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Health reform and behavioral health:. Timing, Financing, Prospects, Controversies Suzanne Gelber Rinaldo, MSW, Ph.D. The Avisa Group September 21 2010 NIDA CTP/CTN Meeting. Overview: Rationale for reform.

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health reform and behavioral health

Health reform and behavioral health:

Timing, Financing, Prospects, Controversies

Suzanne Gelber Rinaldo, MSW, Ph.D.

The Avisa Group September 21 2010


overview rationale for reform
Overview: Rationale for reform
  • Perceptions of inadequacy of health insurance coverage ( 46 M (now 50.7) million without health insurance, (21% of adults, 15.3% of total population) (NHIS, 2009)
  • Perceptions of inequitable restrictions and arbitrary policies and procedures by insurers
  • Health care now 17% of US economy, could be 20% by 2020
  • Safety net systems, including health, SUD and MH, seen as strained, frayed, fragmented, dated, funding shortages
  • Ballooning costs of public and private care with few accompanying improvements in population-based or individual outcomes compared to other sophisticated healthcare systems with lower expenses
  • Inefficiencies perceived in health care and insurance administration that contribute to avoidable costs
  • Inadequate coverage for and attention to public health and prevention initiatives, payment reforms, innovations
overview major substance use disorder and mental health provisions of new law aca 3 23 2010
Overview: Major substance use disorder and mental health provisions of new law (ACA, 3/23/2010)
  • Achieved inclusion of substance use disorder and mental health services in basic “essential” benefits package
  • All “qualified” plans in health insurance exchanges must adhere to parity (Domenici/Wellstone)
  • Medicaid eligibility expansion up to 133% of FPL and for the first time requires new eligibles to receive basic benefits include SUD/MH at parity
  • Chronic disease prevention initiatives are to include SUD/MH; SAMHSA to be consulted
  • Includes SUD/MH professionals in national workforce initiatives
overview provisions
Overview: Provisions
  • Medical homes provisions lists SUD and MH service provider organizations among entities eligible for community health team grants
  • Additional provisions of law:
    • Expand Medicaid coverage to estimated 16 M more beneficiaries
    • Temporary risk pool in place for those with no coverage and pre-existing conditions
    • HIE to supersede risk pool in 2012
    • Sliding scale subsidies for individuals and families up to 400% of FPL
    • Prohibits pre-existing condition exclusions
    • Requires individuals to be insured or to pay penalty – individual mandate phased in later
additional provisions
Additional Provisions
  • Closes Medicare “doughnut hole” for prescription drug coverage
  • Adult children allowed to retain parental coverage up to age 26 as of Sept 2010
  • Created national high risk pool to cover adults with pre-existing conditions as a buy-in until HIE’s are up and running – states need to organize this
  • Could reduce Federal deficit if assumptions are correct – much debate on this going on
  • Some emphasis on co-occurring disorders
  • States receive enhanced FMAP medical assistance percentages/other subsidies, most beginning 2014-2020 although this is subject of much debate
essential benefits under medicaid
Essential Benefits Under Medicaid
  • Benchmark Essential Benefits Package for Medi-Cal (Medicaid) includes:
    • Ambulatory care and emergency services
    • Hospitalization including maternity
    • Mental health and substance abuse services
    • Prescription drugs
    • Rehabilitative/Habilitative Services and devices
    • Lab services
    • Preventive, wellness and disease management services
    • May include medical case management
    • Other services can also be covered but are optional (many now covered by Medi-Cal and Healthy Families are not required)
overview key near term and later provisions
Overview: Key Near Term and later Provisions
  • Near Term:
    • As of 4/1/2010 States have had option to extend Medicaid coverage to childless adults up to 133% of FPL and to receive current FFP
    • As of 6/2010 States could set up high risk pools for uninsured with pre-existing conditions, includes limited federal subsidies)
    • As of September 2010 young adults can stay on parents’ plans up to 26; pre-existing condition exclusions forbidden for children; group or individual plans prohibited from rescinding coverage except for proven fraud; prohibition of lifetime benefit caps and unreasonable annual limits; eliminates cost sharing for preventive services in Medicare and private plans
    • No lifetime limits on $ value of essential benefit package but insurers may have reasonable restrictions on annual benefits
key provisions medium term
Key Provisions: Medium Term
  • 2012 and Beyond:
    • States to initiate premium rate review of private plans, using new medical reimbursement centers (academic or non-profit)
    • Patient-centered Medical homes to be included in Medicaid (not necessarily well adjusted as yet for SUD and MH)
    • Individuals must be covered (individual mandate and guaranteed issue) and must receive benefits summary and coverage information annually
    • No special “executive” health insurance benefits for the highly compensated only
    • % of premiums spent on clinical services and QI must be at least 80-85% (medical loss ratio) – below this consumers get rebates
    • Annual reports required from health plans to HHS starting 3/2012
    • Guaranteed insurance issue regardless of health or risk status
    • No more pre-existing condition exclusions (including those based on claims experience, genetic information, disability)
    • No insurance waiting period longer than 90 days
    • Waivers available to states for innovation, new Medicaid waiver provisions including possible payment reform
    • Note: not all required state activities are supported with Federal grants; some feel that CA’s costs to implement reform could exceed $1B
  • Medicaid
    • Under ACA Medicaid eligibility could expand by 20%
    • Currently many eligibles are still not enrolled newly eligible and currently eligible who enroll will seriously test Medicaid systems and providers
    • Medicaid would have changed asset tests, simplified enrollment, simplified eligibility screening, MOE requirements including enrollment and coverage rules to be more restrictive than now before 2019
    • Dual eligibles (most low income seniors and disabled) will have enhanced care coordination under Medicaid and Medicare
    • Physician fees and procedures fees still set at state levels and may be an issue in some states

Health Insurance Exchanges with navigator programs –state risk pools must change, be accepted by Federal DHHS as the agent of HIE

  • HIE’s must certify “qualified health plans”
  • Must have consumer information portals
  • Must have consumer assistance/ombudspersons
  • Must have consumer friendly HIT
  • Much controversy surrounds cost of reform vs. what it may save, implementation costs,
  • Challenges to ACA from Congress and other sectors should not be underestimated but implementation is proceeding
  • Incoming state Gubernatorial administrations may have different take on essentials and priorities of health reform, including payment incentives for which most plans are not considered ready as yet by the IRS
special challenges for behavioral health
Special challenges for behavioral health
  • Despite some opportunities, focus of ACA is not on SUD or MH except in certain target populations (although other target populations are not addressed)
  • National Council has sponsored FQBHC legislation introduced recently but not clear it will go anywhere; alliances of specialty BH with FQHC’s are needed but challenging
  • Special rules to qualify as an FQHC if specialty providers want to do that (see HRSA site)
  • SUD and MH workforces may not meet enhanced credentialing and training requirements imposed by plans subject to their own HIE qualification
  • Information systems and other infrastructure in behavioral health safety net are still inadequate (encourage sharing with those who have infrastructure) and not easily eligible for HIT/other infrastructure funding aimed more at primary care
  • Controversies and funding challenges over ACA may delay or derail implementation of certain reforms important to behavioral health, including HIT