Mental Health America of WIExpanding What?

Medicaid Benefits Under Health Care Reform

Shel Gross, MPADirector of Public Policy

Learning ObjectivesYou will understand who the new eligibles are under MA expansion and why benefit packages matter.You will understand the range of benefit packages that could be available and the implications for people with mental illnesses.You will be able to identify services that enhance the benefit for people with mental illnesses.

The Expansion Decision PollDefinitely expanding

Definitely not expanding

Im not sure what my state is doing

My state isnt sure what they are doing

The Expansion Decision: The Map

Source: Avalere State Reform Insights, Updated February 25, 2013

First Do No HarmMaintenance of Effort

States must continue current coverage of adults until Jan 1, 2014 and for kids to Sept. 30, 2019

47 states set Medicaid/CHIP eligibility for kids at or above 200%39 states set eligibility for parents below 133%(Kaiser Family Foundation)

Medicaid Contraction is Possible

The New EligiblesAdults without dependent children(childless adults)

Non-disabled, non-elderly, income-based

Original law required coverage up to 133% FPL but this was voided by SCOTUS.

Who Are These Folks?

You Know These FolksMany of these folks are currently served to some degree by the public mental health system or other public systems.

The coverage offered through the expansion can support the public mental health system.

The Coverage GapThe ACA was designed to cover everyone, but if states dont expand MA childless adults under 100%:

Will not be eligible for MedicaidWill not be eligible for premium support in the exchanges (and probably couldnt afford deductibles and copays anyway)

Exchanges: The PollState-run exchange

Partnership exchange

Federally-Facilitated Exchange

Id like to exchange my Governor

Exchanges: The Map

Exchanges: The Map

Exchange BenefitsStates define essential health benefits by selecting a benchmark. They have four options:

Source: The Essential Health Benefits Bulletin, December 16, 2011. Pages 8-9. http://cciio.cms.gov/resources/files/Files2/12162011/essential_health_benefits_bulletin.pdf.

Exchange BenefitsEssential Health Benefitsambulatory patient servicesemergency serviceshospitalizationmaternity and newborn caremental health benefits and substance use disorder servicesprescription drugsrehabilitative and habilitative services and deviceslaboratory servicespreventive and wellness services and chronic disease management pediatric services including oral and vision care

HybridsExpand the Medicaid eligibility but use dollars to purchase commercial health insurance; potentially through the exchanges.

Wisconsin: expand eligibility, but only to 100%; let everyone else use the exchange.Wont receive 100% federal reimbursement.

The Problems With Commercial Plans While there is premium support, deductibles and copays can still be significant.Wisconsins benchmark plan has a $2000 deductible.100% FPL is about $11,500 for a single person.Expected that those under 133% would be on MA.

The typical benefit package has limited MH/SA coverage; general no psychosocial rehab or care management type services.

The Problems With Commercial Plans The chimera of parity.We know that plans are using prior approval to severely limit access to outpatient services.

Generally fewer consumer protections in private plans.Medicaid has multiple levels of review, including fair hearings.Commercial insurers dont get habilitation.

Habilitative ServicesCommercial insurers familiar with rehabilitation:Restoring lost functioning

But for some people with a mental illness certain functions may not have been learned prior to onset.

And an important aspect of treatment is maintaining functioning and reducing likelihood of deterioration.

Habilitative ServicesAccording to the final rule issuers can do either:

provide parity by covering habilitative services benefits that are similar in scope, amount, and duration to benefits covered for rehabilitative services; or

(2) decide which habilitative services to cover and report on that coverage to HHS

Habilitative ServicesHabilitative services means health care services, therapies and devices that are designed to assist individuals in acquiring, improving, or maintaining, partially or fully, skills and functioning for daily living

The focus is not on curing the condition but rather on enabling, improving, maintaining or preventing deterioration of a patients capacity to function.

Contact

The Pros of Exchanges Doctors generally get paid more so this might improve access.

Enhances continuity as people go on and off Medicaid; and many do.

Could potentially supplement the private insurance with wraparound Medicaid benefits for people with serious mental illnesses.

The Pros of Exchanges Exchanges should be better able to meet their goals if more people are enrolled.Increases the size of the group and there could enhance competition.Creates a larger pool in which to share risk.

But, if pool is perceived to be at higher risk of illness it could increase costs.

The Medicaid Coverage DecisionFull Medicaid CoverageMust include all EHBs

Use Benchmark PlanMust include EHBsCan offer full Medicaid to a defined population, such as those with SMICan enhance a basic package with psychosocial rehab or related services.(Bazelon)

The Medicaid Coverage DecisionThose on MA due to disability (SSI/SSDI) still get regular Medicaid.

Opportunity to enroll more in these programs as marketing draws folks out of the woodwork.

But pay attention to premiums and copayments as well, which are allowed to be more onerous for individuals receiving services under the benchmark plans.

A.C.T.Psychosocial rehabilitative services for adultsIn Wisconsin: community support programsFor individuals with serious mental illnessesServices include assessment, treatment planning and care management.

A.C.T.Ongoing treatment services:Family, individual, group psychotherapySymptom managementMedication prescription, administration and monitoringCrisis intervention

A.C.T.Supportive psychotherapies and rehabilitative services:

Symptom management groups.Ongoing monitoring of the member's mental illness symptoms and response to treatment. Teaching of behavioral symptom management techniques to alleviate and manage symptoms not reduced by medication. Assisting the member to adapt to and cope with internal and external stresses. Psycho-education with the family on behalf of the member.

Peer Delivered ServicesMedicaid can pay for peers as part of a psychosocial rehabilitative service.Wisconsin has a process for certifying peer specialistsWork in a wide variety of settings

Wisconsin Association of Peer Specialists:http://waops.sharepoint.com/Pages/default.aspx

Peer Delivered ServicesCommunity Recovery ServicesOffering effective recovery-based services; Assisting members in obtaining services that suit that individual's recovery needs; Teaching problem solving techniques; Teaching members how to identify and combat negative self-talk; Lending their unique insight into mental illness and what makes recovery possible; Attending treatment team and crisis plan development meetings to promote member's use of self-directed recovery tools; Assisting members in developing empowerment skills through self-advocacy and stigma-busting activities.

Supported EmploymentActivities necessary to assist individuals to obtain and maintain competitive employment

supported employment intakeassessmentjob developmentjob placementwork-related symptom managementemployment crisis supportfollow-along supports by an employment specialistemployment specialist time spent with the individual's mental health treatment team and VR counselor.

EPSDTEarly and Periodic Screening, Diagnosis and Treatment:

For youth under age 21Screening scheduleScreening should include developmental and behavioral assessments

EPSDTIf condition is identified then service must be provided if allowed under federal law:

In addition to diagnostic and treatment services covered by Wisconsin MA under applicable provisions of this chapter, any services described in the definition of "medical assistance" under federal law, 42 USC 1396d(a), when provided to EPSDT patients, are covered if the EPSDT health assessment and evaluation indicates that they are needed.

EPSDTExamples of optional benefits:

Dental servicesEyeglasses

Wisconsin also covers specific MH services for kids with severe emotional disturbances:

Child and adolescent day treatmentIntensive in-home psychotherapy

Citation SourcesAvalere State Reform Insights: Http://www.avalerehealth.net/products/state_reform_insights/index.php

Explaining Health Care Reform: Questions About Medicaids Role, Kaiser Commission on Medicaid and the Uninsured, April 2012, www.kff.org

Take Advantage of New Opportunities to Expand Medicaid Under the Affordable Care Act, Bazelon Center for Mental Health Law, July 2012, www.bazelon.org

State Refor(u)m: National Academy of State Health Policyhttp://www.statereforum.org/

Federal WebsitesThe Center for Consumer Information and Insurance Oversight:Federal agency with primary responsibility for imlpementation of the ACA http://cciio.cms.gov/index.html

Listing of benchmark plan details:

http://cciio.cms.gov/resources/data/ehb.html#review%20benchmarks

Health Insurance Marketplace: the place where it will all happen:

http://marketplace.cms.gov/

Wisconsin Medicaid ResourcesWisconsin Medicaid Provider Handbook: Community Support Program https://www.forwardhealth.wi.gov/WIPortal/Online%20Handbooks/Display/tabid/152/Default.aspx?ia=1&p=1&sa=11&s=2&c=61&nt=Covered+Services

Wisconsin Medicaid Provider Handbook: Community Recovery Serviceshttps://www.forwardhealth.wi.gov/WIPortal/Online%20Handbooks/Display/tabid/152/Default.aspx?ia=1&p=1&sa=127&s=2&c=61&nt=Covered+Services

Wisconsin Medicaid Provider Handbook: EPSDThttps://www.forwardhealth.wi.gov/WIPortal/Online%20Handbooks/Display/tabid/152/Default.aspx?ia=1&p=1&sa=24&s=2&c=9ORhttps://www.forwardhealth.wi.gov/WIPortal/ ; click on online handbooks under Provider menu on right; choose program Badger Care Plus and Medicaid; select service area.

ContactShel GrossMental Health America of Wisconsin133 S. Butler St., Rm. 330Madison, WI 53703Ph: 608-250-4368Email: shelgross@tds.net

http://www.mentalhealthamerica.net/go/action/policy-issues-a-z/healthcare-reform

*Wisconsin advocates were talking about the Governors decision not to expand Medicaid and discussions with legislators about reversing this. But when I asked if any of them had been talking about what the coverage would be under an expanded Medicaid program the room fell silent. And yet expanding Medicaid without ensuring an adequate benefit package will undermine the potential benefits for people with MI and others.*Its important to understand some things about the expansion and the new eligibles in order to understand why the coverage question is so critical. Its also important to understand about the state exchanges and the benefit package offered there as that may become a default of coverage option as well. The landscape is changing by the week. *So I wanted to begin by seeing where the states represented in todays audience stand with regard to Medicaid expansion.*The fact is that most of you should probably be saying that your state isnt sure what theyre doing. I want to thank Reggie Williams, an MHA Board member who works with Avalere State Reform Insights to being the only person with the chutzpah to attempt a map of these decisions. I know, that while the map shows that Wisconsin will not expand, based on the Governors proposed budget, that there are many in the legislature interested in reversing that. And Florida seems to have the opposite situation. The fact that these decisions are still being debated means that this discussion about benefit packages is still relevant. And they have implications for costs of expanding or not.*Once the exchanges are available states can reduce their Medicaid coverage if it currently exceeds federal requirements. Wisconsin, which has had a generous program, is proposing to move currently eligible adults over 100% FPL (other than pregnant women) into the exchanges. *What is unique about this population is that it is not categorical; its not dependent upon being a person with a disability, aged, or a single person with dependent children. It is income based. SCOTUS=Supreme Court of the United States.**State and local dollars currently used for un-or underinsured are freed up; need to advocate for reinvestment of all or part of this into mental health services.*One reason why the expansion is important. This gap was created by the SCOTUS decision since Congress assumed everyone under 133% would be covered by MA.*So to begin our consideration of the services available we need to talk about the exchanges, or marketplaces, where individuals in small groups or who dont have employer-sponsored coverage, will be able to purchase insurance. So, again, lets see where our audience stands in terms of your state decisions in this area.**Unlike the expansion, the decisions about who will operate the exchange in each state have already been made. *States had options regarding selection of a benchmark plan. You can find out the details of the plan your state has selected by going to the website listed under Federal Websites at the end of the slides.*However, all benchmark plans must contain the 10 essential health benefits. Must be consistent with state-required benefits (or mandates): include only requirements that a health plan cover specific care, treatment, or services. Does not include mandates which require a health plan to reimburse specific health care professionals. So if your state defines certain services under its mandated benefits, like ACT, these must be provided. But state requirements for certain types of providers, such as peer providers, need not be honored.*The landscape is changing by the week. Arkansas was the first state, as far as I know, to propose using the MA dollars to buy people into the exchanges. I dont know whether or not they are planning to cover some part of deductibles and copays as well.*Whether through the exchanges or some other mechanism. *Of course MA can also have restrictive PA processes.**Were concerned theyll do (2) and what they will cover will be very limited. This is an advocacy opportunity with your state insurance commissioner.*An alternative definition.**Youll hear people talk about churning; going on and off Medicaid as a persons circumstances change. Some states grant Medicaid eligibility for an extended period of time (e.g., 6 mos./year) to limit this and provide stability for enrollees and certainty for providers.**So for those who actually receive Medicaid benefits under the expansion the State has various options. Arguably parity requires states to pay attention of the MH needs of the population when crafting the package.**Resource slide at the end provides links to WI Medicaid handbooks that provide more information about services covered in these areas. *

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*Other states certify as well*Services of a certified peer specialist are a unique service under one of our benefits; community recovery services.*As is supported employment. This should be a good selling point as everyone is interested in promoting employment and states will want to support efforts of individuals with disabilities to move off MA.*While eligibility for youth is not altered at this point under the ACA I wanted to note the importance of EPSDT for this population. *So essentially all MA services are covered for this population if identified as needed through this screening process.****These are links to Wisconsin Medicaid handbooks for the services discussed in this webinar. You can find complete information about eligibility and covered services as well as links to applicable statutes and administrative code.*Are remember MHAs website for HCR, where youll be able to find a recording of this webinar and the slide set.