Update from Washington: ACA Implementation and Funding for SUD Services

1. Update from Washington: ACA Implementation and Funding for SUD Services Gabrielle de la Gueronniere Legal action center October 15, 2013

2. About LAC and the Coalition for Whole Health • Legal Action Center • National law and policy organization that works to fight discrimination against people with histories of addiction, HIV/AIDS, or criminal records • Works for sound public policies in these areas, including policies to ensure access to the full range of needed substance use disorder services • SAAS’s voice in DC • Coalition for Whole Health • A coalition of over 100 national, state, and local organizations working to ensure health reform is successfully implemented for individuals with mental health and substance use disorder needs

3. What We’ll Talk About Today • The federal funding picture • ACA implementation: Ensuring quality SUD coverage and access • Decisions are being made now in state capitals across the country that will impact access to needed MH and SUD services for years to come • The CWH has identified three main priorities for ensuring enrollees can access services • Benefits, parity, network adequacy • We’ll discuss how state-level advocates can influence important policies and what the CWH is doing to assist needed advocacy in the states • CWH toolkit for advocates to facilitate meetings with appropriate state officials

4. Latest on the situation in Washington • Day 15 of the partial federal government shutdown • Closer to a deal in the Senate, unclear what the response will be in the House • Sequestration cuts appear to be back in focus • Due to hit the debt ceiling on Thursday • Continued push by some to delay the ACA; continued unwillingness to agree to any delay by the President • Timeframe and potential next steps • Unclear how things will unfold… • Importance of continued messaging from back home

5. Sequestration in 2014 • Sequestration cuts have been in place since March 2013 • Under current law, the sequestration cuts in 2014 total $109 billion • Even split between defense and non-defense • If Congress fails to agree on appropriations bills that confirm to BCA caps, sequestration cuts begin in January • Impact could be worse than 2013 because agencies are likely to have exhausted reserves and carry-over funds

6. Update on SAPT Block Grant funding • Continued impact of the sequestration cuts • FY 2013 budget and funding process • Upcoming FY 2014 appropriations process and FY 2015 budget process • The role of the SAPT Block Grant as the ACA is implemented • People and services that remain uncovered • Continued advocacy with the administration and Congress • Work with other chronic disease and disabilities groups working to protect safety net funding

7. ACA Implementation Advocacy • Top priorities for the Coalition for Whole Health: • Ensuring all small group and individual market enrollees have access to the full continuum of MH/SUD benefits • Ensuring MH/SUD coverage meets the ACA’s parity requirements and other consumer protections • Ensuring plans have adequate networks of MH/SUD providers to allow access to services without unreasonable delay

8. Plan Certification Health plans must meet a long list of standards to become QHPs that can sell insurance products on the marketplaces Non-grandfathered small group and individual market plans must also meet many of the standards required for marketplace plans States are charged with reviewing plans and taking on additional oversight responsibilities; they need to be paying attention to our issues

9. MH/SUD Benefits • MH and SUD benefits are required essential health benefits • Applies to small group and individual markets • Must be provided at parity with other benefits • All states selected, or had selected for them, a “base-benchmark plan” • Framework is in place to ensure that all EHB categories are covered, even if they are not covered by the benchmark • The benchmark plan is the starting point; the ACA and regulations include some additional protections and allow states and plans some additional flexibility • There will likely be a fair amount of benefit variability across states, and even some variation across plans in a state

10. MH/SUD Benefits • Plans have some flexibility to reduce or even eliminate benchmark-covered benefits, if the state allows it • Coverage must be “substantially equal” to the benchmark • Regulations permit substitution within benefit categories, but give states ability to limit or prohibit substitutions • Any substitutions must be actuarially equivalent • For good or bad, the benchmark is just a starting point • States and regulators should use the framework to ensure plans provide quality coverage in each of the categories, including the MH/SUD category • Plans are required to add in missing benefits under certain circumstances, particularly related to parity and other ACA protections

11. Parity Requirements Small group and individual market plans must meet MHPAEA requirements HHS had made clear that they are relying on states to bring coverage into compliance with the parity requirements Parity oversight needed both at the plan certification and through ongoing plan management Most EHB benchmark plans are small group plans, which haven’t had to comply with MHPAEA

12. Parity Requirements Regulators should carefully review plans to determine whether certain MH/SUD services are covered, and whether MH/SUD medications are on the formulary Regulators should look closely at a plan’s financial requirements and treatment limitations for MH/SUD, to ensure they are no more restrictive than for other benefits Regulators should examine the medical necessity criteria imposed on MH and SUD criteria and compare to the criteria imposed on the plan’s medical/surgical benefits

13. Other Important Consumer Protections • The plan’s MH/SUD coverage must comply with the ACA’s non-discrimination requirements • Benefits must not be designed in a way that discriminates against people with disabilities • Benefits must address the health needs of diverse segments of the population • The plan’s MH/SUD coverage must comply with the ACA’s typical employer coverage requirement • The plan’s MH/SUD benefits category must not be significantly weaker than the other categories

14. Network Adequacy Final exchange regulations require QHPs to have “a sufficient number and type of providers, including providers that specialize in mental health and substance abuse, to assure that all services will be available without unreasonable delay.” Health plans should have the right kinds of providers, in the right places, available at the right times, in sufficient numbers to meet enrollee needs in a timely manner In state-based and partnership marketplaces, the state implements network adequacy In federally-facilitated marketplaces, the federal government implements the network adequacy requirements

15. Network Adequacy • CWH recommends: • Detailed network adequacy reviews at the time a plan requests certification or expansion, at least annually thereafter, and when there are changes in a network • Adequate enrollee to provider and staff ratios • Reasonable proximity to network providers to enrollees of at least two MH and at least two SUD providers, at each point along the continuum, for at least 90% of enrollees • Standards should include urban/suburban/rural distances and accessibility • Enrollees should be able to access emergency care within 24 hours and routine care in 10-14 days, and need 24 hour service availability when medically necessary

16. Timeframe • Plans have submitted proposals which have been reviewed for compliance with ACA • Very important that those responsible for certifying plans pay attention to our issues—they need to know what we care about, even if we can’t respond to specific plan proposals • Open enrollment began on October 1stand continues through March 31st • QHPs must make benefit and coverage details available before people begin to enroll • Violations must be corrected regardless of when they are discovered, but the window between October and January is critical • Coverage begins January 1st but implementation of many important provisions will continue

17. Strategy State advocates in MH/SUD fields should meet with relevant policy-makers in the state, educate them on priorities for certification, and ask them to pay attention to MH/SUD issues Make use of the CWH toolkit that includes background and recommendations on benefits, parity compliance, and network adequacy CWH toolkit also includes “How to talk to your Insurance Commissioner,” “How to talk to your State Legislature,” and similar materials to facilitate meetings State advocates should continue to strengthen relationships with key policymakers and officials

18. Strategy • As specific plan details become available, work to identify potential shortcomings • CWH will work with advocates in states to analyze data related to MH/SUD benefits, parity, and network adequacy • Bring potential violations to the attention of the appropriate regulators • Document violations • HHS needs the information to inform current and future oversight and regulations

19. Upcoming areas of focus • Final parity rule is expected to be released soon; exact timing is (more) unclear due to the partial shutdown • Huge need for education once the rule is released • Continued need to articulate the impact of the sequester cuts and the continued need for strong SAPT block grant funding • Continued work on SUD and MH benefit coverage through the ACA is critically important

20. Questions or for more information • Contact information: • Gabrielle de la Gueronniere, gdelagueronniere@lac-dc.org • Coalition for Whole Health website • www.coalitionforwholehealth.org • http://www.coalitionforwholehealth.org/resources-for-local-advocates/