Health Care Reform: Provisions Related to Mental Illness

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Health Care Reform Provisions Related to Mental
Illness Substance Use Disorders

• Charles Ingoglia
• Vice President, Public Policy
• National Council for Community Behavioral
  Healthcare

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Pending Bills

• House 3 bills reported from 3 committees
• Each slightly different
• HR 3200
• Senate 2 committees
• HELP Committee reported a bill in July
• Finance Committee Framework issued 9/8
• Administration outline very general, follows
  approach that is common in all bills

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Outline of All Proposals

• Universal coverage (95 or so covered) through
• Employers insurance
• Health plan through a health care exchange system
• Medicaid expansions
• Medicare or other government program
• Health insurance reforms
• Quality of care prevention cost containment
  provisions
• Medicaid block grant amendments included

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End Result

• More public MH system-eligible individuals will
  have coverage under Medicaid and private
  insurance
• States will need to expand capacity considerably
  to meet demand
• For IP and basic OP, individuals might choose to
  go outside public system
• How to coordinate when they need additional
  services may become an issue

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Exchange/Gateway System

• All federal bills are relying on a system of
  Exchanges (Gateways in HELP bill) to
• Facilitate access and choice of plan
• Act as a broker for purchase of insurance
• House bill sets up national Exchange allows
  states to set up own or to join together in
  regional Exchanges
• Senate Finance and HELP bills set up state-level
  Exchange (called Gateways in HELP bill)

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Medicaid Eligibility

• Medicaid eligibility expanded (effective 2013 in
  House 2014 in Finance proposal)
• All individuals with incomes under 133 of
  poverty would be eligible (Hs and Finance)
• This is includes single adults with no children
  many of whom are people with SMI
• States must maintain current eligibility rules
  until Exchange is operational

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Impact of Medicaid Expansion

• The uninsured population is primarily low-income
  and many have significant health care needs
• ".....one in five (20) reports a mental health
  problem, such as depression, bipolar disorder,
  autism, dementia, schizophrenia or psychosis.
• Source Medicaid as a Platform for Broader Health
  Reform Supporting High-Need and Low-Income
  Populations, Kaiser Commission on Medicaid and
  the Uninsured, May 2009

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Impact of Medicaid Expansion

• Further Analysis Reveals
• Fully 2.8 million have conditions severe enough
  that they require the intensive services provided
  by specialty multi-service mental health
  organizations like community mental health
  centers.
• This would increase the number of persons served
  in America's public mental health system by 50.
• Source Unmet Mental Healthcare Needs of
  Indigent, Uninsured Americans.
• National Council for Community Behavioral
  Healthcare, July 2009

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Medicaid Requirements HR 3200

• States must keep eligibility rules in place on
  June 16, 2009
• Full federal assumption of costs of the newly
  enrolled (ie up to 133 poverty)
• Require states to enroll new eligibles
• Require states to enter into MoU with the Health
  Insurance Exchange to coordinate enrollment
• Require states to implement other changes in
  bill, such as increased primary care provider
  rates, quality improvement and program integrity
  measures

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Medicaid Requirements Senate

• Finance Committee
• Most newly eligible adults do not get full
  Medicaid coverage
• Only a benchmark benefit package (consistent with
  DRA law)
• Benchmark will at least meet requirements for
  Exchange plan at second (Silver) level
• Adults and children exempted from mandatory
  benchmark enrollment by current law would
  continue to be exempt (PD, medically frail
  special needs)
• Higher federal match for newly eligible group

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Medicaid Amendments HR 3200

• Clarifying amendments
• For juveniles, Medicaid eligibility is suspended
  when in correctional facilities (not terminated)
  Medicaid prevention services, no cost-sharing
• Medicaid plans must cover certain prevention
  services, including tobacco cessation products

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Medicaid Proposals in the Senate

• DSH payments phased down as uninsured numbers
  drop
• New State Plan Option Medical homes for
  beneficiaries with Chronic Illnesses.
• Includes Persons with SMI and CMHCs
• Enhanced FMAP (90 for 2 years)
• Therapeutic Foster Care explicitly allowed and
  defined (also in House bill)

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SCHIP

• HR 3200 terminates SCHIP once provisions of
  reform are in place
• Finance requires states to maintain SCHIP
  eligibility levels thru 2012
• SCHIP income floor set at 250 of FPL
• Beginning 2013, SCHIP beneficiaries enroll in
  Exchange plans with state wraparound that must
  include EPSDT benefits

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Low Income Subsidies

• House bill
• Premium subsidies, sliding scale, for individuals
  up to 400 FPL
• Tax credits for out-of-pocket costs
• Limit 5,000/individuals (10,000/family) on
  total premium out-of-pocket cost sharing
• Finance
• Tax credits on sliding scale for those up to 300
  FPL start in 2013 for those 100-300 in 2014
• Cost-sharing assistance (based on type of plan
  chosen) for those up to 300 FPL
• Those below 300, cap on out-of-pocket at
  2,000/yr

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Purchasing Insurance

• Uninsured and small businesses purchase through
  Exchange/Gateway
• Individuals get some help in choosing plan
• Information provided, including toll-free line
  and web pages
• Requirements that all materials be understandable
  and allow easy comparison of plans
• Navigators authorized in HELP bill
• Ombudsman at state level

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Choice of System for Some

• Uninsured and small businesses purchase through
  Exchange/Gateway
• Individuals get some help in choosing plan
• Information provided, including toll-free line
  and web pages
• Requirements that all materials be understandable
  and allow easy comparison of plans
• Navigators authorized in HELP bill
• Ombudsman at state level

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Insurance Plan Requirement

• Benefits
• Outlined in bills, details thru admin action
• MH and SA mandated in all bills
• Rehabilitation and habilitation in House bill and
  Senate HELP bill
• All children get EPSDT benefit (House bill)
• House bill MH and SA must be at parity
• HELP/Finance Parity only applies to firms with
  50 employees

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Insurance Reforms

• Insurance reforms
• Guaranteed issue and renewal
• No pre-existing condition exclusions
• No lifetime or annual limits ()
• No discrimination on basis of mental or physical
  disability or health status
• Premiums standardized (can vary only by limited
  amount and only based on few factors (age,
  geography, family size, tobacco use).

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Coverage Requirements

• Individuals required to have acceptable coverage
  (penalties imposed, with financial hardship
  exception)amounts vary by bill
• Employers required to have coverage or pay and
  contribute some minimum of costs (varies by
  bill, 60-72.5) or pay penalty
• Exemptions and subsidies available to small
  employers

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Provisions we Like

• Community Living Assistance Services and Supports
• Synopsis This section creates a new national
  insurance program to help adults who have or
  develop functional impairments to remain
  independent, employed and stay a part of their
  communities. Financed through voluntary payroll
  deductions (with opt-out enrollment similar to
  Medicare Part B)

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Provisions we Like

• Mental and behavioral health education and
  training grants Grants are awarded to schools
  for development, expansion, or enhancement of
  training programs in social work, graduate
  psychology, professional training in child and
  adolescent mental health, and pre-service or
  in-service training to paraprofessionals in child
  and adolescent mental health. ( 436)

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Provisions We like

• Senator Jack Reed offered amendment 200 during
  Committee that was passed 14-9
• Community-based mental and behavioral health 50
  million for coordinated and integrated services
  through the colocation of primary and specialty
  care in community-based mental and behavioral
  health settings.

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Substance Use and Mental Health Provisions HR
3200

• Includes Outreach activities to educate
  individuals about Exchange program to include
  those with mental illness
• Auto-enrollment - Individuals who are eligible
  for the Exchange are automatically enrolled in
  appropriate Exchange-participating health
  benefits plan.

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Substance Use and Mental Health Provisions HR
3200

• Discount pharmaceutical pricing (340B) expanded
  to mental health and addiction treatment
  organizations
• Licensed Professional Counselors and Marriage and
  Family Therapists covered in Medicare, Rural
  Health Clinics, and Federally Qualified Health
  Centers
• Promotes the coordination of health services
  (inc. MH) through medical homes and Accountable
  Care Organizations
• Awards grants to mental health professional
  training programs

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Energy and Commerce Committee - amendment

• Amendment offered by Reps. Eliot Engel (D-NY) and
  Doris Matsui (D-CA)
• Creates Federally-Qualified Behavioral Health
  Centers to be certified by SAMHSA.
• First step in the development of national
  standards and benefits for these entities.

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FQBHC- amendment

• Build on definition over time to gain same
  benefits available to Federally Qualified Health
  Centers
• mandatory Medicaid status
• cost-based reimbursement

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State MH Impact of Insurance Expansion

• Individuals over 400 of poverty but who need
  public mh services
• Public agencies can bill private insurance for
  basic care IP, OP therapy and medications (MH
  SA)
• Possibly also partial hospitalization or
  residential treatment
• Unlikely that additional coverage will be
  available
• Nonetheless, new income to public programs

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End Result

• More public MH system-eligible individuals will
  have coverage under Medicaid and private
  insurance
• States will need to expand capacity considerably
  to meet demand
• For IP and basic OP, individuals might choose to
  go outside public system
• How to coordinate when they need additional
  services may become an issue

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Some Danger Going Forward

• SMHAs will need to hold on to current funding as
  legislatures may see opportunity to withdraw
  funds
• Federal advocates will have to ensure SAMHSA
  funds are similarly maintained

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National Council for Community Behavioral
Healthcare

• www.thenationalcouncil.org
• ChuckI_at_thenationalcouncil.org

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