Beginning to Understand National Health Coverage Reform: What PD’s and PI’s Need to Know

1. Beginning to Understand National Health Coverage Reform: What PD’s and PI’s Need to Know by Frank Rider MS, TA Partnership/ National Federation of Families 5 August 2010 Adapted from John O’Brien, Senior Advisor on Healthcare Financing, SAMHSA

2. Affordable Care Act (2010) andChildren’s Health Insurance Program Reauthorization Act (2009) [a.k.a. ”CHIPRA”] Combined, this year’s new landmark health insurance reform laws significantly enhance access to health care, including prevention and treatment services for mental and substance use disorders, for millions of Americans.

3. Children’s Health Insurance Program Reauthorization Act [CHIPRA 2009] • Extends State Children Health Insurance Program to 2013 • Adds $33 Billion between 2009-2013 for this extension • Increases coverage to about 6.5 million additional children • Higher income limit – up to 300% of FPL • Fiscal incentives for states to enroll uninsured children • States must implement eligibility simplification processes (e.g. free school lunch, WIC) • Does not specifically require a state to cover MH/SUD benefits under CHIPRA • If a state does include MH/SUD benefits, then must offer those services at parity with other health care benefits

4. CHIPRA Grant Programs • Outreach and Enrollment • Quality Demonstration Grants • Pediatric Healthcare Quality Measures Program • Research Demonstration and Dissemination Projects • Promote Health Information Technology • Evaluate Care Management, other Provider-Based Models

5. Affordable Care Act - Objectives • Significantly enhance access to health care, including prevention and treatment services • Hold insurance companies accountable to keep premiums down • Prevent denials of care and coverage for people, including for pre‐existing health or medical conditions • Improves health care for seniors and persons living with disabilities • Improves the nation’s fiscal health • Changes payment policies to reward high‐quality care and rein in waste, fraud and abuse.

6. Affordable Care Act – Key Concepts • Healthcare Exchanges • Health Information Exchanges • High Risk Pools • Benchmark Plans • Essential Benefits • Web Portal

7. ACA 2010 – Key Provisions for Children, Youth and Families • Eliminates pre-existing condition exclusions for children (2010) • New home visitation program for young children and families* [priority: families with history of substance use disorders] • Grants for School-Based Health Clinics [includes MH/SA services] • Medicaid coverage extended for youth in times of transition: • Option for states to continue coverage for former foster care children up to age 25 • Allows dependent coverage to age 26 (2010)

8. ACA 2010 – Expanded Coverage • Expands Medicaid to 133% of FPL an estimated 16-20 million new enrollees • Focuses grant dollars on community prevention, and on support services • Expands home and community‐based services options for MH and SUD. • State Medicaid programs may establish “medical homes” for those with chronic illnesses • Grants available for community MH programs to co‐locate with primary and specialty care services.

9. About Mental Health Parity Mental Health Parity and Addiction Equity Act of 2008 • Financial requirements and treatment limitations applied to MH/SUD benefits may be no more restrictive than the predominant requirements or limitations applied to virtually all medical/surgical benefits • The 2008 MHPAEA provisions will now apply to all private health plans that choose to offer MH/SUD • Parity will be required in essential benefits plans offered through the health care exchanges.

10. State-Level Impacts of the Affordable Care Act • Role as payer is expanding • Role in preparing state Medicaid programs now for expansion in 2014 • Role in Health Information Technology is expanding • Role in high risk pools • Role in insurance exchanges • Role in evaluating their state insurance markets and weighing against possible benefits of new CO‐OPs

11. Key ACA 2010 Provisions PREVENTION • Prevention research programs and national prevention plans • Coverage of preventive services in private insurance and Medicare including SBIRT, without cost‐sharing and with a financial incentive to do the same in Medicaid • Prevention Trust Fund • Establishes a national public/private outreach and education campaign re: prevention

12. Key ACA 2010 Provisions TRAINING & RESEARCH • Increased patient‐centered health research • Training grants for behavioral health workforce • Training on MH/SUD for Primary Care Extenders

13. Key ACA 2010 Provisions WORKFORCE DEVELOPMENT SUPPORT • Funding for residencies for behavioral health included with other disciplines • Loan repayment programs • Push towards more national certification standards • Push towards re‐licensure and re‐certification

14. See detailed Affordable Care Act Implementation Timeline at: http://www.whitehouse.gov/healthreform/timeline

15. SAMHSA Roles in Moving Implementation of Affordable Care Act Forward • Consultation regarding health homes in health and community mental health settings) • Primary care/behavioral health integration (both directions) • Centers of Excellence on Depression (up to 10, if funded) • Specific work, with HRSA, re post‐partum depression; and Centers of Excellence for Depression • Work on home visiting program and other initiatives

16. What Are Some Implications for Your Systems of Care? • Support states, providers, individuals and families to understand the changing environment • Prepare to expand both access and capacity to provide mental health and substance use services (workforce) • Facilitate linkage with primary care and other providers • Identifying services that comprise a “good” and “modern” mental health and addiction system: • Develop (new?) services that be used by providers in the insurance exchanges : • consumer‐driven/ consumer-operated, wraparound services • evidence-supported and data-driven approaches • foundational work (prevention, housing, trauma)

17. More Implications for Your Systems of Care • Develop strategies to improve infrastructure (data systems, HIT) • Developing quality measures for behavioral health that can be used for purchasers • recognize funding changes and conform grant spending to leverage sustainable financial support for the full range of services and supports for individuals and families in their recovery and resiliency efforts • Look for opportunities to involve yourselves strategically in collaborations around implementation (e.g. workgroups) at community and state levels. • Let’s all commiserate with and learn from one another.

18. Some Reference Tools for You Gaining a sense of mastery amid the high level of activity surrounding implementation of these new laws may require your communities to attend to, seek out, learn and retrieve a lot of information! So let’s not waste any time in setting you up with a few information resources…

19. http://www.healthcare.gov/“Take health care into your own hands” • Find Insurance Options • Learn about Prevention • Compare Care Quality • Understand the New Law • Information for You: • Families with Children • Individuals • People with Disabilities • Seniors • Young Adults • Employers

20. The DHHS Family of Agencies • OS - Office of the Secretary • ACF - Administration for Children & Families (Child Welfare) • AoA - Administration on Aging • AHRQ - Agency for Healthcare Research & Quality • ATSDR - Agency for Toxic Substances & Disease Registry • CDC - Centers for Disease Control & Prevention • CMS - Centers for Medicare & Medicaid Services • FDA - Food & Drug Administration • HRSA - Health Resources & Services Administration • IHS - Indian Health Service • NIH - National Institutes of Health • OIG- Office of Inspector General • SAMHSA - Substance Abuse & Mental Health Services Administration

21. DHHS Grant Information:http://www.hhs.gov/grants • Find Grant Opportunities • Find available HHS grant opportunities (Grants.gov) • Search/browse forecasted HHS grant opportunities (GrantsForecast) • Find funding opportunities for Faith-Based & Community Organizations (FBCI) • Learn to Manage HHS Grants • Use these Tips for Preparing Grant Proposals • Find HHS grant management information • Learn about the HHS Grants Management Process • See Grants Awarded by HHS and Other Agencies • Locate Grant award information (TAGGS): • Grants By Major Activity Type • Grants By HHS Operating Division • Grants By Recipient Class

22. Questions? TA Partnership – www.tapartnership.org Frank Rider – frider@ffcmh.org

23. Supplement #1 CHIPRA REQUIREMENTS RE DIVERSE POPULATION • Reverses the requirement that immigrant children and pregnant women must reside legally in the United States for five years before obtaining coverage under CHIP. States that cover legal immigrants regardless of entry date are now be eligible for a federal match. • Changes to the citizenship documentation process: • CHIPRA requires states to insure children while citizenship is verified. • States that upgrade their electronic data systems to interface with the Social Security Administration's citizenship information are now eligible for a 90 percent federal match for the expenses associated with the upgrade. • Increase in federal matching rate for translation, interpretation services: • States are eligible for a 75 percent match to provide translation and interpretation services associated with the delivery of medical care and outreach.

24. Supplement #2 HEALTH CARE REFORM FINANCING NOTES • Tax credits for small businesses offering coverage (2010) • Tax credits for individuals purchasing insurance • Vouchers for low‐income individuals not eligible for Medicaid to purchase insurance through exchanges • Increased Medicaid and commercial insurance funding of mental health and substance abuse services • Allows SAMHSA block grant and grant dollars to be focused on recovery and other support services not paid for through insurance benefit

25. Supplement #3 MH PARITY REGULATIONS The interim final regulations to enforce MHPAEA (2008) are effective now, and say: • Financial requirements (such as deductibles, copayments, coinsurance and out of pocket limitations) applicable to MH/SUD benefits can be no more restrictive than the predominant financial requirements applied to substantially all medical/ surgical benefits • The regulations apply this test to six classifications of benefits on a classification‐by‐classification basis: • In patient – in network • In patient – out of network • Out patient – in network • Out patient – out of network • Emergency care • Pharmacy (continued on next slide)

26. Supplement #3 MH PARITY REGULATIONS (continued) • Treatment Limitations mean limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment • The regulation clarifies that there may be both quantitative and non-quantitative treatment limitations, and provides rules for each • Since they are similar to financial requirements, quantitative treatment limitations are subject to the same general test as the financial requirements discussed above • Because non‐quantitative treatment limitations (such as medical management standards, formulary design, and determination of usual/ customary/reasonable amounts) apply differently, the regulation includes a separate parity requirement for them. (continued on next slide)

27. Supplement #3 MH PARITY REGULATIONS (continued) • Parity with respect to Out of Network Benefits: • If a plan or issuer that offers medical/surgical benefits on an out‐of‐network basis also offers MH/SUD benefits, it must offer the MH/SUD benefits on an out‐of‐network basis as well. • Single Deductible between MH/SUD benefits and medical/surgical benefits • Transparency: • MHPAEA requires that the criteria for medical necessity determinations with respect to MH/SUD benefits must be made available to any current or potential participant, beneficiary, or contracting provider upon request • MHPAEA also provides that the reason for any denial of reimbursement or payment for services with respect to MH/SUD benefits must be made available, upon request or as otherwise required, to the participant or beneficiary.

28. Supplement #4 SAMHSA’s TEN STRATEGIC INITIATIVES (2010) • Prevention of Substance Abuse and Mental Illness • Trauma and Justice • Military Families—Active, Guard, Reserve, and Veteran • Health Care Reform • Housing and Homelessness • Jobs and Economy • Health Information Technology for Behavioral Health Providers • Behavioral Health Workforce—Primary and Specialty Care Settings • Data, Quality, and Outcomes • Public Awareness and Support