Transcript Mental Health Parity, the ACA, & Californians with Mental

Mental Health Parity, the ACA,
& Californians with Mental
Health Challenges
What this training will cover
I. Stigma Faced by People with Mental Health
Disabilities
II. Overview of Mental Health Parity –Existing
Federal & State Laws
III. Overview of the Affordable Care Act – New
Federal and State Laws
IV. Intersection of Parity & ACA in California
V. How the Laws Can Reduce Stigma and
Discrimination
Stigma
Stigma faced by people with
mental health challenges
Stigma refers to attitudes and beliefs that
lead people to reject, avoid, or fear those
they perceive as being different.
Discrimination faced by people
with mental health challenges
Unjust deprivation of rights and
opportunities due to stigma
- exclusion or marginalization of people
- denial of equal health / insurance benefit
- less chance of full participation in life
What is mental health parity?
Parity ends disparity or unequal
physical and mental health
insurance coverage
Parity = Equality
Examples of No Parity
Equality of Copayments
Equal Treatment Lengths
1. Different levels of co pays
are banned
2. $15 for outpatient
physical health visit
3. $20 for outpatient mental
health visit
1. Different levels of an
treatment limits are
banned
2. 21 inpatient days for
mental health care
3. 30 inpatient days for
physical health care
California Mental Health
Parity Act
Health care plans issued, amended or
renewed on or after July 1, 2000 provide
coverage for the diagnosis and treatment
of specified mental health conditions under
the same terms and conditions applied to
other medical conditions.
Cal. Health & Safety Code § 1374.72(a)
People protected under CA
parity
- Children with serious emotional disturbances
- People with serious mental illnesses (SMI),
which are defined to include: schizophrenia,
schizoaffective disorder, bipolar disorder,
major depressive disorders, panic disorder,
obsessive-compulsive disorder, pervasive
developmental disorder or autism, anorexia
nervosa, bulimia nervosa
Cal. Health & Safety Code § 1374.72(d)
Equal terms and conditions
Include but not limited to the following:
1. maximum lifetime benefits
2. copayments
3. individual and family deductibles.
Cal. Health & Safety Code § 1374.72(c)
Benefits that must be provided
Include:
1. outpatient services
2. inpatient hospital services
3. partial hospital services
4. prescription drugs, if the plan contract
includes coverage for prescription drugs.
Cal. Health & Safety Code § 1374.72(b)
All “medically necessary”
treatment
9th Circuit found that California parity law
requires that a health plan provide all
“medically necessary treatment” for “severe
mental illnesses,” such as: residential care
for an individual with anorexia
Harlick v. Blue Shield of California 686 F.3d 699 (2012)
Federal parity law
Paul Wellstone and Pete Domenici Mental
Health Parity and Addiction Equity Act of
2008
Federal parity regulations
Equal financial requirements and
treatment limitations between mental
health / substance abuse disorder benefits
and medical/surgical benefits.
See: 26 CFR Pt. 54 (DOT), 29 CFR pt 2590 (DOL), 45 CFR Pt 146 (DHHS), Federal
Register, Vol 78, No.219 68240-68296 (Nov. 13, 2013) [Final Rules Under the Paul
Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008]
Equal terms and conditions
- Quantitative: co-pay, deductibles, number
of visits, lifetime caps
- Non-quantitative: utilization review,
formulary design, step therapy
See: 26 CFR Pt. 54 (DOT), 29 CFR pt 2590 (DOL), 45 CFR Pt 146 (DHHS), Federal
Register, Vol 75, No.21 5410-5451 (Feb. 2, 2010) [interim final rules under the Paul
Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008]
CA & Federal Parity Laws
Specified Diagnoses
Specified Benefits
CA Federal
Y
N
Y
N
Federal parity law requires equality if any
mental health or substance use disorder
benefits are covered.
Federal parity: 6 benefit classes
1.
2.
3.
4.
5.
6.
inpatient, in-network
inpatient, out-of-network
outpatient, in-network
outpatient, out-of-network
emergency care
prescription drugs.
See: Federal Register Vol. 75, No. 21 5413
Benefit coverage
by federal parity
Coverage provided for mental health and
substance abuse disorder benefits in each
classification in which medical/surgical
coverage is provided.
See: Federal Register Vol. 75, No. 21 5413
Do federal parity rules define
inpatient, outpatient or
emergency care?
No. Fed parity regulations say plan terms
defining benefits must be consistent with
generally recognized standards of medical
practice. Plan must apply terms uniformly.
See: Federal Register Vol. 75, No. 21 5413-5414
What is the Affordable Care
Act (ACA)?
The Patient Protection &
Affordable Care Act of 2010
(ACA) = “Obama-Care”
What are the goals of the
Affordable Care Act?
Goal 1: Strengthen Health Care
Objective A: More secure coverage for those insured &
extend affordable coverage to uninsured
Objective B: Improve healthcare quality and patient safety
Objective C: Emphasize primary and preventive care linked
with community prevention services
Objective D: Reduce the growth of healthcare costs while
promoting high-value, effective care
Objective E: Ensure access to quality, culturally competent
care for vulnerable populations
Objective F: Promote the adoption and meaningful use of
health information technology
Source: http://www.hhs.gov/secretary/about/goal1.html [includes other goals]
How does ACA extend affordable
coverage to the uninsured?
How does ACA extend affordable
coverage to the uninsured?
1. Public Medicaid (Medi-Cal in California)
Expansion
2. Private Plans on health insurance
“Exchanges”
a. Individual Mandate
b. Employer Mandate
Will Medi-Cal expand?
California plans to increase Medi-Cal
eligibility to single, childless adults up to
138% of federal poverty level
Source: Committee No. 1 Health & Human Services, Assembly Budget Committee (3/6/13) at:
http://abgt.assembly.ca.gov/sites/abgt.assembly.ca.gov/files/March%206%20%20Affordable%20Care%20Act%20Medi-Cal%20Expansion.pdf
Benefits of Medi-Cal Expansion
1. Insure over 1 million Californians
2. 100% fed $ for 3 yrs, then over 4 yrs up to 10% state match
3. More insured people improves public health for all in CA
4. Infuses millions, possibly billions, of fed $ in CA
5. Insure more people nationally = market stability & cost control
Source: Committee No. 1 Health & Human Services, Assembly Budget Committee (3/6/13)
What are health insurance
Exchanges?
What are Health Insurance
Exchanges?
Organizations set up to help individuals
and small businesses purchase health
insurance policies
“Covered California” is the exchange in CA
What is the individual mandate?
Most Americans must get health coverage
Penalty phased in 2014 through 2016
Exempts certain individuals
What is the employer mandate?
ACA responsibilities apply to employers
with 50 + employees
Penalty for failure to offer minimum
essential coverage to employees
Implementation in 2015
Other ACA provisions include
1. Subsidies
2. Pre-existing condition coverage
3. People under age 26 covered on
parental insurance
Source: http://www.hhs.gov/secretary/about/goal1.html
Intersection of Mental Health
Parity & the ACA for Californians
with Mental Health Challenges
ACA Plans must comply with
federal parity law & provide 10
“essential health benefits”
Essential benefits
1. Ambulatory
2. Emergency
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services
6. Prescription drugs
7. Rehabilitative & habilitative
8. Laboratory
9. Preventative, wellness, chronic disease management
10. Pediatric services, including oral and vision care
See http://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.html
California has adopted Kaiser
HMO Plan as benchmark
Includes following mental health coverage:
– Outpatient mental health services
– Inpatient hospital and intensive psychiatric
treatment programs (includes crisis residential
treatment)
CA benchmark coverage
Services are for the diagnosis or treatment
of Mental Disorders…identified as a
"mental disorder" in the Diagnostic and
Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision (DSM) that
results in clinically significant distress or
impairment of mental, emotional, or
behavioral functioning.
Kaiser Small Group HMO Plan 1637, Plan 30-N, p.33 (Aug. 15, 2011)
Medi-Cal Expansion
1. Provide same array of mental health
services to individuals currently eligible:
Specialty Mental Health Services
2. Provide benchmark /10 essential health
benefits
Parity & ACA can reduce
stigma and discrimination
“Stigma is the most formidable
obstacle to progress in the arena
of mental illness and health.”
Prevention & Wellness Care
1. Help people recognize early signs
2. Connect with support and services
3. Improved Outcomes a. Reduce homelessness
b. Increase employment
c. Avoid unnecessary criminal justice
involvement and hospitalization
Rehabilitation & Recovery
1.
2.
3.
4.
5.
Individualized Services
Peer Support
Self-Help or Consumer-run Services
Cultural & Linguistic Competence
Improved Outcomes a. Help people attain their goals
b. Support living in most integrated setting
Policy Paper on Recovery-Focused
Hospital Diversion & Aftercare
1. Best practices on pathways to home &
community services
2. Cost and quality analysis of model crisis
alternatives to hospitalization
3. Recovery-based policy recommendations
4. Coordination between private plans and
the public mental health system
Alternatives to Acute Hospital
-
Outreach / Prevention
Crisis Lines / Crisis Clinics
Mobile Crisis Intervention
Crisis Stabilization Units / Urgent Care Units
Crisis Residential Treatment Facilities
Crisis Respite
Integrated Services
–
–
–
–
Full Service Partnership (FSP)
Assertive Community Treatment (ACT)
Wraparound
System of Care
Disclaimer
This area of the law is rapidly developing.
These provisions are not intended to
include all federal and state laws,
regulations, policy directives or other
relevant references. Further legal research
is required. The intent here is to provide a
general overview of these topics.
Disability Rights California is
funded by a variety of sources, for a
complete list of funders, go to
http://www.disabilityrightsca.org/
Documents/ListofGrantsAndContracts.html.
CalMHSA
The California Mental Health Services Authority
(CalMHSA) is an organization of county governments
working to improve mental health outcomes for
individuals, families and communities. Prevention and
Early Intervention programs implemented by CalMHSA
are funded by counties through the voter-approved
Mental Health Services Act (Prop 63). Prop. 63
provides the funding and framework needed to expand
mental health services to previously underserved
populations and all of California’s diverse
communities.