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Pennsylvania Physical Health – Behavioral HealthLearning Community

Pennsylvania Essential Health Benefit Recommendations

The Physical Health-Behavioral Health Learning Community (Learning Community), comprised of leading organizations responsible for the provision of health care services in Pennsylvania, finds it critically important that Pennsylvania’s Essential Health Benefit (EHB) package be designed in a way that ensures that the physical health, mental health and substance use disorder needs of children, youth, adults, and older adults are well met. As the state’s leading health care practitioner and provider organizations, the Learning Community seeks to ensure that the Patient Protection and Affordable Care Act (ACA) is effectively implemented for people with the full range of physical health, mental health and substance use disorder service needs. The Learning Community offers the following specific recommendations to ensure adequate coverage for physical, behavioral, and co-occurring conditions and asks that the Health Insurance Exchange promotes the coordination of physical health and behavioral health care services.

Compensation/Reimbursement for ServicesAs the Health Insurance Exchange is created and the health care delivery system evolves, it is critical that purchase of service compensation and reimbursement structures, be they fee-for-service, sub-capitation, case rate or other agreed upon model, reflect the full market value of service delivery and provider operations. As practitioners and providers of physical, behavioral, and coordinated health care Learning Community members are committed to high quality, state of the art, cost effective care that delivers optimal outcomes for our patients. The Learning Community and its member organizations stand ready to work with the Health Insurance Exchange and other stakeholders to achieve real and necessary returns on the investment in health care.

Presented here are the EHBs, service, and leadership recommendations critical to the care and well-being of Pennsylvania’s participants in the Health Insurance Exchange.

Primary Care Screening and Coordination of CareThe EHB array must include recognized screening procedures developed and recommended based on national standards of care. Health care screening must be used to identify indications of an existing or incipient physical health, developmental, neurological, mental health or substance use disorder. Screenings conducted in primary care, person centered health homes or other ambulatory health care settings are critically important for the early identification, referral, diagnosis and treatment of a broad range of mental health and substance use disorders as well as many developmental and neurological disorders requiring coordination of care by physical health and behavioral health practitioners. In Pennsylvania Community Providers Association, Pennsylvania Chapter of the American Academy of Pediatrics, Pennsylvania Academy of Family Physicians, Pennsylvania Association of Community Health Centers, Pennsylvania Psychiatric Society, Pennsylvania Psychiatric Leadership Council, and the Pennsylvania Coalition of Nurse Practitioners, Pennsylvania Association Psychiatric Healthcare Systems, Pennsylvania Psychological Association, Hospital and Healthsystem Association of Pennsylvania, Pennsylvania Medical Society .


addition to behavioral health care, dental, vision and hearing screening and treatment are important elements of basic, well coordinated health care. The Learning Community recommends that the EHB package include these service categories for patients across the life span. The Learning Community also recommends that Pennsylvania use the established Medicaid and Children’s Health Insurance Program benefits as the model for pediatric health and behavioral health benefits in the Health Insurance Exchange.

Behavioral Health Care Services (and Related Physical Health Care) Including: Preventive and early intervention services, including services provided with the

goal of early detection and minimization of the ill effects and causes of psychiatric, neuropsychiatric and developmental conditions;

Outpatient treatment, including medically necessary services performed or prescribed by mental health or substance abuse professionals, such as assessment, psychotherapy, medication, and other generally accepted, medically necessary behavioral health treatment;

Behavioral interventions for physical conditions; Case management and rehabilitation services provided in a nonhospital based

facility, at a hospital, the office of a health care professional, or, if medically appropriate, in-home or through telecommunications;

Enhanced benefits for persons with serious and pervasive mental disorders; Inpatient hospital care, including generally accepted and medically necessary

hospital services, such as diagnostic and therapeutic care, professional services or detoxification.

Emergency care, including mobile and facility based crisis and emergency intervention, stabilization and disposition management services delivered by emergency medical or emergency behavioral health personnel in community and other settings;

Prescription psychotropic drug coverage, including medications approved for the treatment of adult mental illness and substance use disorders and consensus-based “off label” medications used in the treatment of child and adolescent mental illness and substance use disorders;

Residential care, including nonhospital residential care for the treatment of the addiction to alcohol or other drugs;

Telemedicine, medical and behavioral telemetry, and patient monitoring/support equipment and services for patient care, consultation, therapeutic intervention and coordination of physical health and behavioral health care services; and

Recovery support services, including recovery coaching and peer support.

Physical Health Care Services (and Related Behavioral Health Care) Including: Wellness and preventive services, including consumer and family education on

Pennsylvania Community Providers Association, Pennsylvania Chapter of the American Academy of Pediatrics, Pennsylvania Academy of Family Physicians, Pennsylvania Association of Community Health Centers, Pennsylvania Psychiatric Society, Pennsylvania Psychiatric Leadership Council, and the Pennsylvania Coalition of Nurse Practitioners, Pennsylvania Association Psychiatric Healthcare Systems, Pennsylvania Psychological Association, Hospital and Healthsystem Association of Pennsylvania, Pennsylvania Medical Society .


maintaining healthy weight, good nutrition, substance use prevention, and other aspects of a healthy lifestyle, including social and emotional wellness;

Primary health care prevention, early identification, and treatment, including age appropriate outpatient, inpatient, and home-based primary health care (and coordinated behavioral health education, screening, treatment and rehabilitative services);

Prescription drug coverage; Rehabilitation services, including occupational therapy, physical therapy,

speech and hearing, nutrition and diet counseling; Evidence-based home health care for infants and toddlers; Telemedicine, medical and behavioral telemetry, and patient monitoring and

support equipment and services for patient care, consultation, therapeutic intervention and coordination of physical health and behavioral health care services;

Comprehensive chronic disease management, including intensive case management for persons with severe physical, mental and addictive disease;

Care coordination and health promotion, including care coordination services for children, adults, and older adults with a behavioral health, intellectual disability, neurological or other co-occurring diagnosis secondary to a physical health care condition; and

Patient and family support, including education and self-management assistance for persons with severe mental illness and/or substance use disorders and appropriate referral to community and social support services.

Comprehensive and Coordinated Health Care and Sick Care Service SystemLearning Community member organizations recognize and support the evolving health care system efforts to facilitate the delivery of effective and coordinated services in a manner that reflects the rural, urban and suburban communities served by our members. Approaches and models like medical homes, person-centered health homes, co-located health care and behavioral health care services, mobile services, telemedicine and telemetry supported patient care are all growing and evolving means to improve patient care in clinically and economically important ways. Covered benefits must include the full continuum of best available, evidence-based or consensus-based practice. Newer interventions and those that are in development show tremendous promise in helping people avoid disease, better comply with treatment, and sustain long-term recovery. The Health Insurance Exchange should employ appropriate quality measures for services aimed at producing the best possible outcome for each individual. Our organizations support the EHBs for prevention, intervention, treatment and rehabilitative services delineated here. We believe that the site of care, level of care and the coordination and co-location of physical, behavioral, dental, adjunctive health care and rehabilitative services must be flexibly designed and



driven by the community context, resources and local leadership in the regional health care delivery systems.

Practitioner and Provider Role in EHB Design, Administration and MaintenanceOur organizations urge that the state and the Health Insurance Exchange include health care, behavioral health care and integrated health care leaders in the initial and ongoing design, administration and oversight of health benefits. The leadership of our organizations shares the broader community interest in providing high quality health care that is effective, efficient, accessible, and reflects the current standards and practices in comprehensive, coordinated health care. The science, technology and practice of physical and behavioral health care are evolving at an unprecedented rate. The role of health care and behavioral health care practitioner and management leaders in the design and evolution of health care benefits, system administration, purchase of care and desirable community outcomes is essential. As critical elements of quality assurance and performance improvement our organizations strongly recommend the inclusion of practitioner and provider system satisfaction measure and reporting, as well as consumer satisfaction measures and reporting. Inclusion of both consumer and provider service system measures and input will enable insurance exchanges to refine and improve operations, efficiencies and outcomes.

Practitioner and Provider Advocacy of Patient Care Equality and InclusionNo health benefits established as essential can be subject to denial based on age, expected length of life, present or predicted disability. None of the categories of essential health benefits may result in discrimination with respect to children, adults, or older adults with severe mental illness, substance use disorder, intellectual or developmental disorder. This language is particularly relevant with respect to rehabilitation services and chronic disease management. Enforcement of these protections must be included among the highest priorities for implementation and ongoing administration of the state’s health insurance industry, including health insurance exchanges.

These recommendations reflect the current and evolving perspective of the Learning Community, a health care integration work group, that includes: Pennsylvania Community Providers Association, Pennsylvania Chapter of the American Academy of Pediatrics, Pennsylvania Academy of Family Physicians, Pennsylvania Association of Community Health Centers, Pennsylvania Psychiatric Society, Pennsylvania Psychiatric Leadership Council, and the Pennsylvania Coalition of Nurse Practitioners, Pennsylvania Association Psychiatric Healthcare Systems, Pennsylvania Psychological Association, Hospital and Health System Association of Pennsylvania, and the Pennsylvania Medical Society . The work group can be contacted through Connell O’Brien at [email protected] or Brent Ennis at [email protected].


mailto:[email protected]

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