ACA, Realignment of EPSDT, Parity, Mild/Moderate to HMOs It’s a Whole new world, Or is it?

1. ACA, Realignment of EPSDT, Parity,Mild/Moderate to HMOsIt’s a Whole new world,Or is it? Rusty Selix California Council of Community Mental Health Agencies CMHACY 2014

2. ACA and MH Federal Parity • MediCal 100% FFP for low income adults not already eligible through disability or children • Includes TAY – foster care graduates • Eliminates pre existing conditions as barrier to private insurance • Healthy families to MediCal • Full parity for all plans- SUD MediCal

3. MediCal Managed Care Expanded • Covers whatever is medically necessary but does not meet county mental health standard of potential functional impairment (for adults) • Children slightly broader • Medication Management/ Mild/moderate • Plans have formed modest networks • Medicare rates - enough for others • without our members in most counties • Santa Clara providers included at county rates

4. MOUs between counties and plans • Establish screening, assessment, referrals • Right now can vary by county • State and plan standardization likely soon • No one falls between the cracks • One or the other must provide the care • Could have disputes over payments • More will ask plans for care • County responsibilities unchanged

5. Screening and Assessment • No current state requirement for kids • Screening tools by plans and counties • Assessment by MH professional by either • generally by plan • Plan either provides or refers • Referral to county then to provider • Provider authorization from plan or county

6. Higher Costs Under Counties • Commercial contracts have lower overhead • Less documentation required • Other states have similar pattern • Plans still must meet CMS Medicaid rules • State oversight different – what can we learn • State and counties have added requirements • Providers can set up separate corporation

7. Future Structural Changes? • No one is proposing an end to carve out • CMS letter based on audits and lack of action • Service Integration under current financing • Need to learn how plans comply with CMS on billing with much lower costs • Federal Financing structure could change from fee for service to capitation • Might require competitive bidding on all services

8. Goal of Seamless Integration • Screening in primary care • For adults includes SBIRT and PHQ-2 • Children nothing required yet • EPSDT Performance Outcomes to address • Evaluation by health plan • Referrals, co-location or warm hand off • Who will be missed? • What are issues and challenges?

9. End Fail First System? • People currently in public mental health system get referred after hitting a bottom • Special ed, child welfare, juv. justice, hospital • Substantial functional impairment at intake • Almost always SED condition that has been present and diagnosable for years • Mental Health system itself can’t change this

10. Help at First Possible Sign • School mental health partnerships can identify and support all children • Get help years before they need special ed • Primary care and ER see almost everyone • Universal screening and coordination can identify mental illnesses early in their onset • More people will be referred for care • Less disability and less long term costs

11. Nearly All Will Meet County Criteria – my belief • Most common MH treatment is prescription for anti –depressant by primary care MD • Most so called mild – moderate will not result in a referral to MH professional • Most of MH by plans will be medication management for ADHD • I could be wrong

12. Realignment Formula Adjustments • EPSDT and Alcohol & Drug are sub allocation entitlements inside Behavioral Health Account of 2011 Realignment • For future years total growth is adjusted by spending on those programs and each county’s share of growth is adjusted by its utilization of those funds • State still needs to clarify so counties don’t think $$ are capped –letter promised soon • When will state do the allocations?

13. State HHS call to Patrick Gardner • Mike Wilkening Undersecretary called • Closing in on a decision expected in next few days • Memorialized in ACIN - letter to counties • Reimburse counties out of this year's growth account for net expenditures above the total allocation for behavioral sub account programs.   • Expect letter to address considerations for future growth allocations that include: • incentives for EPSDT investment and improving access and performance, probably tied to the POS process.

14. Realignment Growth is Growing • MH share of growth was limited until child welfare got $200 million of growth • Will be met in two years instead of 3 • MH will get larger share of growth from 14-15 • First call on growth to satisfy net growth in EPSDT and Alcohol & Drug • Reduce base for underspending counties • Unclear about adult MediCal • Rest to counties by formula

15. Katie A and Realignment • Implementation starting • $$ were included in realignment • Part of EPSDT • Questions about funding adequacy • Possible augmentation through claim/suit under Prop 30 if it is viewed as new mandate

16. EPSDT Outcomes • Subject matter experts meeting regularly • First phase uses existing data • After that a choice between developing priority additional data like Adult System of Care or build something more comprehensive statewide • Special Katie A requirements • Screening and referral elements

17. Excellence in Mental Health Act • Just passed Congress and signed into law • Part of Medicare payment for MDs law • Creates FQBHC funding intended to approximate federal status for FQHCs • 2017 - 8 States to get 90% FFP for outpatient MH and SUD for SED/SMI for 2 years • Details through 2015 regs and 2016 plans • Could be worth $$ Billions in California • Efforts to make permanent and nationwide

18. Many Terms need to be defined • Can a county be an FQBHC or must certification be for each specific location • What is Serious Mental Illness • What services are covered • Inpatient and residential excluded • Must serve all on sliding scale • does that include undocumented immigrants?

19. Future full of hope and possibility • Screening and early identification seems certain to become a norm • TAY can keep MediCal • Funding picture brighter • Outcomes will improve care • Address paperwork burden? • Coordination and integration growing • Primary Care + Schools + Alcohol and Drug • Opportunity to serve whole family

20. Contact Information Rusty Selix rselix@cccmha.org 916-557-1166 ext. 0 or cell 916-205-7777 Michele Peterson mpeterson@cccmha.org 916-557-1166 ext. 111 or cell 916-217-6431