Mental Health and SUD: Opportunities in Health Reform

1. Mental Health and SUD: Opportunities in Health Reform Barbara Edwards, Director Disabled and Elderly Health Programs Group Center for Medicaid, CHIP, and Survey & Certification Centers for Medicare & Medicaid Services October 14, 2010

2. CMCS and Behavioral Health • Medicaid is the largest payer for mental health services in the United States • In 2007, Medicaid funding comprised 58% of State Mental Health Agency revenues for community mental health services • Comprehensive services available through Medicaid; many are optional under Medicaid so state’s have considerable flexibility in benefit design

3. Medicaid MH/SA Service Users Source: SAMHSA

4. Medicaid Expenditures for MH/SA Service Users Source: SAMHSA

5. MH/SUD: DEHPG Goals • Federal policy supports the offer of effective services and supports • Improved integration of physical and behavioral health care • Person-centered, consumer-directed care that supports successful community integration • Improved accountability and program integrity to assure Medicaid is a reliable funding option

6. A System of Coverage Medicaid/ CHIP Exchange Employer Coverage

7. Affordable Care Act: Sources of Coverage Under Age 65 (2019) 24m 51m 22m 25m 159m Source: Congressional Budget Office, March 2010

8. New Paradigm Not a “safety net” but a full partner in assuring coverage for all Eligible = enrolled Essential to make a systemout of different components to achieve coverage, quality and cost containment objectives

9. Newly Eligible Individuals • An estimated 5.4 million people that are currently uninsured with a MH/SUD problem would gain coverage under the ACA • 50% of those individuals likely to be served Medicaid. Donohue J, R Garfield, and J Lave, “The Impact of Expanded Health Insurance Coverage on Individuals with Mental Illnesses and Substance Abuse Disorders” ASPE Report April 2010.

10. Benefit Design Issues • The new Medicaid expansion population must receive benchmark or benchmark-equivalent coverage • Benchmark plans: comparable to Federal Employee Blue Cross/Blue Shield Health Benefits, State’s employee health insurance plan, or State’s largest commercial HMO plan • Benchmark equivalent: Actuarially equivalent to above plans

11. ACA and Benchmark Plans • In 2014, benchmark and benchmark equivalent plans must begin providing at least “essential health benefits” (section 1302 (b)) • “Mental health and substance use disorder services, including behavioral health treatment” are included as a category within “essential health benefits” • MHPAEA/MH Parity applies • Secretary will issue guidance

12. Medicaid for ABD • New eligibility option not available to those eligible for SSI or those 65 years of age and older • New benchmark plan does not change state options regarding “traditional” Medicaid, including ABD

13. ACA: Medicaid Behavioral Health • Provides new state plan and grant opportunities that include opportunities to address mental health and/or substance use disorder • Implementation teams within CMCS seek to engage stakeholders • Engagement strategies vary, based on topic, timetable

14. ACA: Medicaid Behavioral Health • 1915 (i) – waiver-like services offered under State Plan Option (10-1-2010) • Can target populations • Adds additional service, income options • Extends and expands Money Follow the Person • Enhanced FMAP available through 2016 • Enables a new solicitation

15. ACA: Medicaid Behavioral Health • Health home, chronic conditions (1-1-2011) • MH, SUD are conditions that are eligible • Enhanced FMAP for 8 quarters • State/SAMHSA collaboration • Community First Choice (10-1-2011) • Enhanced FMAP for Community attendant services • Balancing Incentives Program (10-1-2011) • Enhanced FMAP for HCBS for 5 years

16. Non-ACA Priority Provisions • MHPAEA/Mental Health Parity - applies to Medicaid managed care plans (MCOs), CHIP State Plans, and benchmark plans • Targeted Case Management option – final regulations • Rehabilitation option

17. Opportunity for System Transformation • This is a time of unprecedented opportunity to transform the system of care for individuals with disabilities • CMS’ new Administrator, Dr. Donald Berwick, M.D., has articulated how this transformation can be achieved…

18. The “Triple Aim” Population Health Per Capita Cost Experience Of Care

19. The Foundation for a Redesigned Service System for Individuals with Chronic Conditions

20. Person Centered • Person centered plans of care • Individuals and people important to them • Functional assessments • Individual’s experience of care

21. Individual Control • Choice • Self-direction through both waivers and state plan options • EHR • Education, Information

22. Quality • CHIPRA and Adult Quality Measures • Quality Improvement Program development • Quality reporting imbedded in new HCBS services

23. Integration • Single entry point/no wrong door (ADRC funding) • Models of integration • primary, acute, LTC • behavioral health and physical health • Medicare and Medicaid

24. “Good and Modern” • CMCS is very interested in SAMHSA’s initiative • Looking for new opportunities to collaborate to encourage effective Medicaid coverage and services