Coverage for Care, What’s at Stake?

1. Coverage for Care, What’s at Stake?

2. Agenda • Coverage for care overview • Health insurance customer protections • New Health Insurance Marketplace • How will Medicaid change? • What does it mean for our state? • Call to action

3. 50 million Americans Uninsured (2009)

4. Financing Mental Health Care Source: Garfield (2011) Mental Health Financing in the US: A Primer Kaiser Commission on Medicaid and the Uninsured

5. Coverage for CareFederal/State Programs • Medicaid: • Health finance program for the poor • Only covers some lower income people • Broad array of community mental health services • Does not cover inpatient care age 22 – 64 • Children’s Health Insurance Program (CHIP) • Children not covered by Medicaid 100% - 200% FPL • May or may not offer full range of Medicaid services

6. Coverage for CareFederal Programs • Medicare: • Seniors, people who received SSDI for >24 months • Limited array of mental health services • Medicaid beneficiaries with very low incomes may also qualify for Medicaid (dual-eligibles) • Veterans/Military: • VA health care: limited eligibility, but wide array of mental health services • TRICARE resembles private insurance

7. Coverage for Care State and Local Public Systems • State and county mental health authorities • Serve people who fall through the cracks • Provide services not covered by Medicaid

8. Private Health Insurance • Employer sponsored or purchased by individual/family • Varied benefits • Mental health parity requirements vary • Limited array of mental health benefits typical • Wider provider network

9. New Consumer Protections Since 2010 2014 and forward, Individual & small group plans Essential health benefits (EHB) MH/BH/SUD parity required No denial for pre-existing conditions No annual limits Guaranteed coverage Rates can only differ based on: Age, geographic area, tobacco use, family size User friendly benefits statement • Youth up to age 26 covered on parent’s health plan • Children no denial for pre-existing conditions • No lifetime limits on benefits • Temporary high-risk pools • Rescission: Cannot drop for intense service need • Appeals process for denials • Medical Loss Ratio: 80-85% spent on direct care

10. “My 21 year old daughter has had major depression since she was a child. We were very worried about health insurance when she wanted to leave home. Now she can stay on our health plan until she is 26.” The new health law allows parents to keep adult children on their plan until age 26.

11. Uninsured Adults with Mental Illness US: Total of 45.6 million adults with mental illness Source: SAMHSA, National Survey of Drug Use and Health, 2011

12. New Coverage Options • Health Insurance Marketplace:private coverage • Individuals • Small Employers (SHOP) • Medicaid expansion: 0 -138% FPL • Parity required: 62M Americans Benefit • All individual and small group plans • All Medicaid Alternative Benefit Plans (Medicaid expansion) • Traditional Medicaid managed care plans

13. Health Insurance Marketplace= Health Insurance Exchange Goals: Good health coverage at affordable cost • Regulates: “Qualified Health Plans” “Essential Health Benefits” • Rates Qualified Health Plans • Unified online application for exchange, Medicaid, CHIP • Toll-free telephone hotline • Website to compare health plan information • Standardized format to present health benefit options • Electronic calculator to figure of coverage

14. Qualified Health Plans (QHP) Only Qualified Health Plans allowed in Health Insurance Marketplaces • Must provide Essential Health Benefits • Insurer must meet requirements: • In good standing with the State • Offers at least: • One silver and • One gold plan • Offers the same premium for qualified health plans inside and outside the Marketplace Source: Illinois Department of Insurance

15. INDIVIDUALS Tax Credits for Premium Subsidies Cost-Sharing Subsidies Reduced OOP limits, annual cap $6,350 (premium + deductible) SMALL BUSINESS Small business Health Options Program (SHOP) Help small employers enroll employees in qualified health plans Small Business Tax Credit Health Insurance Marketplace Incentives

16. Individual & Employer Penalties • Individual: 2014 forward, greater of… • 2014: $95 or 1% household income • 2015: $325 or 2% household income • 2016 and beyond: $695 or 2.5% household income • Employer: 2015 forward • Applies to employers with 50 or more employees • Penalties from $2,000 to $3,000 per employee, • If employer fails to offer coverage or offers bare bones coverage • Exempted: • Below tax filing threshold (Single, $10K, Jointly $20,000) • Religious reasons • Tribal member • Undocumented immigrant • Incarcerated • If no plan is less than 8% annual household income

17. Who Should Apply? • 85% of Americans already have health coverage that meets ACA requirements – no need to apply • Private insurance • Medicare • Medicaid • VA benefits • 15% may want to apply • Uninsured • Underinsured • High health costs • Premiums, deductibles, out of pocket costs • High health needs • Care you need is not covered

18. Essential Health Benefits • Outpatient clinic services • Emergency services • Hospital care • Maternity, newborn care • Mental health, behavioral health, substance use care • Prescription drugs • Rehabilitative & habilitative services • Laboratory services • Children’s services, dental & vision care • Wellness, disease management

19. Benefit Continuity Essential Benefits Package Source: Sommers, B.D. & Rosenbaum, S. (2011). Health Affairs. Presented by S Fields, NAMI 2011.

20. “I had a 4.0 GPA in school but I dropped out after my insurance stopped covering my medication. I started hanging out with the wrong crowd and self-medicating just to get away from the pain and confusion. Now I’m trying to get back on track, but every day is a struggle.” The new health law requires Medicaid expansion and health insurance marketplace plans to provide medication and lab work, but advocacy is needed.

21. Expanded Medicaid Eligibility

22. “I was married and working, but stopped taking my medications because I didn’t feel sick. Things went downhill fast. My wife left me, I lost my job and had to move back in with my parents.” • The Affordable Care Act provides a second chance in states that expand Medicaid. Anyone with an income below 138 % FPL can enroll in Medicaid and get treatment. It is also easier to return to work because private insurance with mental health benefits will be available. • NEW DONUT HOLE! In states that do not expand Medicaid people with incomes below 100 percent FPL will notget federal financial help to buy a private plan.

23. Medicaid ExpansionAny uninsured ≤ 138% FPL • 100% federal match for newly Medicaid eligible: 2014 – 2016 • Reduced gradually to 90% federal match, 2020 forward • Source: Kaiser Family Foundationhttp://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/#note-1

24. Eligibility and Financial Assistance Question:Do the new rules help me get Medicaid? Answer:IF your state expands Medicaid and IF your income is at or below 138% of Federal Poverty Level, then yes.  Question:Are you eligible for government help buying insurance? Answer:The government will help pay part of premiums and out-of-pocket costs for people with incomes between 100 percent and 400 percent of the federal poverty level.

25. The Marketplace is OPENEnroll TODAYwww.healthcare.gov • Enrollment assistance - 24/7 call center • Toll free: 1-800-318-2596 • TTY/TDD: 1-855-889-4325 for assistance • English, Spanish, 150 languages

26. In-State Update

27. Call to Action • Contact your legislator today! Call or email! • Visit state legislature website for contact information • Schedule a visit in the district • ASK: • Health care coverage will help people with mental illness recover and contribute to their communities. • Can I count on your support to expand good, affordable health coverage to all households with incomes from 0 to 138 percent of poverty? • Can I count on you to advocate for mental health coverage on par with medical/surgical care?

28. QUESTIONS? Thank you! Presenter name Title Contact information