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Mental Health and SUD: Opportunities in Health Reform. Barbara Edwards, Director Disabled and Elderly Health Programs Group Center for Medicaid, CHIP, and Survey & Certification Centers for Medicare & Medicaid Services October 14, 2010. CMCS and Behavioral Health.

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mental health and sud opportunities in health reform

Mental Health and SUD: Opportunities in Health Reform

Barbara Edwards, Director

Disabled and Elderly Health Programs Group

Center for Medicaid, CHIP, and Survey & Certification

Centers for Medicare & Medicaid Services

October 14, 2010

cmcs and behavioral health
CMCS and Behavioral Health
  • Medicaid is the largest payer for mental health services in the United States
  • In 2007, Medicaid funding comprised 58% of State Mental Health Agency revenues for community mental health services
  • Comprehensive services available through Medicaid; many are optional under Medicaid so state’s have considerable flexibility in benefit design
mh sud dehpg goals
MH/SUD: DEHPG Goals
    • Federal policy supports the offer of effective services and supports
    • Improved integration of physical and behavioral health care
  • Person-centered, consumer-directed care that supports successful community integration
  • Improved accountability and program integrity to assure Medicaid is a reliable funding option
a system of coverage
A System of Coverage

Medicaid/

CHIP

Exchange

Employer Coverage

affordable care act sources of coverage under age 65 2019
Affordable Care Act: Sources of Coverage Under Age 65 (2019)

24m

51m

22m

25m

159m

Source: Congressional Budget Office, March 2010

slide8

New Paradigm

Not a “safety net” but a full partner in assuring coverage for all

Eligible = enrolled

Essential to make a systemout of different components to achieve coverage, quality and cost containment objectives

newly eligible individuals
Newly Eligible Individuals
  • An estimated 5.4 million people that are currently uninsured with a MH/SUD problem would gain coverage under the ACA
  • 50% of those individuals likely to be served Medicaid.

Donohue J, R Garfield, and J Lave, “The Impact of

Expanded Health Insurance Coverage on Individuals with

Mental Illnesses and Substance Abuse Disorders”

ASPE Report April 2010.

benefit design issues
Benefit Design Issues
  • The new Medicaid expansion population must receive benchmark or benchmark-equivalent coverage
    • Benchmark plans: comparable to Federal Employee Blue Cross/Blue Shield Health Benefits, State’s employee health insurance plan, or State’s largest commercial HMO plan
    • Benchmark equivalent: Actuarially equivalent to above plans
aca and benchmark plans
ACA and Benchmark Plans
  • In 2014, benchmark and benchmark equivalent plans must begin providing at least “essential health benefits” (section 1302 (b))
  • “Mental health and substance use disorder services, including behavioral health treatment” are included as a category within “essential health benefits”
  • MHPAEA/MH Parity applies
  • Secretary will issue guidance
medicaid for abd
Medicaid for ABD
  • New eligibility option not available to those eligible for SSI or those 65 years of age and older
  • New benchmark plan does not change state options regarding “traditional” Medicaid, including ABD
aca medicaid behavioral health
ACA: Medicaid Behavioral Health
  • Provides new state plan and grant opportunities that include opportunities to address mental health and/or substance use disorder
  • Implementation teams within CMCS seek to engage stakeholders
  • Engagement strategies vary, based on topic, timetable
aca medicaid behavioral health14
ACA: Medicaid Behavioral Health
  • 1915 (i) – waiver-like services offered under State Plan Option (10-1-2010)
    • Can target populations
    • Adds additional service, income options
  • Extends and expands Money Follow the Person
    • Enhanced FMAP available through 2016
    • Enables a new solicitation
aca medicaid behavioral health15
ACA: Medicaid Behavioral Health
  • Health home, chronic conditions (1-1-2011)
    • MH, SUD are conditions that are eligible
    • Enhanced FMAP for 8 quarters
    • State/SAMHSA collaboration
  • Community First Choice (10-1-2011)
    • Enhanced FMAP for Community attendant services
  • Balancing Incentives Program (10-1-2011)
    • Enhanced FMAP for HCBS for 5 years
non aca priority provisions
Non-ACA Priority Provisions
  • MHPAEA/Mental Health Parity - applies to Medicaid managed care plans (MCOs), CHIP State Plans, and benchmark plans
  • Targeted Case Management option – final regulations
  • Rehabilitation option
opportunity for system transformation
Opportunity for System Transformation
  • This is a time of unprecedented opportunity to transform the system of care for individuals with disabilities
  • CMS’ new Administrator, Dr. Donald Berwick, M.D., has articulated how this transformation can be achieved…
the triple aim
The “Triple Aim”

Population

Health

Per Capita

Cost

Experience

Of Care

the foundation for a redesigned service system for individuals with chronic conditions
The Foundation for a Redesigned Service System for Individuals with Chronic Conditions
person centered
Person Centered
  • Person centered plans of care
  • Individuals and people important to them
  • Functional assessments
  • Individual’s experience of care
individual control
Individual Control
  • Choice
  • Self-direction through both waivers and state plan options
  • EHR
  • Education, Information
quality
Quality
  • CHIPRA and Adult Quality Measures
  • Quality Improvement Program development
  • Quality reporting imbedded in new HCBS services
integration
Integration
  • Single entry point/no wrong door (ADRC funding)
  • Models of integration
    • primary, acute, LTC
    • behavioral health and physical health
    • Medicare and Medicaid
good and modern
“Good and Modern”
  • CMCS is very interested in SAMHSA’s initiative
  • Looking for new opportunities to collaborate to encourage effective Medicaid coverage and services