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Health Care Reform and Beyond: Moving Our National Drug Policy Forward
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Health Care Reform and Beyond: Moving Our National Drug Policy Forward

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  1. Health Care Reform and Beyond: Moving Our National Drug Policy Forward Gabrielle de la Guéronnière, Legal Action Center Kansas Association of Addiction Professionals Annual Conference, October 14, 2010

  2. 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

  3. Parity and Healthcare Reform:A Time of Tremendous Opportunity • Greater understanding of addiction as preventable, treatable chronic health condition • Expansion of coverage of addiction treatment in both private and public insurance, at parity with medical/surgical benefits • Inclusion of substance use prevention in chronic disease prevention initiatives • Identification of the addiction service workforce as part of the health workforce

  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 • Work in Washington • Implementation of these federal laws • Focus of the work at SAMHSA and ONDCP • Continued advocacy for the people we serve 4

  5. Parity: Key Things to Keep in Mind • Still a 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. 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. 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. 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. 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 • Additional challenges anticipated • Compliance and enforcement—need for education and outreach

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

  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. 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. 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. 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. 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. 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. 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: • Whether additional examples on non-quantitative treatment limitations/how parity analysis applies would be helpful • Whether/how the MHPAEA addresses the scope of services/continuum of care issue • What additional information would be helpful to ensure compliance with disclosure requirements

  20. Enforcing the Requirements of the MHPAEA • State insurance departments—primary enforcers! • Centers for Medicare and Medicaid Services (CMS) • Department of Labor (DOL) • Internal Revenue Service (IRS)

  21. 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 already effective • Most in 2014 • Full implementation by 2019 • Estimated that 95 percent of the legal population will have health insurance when law is fully implemented

  22. 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

  23. 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

  24. 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

  25. Parity Implementation: Ongoing Work in Washington • Areas of focus for regulators and the field • Scope of services • Work with Centers for Medicare and Medicare Services (CMS) on application of parity to Medicaid managed care plans • Intersection with health care reform implementation • Ensuring that information flows well in both directions • Monitoring compliance and encouraging state and federal activity and response • Engaging our champions to continue the fight for strong consumer protections

  26. Healthcare Reform Implementation: 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. Next Steps: Implementing Healthcare Reform • The regulatory process—scope and speed! • Educating HHS (CMS, HRSA) and other key agencies about our world • SAMHSA’s leadership on healthcare reform: working internally and with stakeholders to determine what people need—then who should purchase which services • Defining the essential benefit package • Areas needing additional analysis/clarity: prevention, recovery supports, adult residential treatment and adolescent services

  28. Next Steps: Implementing Healthcare Reform (cont’d) • Discussions about improving coordination of addiction, mental health and primary health care—integration? • Conversations about potential changes to purposes of existing funding streams in light of healthcare reform • Substance use prevention—potential for major changes • Timing and prioritization • Dollars to align with priorities in current funding environment?

  29. Focus of Our Advocacy in the Implementation Process • Implementing the federal parity and healthcare reform laws: • Continued work together—the Coalition for Whole Health • Responding to proposed regulations with one strong, cohesive voice • Connecting our work in Washington with implementation efforts around the country • Ensuring that experts are at the table • Continuing to serve as a resource to decision-makers, finding the best ways to engage our champions • The Moving the Field Forward Alliance—helping providers get ready for implementation

  30. Focus of Our Advocacy in the Implementation Process (cont’d) • Continued outreach and education—within and outside of our field • Anticipating arguments against full inclusion and gathering/bolstering what we need • Protecting the healthcare safety net—the SAPT Block Grant and other key programs • Protecting substance use prevention • Sustaining support for strategies/interventions/services not covered by the new laws • Continuing to fight for stronger protections for people in need of care and supports

  31. Discussion and Questions Gabrielle de la Guéronnière Director for National Policy Legal Action Center/National HIRE Network gdelagueronniere@lac-dc.org 202-544-5478 (phone) 202-544-5712 (fax) www.lac.org www.hirenetwork.org 31