BEGINNING TO UNDERSTAND NATIONAL HEALTH COVERAGE REFORM:

WHAT PD’S AND PI’S NEED TO KNOW

by Frank Rider MS, TA Partnership/

National Federation of Families

5 August 2010

Adapted from John O’Brien,

Senior Advisor on Healthcare Financing, SAMHSA

Affordable Care Act (2010) and

Children’s Health Insurance Program

Reauthorization Act (2009) [a.k.a. ”CHIPRA”]

Combined, this year’s new landmark health insurance reform laws significantly enhance access to health care, including prevention and treatment services for mental and substance use disorders, for millions of Americans.

Children’s Health Insurance Program Reauthorization Act [CHIPRA 2009]

Extends State Children Health Insurance Program to 2013 Adds $33 Billion between 2009-2013 for this extension Increases coverage to about 6.5 million additional children

Higher income limit – up to 300% of FPL Fiscal incentives for states to enroll uninsured children States must implement eligibility simplification

processes (e.g. free school lunch, WIC) Does not specifically require a state to cover MH/SUD

benefits under CHIPRA If a state does include MH/SUD benefits, then must offer

those services at parity with other health care benefits

CHIPRA Grant Programs

Outreach and Enrollment Quality Demonstration Grants Pediatric Healthcare Quality Measures

Program Research Demonstration and Dissemination

Projects Promote Health Information Technology Evaluate Care Management, other Provider-

Based Models

Affordable Care Act - Objectives

Significantly enhance access to health care, including prevention and treatment services

Hold insurance companies accountable to keep premiums down

Prevent denials of care and coverage for people, including for pre‐existing health or medical conditions

Improves health care for seniors and persons living with disabilities

Improves the nation’s fiscal health Changes payment policies to reward high‐quality care

and rein in waste, fraud and abuse.

Affordable Care Act – Key Concepts

Healthcare Exchanges Health Information Exchanges High Risk Pools Benchmark Plans Essential Benefits Web Portal

ACA 2010 – Key Provisions for Children, Youth and Families

Eliminates pre-existing condition exclusions for children (2010)

New home visitation program for young children and families* [priority: families with history of substance use disorders]

Grants for School-Based Health Clinics [includes MH/SA services]

Medicaid coverage extended for youth in times of transition:

→ Option for states to continue coverage for former foster care children up to age 25

→ Allows dependent coverage to age 26 (2010)

ACA 2010 – Expanded Coverage

Expands Medicaid to 133% of FPL an estimated 16-20 million new enrollees

Focuses grant dollars on community prevention, and on support services

Expands home and community‐based services options for MH and SUD.

State Medicaid programs may establish “medical homes” for those with chronic illnesses

Grants available for community MH programs to co‐locate with primary and specialty care services.

About Mental Health Parity

Mental Health Parity and Addiction Equity Act of 2008

Financial requirements and treatment limitations applied to MH/SUD benefits may be no more restrictive than the predominant requirements or limitations applied to virtually all medical/surgical benefits

The 2008 MHPAEA provisions will now apply to all private health plans that choose to offer MH/SUD

Parity will be required in essential benefits plans offered through the health care exchanges.

State-Level Impacts of the Affordable Care Act

Role as payer is expanding

Role in preparing state Medicaid programs now for expansion in 2014

Role in Health Information Technology is expanding

Role in high risk pools

Role in insurance exchanges

Role in evaluating their state insurance markets and weighing against possible benefits of new CO‐OPs

Key ACA 2010 Provisions

PREVENTION

Prevention research programs and national prevention plans

Coverage of preventive services in private insurance and Medicare including SBIRT, without cost‐sharing and with a financial incentive to do the same in Medicaid

Prevention Trust Fund Establishes a national public/private outreach

and education campaign re: prevention

Key ACA 2010 Provisions

TRAINING & RESEARCH

Increased patient‐centered health research

Training grants for behavioral health workforce

Training on MH/SUD for Primary Care Extenders

Key ACA 2010 Provisions

WORKFORCE DEVELOPMENT SUPPORT

Funding for residencies for behavioral health included with other disciplines

Loan repayment programs Push towards more national certification

standards Push towards re‐licensure and re‐

certification

See detailed Affordable Care Act Implementation Timeline at:

http://www.whitehouse.gov/healthreform/timeline

SAMHSA Roles in Moving Implementation of Affordable

Care Act Forward Consultation regarding health homes in

health and community mental health settings)

Primary care/behavioral health integration (both directions)

Centers of Excellence on Depression (up to 10, if funded)

Specific work, with HRSA, re post‐partum depression; and Centers of Excellence for Depression

Work on home visiting program and other initiatives

What Are Some Implications for Your Systems of Care?

Support states, providers, individuals and families to understand the changing environment

Prepare to expand both access and capacity to provide mental health and substance use services (workforce)

Facilitate linkage with primary care and other providers

Identifying services that comprise a “good” and “modern” mental health and addiction system:

Develop (new?) services that be used by providers in the insurance exchanges : consumer‐driven/ consumer-operated, wraparound

services

evidence-supported and data-driven approaches

foundational work (prevention, housing, trauma)

More Implications for Your Systems of Care

Develop strategies to improve infrastructure (data systems, HIT)

Developing quality measures for behavioral health that can be used for purchasers

recognize funding changes and conform grant spending to leverage sustainable financial support for the full range of services and supports for individuals and families in their recovery and resiliency efforts

Look for opportunities to involve yourselves strategically in collaborations around implementation (e.g. workgroups) at community and state levels.

Let’s all commiserate with and learn from one another.

Some Reference Tools for You

Gaining a sense of mastery amid the high level of activity surrounding implementation of these new laws may require your communities to attend to, seek out, learn and retrieve a lot of information!

So let’s not waste any time in setting you up with a few information resources…

http://www.healthcare.gov/ “Take health care into your own hands”

Find Insurance Options Learn about Prevention Compare Care Quality Understand the New Law Information for You:

→ Families with Children→ Individuals→ People with Disabilities→ Seniors→ Young Adults→ Employers 

The DHHS Family of Agencies

OS - Office of the Secretary ACF - Administration for Children & Families (Child Welfare) AoA - Administration on Aging AHRQ - Agency for Healthcare Research & Quality ATSDR - Agency for Toxic Substances & Disease Registry CDC - Centers for Disease Control & Prevention CMS - Centers for Medicare & Medicaid Services FDA - Food & Drug Administration HRSA - Health Resources & Services Administration IHS - Indian Health Service NIH - National Institutes of Health OIG- Office of Inspector General SAMHSA - Substance Abuse & Mental Health Services

Administration

DHHS Grant Information:http://www.hhs.gov/grants

Find Grant Opportunities Find available HHS grant opportunities (Grants.gov) Search/browse forecasted HHS grant opportunities (GrantsForecast) Find funding opportunities for Faith-Based & Community Organizations

(FBCI)

Learn to Manage HHS Grants Use these Tips for Preparing Grant Proposals Find HHS grant management information Learn about the HHS Grants Management Process

See Grants Awarded by HHS and Other Agencies Locate Grant award information (TAGGS): Grants By Major Activity Type Grants By HHS Operating Division Grants By Recipient Class

Questions?

TA Partnership – www.tapartnership.org

Frank Rider – frider@ffcmh.org

Supplement #1CHIPRA REQUIREMENTS RE DIVERSE

POPULATION

Reverses the requirement that immigrant children and pregnant women must reside legally in the United States for five years before obtaining coverage under CHIP. States that cover legal immigrants regardless of entry date are now be eligible for a federal match.

Changes to the citizenship documentation process: CHIPRA requires states to insure children while citizenship is verified. States that upgrade their electronic data systems to interface with the

Social Security Administration's citizenship information are now eligible for a 90 percent federal match for the expenses associated with the upgrade.

Increase in federal matching rate for translation, interpretation services: States are eligible for a 75 percent match to provide translation and

interpretation services associated with the delivery of medical care and outreach.

Supplement #2HEALTH CARE REFORM FINANCING

NOTES

Tax credits for small businesses offering coverage (2010)

Tax credits for individuals purchasing insurance Vouchers for low‐income individuals not eligible for

Medicaid to purchase insurance through exchanges Increased Medicaid and commercial insurance funding

of mental health and substance abuse services Allows SAMHSA block grant and grant dollars to be

focused on recovery and other support services not paid for through insurance benefit

Supplement #3

(continued on next slide)

MH PARITY REGULATIONS

The interim final regulations to enforce MHPAEA (2008) are effective now, and say:

Financial requirements (such as deductibles, copayments, coinsurance and out of pocket limitations) applicable to MH/SUD benefits can be no more restrictive than the predominant financial requirements applied to substantially all medical/ surgical benefits

The regulations apply this test to six classifications of benefits on a classification‐by‐classification basis: In patient – in network In patient – out of network Out patient – in network Out patient – out of network Emergency care Pharmacy

Supplement #3

(continued on next slide)

MH PARITY REGULATIONS (continued)

Treatment Limitations mean limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment

The regulation clarifies that there may be both quantitative and non-quantitative treatment limitations, and provides rules for each

Since they are similar to financial requirements, quantitative treatment limitations are subject to the same general test as the financial requirements discussed above

Because non‐quantitative treatment limitations (such as medical management standards, formulary design, and determination of usual/ customary/reasonable amounts) apply differently, the regulation includes a separate parity requirement for them.

Supplement #3MH PARITY REGULATIONS (continued)

Parity with respect to Out of Network Benefits: If a plan or issuer that offers medical/surgical benefits on an

out‐of‐network basis also offers MH/SUD benefits, it must offer the MH/SUD benefits on an out‐of‐network basis as well.

Single Deductible between MH/SUD benefits and medical/surgical benefits

Transparency: MHPAEA requires that the criteria for medical necessity

determinations with respect to MH/SUD benefits must be made available to any current or potential participant, beneficiary, or contracting provider upon request

MHPAEA also provides that the reason for any denial of reimbursement or payment for services with respect to MH/SUD benefits must be made available, upon request or as otherwise required, to the participant or beneficiary.

Supplement #4SAMHSA’s TEN STRATEGIC INITIATIVES

(2010)

1. Prevention of Substance Abuse and Mental Illness

2. Trauma and Justice

3. Military Families—Active, Guard, Reserve, and Veteran

4. Health Care Reform

5. Housing and Homelessness

6. Jobs and Economy

7. Health Information Technology for Behavioral Health Providers

8. Behavioral Health Workforce—Primary and Specialty Care Settings

9. Data, Quality, and Outcomes

10. Public Awareness and Support