affordable Care Act and

Impact on Psychiatry and Patients.

June 29, 2012


The Patient Protection and Affordable Care Act (ACA), which was upheld by the Supreme Court on June 28, 2102, provides important protections and benefits to patients, both in its general insurance provisions and in parts of the law that specifically reference coverage of treatment of mental health, including substance use disorders.  APA’s Board of Trustees voted to join the American Medical Association in supporting the ACA primarily because of the law’s positive impact on patients.


Protections that are particularly important to psychiatric patients include:


o   Prohibition on pre-existing condition exclusions or other discrimination based on health status.  Plans cannot exclude those with MI and SUD, and they cannot discriminate against or drop coverage of individuals who have had a psychiatric illness.

o   Prohibition on lifetime and annual dollar limits starting in 2014.

o   Dependent coverage allowing unmarried individuals to remain on their parents’ insurance until age 26 (helps those with SPMI typically emerging in adolescence).

o   Coverage of MI and SUD is required as part of the “core benefits” package that must be offered in the state insurance exchanges established by the law.

o   When fully phased in, coverage of MI and SUD must be at parity with other medical and surgical benefits for all plans sold in the exchanges.  This is “real parity, with teeth.”

o   Expanded Medicaid coverage up to 133% of poverty with 100% federal match for the first three years will provide a major pathway to insurance for the poor and near-poor.

o   The requirement that individuals have insurance means that the pool of insured individuals is as large and broad as possible.  This spreads the risk, helps hold down premium costs, and avoids adverse selection problems.

o   Subsidies for those with lower incomes helps make insurance purchased in the state exchanges more affordable.  This helps address “health insurance versus low-income employment” that can be a significant issue for psychiatric patients (i.e., work versus welfare).

o   Closing the Medicare drug benefit’s “doughnut hole” (where coverage lapses before kicking in again), which will help reduce patients’ out-of-pocket costs for psychiatric and other medications.

o   Restoring benzodiazepines and smoking cessation medication to Medicaid drug coverage.


Other provisions of note include:

o   Postpartum depression and psychosis research, education and screening.

o   The establishment of national Centers of Excellence for Depression treatment.

o   Increased funding for Community Mental Health Centers.

o   The establishment of a demonstration project to address a conflict between federal law requiring free-standing psychiatric hospitals to stabilize or admit emergent patients and another (Medicaid) law (the so-called IMD exclusion) that bars payments for the services provided.  The grants were recently announced.

o   Workforce provisions potentially benefit psychiatrists serving in medically underserved areas.

o   The law extended a special, temporary 5% “bump” in payments for psychiatric CPTs under Medicare.  This bump was beneficial to APA members but has since lapsed.


In short:

  • The ACA ensures that all Americans will have access to affordable health insurance that meets core coverage standards, including APA-advocated parity for treatment of mental health and substance use disorders.
  • Psychiatric patients can’t be denied coverage because through no fault of their own they have had a psychiatric illness.  And they can’t be dropped by their insurance for getting treatment, nor will they have to worry that their insurance benefits will run out when they are most in need of treatment. 
  • These and other provisions in the law expand access to psychiatric treatment for millions of Americans.
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