Needs for publicly funded behavioral health services under the Patient Protection and Affordable Care Act (ACA): What gaps will remain?

Transcription

1 Needs for publicly funded behavioral health services under the Patient Protection and Affordable Care Act (ACA): What gaps will remain? February 4, 2014 Stan Dorn Senior Fellow, Health Policy Center Support for this Webinar provided by the Substance Abuse and Mental Health Services Administration

2 Overview I. Key features of the ACA II. Who will remain uninsured under the ACA? III. Among the newly insured, what coverage gaps will remain? 2

3 I KEY FEATURES OF THE ACA 3

4 Insurance affordability program (IAP) #1: adult Medicaid expansion Median state pre-aca Working parents covered up to 68 percent of the federal poverty level (FPL) Non-working parents covered up to 41% FPL Childless adults not eligible, unless they are pregnant or disabled ACA as enacted: mandatory coverage of adults up to 138% FPL Supreme Court decision in June 2012: state option to expand 25 states plus DC have chosen to expand Details of coverage for newly eligible adults Highly enhanced federal medical assistance percentage (FMAP) 100% in CY Slow decline thereafter, reaching 90% in 2020 and beyond Benchmark benefits package, subject to parity requirements Benefits based on commercial coverage; states pick a current private plan Medically frail adults exempt from benchmark benefits Without a formal disability determination, adults under 138% FPL are covered as newly eligible adults, with high FMAP Coverage category is a function of timing and individual choice 4

5 IAP #2: Marketplace subsidies Health insurance marketplaces (HIMs) offer competing qualified health plans (QHPs) 16 states plus DC have state-based marketplaces (SBMs) 27 states have federally-facilitated marketplaces (FFMs) 7 states have partnership marketplaces, with duties split between federal and state governments Health insurance premium tax credits (PTCs) Reduce premiums for the second-lowest-cost silver plan to specified percentages of income, depending on FPL If a consumer chooses a QHP with a higher or lower premium, the consumer pays (or saves) the difference PTCs payable in advance to QHPs monthly, when premiums are due Advance PTC beneficiary must reconcile advance payments with PTC amount based on year-end federal income tax return. May owe money to IRS or get an additional refund. 5

6 Marketplace metal levels Metal level Minimum actuarial value (AV) Deductible Examples of cost-sharing Primary care copay Other features Platinum 90% None $25 $2,000 out-of-pocket maximum (could be up to $6,350) $500 $20 $1,000 OOP max Gold 80% $1,000 $20 $3,000 OOP max $1,000 $15 $3,000 OOP max Silver 70% $3,000 $30 $150 ER copay $2,400 $30 $5,000 OOP max Bronze 60% $3,250 $30 40% ER copay $6,300 None $150 ER copay Catastrophic 50% $6,350 $30 $6,350 OOP max 6

7 QHPs (and other non-grandfathered plans) must cover essential health benefits (EHBs) 10 required general service categories Ambulatory patient services Emergency services Hospitalization Maternity/newborn care Mental health/substance abuse/ behavioral health Preventive/wellness services, chronic disease management Pediatric services, including oral and vision Prescription drugs Rehabilitative and habilitative services/devices Laboratory services Preventive services recommended by the US Preventive Services Task Force No out-of-pocket cost-sharing Mental health parity required State selects commercial plan that provides template for specifics (e.g., amount, duration and scope) 7

8 Tax credits Tax credit eligibility requirements: Not offered employer-sponsored insurance (ESI) the ACA defines as affordable and offering minimum value Almost all ESI meets these definitions Income not above 400 percent FPL Income not below 138% FPL in a state that expands Medicaid 100% FPL in a state that does not expand Medicaid Citizen or lawfully present immigrant If enrolled in second-lowest-cost silver plan, consumer pays Up to 133% FPL, 2% of income 133% to 150% FPL, 3% to 4% of income 150% to 200% FPL, 4% to 6.3% of income 200% to 250% FPL, 6.3% to 8.05% of income 250% to 300% FPL, 8.05% to 9.5% of income 300% to 400%, FPL 9.5% of income 8

9 For tax credit recipients at or below 250% FPL, subsidies can also include cost-sharing reductions that raise AV above the Silver (70%) level FPL Actuarial value (AV) 0%-150% FPL 94% 150%-200% FPL 87% 200%-250% FPL 73% More than half of all subsidy beneficiaries are likely to receive cost-sharing reductions (CSRs) CSRs are limited to tax credit recipients enrolled in Silver-level plans Plan adjusts cost-sharing rules to meet AV standards HHS makes monthly CSR payments to the plan HHS and each plan reconcile CSRs after the end of the year, based on actual experience 9

10 Other features of ACA Individual coverage requirement ESI satisfies the requirement Exemptions Income too low to be required to file income tax returns Cost of insurance exceeds 8% of income Religious prohibition against health insurance Hardship, to be defined by HHS Includes people <138% FPL in states not expanding Medicaid Undocumented immigrants Penalty amount 2014: $95 or 1% of income, whichever is higher 2015: $325 or 2% of income 2016 and beyond: $625 or 2.5% of income Enforcement limited to tax refund denial Employer penalties for firms with >50 FTE employees whose workers use tax credits to purchase coverage Either firm does not offer ESI or ESI is unaffordable or < minimum value Streamlined and simplified eligibility determination Supported by 90% FMAP for Medicaid eligibility IT investment 10

11 II. WHO WILL REMAIN UNINSURED UNDER THE ACA? 11

12 Many people ineligible for IAPs will be uninsured 1. Undocumented immigrants 2. In states that do not expand Medicaid: Childless adults under 100% FPL Parents between pre-aca maximum and 100% FPL 3. People with incomes above 400% FPL 4. People offered ESI that the ACA defines as affordable If the worker s premium for worker-only coverage is 9.5% of income or less, the coverage is deemed affordable Cost for dependents is irrelevant, under IRS interpretation of ACA s language Generally won t hurt children, as long as CHIP is around Spouses may be left without coverage 12

13 Some people eligible for IAPs will be uninsured People who don t know About IAPs That they might qualify for IAPs People who don t enroll, for behavioral reasons Procrastination, aversion to paperwork, perceived difficulty of enrollment process People who find QHP coverage unaffordable, even with subsidies People who qualify for advance tax credits but don t take them, fearing adverse tax consequences People who oppose the ACA What about the individual coverage requirement? Will induce some coverage, but probably not 100% effective Nearly universal coverage in Massachusetts but 13.9% of drivers didn t have auto insurance in 2009, according to the Insurance Research Council 13

14 Among pre-aca uninsured, eligibility for IAPs under the ACA (millions) Includes 6.6 million poor adults who would qualify for Medicaid under expansion Ineligible 4.7 Eligible for HIM subsidies 10.4 States expanding Medicaid States not expanding Medicaid Eligible for Medicaid/CHIP 14

15 Estimated number of uninsured under full ACA implementation(millions) Includes 6.6 million poor adults who would qualify for Medicaid under expansion Ineligible 2.7 Eligible for HIM subsidies 4.7 States expanding Medicaid States not expanding Medicaid Eligible for Medicaid/CHIP 15

16 Estimated impact of ACA on number of uninsured (millions) Uninsured without ACA Uninsured under ACA % drop % drop States expanding Medicaid States not expanding Medicaid 16

17 If all states expanded Medicaid eligibility, who would be uninsured? Medicaid/CHIP eligibles, 38% Subject to mandate, 28% Undocumented immigrants, 26% Exempt from mandate b/c of affordability, 8% N=22.1 million 17

18 III. AMONG THE NEWLY INSURED, WHAT COVERAGE GAPS WILL REMAIN? 18

19 Medicaid Traditional limitations, such as: Exclusion of coverage for Institutions for Mental Disease (IMDs) Limitations on residential substance abuse treatment Coordinating physical and behavioral health care services Provider networks New questions, in states that expand Medicaid How robust will benchmark benefits be? What are the comparative advantages, for beneficiaries, of benchmark benefits vs. standard Medicaid for adults? How will states define and administer exemptions from benchmark benefits? What is the impact of the state s incentive to have people with disabilities <138% FPL covered as newly eligible adults, rather than through a disability-based category? Key to FMAP: obtaining a formal disability determination Are beneficiaries able to choose their coverage category? 19

20 HIM coverage Will people save money on premiums by choosing bronze plans, with very high deductibles? Will people eligible for cost-sharing reductions understand that those reductions only apply to silver-level QHPs? Will QHPs structure their benefits to deter enrollment by costly consumers? Potential liability for treble damages under the Federal False Claims Act Will QHPs unduly limit provider networks to keep their premiums low, thereby gaining market share? How will QHPs meet the ACA s requirement that members can request and obtain clinically appropriate drugs not otherwise covered? Will out-of-pocket cost-sharing deter utilization of needed care? Will benchmark benefit packages derived from commercial plans meet the needs of people with severe mental illness? How will mental health parity be defined, administered, and enforced? How will habilitation services to help patients achieve functionality be defined and covered? ACA gives states especially great flexibility to define this benefit 20

21 Conclusion The ACA will greatly reduce the number of uninsured Many people will remain uninsured, especially in states that do not expand Medicaid eligibility Publicly administered behavioral health programs should be able to tap into new revenue sources, especially in states that expand Medicaid eligibility Publicly funded behavioral health programs will still be needed to Serve the uninsured Help the uninsured qualify for Medicaid and other subsidized health coverage Fill gaps in Medicaid and private coverage 21

22 Sources Slide 4: Donna Cohen Ross and Caryn Marks. Challenges of Providing Health Coverage for Children and Parents in a Recession: A 50 State Update on Eligibility Rules, Enrollment and Renewal Procedures, and Cost-Sharing Practices in Medicaid and SCHIP in Center on Budget and Policy Priorities and the Kaiser Commission on Medicaid and the Uninsured (KCMU). January KCMU. Status of State Action on the Medicaid Expansion Decision. Slide 5: KCMU. State Decisions For Creating Health Insurance Marketplaces. Slide 6: Selected QHPs on various websites for insurers and state-based marketplaces Slide 13: Insurance Research Council. Uninsured Motorists, 2011 Edition. April 1, Slides 14-16: Matthew Buettgens, Genevieve M. Kenney, Hannah Recht, and Victoria Lynch. Eligibility for Assistance and Projected Changes in Coverage Under the ACA: Variation Across States. Prepared by the Urban Institute for the Robert Wood Johnson Foundation (RWJF). October Slide 17: Matthew Buettgens, Bowen Garrett, and John Holahan. America Under the Affordable Care Act. Prepared by the Urban Institute for RWJF. December