Essential Benefits and Medicaid Expansion

1. Essential Benefits and Medicaid Expansion Prepared or at least gathered by Gregory Robinson Washington Community Mental Health Council Administrative Services Division Conference October 25, 2012

2. Questions? • Feel free to ask questions at any time • A good question is rewarded • All of my answers start with “It depends” even if I forget to say it • Be sure to ask me to explain any unfamiliar TLA

3. Affordable Care Act • Affordable Care Act passed Supreme Court muster • Effective January 1, 2014, Medicaid will be expanded to include individuals between the ages of 19 up to 65 with income up to 133% FPL based on Modified Adjusted Gross Income (MAGI) • Medicaid is a Federal/State partnership program so states must decide whether or not to expand Medicaid to “newly eligible”

16. Reason for Concern • Services to “newly eligible” or MAGI Medicaid will be eligible for enhanced Federal match – 100% match for first three years, dropping in stages to 90% by 2020 • Services to classic Medicaid will continue to be matched at regular rate • Advocates worry that the state has a major incentive to enroll new applicants in MAGI, and leave them there

17. Essential Health Benefits Medicaid expansion benefits need to be actuarially equivalent to benchmark plan, with coverage in 10 essential benefits areas: • Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder services, including behavioral health treatment • 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

20. Email from HCA 9/28/12 Q. What is not clear to me is the benefit design for individuals in Medicaid expansion, particularly mental health benefits.  Currently in classic Medicaid actuarial analysis produces a per member per month payable to Regional Support Networks, who use Access to Care standards to authorize benefits.  What about Medicaid expansion adults?  How will that work? A. At this time HCA is waiting for future direction from CMS on the benefit design for the Newly Eligible Group. Once this guidance is received, HCA will be able to share additional information on the benefit design with our stakeholders.