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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
    • 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




Employer Coverage

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






Source: Congressional Budget Office, March 2010


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”



Per Capita



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
  • CHIPRA and Adult Quality Measures
  • Quality Improvement Program development
  • Quality reporting imbedded in new HCBS services
  • 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