Health Care Reform and Parity-An Overview

1. Health Care Reform and Parity-An Overview Nassau County Heroin Treatment Task Force Tracie M. Gardner Director of NYS Policy December 7, 2012

2. Legal Action Center • Legal and Policy Advocacy for people with addiction histories, criminal records, and HIV/AIDS • Fighting discrimination • Advocating for the expansion of services and resources • Co-Chair on national level of the Coalition for Whole Health, over 100 national, state and local members advocating for strong ACA implementation for MH/SUD. H • Helped to create NY Coalition for Whole Health

3. Parity and Health Care Reform: A Time of Tremendous Opportunity • Landmark victories in health coverage for substance use disorders and mental health • Mental Health Parity and Addiction Equity Act prohibits discrimination • The Affordable Care Act (ACA) aims to expand SUD care dramatically by requiring coverage at parity in both health insurance exchanges and Medicaid expansion

4. Essential Health Benefits • The 10 required categories of service: • Ambulatory Services • Prescription Drugs • Emergency Services • Rehabilitative and Habilitative Services and Devices • Maternity and Newborn Care • Laboratory Services • Mental Health and Substance Use Disorder Services • Preventive & Wellness Services and Chronic Disease Management • Hospitalization • Pediatric Services

5. Essential Health Benefits • EHB will have a direct impact on over 70 million Americans • Where the EHB is required, parity is required • ACA improves on the federal parity law: SUD/MH benefits required and must be provided at parity

6. Essential Health Benefits—who decides the specifics? • The 10 EHB categories are in statute: HHS giving states strong role with no federal EHB definition • For States that do not choose, largest small group is default • BUT states must ensure parity! • So: States will have lots of flexibility, But must include SUD at parity, But will have lots of flexibility

7. NY chose Oxford as its benchmark plan • Advocacy extremely important to take advantage of this extraordinary opportunity: • Evaluate the benchmark plan • Ensure compliance with Parity • Identify what is not included

8. NY chose Oxford as its benchmark plan • We need to ensure that NY’s essential health benefit addresses: • Long-term recovery and a chronic care approach • Include full continuum of prevention, treatment, habilitation and rehabilitation • Residential treatment when appropriate • Prescribed medications when appropriate, including all approved medications for SUD/MH

9. Other Issues Related to Health Care reform: Medicaid expansion • Expansion to everyone below 133% FPL, including childless adults for the first time in most states • Approximately 16 million new enrollees • Enormous opportunity to close treatment gap: Huge Opportunity for Criminal Justice population • States will also be deciding benefits for Medicaid expansion: Must meet EHB and parity requirements, similar “benchmarking” process for Medicaid expansion as with EHB • Federal government to pay enhanced match rate for expansion population: eventually 90% in all states

10. Other Issues Related to Health Care reform: Health Insurance Exchanges • Competitive State-based marketplaces for small employers and individuals to pool risk and purchase insurance • Plans will have to meet EHB and parity requirements and other consumer protections • Plans will have to maintain an adequate network of providers, including SUD/MH providers, to ensure all services are accessible without unreasonable delay

11. Important ACA Implementation activities • There are several provisions in the proposed rule on Essential Health Benefits that we like, including the following: • The proposed regulations make clear that the requirements of the Mental Health Parity and Addiction Equity Act apply in the context of the EHB. • We support allowing states the flexibility to choose the base benchmark option that works best for them while still retaining the state mandates that were in place at the end of last year, as state benefit mandates are important to provide stronger protections to consumers. • We support expanding the number of prescription drugs that the EHB will offer to include what will likely be a wider range of covered medications.

12. Important ACA Implementation activities • We'll be finishing the comments for CWH in next week or so and then collecting signatures from as many groups as possible and submitting them to HHS plus urging as many as possible to submit their own similar comments.

13. Other important ACA implementation activities • Inclusion of addiction in integrated care initiatives: Health homes and accountable care organizations • Inclusion of substance use prevention in chronic disease prevention initiatives • Identification of the addiction service workforce as part of the health workforce

14. Protecting SUD Safety Net Funding • Recognition that ACA coverage provisions do not go into effect until 2014 and will take years to fully implement • Likely some SUD services will not be covered in some states and not everyone in need will be insured: especially true for criminal justice system • Huge need for continued strong federal funding before the ACA is fully implemented and beyond • Need strong and united advocacy in Washington and states

15. Parity Requirements • Insurers are prohibited from refusing to cover SUD treatment that they cover for other medical/surgical conditions • Discrimination in quantitative and non quantitative limitations PROHIBITED • Insurers are prohibited from providing poorer coverage for SUD than they provide for other medical/surgical conditions: • Insurers cannot charge more or allow fewer visits for MAT than comparable medical/surgical conditions, and cannot use more restrictive utilization review, managed care, etc.

16. Eliminate Discrimination • Danger of discrimination by insurers: Refusal to cover assessments or treatment ordered by court or other CJ agency

17. Other important developments (outside of ACA and parity): • Meaningful Use—Incentivizing EHR systems to incorporate our data On November 7, 2012 The Office of the National Coordinator for Health IT (ONC), released a Request for Comments (RFC) regarding the Stage 3 Definition of Meaningful Use of Electronic Health Records (EHRs). There are a number of topics within this RFC that are of importance to the behavioral health community including consent management in electronic health information exchange and access to prescription drug monitoring program datahttp://www.healthit.gov/sites/default/files/hitpc_stage3_rfc_final.pdf

18. Other important developments (outside of ACA and parity): • BHOs at the MRT Behavioral Health Subcommittee • October 18, 2012 Meeting http://www.health.ny.gov/health_care/medicaid/redesign/docs/bh_bene_man_care_ppt.pdf • Behavioral Health Subcommittee recommendations • Managed care approaches using risk-bearing SNPs and/or BHOs should be developed. In NYC, full-benefit SNPs should be developed to include mental health, physical health, and substance abuse populations. • SNPs/BHOs should be given responsibilities to pay for inpatient care at State psychiatric hospitals and to coordinate discharge planning. This will help reduce incentive for BHOs/SNPs to institutionalize people in State psychiatric hospitals. • Advance the core principle that manage care approaches for people with behavioral health care needs should assist enrollees in recovery and in functioning in meaningful life roles