NATIONAL HEALTH REFORM:ADDICTION AND BEHAVIORAL

HEALTH FUNDING OPPORTUNITIES

LA CHAMPS Community and Interfaith Partnership ConferenceCalifornia EndowmentSeptember 30, 3011Suzanne Gelber Rinaldo, MSW, Ph.D., President, Avisa Group

OVERVIEW: REASONS FOR REFORM Lack or incompleteness of health insurance coverage today: Estimated

50 M without health insurance, (21% of adults, 15.3% of total population) (NHIS, 2009); addiction and mental health benefits often not provided at parity with medical conditions despite laws

Arbitrary restrictions, limited coverage for addiction and behavioral health, administrative inefficiencies and mysterious policies and procedures amongst many insurers

Increasing care access and income/outcome disparities for lower income children and families, including avoidable illness and mortality due to substance use and behavioral health disorders

Health care now 17% of US economy, costs forecast to be 20% by 2020 Public health safety net systems and facilities, including emergency

care, overall health, addiction treatment and MH, widely seen as strained, fragmented, dated, constant funding and staff shortages but growing demand from public

Rapidly increasing costs of public and private healthcare but fewer related improvements in outcomes; current system does not compare well to other national healthcare systems with lower expenses

Inadequate coverage for and attention to family and community public health and prevention initiatives, payment reforms, innovations

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FEDERAL, STATE, COUNTY AGENCIES CHANGING: OPPORTUNITY INCREASING Major changes occurring in Federal agency organization, staffing

and policy, new emphasis on prevention and integration as well as funding of HIT, integration, innovation, new health homes, insurance exchanges and funding for other innovative initiatives

Health reform causing changes including greater addiction/MH/primary care integration at state, county levels in public sector policy, organization and funding: happening now in CA and Los Angeles

Changes also occurring in SAPTBG block grant; SAMHSA allocating it so that states can use it for non Medicaid services and patients, including recovery support services that Medicaid will not cover

Block grant changes and use of Medi-Cal will free up funding Challenge: proposed State agency leadership, legal, budget,

realignment (AB 109) changes can be distracting to CA/other states and counties health reform implementation

Court challenges continue to reform law, and are affecting state legislatures, agencies and plans ; but changes and regulations are being put in place nevertheless 3

SUD/MH UPCOMING MILESTONES TIMELINE

2011: Temporary High Risk Pools in Place, HIE’s now in development Medicaid State Plan Option Amendments for Health Homes (survey states 2014) Prevention and Public Health Fund, National Prevention, Health Promotion and Public

Health Council School Based Health Centers: Include SUD/MH Incentives for Prevention of Chronic Disease: CMS (Grants FY 2010-14) Community Prevention Transformation Grants Expansion of Home and Community Based Services: CMS Grants to Accredited Programs and MH Organizations to train BH Professionals Dual Eligible Demonstration Grants Begin (go through 2017) Grants awarded from SAMHSA/HRSA/CMS to co-locate primary and specialty SUD/MH

services, including one in Los Angeles

2012 Medicare ACO’s, SNP’s begin under Medicare Begin changes in MH/SAPT Block Grants (SUD/MHBG’s together); now only one

application, still not co-mingled funding

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SUD/MH TIMELINE: UPCOMING CA AND NATIONAL MILESTONES2014 Medicaid Expansion to Childless Adults Under 133% of

FPL – expectation of additional 32 Million Covered; with 5-6 M with SUD/MH needs expected

CA also has expansion waiver up to 400% of poverty; SAMHSA working with CA on how many will need MH/SUD in this population

Managed Care Expected in CA for Most Added Populations ( CMS waivers in place)

Medicaid Benchmark Plans Required to be at Full Addiction/MH Parity

HIE’s expect to be fully operable with qualified health plans and parity, benefit package that include SUD/MH

Challenge: expect significant exchange of patients due to eligibility changes amongst HIE, Medicaid, Other Public Funds, including block grants

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OVERVIEW: MAJOR SUBSTANCE USE DISORDER AND MENTAL HEALTH PROVISIONS OF LAW (PPACA, 3/23/2010)

Achieved inclusion of substance use disorder and mental health services in basic “essential” benefits packages for 2012

All “qualified” plans in upcoming health insurance exchanges (HIE’s) must adhere to addiction/MH Parity (Domenici/Wellstone); implementation underway

Medicaid eligibility expansion up to 133% of FPL and for the first time requires new eligibles to receive essential benefits to include SUD/MH at parity

CMS chronic disease prevention initiatives and grants are to include SUD/MH; SAMHSA consulted on funding

Reform includes SUD/MH professionals in national health workforce initiatives for the first time 6

OVERVIEW: PROVISIONS Medical homes provisions for 2014 lists SUD and MH

service provider organizations among entities eligible for community health team grants; accountable care organizations (ACO’s) that house medical homes may include/contract with SUD and MH specialists

Additional significant provisions of law: Expands Medicaid coverage to estimated 16-32 M more

beneficiaries, including those with SUD and MH diagnoses; governors debating this expansion now and administration has given some flexibility to them

CA temporary risk pool now in place for those with no coverage and pre-existing conditions; enrollment lower than expected nationally but beginning social marketing push

HIE’s to supersede risk pools in 2014 (CA is ramping up) HIE’s will have sliding scale subsidies for individuals and families

up to 400% of FPL in CA Prohibits pre-existing condition exclusions for children and adults Currently requires individuals to be insured or to pay penalty –

individual mandate phased in 2014 if it survives court challenges7

ADDITIONAL IMPORTANT PROVISIONS

Closes Medicare “doughnut hole” for prescription drug coverage

Adult children allowed to retain parental coverage up to age 26 as of Sept 2010; number of children needing MH/SUD not estimated

Some emphasis on co-occurring disorders States receive enhanced FMAP medical

assistance percentages/other subsidies, most beginning 2014-2020, although this is subject of much debate

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CA HEALTH INSURANCE EXCHANGE Already ramping up; had existing temporary high

risk pool to cover uninsured with pre-existing conditions

2-3 M in CA may be eligible for subsidized coverage/Federal tax credits in HIE

Will have selected “qualified” plan contracts with emphasis on quality, outcomes

No denials of coverage for pre-existing conditions including addiction/MH

Expected to cover mostly individuals and small businesses

Implementation/establishment grant in hand Deciding on eligibility and enrollment

determination processes9

ESSENTIAL BENEFITS UNDER MEDICAID, KEY REFORM VEHICLE Benchmark Essential Benefits Package for 2014

Medi-Cal (Medicaid) includes:

Ambulatory care and emergency services Hospitalization including maternity Mental health and substance abuse services Prescription drugs Rehabilitative/Habilitative Services and devices Lab services Preventive, wellness and disease management

services May include medical case management Other services can also be covered but are optional

(some now covered by Medi-Cal and Healthy Families are not considered essential)

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MEDI-CAL BASICS (2009-10, KAISER)

Total Medi-Cal Enrollees: 10, 511,100 % of CA Residents with Medicaid 2010: 29% FMAP CA: 50% Drug Medi-Cal: SUD population carved out of regular

Medi-Cal, not managed care, based on MOU with Medi-Cal, administered by ADP but likely moving to DHCS/DHHS

Covers 5 modalities: Narcotic Treatment, Naltrexone OP, ODF Counseling; Day Care Rehabilitative; Perinatal Residential

Sobky/Smoley case (1994): Federal Court decision re methadone in CA but could affect other SUD/MH/health services under Medi-Cal

133% expansion 2014 affects $14,400 individuals and $29,327 families

Additional expansion in CA waiver up to 400% affects individuals with incomes up to $43,320 and $88,000 for families

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REQUIREMENTS COULD AFFECT ADDICTION/MH, MEDI-CAL AND REALIGNMENT

Must have reasonable and timely standards and processes for eligibility determination and medical necessity determination

Must provide timely (reasonable promptness – no long waiting lists caused by low funding) and equal access to care for covered persons

“Statewideness” in effect/comparability of services and access across all counties required

No arbitrary distinctions in coverage allowed that are based solely on diagnosis, type of illness or condition 12

KEY PROVISIONS: MEDIUM TERM 2012 and Beyond:

States to initiate premium rate review of private plans, using new medical reimbursement technical assistance

Patient-centered Medical homes to be included in Medicaid (not necessarily adjusted as yet for SUD and MH)

Individuals must be covered (individual mandate and guaranteed issue) and must receive benefits summary and coverage information annually

No special “executive” health insurance benefits for the highly compensated only

Medical Loss Ratio Regulated: % of health plan premiums spent on clinical services and QI must be at least 80-85% (medical loss ratio) – below this consumers supposed to receive rebates – much debate, lawsuits

Annual reports required from health plans to HHS starting 3/2012 Guaranteed insurance issue regardless of health or risk status No more pre-existing condition exclusions (including those based on

claims experience, genetic information, disability) No insurance waiting period longer than 90 days Waivers available to states for innovation, new Medicaid waiver

provisions including possible payment reform Note: not all required state activities are supported with Federal

grants; some feel that CA’s costs to implement reform could exceed $1B

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OPPORTUNITIES

Medicaid Under ACA Medicaid eligibility could expand by 20%:

working on estimates of addicted persons/mh newly eligible for Medicaid – could be 32M added to rolls

Currently many eligible are not enrolled; newly eligible and currently eligible who enroll will seriously test Medicaid systems and providers

Medicaid would have changed asset tests, simplified enrollment, simplified eligibility screening, MOE requirements including enrollment and coverage rules to be more restrictive than now before 2019

“Dual eligibles” (most low income seniors and disabled) will have enhanced care coordination under Medicaid and Medicare

Physician fees and procedures fees still set at state levels

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Health Insurance Exchanges HIE’s must certify “qualified health plans” Must have consumer information portals Must have consumer assistance/ombudspersons Must have “consumer friendly” HIT Some argument surrounds cost of reform vs. what it

may save, implementation costs CA Governor and state legislature may have different

take on essentials and priorities of health reform, including provider payment levels and incentives

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Opportunities - Continued

SPECIAL CHALLENGES: OVERALL AND FOR ADDICTION/BEHAVIORAL HEALTH Addiction and MH in certain target populations addressed but not

emphasized overall NCCBH working with SAMHSA; alliances of specialty BH with FQHC’s are

needed but challenging to engineer (FQHC’s may want to hire own employees)

Special rules to qualify as an FQHC if specialty providers want to do that (see HRSA site); FQHC’s may not welcome specialty SUD/MH external providers or contractors

SUD and MH workforces may not meet enhanced credentialing and training requirements imposed by “qualified” plans that subject to their own HIE qualification

Information systems and other infrastructure in behavioral health safety net still inadequate (encourage sharing with those who have infrastructure) however, via SAMHSA, now easily eligible for HIT/other infrastructure funding aimed more at primary care

Need to act “as if”; best chance of success Eligibility changes may move patients back and forth between HIE and

Medicaid Families and individuals need to participate to urge and support greater

emphasis on addiction and behavioral health concerns in primary care16