Materials To Support Presentations

Transcription

1 Health Reform and Parity Speaker s Bureau 1 Materials To Support Presentations 12/1/2010

2 Slides On Health Reform and Parity 2 This slide deck is designed to provide component pieces that can be used to create your presentation. For each component there is an estimated time required for delivery. Where appropriate, sources and caveats are noted. This set of slides is organized in six components: What the Affordable Care Act (ACA) does/who is covered Effective dates for ACA provisions/impact What ACA provisions have been implemented/impact How ACA impacts prevention and treatment of Mental Health & Substance Use conditions Parity construct, law, regulations, impact, compliance Implications for states and provider organizations Two Summarizing Slides Are Provided At The End

3 How Slides Are To Be Used 3 The Department and Agency wish to retain fidelity with these messages The slides are presented in the Agency template to facilitate their use. An introductory slide is provided These slides can be used either to support a complete presentation or to a part of a broader presentation Health reform and parity impact all other strategic initiatives. As such, it is likely that this content may be useful in explaining and supporting constructs in other Agency presentations The use of graphics was minimized since it is assumed that the content of these slides will be extracted and used as part of many different presentations.

4 Ongoing Content Support 4 The ACA is a long and complex law. Regulations and programs to implement it will be phased in over the next four years It is possible that the law will be amended as it is being implemented to clarify or alter provisions Similarly, the parity law and regulations are technical in nature SAMHSA s health reform and parity workgroup monitors and seeks to influence decisions made regarding implementation of the ACA and parity laws and regulations SAMHSA s Health Reform and Parity Speaker s Bureau periodically will update these slides to ensure that you have access to the most up to date information It is likely that you will have questions or be asked questions about heath reform and parity. The Speaker s Bureau will research and answer these questions. Your inquiries should be directed to Bill Hudock william.hudock@samhsa.hhs.gov or

5 Title of Presentation Name Title Substance Use and Mental Health Services Administration

6 What ACA Does/Who is Covered 6 The following ten slides summarize what the ACA does, who is covered and how it impacts those who are at risk for or have need for treatment of mental health and/or substance use conditions This material takes about twenty minutes to fully cover The first two slides can be used to provide a three five minute summary They are followed by two additional slides that explain in more detail the Medicaid changes and the Medicaid Demonstration Projects. Each of these slides can be covered in two four minutes

7 Patient Protection and Affordable Care Act (ACA) 7 The Act Does Several Things: Expands Insurance Coverage Institutes Insurance Reforms Builds Infrastructure To Provide Improved Health Outcomes Puts In Motion Structural Changes To How Healthcare Delivery Is Structured & Financed Goals of Act Are To: Increase Access Provide Comprehensive Care Better Health Outcomes Control Costs

8 Most Provisions of ACA Are Implemented Over The Next Four Years 8 Phased Implementation Is Needed To: Build Needed Infrastructure Plan and Implement Provisions Well Changes To Benefits and Insurance Reforms Began To Be Implemented In 2010 Some Provisions Must Be Implemented Over Several Years Major Coverage Expansion Occurs in 2014 Longer term Benefits Result From Sum of Structural and Cultural Changes

9 Expanded Health Insurance Coverage Insurance Coverage Expands From 83% to 94% Individual Mandate Applies Subsidies For Those Under 400% FPL Medicaid Eligibility Set At 133% FPL Medicaid Expands from 34 to 50 Million 25 Million Get Insurance Through State Exchanges

10 Result of Coverage Expansion 10 Result of Change in Coverage for non elderly individuals (by 2019) 158 M will have coverage through employers 50 M will have coverage through Medicaid/CHIP 25 M will have coverage through exchanges 26 M will have coverage through non group plans 26 M will remain uninsured Source: Congressional Budget Office

11 Impact on Coverage Expansion Prior to implementation of coverage expansion: 39% of individuals served by State Mental Health Authorities have no insurance 61% of the individuals served by State Substance Abuse Agencies have no insurance Many of these individuals will be covered in 2014 (or sooner) most likely by the expansion in Medicaid

12 What Do We Know About the Newly Covered? 12 Annual Insurance Coverage 47% of poor adults have insurance at some point in the year 35% are uninsured all year 18% are insured all year 60% forgo medical care due to coverage Conditions are more acute when they present Care is more costly Source: Center on Budget and Policy Priorities

13 What Do We Know About the Newly Covered? 13 Traits <100% Poor or fair physical health FPL % >200% FPL 25% 18% 11% Poor or fair mental health 16% 11% 6% Source: Center on Budget and Policy Priorities

14 What Do We Know About the Newly Covered? 14 Individuals Near the Federal Poverty Level More diverse group than we think 40% under the age of 29 56% are employed or living with their families Conditions are more acute when they present Care is more costly Source: Center on Budget and Policy Priorities

15 What Do We Know About Coverage? Requirement To Have Essential Benefit Coverage In Exchanges Final Decisions Not Yet Made Categories Mandated By Law: Mental health and substance abuse services Rehabilitation and habilitation services Pharmacy Preventive and wellness services

16 Impact of Affordable Care Act 16 Focus on coordination between primary care and specialty care: Significant enhancements to primary care Workforce enhancements Increased funding to SAMHSA, HRSA and IHS Bi directional MH/SUD in primary care through FQHCs Primary care in MH/SUD settings through CMHCs and other agencies Services and technical assistance Health Homes and Accountable Care Organizations

17 Changes To Medicaid 17 Medicaid Expansion to Childless Adults under 133% FPL Increased FMAP amounts for expansion population % FMAP % % 2019 and thereafter 90% Benchmark Plans: Mental Health/Substance Use Disorder at Parity 1/1/2014 Amendment to Rehabilitation Option under Medicaid 1/1/2013 Expand Home and Community Based Services FY2011 enacted State can participate for a five year period and can renew for an additional five years Continued Medicaid Coverage for Foster Children Expires 1/1/2019 Reduction in Medicaid DSH 10/1/2011 Reductions based on State uninsured levels

18 Medicaid Demonstration Programs 18 Medicaid Integrated Care Demonstration Project 1/1/ /31/2016 No later than one year after demonstration project is finished, evaluation report due Dual Eligible Demonstration Project Five year grant period, can be extended for an additional five years Emergency Psychiatric Demonstration Projects FY2011 $75 million, funds available until 12/31/2015 Report due to Congress by 12/31/2015 Payment Bundling Pilot Pilot Project can begin anytime AFTER 1/1/2016 Medicare Accountable Care Organizations 1/1/ /31/2016 Demonstration Project No later than 1/1/2012 establish shared saving program Special Needs Plans under Medicare Advantage (MA) 1/1/2011 Secretary to periodically evaluate and revise risk adjustment system 1/1/2012 Secretary require a MA organization offering a specialized MA plan for special needs individuals be approved by the National Committee for Quality Assurance Individuals enrolled in a Specialized MA plan for special needs individuals prior to January 1, 2010, are transitioned to a plan or program described in subparagraph A by no later than January 1, 2013

19 Effective dates for ACA provisions/impact 19 The next two slides summarize the effective dates of key ACA provisions and the impact that they are designed to have These provisions can be explained in 5 7 minutes Covering only the first slide provides a good brief explanation of this in 1 3 minutes Beyond that there are two slides that explain the timing of grants and programs of interest to the field. These can be covered in 5 7 minutes

20 Elements of Expanded Coverage 1/1/

21 Timelines for Provisions of Interest * =authorized but not yet funded

22 Grants and Programs of Interest 22 Mental Illness with Co Occurring Primary Care Conditions Grants FY2010 $50 million FY2011 FY2014 sums as may be necessary Mental Health and Post Partum Women Study FY2010 FY2019, report due no lather than 5 years after enactment Medicaid State Plan Amendment for Health Homes Beginning 1/1/2011 states have option for state plan amendment, Secretary can award planning grants 1/1/2014 survey states using state plan By 1/1/2017 Secretary must complete an evaluation report to Congress Primary Care Extension Program FY2011 and FY2012 $120 million FY2013 and FY2014 such sums necessary 2 year planning grants and 6 year program grants

23 Grants and Programs of Interest 23 Maternal, Infant and Early Childhood Home Visiting Program No later than 6 months after enactment States conduct a needs assessment Report due 3 years after the initial start of the program Final report due 12/31/2015 FY2010 $100 million FY2011 $250 million FY2012 $350 million FY2013 $400 million FY2014 $400 million School Based Health Centers include Mental Health/Substance Use Disorders Grants FY2010 FY2014 National Prevention Strategy 7/1/2010 1/1/2015 submit annual National Prevention and Health Promotion Strategy Report to Congress and President Grants to Accredited Programs and Mental Health Organizations for training Behavioral Health Professionals FY2010 FY2013 Varied Amounts Available

24 What ACA provisions have been implemented/ What Impact It Is Having 24 The next two slides summarize in 2 5 minutes the provisions of the ACA that already are in place

25 Provisions of Health Reform Now In Place 25 Consumer Protections Protect 194 million Americans with private insurance : Insurers can no longer deny children under 19 coverage for a preexisting condition Insurance companies can t cancel your policy if you get sick or have not committed fraud no more lifetime caps on how much insurers will pay You have a right to appeal, including external appeal

26 Provisions of Health Reform Now In Place 26 Additions To Coverage: Medicare prescription drug beneficiaries who hit the socalled doughnut hole gap in catastrophic coverage will receive about $2 billion in drug discounts next year. Over 1 million seniors in doughnut hole received $250 checks this year Consumers in new health plans will be able to: Receive cost free preventive services such as screenings, vaccinations and counseling without any out of pocket costs. Keep young adults on a parent s plan until age 26 Choose a primary care doctor, ob/gyn and pediatrician Use the nearest emergency room without penalty

27 Implications for States and Providers 27 The next two slides highlights some of the key areas in which the ACA will reshape the environment and in some cases the mission of the states and provider organizations This slide takes 5 7 minutes to cover fully, but can be used as an illustrative list in 1 2 minutes

28 Implications For States & Providers 28 Need For Infrastructure To Work With Insurance Grant Funds Reconceptualized To Not Duplicate Insured Benefits Medicaid Changes and State Insurance Mandates Integration of MH/SU with Primary Care Health Homes and Accountable Care Organizations Electronic Health Records Payment Reform Pilot Programs Evidence Based Practices Licensure and Credentialing Standards

29 Block Grants Addendum focus on State s HCR readiness 2011 Proposed Changes to BG Application and regulations Proposed needs assessment for uninsured Planning for FY 2014 Implementation Joint Planning Efforts with MH States Enhancing/Beginning Service Management Efforts Use of technology for service delivery Greater Accountability More specific information on what is purchased through BG dollars Performance strategies that mirror National Quality Strategies (1/1/2011) 2014 and beyond Services that are not covered by Medicaid/insurance Individuals that are not covered by 3 rd party insurance Other (TBD)

30 Slides on Parity 30 The following slides reflect the Wellstone Domenici Mental Health Parity and Addictions Equity Act of 2008 The total presentation (11 slides) provides about minutes of material The second sixth slides provide a 5 7 minute summary of the Act and Regulations.

31 What Are The Key Concepts? 31 Parity What Is It? Why Does Parity Matter? Who Does The Law/Regulations Cover? How Is Parity Determined? How Are Complaints and Appeals Addressed? How Health Reform Advances Parity and Access To Care State and Provider Implementation Considerations

32 What Is Parity? 32 Dictionary equal or equivalent, at symmetry, not favoring one over another, fairly matched Parity As A Legal Construct: A group of State Laws Beginning In the mid 1990s Over Half of States Have Some Form of Parity Law 1996 Federal Mental Health Parity Act: Prohibit different annual and lifetime dollar limits did not extend to substance use 2008 Medicare Improvements for Patients and Providers Act By 1/1/2014 Phases out higher coinsurance for outpatient mental health care 2008 Federal Mental Health Parity and Addictions Equity Act: Effective October 3, 2009 Regulations Effective As Policies Renew On/After July 1, Health Reform Law Expands To Broader Population In 2014 and Puts in Place Incentives for Integrated Care

33 Parity Why Does It Matter? 33 Historical Discrimination Additional Financial Costs Annual and Lifetime Maximums on Benefits Stricter Management of the Benefit Medical Necessity Treatment Limitations Goal Of Parity Law Is To: Increase Access To Treatment Remove Discriminatory Financial Costs More Equal Treatment For These Medical Conditions

34 Who Does The Law and Regulations Cover? Employer Based Insurance of Groups Over 50 Lives which choose to offer both a mental health or substance use condition benefit as well as medical/surgical benefits Million Covered By Private Employer Plans 29 Million Covered By State and Local Government Plans Medicaid Managed Care Plans, But Scope Unclear At This Time 33.4 Million Union Negotiated Plans and Some Government Plans (not Medicare, VA, Tricare, FEHBP, Medicaid) Through Health Reform Parity Protections Extended: Individuals and Small Group Employer Plans Thru Exchanges Million Newly Eligible Medicaid Recipients Thru Benchmark Plans Million CHIP Enrollees Million Total Impacted = million 80+% of population and growing

35 What Is Excluded From Parity Requirement? 35 The law does not require that an employer offer mental health and/or substance use benefits The law permits an employer to limit the diagnosis which will be covered The law provides a possible cost exemption: If cost is more than 2% greater in first year due to parity employer can request exemption for next year. If cost in subsequent year is 1% greater due to parity employer can request exemption for further year.

36 How Is Parity Determined? 36 The Law Stipulates: Covered group health insurance plans that offer both medical/surgical and mental health/ substance use benefits must offer them at parity Parity Is Defined To Include: Financial requirements including deductibles, coinsurance, copayments, and other cost sharing requirements, as well as annual and lifetime limits on the total amount of coverage. Treatment limitations include restrictions on the number of visits or days of coverage, or Other limits on the duration and scope of treatment. Does Not Preempt Stricter State Laws This Impacts State Regulated Insurance Policies, But Not Self Insured Plans

37 Regulatory Standards For Determining Parity 37 MH/SUD benefits may not be subject to any separate cost sharing requirements or treatment limitations that only apply to such benefits If a group plan provides for out of network medical/surgical benefits, it must provide for out of network mental health and substance use benefits Standards for medical necessity determinations and reasons for any denial of benefits relating to MH/SUD must be disclosed upon request

38 Non Quantitative Treatment Limitations 38 Nonquantitative treatment limitations include medical management, step therapy and preauthorization. Processes, strategies, evidentiary standards, or other factors used in applying the nonquantitative treatment limitations to MH/SUD benefits to MH/SUD in a classification are comparable to and applied no more stringently than what is applied to medical/surgical benefits except to the extent that recognized clinically appropriate standards of care may permit a difference.

39 Appeals and Complaints Process 39 Reasons for Denials must be provided Criteria for Medical Necessity Available Upon Request Appeals related to Fully Insured Plans can be directed to State Insurance Commissioner Department of Labor has primary federal responsibility Call toll free EBSA (3272). CMS has secondary federal responsibility Call toll free extension

40 Issues Potentially Requiring Additional Clarification 40 Illustrate application of nonquantitative treatment limitation rule to other features of medical management or general plan design; Whether and to what extent MHPAEA addresses the scope of services or continuum of care ; How to comply with disclosure requirement for medical necessity criteria and denials of mental health or substance use disorder benefits; and Implementing requirements for the increased cost exemption

41 Next Steps Regarding Parity? 41 Lawsuit Sought Injunction Not Granted Regulations Effective On Renewal For Plans Beginning on 7/1/10 Good Faith Test Applies From 10/3/09 To Date Regulations Are Effective 5443 Comments Received on Interim Final Regs. Parity Study 2012 Report to Congress Drafting of Additional Guidance and Final Regulations Advocacy for Expansion or Contraction of Construct of Parity

42 Concluding Thoughts 42 The next two slides provide a summary of the changes that will take place because of the ACA and MHPAEA law They can be covered in 1 3 minutes

43 Final Thoughts 43 ACA and MHPAEA Will Meaningfully Help Those Who Are At Risk For or Need Behavioral Health Services Change Is Complex and Imperfect It Takes Time New Partnerships and Ways of Doing Business Will Be Needed We Who Serve Others Will Need To Keep Up With The Changes We Need To Keep Our Compass On True North

44 True North For SAMHSA 44 Four Simple Truths: Behavioral Health Is Essential To Health Prevention Works Treatment Is Effective People Recover

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