Mental Health America of WI

1
Mental Health America of WI

• Expanding What?
• Medicaid Benefits Under
• Health Care Reform
• Shel Gross, MPA
• Director of Public Policy

2
Learning Objectives

• You will understand who the new eligibles are
  under MA expansion and why benefit packages
  matter.
• You will understand the range of benefit packages
  that could be available and the implications for
  people with mental illnesses.
• You will be able to identify services that
  enhance the benefit for people with mental
  illnesses.

3
The Expansion Decision Poll

• Definitely expanding
• Definitely not expanding
• Im not sure what my state is doing
• My state isnt sure what they are doing

4
The Expansion Decision The Map
Source Avalere State Reform Insights, Updated
February 25, 2013
5
First Do No Harm

• Maintenance of Effort
• States must continue current coverage of adults
  until Jan 1, 2014 and for kids to Sept. 30, 2019
• 47 states set Medicaid/CHIP eligibility for kids
  at or above 200
• 39 states set eligibility for parents below 133
• (Kaiser Family Foundation)
• Medicaid Contraction is Possible

6
The New Eligibles

• Adults without dependent children
• (childless adults)
• Non-disabled, non-elderly, income-based
• Original law required coverage up to 133 FPL but
  this was voided by SCOTUS.

7
Who Are These Folks?

• Approximately one in six of uninsured below 133
  has a severe mental disorder.
• Many others have less serious mental health
  conditions.
• Half have incomes below 50 FPL many are
  homeless and about one quarter have a serious
  mental illness.
• (Bazelon)

8
You Know These Folks

• Many of these folks are currently served to some
  degree by the public mental health system or
  other public systems.
• The coverage offered through the expansion can
  support the public mental health system.

9
The Coverage Gap

• The ACA was designed to cover everyone, but if
  states dont expand MA childless adults under
  100
• Will not be eligible for Medicaid
• Will not be eligible for premium support in the
  exchanges (and probably couldnt afford
  deductibles and copays anyway)

10
Exchanges The Poll

• State-run exchange
• Partnership exchange
• Federally-Facilitated Exchange
• Id like to exchange my Governor

11
Exchanges The Map
12
Exchanges The Map
13
Exchange Benefits

• States define essential health benefits by
  selecting a benchmark. They have four options

Source The Essential Health Benefits Bulletin,
December 16, 2011. Pages 8-9. http//cciio.cms.go
v/resources/files/Files2/12162011/essential_health
_benefits_bulletin.pdf.
14
Exchange Benefits

• Essential Health Benefits
• ambulatory patient services
• emergency services
• hospitalization
• maternity and newborn care
• mental health benefits and substance use disorder
  services
• prescription drugs
• rehabilitative and habilitative services and
  devices
• laboratory services
• preventive and wellness services and chronic
  disease management
• pediatric services including oral and vision care

15
Hybrids

• Expand the Medicaid eligibility but use dollars
  to purchase commercial health insurance
  potentially through the exchanges.
• Wisconsin expand eligibility, but only to 100
  let everyone else use the exchange.
• Wont receive 100 federal reimbursement.

16
The Problems With Commercial Plans

• While there is premium support, deductibles and
  copays can still be significant.
• Wisconsins benchmark plan has a 2000
  deductible.
• 100 FPL is about 11,500 for a single person.
• Expected that those under 133 would be on MA.
• The typical benefit package has limited MH/SA
  coverage general no psychosocial rehab or care
  management type services.

17
The Problems With Commercial Plans

• The chimera of parity.
• We know that plans are using prior approval to
  severely limit access to outpatient services.
• Generally fewer consumer protections in private
  plans.
• Medicaid has multiple levels of review, including
  fair hearings.
• Commercial insurers dont get habilitation.

18
Habilitative Services

• Commercial insurers familiar with
  rehabilitation
• Restoring lost functioning
• But for some people with a mental illness certain
  functions may not have been learned prior to
  onset.
• And an important aspect of treatment is
  maintaining functioning and reducing likelihood
  of deterioration.

19
Habilitative Services

• According to the final rule issuers can do
  either
• provide parity by covering habilitative services
  benefits that are similar in scope, amount, and
  duration to benefits covered for rehabilitative
  services or
• (2) decide which habilitative services to cover
  and report on that coverage to HHS

20
Habilitative Services

• Habilitative services means health care services,
  therapies and devices that are designed to assist
  individuals in acquiring, improving, or
  maintaining, partially or fully, skills and
  functioning for daily living
• The focus is not on curing the condition but
  rather on enabling, improving, maintaining or
  preventing deterioration of a patients capacity
  to function.

21
Contact
22
The Pros of Exchanges

• Doctors generally get paid more so this might
  improve access.
• Enhances continuity as people go on and off
  Medicaid and many do.
• Could potentially supplement the private
  insurance with wraparound Medicaid benefits for
  people with serious mental illnesses.

23
The Pros of Exchanges

• Exchanges should be better able to meet their
  goals if more people are enrolled.
• Increases the size of the group and there could
  enhance competition.
• Creates a larger pool in which to share risk.
• But, if pool is perceived to be at higher risk of
  illness it could increase costs.

24
The Medicaid Coverage Decision

• Full Medicaid Coverage
• Must include all EHBs
• Use Benchmark Plan
• Must include EHBs
• Can offer full Medicaid to a defined population,
  such as those with SMI
• Can enhance a basic package with psychosocial
  rehab or related services.
•   (Bazelon)

25
The Medicaid Coverage Decision

• Those on MA due to disability (SSI/SSDI) still
  get regular Medicaid.
• Opportunity to enroll more in these programs as
  marketing draws folks out of the woodwork.
• But pay attention to premiums and copayments as
  well, which are allowed to be more onerous for
  individuals receiving services under the
  benchmark plans.

26
A.C.T.

• Psychosocial rehabilitative services for adults
• In Wisconsin community support programs
• For individuals with serious mental illnesses
• Services include assessment, treatment planning
  and care management.

27
A.C.T.

• Ongoing treatment services
• Family, individual, group psychotherapy
• Symptom management
• Medication prescription, administration and
  monitoring
• Crisis intervention

28
A.C.T.

• Supportive psychotherapies and rehabilitative
  services
• Symptom management groups.
• Ongoing monitoring of the member's mental illness
  symptoms and response to treatment.
• Teaching of behavioral symptom management
  techniques to alleviate and manage symptoms not
  reduced by medication.
• Assisting the member to adapt to and cope with
  internal and external stresses.
• Psycho-education with the family on behalf of the
  member.

29
Peer Delivered Services

• Medicaid can pay for peers as part of a
  psychosocial rehabilitative service.
• Wisconsin has a process for certifying peer
  specialists
• Work in a wide variety of settings
• Wisconsin Association of Peer Specialists
• http//waops.sharepoint.com/Pages/default.aspx

30
Peer Delivered Services

• Community Recovery Services
• Offering effective recovery-based services
• Assisting members in obtaining services that suit
  that individual's recovery needs
• Teaching problem solving techniques
• Teaching members how to identify and combat
  negative self-talk
• Lending their unique insight into mental illness
  and what makes recovery possible
• Attending treatment team and crisis plan
  development meetings to promote member's use of
  self-directed recovery tools
• Assisting members in developing empowerment
  skills through self-advocacy and stigma-busting
  activities.

31
Supported Employment

• Activities necessary to assist individuals to
  obtain and maintain competitive employment
• supported employment intake
• assessment
• job development
• job placement
• work-related symptom management
• employment crisis support
• follow-along supports by an employment specialist
• employment specialist time spent with the
  individual's mental health treatment team and VR
  counselor.

32
EPSDT

• Early and Periodic Screening, Diagnosis and
  Treatment
• For youth under age 21
• Screening schedule
• Screening should include developmental and
  behavioral assessments

33
EPSDT

• If condition is identified then service must be
  provided if allowed under federal law
• In addition to diagnostic and treatment services
  covered by Wisconsin MA under applicable
  provisions of this chapter, any services
  described in the definition of "medical
  assistance" under federal law, 42 USC 1396d(a),
  when provided to EPSDT patients, are covered if
  the EPSDT health assessment and evaluation
  indicates that they are needed.

34
EPSDT

• Examples of optional benefits
• Dental services
• Eyeglasses
• Wisconsin also covers specific MH services for
  kids with severe emotional disturbances
• Child and adolescent day treatment
• Intensive in-home psychotherapy

35
Citation Sources

• Avalere State Reform Insights
• Http//www.avalerehealth.net/products/state_refor
  m_insights/index.php
• Explaining Health Care Reform Questions About
  Medicaids Role, Kaiser Commission on Medicaid
  and the Uninsured, April 2012, www.kff.org
• Take Advantage of New Opportunities to Expand
  Medicaid Under the Affordable Care Act, Bazelon
  Center for Mental Health Law, July 2012,
  www.bazelon.org
• State Refor(u)m National Academy of State Health
  Policy
• http//www.statereforum.org/

36
Federal Websites

• The Center for Consumer Information and Insurance
  Oversight
• Federal agency with primary responsibility for
  imlpementation of the ACA
• http//cciio.cms.gov/index.html
• Listing of benchmark plan details
• http//cciio.cms.gov/resources/data/ehb.htmlrevi
  ew20benchmarks
• Health Insurance Marketplace the place where
  it will all happen
• http//marketplace.cms.gov/

37
Wisconsin Medicaid Resources

• Wisconsin Medicaid Provider Handbook Community
  Support Program
• https//www.forwardhealth.wi.gov/WIPortal/Online2
  0Handbooks/Display/tabid/152/Default.aspx?ia1p1
  sa11s2c61ntCoveredServices
• Wisconsin Medicaid Provider Handbook Community
  Recovery Services
• https//www.forwardhealth.wi.gov/WIPortal/Online2
  0Handbooks/Display/tabid/152/Default.aspx?ia1p1
  sa127s2c61ntCoveredServices
• Wisconsin Medicaid Provider Handbook EPSDT
• https//www.forwardhealth.wi.gov/WIPortal/Online2
  0Handbooks/Display/tabid/152/Default.aspx?ia1p1
  sa24s2c9
• OR
• https//www.forwardhealth.wi.gov/WIPortal/
  click on online handbooks under Provider menu
  on right choose program Badger Care Plus and
  Medicaid select service area.

38
Contact

• Shel Gross
• Mental Health America of Wisconsin
• 133 S. Butler St., Rm. 330
• Madison, WI 53703
• Ph 608-250-4368
• Email shelgross_at_tds.net
• http//www.mentalhealthamerica.net/go/action/polic
  y-issues-a-z/healthcare-reform