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ACA Implications in Mental Health


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2011 Virginia Rural Health Summit presentation

Published in: Health & Medicine
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ACA Implications in Mental Health

  1. 1. The Affordable Care Act, Behavioral Health and Implications For Rural Communities William J. Hudock Senior Public Health Advisor Substance Use and Mental Health Services Administration
  2. 2. Patient Protection and Affordable Care Act (ACA) <ul><li>The Act Does Several Things: </li></ul><ul><li>Expands Insurance Coverage </li></ul><ul><li>Institutes Insurance Reforms </li></ul><ul><li>Builds Infrastructure To Provide Improved Health Outcomes </li></ul><ul><li>Puts In Motion Structural Changes To How Healthcare Delivery Is Structured & Financed </li></ul><ul><li>Goals of Act Are To: </li></ul><ul><li>Increase Access </li></ul><ul><li>Provide Comprehensive Care  Better Health Outcomes </li></ul><ul><li>Control Costs </li></ul>
  3. 3. Most Provisions of ACA Are Implemented Over The Next Four Years <ul><li>Phased Implementation Is Needed To: </li></ul><ul><ul><li>Build Needed Infrastructure </li></ul></ul><ul><ul><li>Plan and Implement Provisions Well </li></ul></ul><ul><li>Changes To Benefits and Insurance Reforms Began To Be Implemented In 2010 </li></ul><ul><li>Some Provisions Must Be Implemented Over Several Years </li></ul><ul><li>Major Coverage Expansion Occurs in 2014 </li></ul><ul><li>Longer-term Benefits Result From Sum of Structural and Cultural Changes </li></ul>
  4. 4. Expanded Health Insurance Coverage - 2014 <ul><li>Insurance Coverage Expands From 83% to 94% </li></ul><ul><li>Individual Mandate Applies </li></ul><ul><li>Subsidies For Those Under 400% FPL </li></ul><ul><li>Medicaid Eligibility Set At 133% FPL + 5% Income Disregard = 138% FPL </li></ul><ul><li>Medicaid Expands from 34 to 50 Million </li></ul><ul><li>25 Million Get Insurance Through State Exchanges </li></ul><ul><li>Pre-existing Condition Limitation Prohibited – 129 Million Americans Protected </li></ul>
  5. 5. Result of Coverage Expansion <ul><li>Result of Change in Coverage for non-elderly individuals (by 2019) </li></ul><ul><ul><li>158 M will have coverage through employers </li></ul></ul><ul><ul><li>50 M will have coverage through Medicaid/CHIP </li></ul></ul><ul><ul><li>25 M will have coverage through exchanges </li></ul></ul><ul><ul><li>26 M will have coverage through non-group plans </li></ul></ul><ul><ul><li>26 M will remain uninsured </li></ul></ul><ul><ul><li>Source: Congressional Budget Office </li></ul></ul>
  6. 6. Impact on Rural Populations <ul><li>Rural Populations Currently More Apt To Be Uninsured </li></ul><ul><ul><li>36% of Employers Don’t Offer Coverage </li></ul></ul><ul><ul><li>40% of Self-Employed Not Insured </li></ul></ul><ul><li>30.6% of Rural Population Eligible for Subsidies </li></ul><ul><li>Adults and Children More Apt To Qualify For Current and Expanded Medicaid Coverage </li></ul><ul><li>Source: Rural Policy Research Institute </li></ul>
  7. 7. Impact on Coverage Expansion <ul><li>Prior to implementation of coverage expansion: </li></ul><ul><li>39% of individuals served by State Mental Health Authorities have no insurance </li></ul><ul><li>61% of the individuals served by State Substance Abuse Agencies have no insurance </li></ul><ul><li>Many of these individuals will be covered in 2014 (or sooner)—most likely by the expansion in Medicaid </li></ul>
  8. 8. What Do We Know About the Newly Covered? <ul><li>Annual Insurance Coverage </li></ul><ul><ul><li>47% of poor adults have insurance at some point in the year </li></ul></ul><ul><ul><li>35% are uninsured all year </li></ul></ul><ul><ul><li>18% are insured all year </li></ul></ul><ul><li>60% forgo medical care due to coverage </li></ul><ul><ul><li>Conditions are more acute when they present </li></ul></ul><ul><ul><li>Care is more costly </li></ul></ul><ul><li>Source: Center on Budget and Policy Priorities </li></ul>
  9. 9. What Do We Know About the Newly Covered? Source: Center on Budget and Policy Priorities Traits <100% FPL 100-200% >200% FPL Poor or fair physical health 25% 18% 11% Poor or fair mental health 16% 11% 6%
  10. 10. What Do We Know About Coverage? <ul><li>2014 - Requirement To Have Essential Benefit Coverage In Exchanges </li></ul><ul><li>Final Decisions Not Yet Made – Categories Mandated By Law: </li></ul><ul><ul><ul><li>Mental health and substance abuse services </li></ul></ul></ul><ul><ul><ul><li>Rehabilitation and habilitation services </li></ul></ul></ul><ul><ul><ul><li>Pharmacy </li></ul></ul></ul><ul><ul><ul><li>Preventive and wellness services </li></ul></ul></ul>
  11. 11. Provisions Of Interest To Rural Areas <ul><li>National Quality Strategy Core Principles Include All Service Locations & Goal To Eliminate Disparities in Care </li></ul><ul><li>Workforce Provisions Address Health Professional Shortages – Loan Repayment and Scholarships through National Health Service Corps. </li></ul><ul><li>Major Increases in Federally Qualified Health Centers </li></ul><ul><li>Incentives to Adopt Electronic Health Records </li></ul><ul><li>Increased Focus on Telemedicine </li></ul>
  12. 12. Impact of Affordable Care Act <ul><li>Focus on coordination between primary care and specialty care: </li></ul><ul><ul><li>Significant enhancements to primary care </li></ul></ul><ul><ul><ul><li>Workforce enhancements </li></ul></ul></ul><ul><ul><ul><li>Increased funding to SAMHSA, HRSA and IHS </li></ul></ul></ul><ul><ul><ul><li>Bi-directional </li></ul></ul></ul><ul><ul><ul><ul><li>MH/SUD in primary care through FQHCs </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Primary care in MH/SUD settings through CMHCs and other agencies </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Services and technical assistance </li></ul></ul></ul></ul><ul><ul><li>Health Homes and Accountable Care Organizations </li></ul></ul>
  13. 13. Changes To Medicaid <ul><li>Medicaid Expansion to Childless Adults under 133% FPL </li></ul><ul><ul><li>Increased FMAP amounts for expansion population </li></ul></ul><ul><ul><li>2014 – 2016 100% FMAP </li></ul></ul><ul><ul><li>2017 95% </li></ul></ul><ul><ul><li>2018 94% </li></ul></ul><ul><ul><li>2019 and thereafter 90% </li></ul></ul><ul><li>Benchmark Plans: Mental Health/Substance Use Disorder at Parity - 1/1/2014 </li></ul><ul><li>Amendment to Rehabilitation Option under Medicaid - 1/1/2013 </li></ul><ul><li>Expand Home and Community-Based Services </li></ul><ul><ul><li>FY2011 enacted </li></ul></ul><ul><ul><li>State can participate for a five year period and can renew for an additional five years </li></ul></ul><ul><li>Continued Medicaid Coverage for Foster Children – Expires 1/1/2019 </li></ul><ul><li>Reduction in Medicaid DSH – 10/1/2011 </li></ul><ul><ul><li>- Reductions based on State uninsured levels </li></ul></ul>
  14. 14. Medicaid Demonstration Programs <ul><li>Medicaid Integrated Care Demonstration Project </li></ul><ul><ul><li>1/1/2012 – 12/31/2016 </li></ul></ul><ul><ul><li>No later than one year after demonstration project is finished, evaluation report due </li></ul></ul><ul><li>Dual Eligible Demonstration Project </li></ul><ul><ul><li>Five year grant period, can be extended for an additional five years </li></ul></ul><ul><li>Emergency Psychiatric Demonstration Projects </li></ul><ul><ul><li>FY2011 $75 million, funds available until 12/31/2015 </li></ul></ul><ul><ul><li>Report due to Congress by 12/31/2015 </li></ul></ul><ul><li>Payment Bundling Pilot </li></ul><ul><ul><li>Pilot Project can begin anytime AFTER 1/1/2016 </li></ul></ul><ul><li>Medicare Accountable Care Organizations </li></ul><ul><ul><li>1/1/2012 – 12/31/2016 Demonstration Project </li></ul></ul><ul><ul><li>No later than 1/1/2012 establish shared saving program </li></ul></ul><ul><li>Special Needs Plans under Medicare Advantage (MA) </li></ul><ul><ul><li>1/1/2011 Secretary to periodically evaluate and revise risk adjustment system </li></ul></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>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 </li></ul></ul>
  15. 15. Elements of Expanded Coverage 1/1/2014
  16. 16. Timelines for Provisions of Interest * =authorized but not yet funded 2010
  17. 17. Grants and Programs of Interest <ul><li>Mental Illness with Co-Occurring Primary Care Conditions Grants </li></ul><ul><ul><li>FY2010 $50 million </li></ul></ul><ul><ul><li>FY2011 – FY2014 sums as may be necessary </li></ul></ul><ul><li>Mental Health and Post Partum Women </li></ul><ul><ul><li>Study FY2010 – FY2019, report due no later than 5 years after enactment </li></ul></ul><ul><li>Medicaid State Plan Amendment for Health Homes </li></ul><ul><ul><li>Beginning 1/1/2011 states have option for state plan amendment, Secretary can award planning grants </li></ul></ul><ul><ul><li>1/1/2014 survey states using state plan </li></ul></ul><ul><ul><li>By 1/1/2017 Secretary must complete an evaluation report to Congress </li></ul></ul><ul><ul><li>Primary Care Extension Program </li></ul></ul><ul><ul><ul><li>FY2011 and FY2012 $120 million </li></ul></ul></ul><ul><ul><ul><li>FY2013 and FY2014 such sums necessary </li></ul></ul></ul><ul><ul><ul><li>2 year planning grants and 6 year program grants </li></ul></ul></ul>
  18. 18. Grants and Programs of Interest <ul><li>Maternal, Infant and Early Childhood Home Visiting Program </li></ul><ul><ul><li>No later than 6 months after enactment States conduct a needs assessment </li></ul></ul><ul><ul><li>Report due 3 years after the initial start of the program </li></ul></ul><ul><ul><li>Final report due 12/31/2015 </li></ul></ul><ul><ul><li>FY2010 $100 million FY2011 $250 million </li></ul></ul><ul><ul><li>FY2012 $350 million FY2013 $400 million </li></ul></ul><ul><ul><li>FY2014 $400 million </li></ul></ul><ul><li>School-Based Health Centers include Mental Health/Substance Use Disorders </li></ul><ul><ul><li>Grants FY2010 – FY2014 </li></ul></ul><ul><li>National Prevention Strategy </li></ul><ul><ul><ul><li>7/1/2010 – 1/1/2015 submit annual National Prevention and Health Promotion Strategy Report to Congress and President </li></ul></ul></ul><ul><li>Grants to Accredited Programs and Mental Health Organizations for training Behavioral Health Professionals </li></ul><ul><ul><li>FY2010 – FY2013 Varied Amounts Available </li></ul></ul>
  19. 19. Provisions of Health Reform Now In Place <ul><li>Consumer Protections Protect 194 million Americans with private insurance : </li></ul><ul><ul><li>Insurers can no longer deny children under 19 coverage for a preexisting condition </li></ul></ul><ul><ul><li>Insurance companies can’t cancel your policy if you get sick or have not committed fraud </li></ul></ul><ul><ul><li>no more lifetime caps on how much insurers will pay </li></ul></ul><ul><ul><li>You have a right to appeal, including external appeal </li></ul></ul>
  20. 20. Provisions of Health Reform Now In Place <ul><li>Additions To Coverage: </li></ul><ul><li>Medicare prescription drug beneficiaries who hit the so-called ‘doughnut hole’ gap in catastrophic coverage will receive 50% discount on brand name drugs this year. </li></ul><ul><li>Over 1 million seniors in ‘doughnut hole’ received $250 checks in 2010 </li></ul><ul><li>Consumers in new health plans will be able to: </li></ul><ul><ul><li>Receive cost-free preventive services such as screenings, vaccinations and counseling without any out-of-pocket costs. </li></ul></ul><ul><ul><li>Keep young adults on a parent’s plan until age 26 </li></ul></ul><ul><ul><li>Choose a primary care doctor, ob/gyn and pediatrician </li></ul></ul><ul><ul><li>Use the nearest emergency room without penalty </li></ul></ul>
  21. 21. Final Thoughts <ul><li>ACA Will Meaningfully Help Those Who Are At Risk For or Need Behavioral Health Services </li></ul><ul><li>Change Is Complex and Imperfect – It Takes Time </li></ul><ul><li>New Partnerships and Ways of Doing Business Will Be Needed </li></ul><ul><li>We Who Serve Others Will Need To Keep Up With The Changes </li></ul><ul><li>We Need To Keep Our Compass On True North </li></ul>
  22. 22. True North For SAMHSA <ul><li>Four Simple Truths: </li></ul><ul><li>Behavioral Health Is Essential To Health </li></ul><ul><li>Prevention Works </li></ul><ul><li>Treatment Is Effective </li></ul><ul><li>People Recover </li></ul>