Title: Paths to Payment under Medicaid: The Web We Weave for Mental
1Paths to Payment under Medicaid The Web We
Weave for Mental Substance Use Disorders
Treatment
Rita Vandivort-Warren Organization and Financing
Branch Div of Services Improvement, CSAT
2MH/SA Treatment is 7.5 Percent of All Health,
2001
SA 1.3 SA 18.3 billion
MH 6.2 MH 85.4 billion
All Health, 2001 All Health 1,372.5 B
MH/SA 7.5 104 billion
3The Proportion of Public Spending in SA Treatment
Grew between 1991 and 2001
All SA, 2001 Public, 76
All Health 2001 Public, 45
All SA, 1991 Public, 62
All SA 11.4 B Public 7.1 B Private 4.3 B
All Health 1,373 B Public 613 B Private
759 B
All SA 18.3 B Public 13.8 B Private 4.5 B
4Private and Public Average Annual Growth Rate,
1991 - 2001
Average Annual Growth Rate
5State Counties Design and Administer 63 of
All SA Spending in 2001
6Public Payments to SA Grew Faster Annual Growth
Rates, 1991 to 2001
Overall SA Growth Rate 4.8
7Private Insurance Over All SA Services,
19922001
8Percent Change in SA Outpatient Services,
19922001
9- Although Medicaid Portion of All MH/Sa Tx
Spending is Large, Especially MH - 27 of all MH
- 19 of all SA
SUD Tx 1.5
MH Svc 10
Medicaid MH/SA as Portion in Total Medicaid
Spending
All Medicaid 225, 511 Billion
10SA/MH of All Expenditures, Each Payer, 2001
Medicaid includes Federal and State Dollars
Other Federal includes VA, DOD, Block Grant etc
22.3
11State Childrens Health Insurance Program (SCHIP)
Facts
- 1997, Title XXI, SCHIP States choose either
Medicaid expansion, separate commercial MCO/HMO
plan with narrow and limited benefits for MH/SA - If Medicaid expansion, EPSDT entitlement
- Separate SCHIP plans,
- No SA requirements weak MH
- no prevention or screening requirement
- medical necessity only to cure not ameliorate
- In 2004, SCHIP enrolled 3.9 million children,
Medicaid 41.3 million children - Deficit Reduction Act Prohibit SCHIP for
childless adults
12SCHIP State Design, 2002
MH/SA Benefits in 36 Separate Programs 16 states
provide MH benefit available through Medicaid
20 states separate benefit, usually both SA and
MH, with limits
13Coverage Limitations for MH/SA for 21 Separate
SCHIP Programs
- States That Have
- Coverage- Limit Day/
- 4 3 (75)
- 17 16 (94)
- 21 20 (95)
- 5 ?
- 6 ?
- 21 19 (90)
- 21 17 (81)
-
- Inpatient Only for Detox
- Inpatient SA Tx Detox
- Outpatient SA
- Opioid Treatment
- Residential Treatment
- Inpatient MH
- Outpatient MH
In 9 of 21 States, Combined MH and SA Benefits
14MH/SA Services Paths to Inclusion Under Medicaid
Coverage
- Waivers and Managed Care Program
- EPSDT for Children and Youth
- Through State Plan Amendment
- Rehab Option
- Targeted Case management
- Other Providers
- Clinic Services
- Collateral Contacts
15Waivers and Managed Care
- Waivers to mandatory enroll Medicaid
beneficiaries - 1915b Waiver
- largely irrelevant as 1997 Balanced Budget
Amendment allowed involuntary managed care
enrollment without waiver if certain consumer
protections - Under 2006 Deficit Reduction Act (DRA), Medicaid
programs need not meet standards of
comparability, statewidedness, freedom of choice
(State Medicaid Director, 3/06, 06-008) - 1915c Home and Community Based Waiver Under 2006
Deficit Reduction Act (DRA), can implement svc
without waivers and now IMD less an obstruction - 1115 Waiver Research support state health
reform i.e. HIFA more states are using,
especially to make special agreements on aspects
that CMS doesnt like IGT, UPL, DSH
16Recent 1115 Waivers Changing Key Medicaid
Elements (C. Mann)
- Conversion to defined contribution (away from
defined benefit) - Annual dollar caps on benefits
- Enrollment caps allowed
- EPSDT waived (in one state)
- Per person and global caps on federal
- Inter Govt Transfer to Certified Public Expenses
(CPE) - DSH into Safety Net Care Fund (SNCF)
- In Waiver Approval Processing
- Closed negotiations between CMS and Gov/State
agency State seeks input, CMS does not - States negotiate to keep - FL in UPL MA in
DSSH - No written rules States ask Did I get as good
a deal?
17 EPSDT Early Periodic Screening, Diagnosis
Treatment
- EPSDT mandate passed in 1969, but expanded in
1989 to explicitly include Mental illnesses
(include SUD) and developmental delays - Must cover all svcs Medicaid pays, even if not in
State Medicaid state plan - When studied MHSA screening instruments, 16
states recommended tool for MH 4 states for SA - Primary care MDs often dont screen because
dont know what to do with a positive screen
build it - Children lt19 y/o in DRA Benchmark Plan
- must have wraparound of EPSDT services state
plan must specify how ensure - Not clear what this includes
18Designing Medicaid 3 options Services,
Eligibility Provider Payments
- MANDATORY SVC
- Inpatient hospital services
- Outpatient hospital services
- Physician services
- Lab/X-ray
- Nursing facility care
- FQHC/Rural health clinic services
- EPSDT services for all children
- Nurse midwife/nurse practitioner
- Family planning services
- Home health care
- OPTIONAL SVC
- Prescription Drugs
- Clinic Services
- Inpatient psychiatric services for individuals
under 21 - Other practitioners
- Collateral Contacts
- Targeted case management
- Diagnostic, screening, prevention and
rehabilitation Rehab Option - Transportation
- Dental, eyeglasses, podiatry
19Rehabilitation Option under Medicaid Through
State Plan Amendment
- Major pathway for including IOP, other community
based and consumer run services - Services can be screening, diagnostic,
prevention, and rehabilitation services - Instead of medical necessity, can be to
maintain functioning or prevent conditions - Still provided by or under supervision of
licensed staff - Define clearly what services are
- Require services must meet specific goals in
individual service plan - Presidents 2007 Budget, stating Medicaid is the
payer of last resort, - REGS redefine allowable costs under Rehab Option
and DSSH, - REGS will prohibit school administrative charges,
transportation costs under IDEA, - LEG change administrative matching rate on
targeted CM to 50
20Use Other Optional Categories covering MH/SA
Providers
- Clinic Services Are diagnostic, therapeutic or
rehabilitative svc under direction of MD Can
incorporate MHSA clinics, non-MD therapist - Other Providers medical or remedial care by
licensed practitioners within scope of practice - Targeted Case management svcs to assist
individuals to get needed tx may be limited to
MH or AIDs/HIV - Collateral Contacts contacts with family members
or other significant others to the person in
treatment
21In 8 States, SA Services in St Plans
Service Rehab TCM Clinic lt21 EPSDT
IOP/PH- 4/8 St FL, GA, IL, VA GA GA, VA
Casemgt 2/8 St GA, SC
Opioid 3/8 St AZ, GA, VT GA
Resident 3/8 St IL, VA, VT IL
- States have latitude in how define the services
under Optional Categories - States can exercise multiple Options for same
service - States have used different Optional Categories to
cover the same service - State optional service definition approved in one
state may not be approved in another
222006 Deficit Reduction Act (DRA)
- Harder to qualify
- Citizen documentation requirement
- Assets transfer look back 5 yrs from 3 yrs
- Greater co-payment under Medicaid
ltFPL 100 -150 FPL gt 150 FPL
Premium N N Y
Cost Share N Y to 10 income Y to 20 income
Not Preferred Drugs Nominal cost share Nominal cost share Up to 20 cost share
- Not pay premium (up to 5 of income) in 60 days,
can terminate - If enforceable, providers can turn clients away
- Not cost share on prevention to kids, pregnancy
svcs, family planning, and proper Emergency Room
svc
232006 Deficit Reduction Act (DRA)
- SChipping away Benchmark Plans, primary care
benefit, - MH (SUD?) 75 actuarial value (with pharm,
vision, hearing) but if benchmark does not
include MH, state need not include - Exempt from participation pregnant, blind, dual,
institutional, foster care, hospice, sp needs
children - If exempt individual opts for Benchmark plan,
state must show informed consent, including
benefits comparison - Benchmark plans guarantee access to FQHC and RHC
- Home and community based without waivers
- Needs based criteria otherwise need institution-
developed by states - Independent assess plan may self-direct
purchase care - Can cap numbers served waitlist for services
- Svc respite care, family support, supported
employment - Targeted case management emphasized medical
service, excludes for CM in child welfare or
foster care seem chg to preclude IDEA
24More DRA Demonstration Programs
- Health Opportunity Accounts similar to under
Medicare, states pre-fund an account that client
self directs care, roll over unspent , retain a
portion if leave Medicaid up to 10 state demos
for 5 yrs requires annual deductible pymt rate
not gt 125 Medicaid rate - Home Com-Based Alternative to Psych Residential
Treatment Facilities for Kids up to 10 states
218 over 5s Demos on cost-effectiveness of
alternatives to child psych residential care
but must meet all HCBS waiver requirements, i.e.
budget neutral - Money Follows the Person Rebalancing for
residents of OCF-MR, hospital, nursing home, or
IMD States awarded will receive up to 90
federal match for home and community based
services but maintenance of effort required - Added 3 to 4 Million dollars annually to expand
the family information centers under maternal
Child Health BG - 07 25 states, 08 40 states, 09
all states - TANF- increased state requirements of work
participation, decrease flexibility
25 Implement FY02 and Planned FY03 Cost Containment
Strategies (Kaiser, 5/2003)
26Covering MH SA Under Medicaid
- Golden Rule Even if build a beautiful system,
State must fund it - CHC/FQHC/RHC, mandated provider, collaborations?
- CMS for IMD, SA is Mental Disorder, Joint MH/SA
Benefits? - Commercial plans dont differentiate MH SA
benefits as SCHIPPing, could follow this
pattern? - DRA flexibility in home and community based
options without waivers or cost effective
formula no comparability, easier to target to
specific disorders - Self directed care and Health Opportunity
accounts more flexible spending on services? - Medicaid another Payer of Least Resort, but
DRA only state options - Cant ignore Medicaid but must also look
elsewhere too