Mental Health America of WI

The Promise and Challenge ofThe Affordable Care Act:

What’s Up?

***********************Shel Gross, MPA

Director of Public Policy

The Promise of the ACA

We’ve been asking to be treated as first class citizens;

ACA does that.

-National Council webinar

Mental Health and Substance Use Disorder (MH/SU)Treatments are part

of Essential Health Benefits

and

Must be provided at parity.

The Promise of Parity

Parity in EHBs

Essential Health Benefits• Ambulatory services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder services • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and wellness services• Chronic disease management• Pediatric services, including oral and vision care

Inpatient/Outpatient

Transitional Treatment Services:

Parity in Wisconsin

• Use of prior approval to limit access.• Unfamiliarity with “transitional

treatment services”.• Limited medication

formularies.• Workforce issues, especially

substance use providers.

Parity: The Challenge

• Final federal regulations just came out.

• Call that one plan is charging “specialty” copay amount.

• Very limited provider networks in Marketplace plans.

Parity: What’s New

• Support clients in appealing denials of authorization requests, including independent review process through OCI.

• Work with your professional organizations to elevate the issue.

• Feel free to contact me so we can work with OCI to explore whether parity regulations are being honored.

Parity: What You Can Do

Medicaid Expansion(and contraction)

• Governor expanded Medicaid to “childless adults” under 100% FPL– Standard Plan

• Governor reduced eligibility for parents and caretakers to 100% FPL

• Pregnant women, children and people on SSI/SSDI remain covered at current levels.

• Governor calling for delay in enrollment for those losing Medicaid and HIRSP.

• Will also affect those “childless adults” currently receiving or hoping to receive Medicaid.

Medicaid: What’s New

Medicare

If you are on Medicare you are not eligible to buy plans on the exchanges.

Integration: The Promise

Growing recognition that we can’t bend the cost curve without addressing

chronic health conditions

And

We can’t address chronic health conditions without addressing mental

health

Integration: The Promise

• State option for “health homes” for people with serious mental illnesses; 90% federal funding for 2 years.

• Post-partum depression

campaign.

• Prevention services at no cost

include depression and substance use screening.

Integration: The Challenges

• Reorganizing primary care.

• Training/support for primary care

docs.

• Workforce concerns; use of

ancillary staff.

• Workforce issues; primary care mental health.

Integration: What’s New

• Integrated care pilot in NC Wisconsin.• Proposal for child psychiatry access line

passed State Assembly.

Insurance Reforms

• No pre-existing condition exclusions

• Guaranteed issue

• Essential Health Benefits

• Premiums can’t be based on health status (but can charge more for smokers!)

Insurance Reforms

Healthcare.gov

• Problems with healthcare.gov• Keeping insurance if you like it:

–The ACA did not allow plans with poorer coverage to be sold, so some people were being cancelled.

–President said states/insurers could renew plans for 2014.

Insurance Reforms: What’s New

• Speed bump or train wreck?

Big problem if younger, healthier people fail to enroll.

Insurance Reforms: What’s New

Enrollment: The Challenges

• According to Massachusetts Bureau of SA Services 20-25% of acute service presentations (primarily detox) are uninsured. These are disproportionately

young men who are

otherwise physically

healthy.

Enrollment: The Challenges

• In Mass., half of patients with MH and SUD conditions in focus groups were avoidably disenrolled at least once from their health insurance in the past year.

Substance Abuse and Mental Health Services Administration. Enrollment and Disenrollment in Subsidized Health Insurance: Lessons Learned in

Massachusetts. November 2011

• Unfamiliarity with health insurance and its value

• Individuals with SUD new to health care system

• Lack of awareness about eligibility

• Cost concerns:

• Smoker’s penalty: 50% higher premium

• Almost half of cigarettes are smoked by person’s with MH/SU disorders.

Enrollment: The Challenges

• Distrust of government programs

• Lack of decision-making skills

• Churn: changes from Medicaid

to private plans

• Complicated enrollment

process

Enrollment: The Challenges

• Make sure you and your staff are educated:

• SAMHSA toolkit

• Enrollment for Health Wisconsin

• Get the Word Out

• Enroll America

Enrollment: What you can do

• Engage with Regional Enrollment Networks

• Engage with consumer groups in your area

Enrollment: What you can do

•Enrollment for Health Wisconsin

Enrollment Directory; information about Regional Enrollment Networks; links to information for consumers and providers.

http://e4healthwi.org/

•SAMHSA Toolkit

35 minute narrated powerpoint, walks you through key information about the ACA and also the various resources and materials available. Good for administrative staff.

http://www.ncmhr.org/affordable-care-act/enrollment.htm

Resources

•Mental Health America

ACA Toolkit: Links to many mental health specific resources, such as those related to parity implementation in the ACA.

http://www.mentalhealthamerica.net/go/policy/aca101/toolkit

•Enroll America

Links to brochures and fact sheets; materials for providers on best ways to communicate with your clients about the ACA.

http://www.enrollamerica.org/

Resources

Contact Info

Shel Gross

Mental Health America of WI

608-250-4368

shelgross@tds.net