Update from Washington: National Health Care Reform and Beyond

1. Update from Washington: National Health Care Reform and Beyond

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3. 3 Legal Action Center Advocacy for people with addiction histories, criminal records and HIV/AIDS Thirty-five year history of advocacy Work in Washington, D.C. Federal policy work Advocating for the expansion of services and resources for people with addiction histories, criminal records and HIV/AIDS Fighting discrimination�legal and policy barriers in place for people with addiction histories and criminal records

4. 4 What We�ll Discuss Today The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) Highlights of the law and recently released regulations The Patient Protection and Affordable Care Act Overview of key addiction-related provisions of the legislation Next steps Implementation of these federal laws Additional work in Washington Continued advocacy for the people we serve

5. 5 Key Things to Keep in Mind Preliminary discussion Statutes/guidance do not answer everything, lots of remaining questions/ambiguity Scope of services/continuum of care not defined Tremendous amount of guidance expected over next number of years Number of leverage points for influence and advocacy�lots of decision-making at the state level

6. 6 Policy Goals of the MHPAEA Eliminating certain forms of discrimination in insurance coverage of mental health and addiction treatment benefits Expanding access to treatment for people with mental illness and/or addiction

7. 7 Background of the MHPAEA The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) became Public Law 110-343 in October 2008 The MHPAEA prohibits group health plans that currently offer coverage for drug and alcohol addiction and mental illness from providing those benefits in a more restrictive way than other medical and surgical procedures covered by the plan

8. 8 The MHPAEA: Key Things to Keep in Mind The federal parity law does not: Apply to individual or small group plans (plans with less than 50 employees) Require plans to offer MH and SUD benefits Parity requirements are only for large group health plans that choose to offer MH and/or SUD benefits Certain plans can opt out Group health plans whose costs increase more than two percent in the first year and one percent after that Non-federal governmental employers providing self-funded group health plan coverage

9. 9 The MHPAEA: More Key Things to Keep in Mind State laws providing greater consumer protections remain in effect State laws providing greater coverage, rights, methods of access to treatment and consumer protections NOT preempted Continuing ability of plans to manage benefits Certain managed care organizations contesting regs�recent lawsuit filed Compliance and enforcement�need for education and outreach

10. 10 Status and Purpose of the MHPAEA Regulations The MHPAEA Interim Final Rule and accompanying guidance was published in the Federal Register February 2nd Group health plans and issuers with plan years beginning on or after July 1, 2010 required to comply Seeks to provide greater clarity and guide implementation of the MHPAEA

11. 11 Terms Defined in Central Analysis to Determine Parity Compliance The MHPAEA prohibits group health plans/health insurers offering SUD or MH benefits from applying financial requirements or treatment limitations to SUD or MH benefits that are more restrictive than the predominant financial requirements or treatment limitations applied to substantially all medical/surgical benefits

12. 12 Rule Defines Key Terms: Financial Requirements Financial requirements Deductibles Copayments Coinsurance Out-of-pocket maximums

13. 13 Rule Defines Key Terms: Treatment Limitations Rule distinguishes between quantitative treatment limitations and non-quantitative treatment limitations Quantitative treatment limitations Day or visit limits Frequency of treatment limits

14. 14 Rule Defines Key Terms: Treatment Limitations (cont�d) Non-quantitative treatment limitations Medical management tools Rule includes an �illustrative� non-exhaustive list: Medical management standards Prescription drug formulary design Fail-first policies/step therapy protocols Standards for provider admission to participate in a network Determination of usual, customary and reasonable amounts Conditioning benefits on completion of a course of treatment Processes/factors used to apply non-quantitative treatment limitations to SUD or MH benefits have to be comparable to and applied no more stringently than the processes/factors used to apply to medical/surgical benefits

15. 15 Comparing Medical/Surgical Benefits with SUD and MH Benefits Rule states that group health plans offering benefits for an SU or MH condition or disorder must provide those benefits in each classification for which any medical/surgical benefits are provided If the plan provides medical/surgical benefits in one of the classifications but does not provide SUD or MH benefits in that classification, that would constitute a treatment limitation

16. 16 Parity Analysis for Financial Requirements and Treatment Limitations: Same Type in Same Classification of Benefits Rule specifies that, when examining whether SUD or MH benefits are being offered at parity with other medical/surgical benefits, must compare financial requirement or treatment limitation only with financial requirements or treatment limitations of the same type within the same classification

17. 17 Additional Highlights from the MHPAEA Rule/Guidance Guidance affirms that the MHPAEA does not preempt any State laws except those that would prevent the application of the MHPAEA Rule affirms that, for group plans offering MH or SUD benefits, where out-of-network medical/surgical benefits are provided, must also be provided for MH and SUD benefits

18. 18 Additional Highlights from the MHPAEA Rule/Guidance Regulations prohibit certain plan activities aimed at avoiding compliance with parity Separate classifications for specialists and generalists Separate cost-sharing requirements or treatment limitations only imposed on SUD or MH benefits Separate plans or benefit packages Parity requirements do apply to prescription drugs Discussion of Employee Assistance Programs (EAPs)

19. 19 Areas Identified as Subject to Additional Regulatory Action on the MHPAEA Medicaid managed care plans Provision on exemption based on cost increase Departments specifically requested comments on: Non-quantitative treatment limitations Scope of services/continuum of care issue Disclosure requirements

20. 20 Background of the �Patient Protection and Affordable Care Act� The Patient Protection and Affordable Care Act (PPACA) was signed into law on March 23, 2010 Timing Certain provisions immediately effective Most in 2014 Full implementation by 2019 Estimated that 95 percent of the legal population will be covered

21. 21 Major Provisions of the PPACA Reforms certain insurance market practices Creates health exchanges Requires individuals to carry health insurance or pay a financial penalty Provides sliding scale subsidies to help people buy health coverage Expands Medicaid eligibility Creates a national high-risk pool for adults with preexisting conditions to buy into until implementation

22. 22 Key Addiction- and Mental Health-Related Provisions in the PPACA SUD/MH services included in the basic benefits package Individual and small group plans States can allow large employers to participate in the exchanges in 2017 All plans in the exchange must adhere to the provisions of the MHPAEA Building on the MHPAEA�SUD/MH benefits required and must be provided at parity; extension to individual and small group plans Requires that newly-eligible Medicaid enrollees, including childless adults, receive adequate health coverage that includes SUD/MH coverage at parity with coverage of medical/surgical benefits

23. 23 Key Addiction- and Mental Health-Related Provisions in the PPACA (cont�d) Includes SUD/MH in chronic disease prevention initiatives Includes SUD/MH workforce in health workforce development initiatives Makes SUD prevention, treatment, and MH service providers eligible for community health team grants aimed at supporting medical homes

24. 24 Next Steps: Implementing Parity Implementing the MHPAEA: Additional guidance? Scope of services Medicaid managed care Intersection with state laws Continued work with state policy-makers Ongoing lawsuit/challenges to the law Inclusion of non-quantitative treatment limitations Cost Fighting violations of both the letter and spirit of the law Tremendous need for education to ensure compliance

25. 25 Next Steps: Implementing Healthcare Reform Implementing the new healthcare reform law: Enormous scope of the regulatory process�moving forward quickly! SAMHSA�s focus Educating HHS (CMS, HRSA) and other key agencies about our world Working internally and with stakeholders to first determine what people need�then who should purchase which services Discussions about improving coordination of care�integration? Conversations about potential changes to purposes of existing funding streams in light of healthcare reform ONDCP�s focus Healthcare reform�work within the Obama Administration Working more closely with primary care Dollars to align with priorities in current funding environment?

26. 26 Next Steps: Implementing Healthcare Reform (cont�d) Key areas of focus: Services in minimum benefit package Changes to Medicaid and Medicare Intersection with parity Work with primary care Models of care Prevention Recovery support services Workforce and other service delivery issues Health information technology

27. 27 Implementation: Next Steps for the Field Implementing the parity and healthcare reform laws: Ensuring that addiction experts are at the table Developing specific recommendations and advocating for their inclusion�cohesion of the field Engaging our Congressional champions in the regulatory process Protecting the healthcare safety net�the SAPT Block Grant and other key programs Sustaining support for strategies/interventions/services not covered by the new law Continuing to fight for stronger protections for people in need of care and supports

28. 28 Discussion and Questions Gabrielle de la Gueronniere (gdelagueronniere@lac-dc.org) 202-544-5478 www.lac.org

29. Beyond Healthcare Reform Moving the Addiction Field forward

30. All of this impacts how we: Reach patients (yes, patients) Organize care Deliver services Finance what we do for the 23 MILLION people with this condition

31. SO WHAT�S THE PROBLEM? Surprise! Change of any kind is difficult. Simplistically, our providers fall into three categories.

32. Early Adopters

33. Enough said

34. And� the Deer in the Headlights

35. So, what can we do?

36. Strategy for Transformation The intervention should include: Where we are headed Why it�s a good thing How the change will happen Opportunities and Threats Strategies for surviving and thriving Business Tools Advocacy, Advocacy, Advocacy

37. Strategy for Transformation Moving the message Provider trainings by state or region E-strategies NIATx tools and ACTION Campaign SAAS dissemination with associations Addiction field media SAMHSA and other government agencies

38. Where change will come from: Federal policies, regs, contracts State policies, regs, contracts Provider initiatives Patients and their families Payers: private and public Strategy for Transformation

39. Targets of advocacy SAMHSA ONDCP FQHC Primary Care Insurance industry MCOs States Insurance Commissioners �to name a few Strategy for Transformation

40. Strategy for Transformation Role of the Block Grant Transition funding Cover the uninsured Services for �habilitation� Wrap-around services Recovery support services

41. The Key : Provider Associations Service providers cannot, nor should they, drive this road alone. They have information and experiences that often go untapped.

42. The Key : Provider Associations Associations play a crucial role in providing avenues for exchange sharing the challenges, successes and opportunities.

43. The Key : Provider Associations True transformation will not happen without it.

44. There is an undeniable need� But if the demand creates a void, someone else will step in and fill it.

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46. Take a step as an agency� Decide if your business is worth investing in, if so: 1. Join and participate in your association 2. Join the Niatx ACTION Campaign 3. Attend the SAAS/NIATx conference 4. Budget for Planning 5. Budget for Training 6. Budget for Assistance

47. Take a step as an association� Decide if the NC system is worth investing in, If so: Develop a plan of action 2. Plan a 1-2 day(s) provider training 3. Reach out to other �non traditional� advocacy groups 4. Actively participate at the Nat�l level 5. Network and learn from other associations

48. There�s work to be done� Becky Vaughn State Associations of Addiction Services 236 Massachusetts Ave. Ste 505 Washington, DC 20002 202-546-4600 bvaughn@saasnet.org