Mental Health America of WI

Expanding What?

Medicaid Benefits Under Health Care Reform

Shel Gross, MPA Director of Public Policy

Learning Objectives

• You 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 Poll • Definitely expanding • Definitely not expanding • I’m not sure what my state is doing • My state isn’t sure what they are doing

The Expansion Decision: The Map

CA OR AK WA NV ID AZ UT State Commitment to Expand Medicaid Eligibility MT WY HI NM CO ND SD NE KS TX OK MN IA MO AR WI LA IL IN MI OH PA WV VA ME NY VT NH MA CT RI NJ DE MD DC KY TN NC SC MS AL GA FL

Will Expand (21) Leaning Yes (7) Leaning No (5) Will Not Expand (16) Undecided (2) Source: Avalere

State Reform Insights

, Updated February 25, 2013

First Do No Harm

Maintenance 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 Eligibles

Adults 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?

• Approximately one in six of uninsured below 133% has a severe mental disorder.

• Many others have less serious mental health conditions.

• Half have incomes below 50% FPL; many are homeless and about one quarter have a serious mental illness.

(Bazelon)

You Know These Folks Many 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 Gap

• The ACA was designed to cover everyone, but if states don’t expand MA childless adults under 100%: – Will not be eligible for Medicaid – Will not be eligible for premium support in the exchanges (and probably couldn’t afford deductibles and copays anyway)

Exchanges: The Poll

• State-run exchange • Partnership exchange • Federally-Facilitated Exchange • I’d like to exchange my Governor

Exchanges: The Map

Exchanges: The Map

Exchange Benefits

 States define essential health benefits by selecting a benchmark. They have four options: One of the three largest small group plans in the state One of the three largest state employee health plans One of the three largest national federal employee health plan options The largest HMO plan offered in the state’s commercial market Source: The Essential Health Benefits Bulletin, December 16, 2011. Pages 8-9. http://cciio.cms.gov/resources/files/Files2/12162011/essential_health_benefits_bull etin.pdf

.

Exchange Benefits

Essential Health Benefits

• ambulatory patient services • emergency services • hospitalization • maternity and newborn care • mental health benefits and substance use disorder services • prescription drugs • rehabilitative and habilitative services and devices • laboratory services • preventive and wellness services and chronic disease management • pediatric services including oral and vision care

Hybrids

• Expand 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.

– Won’t receive 100% federal reimbursement.

The Problems With Commercial Plans

•

While there is premium support, deductibles and copays can still be significant.

– Wisconsin’s 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 don’t get “habilitation.”

Habilitative Services

Commercial 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 Services

According to the final rule issuers can do either:

(1) 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 Services

Habilitative 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 patient’s 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 Decision

1. Full Medicaid Coverage

• Must include all EHBs

2. Use Benchmark Plan

• Must include EHBs • Can offer full Medicaid to a defined • population, such as those with SMI Can enhance a basic package with psychosocial rehab or related services.

(Bazelon)

The Medicaid Coverage Decision

• Those 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 adults • In Wisconsin:

community support programs

• For individuals with serious mental illnesses • Services include assessment, treatment planning and care management.

A.C.T.

•

Ongoing treatment services:

– Family, individual, group psychotherapy – Symptom management – Medication prescription, administration and monitoring – Crisis 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 Services

•

Medicaid can pay for peers as part of a psychosocial rehabilitative service

.

– Wisconsin has a process for certifying peer specialists – Work in a wide variety of settings

Wisconsin Association of Peer Specialists:

– http://waops.sharepoint.com/Pages/default.aspx

Peer Delivered Services

Community Recovery Services

• Offering 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 Employment

Activities necessary to assist individuals to obtain and maintain competitive employment

• supported employment intake • assessment • job development • job placement • work-related symptom management • employment crisis support • follow-along supports by an employment specialist • employment specialist time spent with the individual's mental health treatment team and VR counselor.

EPSDT

Early and Periodic Screening, Diagnosis and Treatment:

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

EPSDT

If 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.

EPSDT

Examples of optional benefits:

• Dental services • Eyeglasses

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

• Child and adolescent day treatment • Intensive in-home psychotherapy

Citation Sources

• Avalere State Reform Insights: Http://www.avalerehealth.net/products/state_reform_insights/index.php

• Explaining Health Care Reform: Questions About Medicaid’s 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 Policy http://www.statereforum.org/

Federal Websites

• The 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 Resources

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

Contact

Shel Gross Mental Health America of Wisconsin 133 S. Butler St., Rm. 330 Madison, WI 53703 Ph: 608-250-4368 Email: [email protected]

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