7/26/2016 Behavioral Health Financing, Medicaid and Collaboration In Challenging Times Mitchell Berger, MPH Office of Policy, Planning, and Innovation, SAMHSA Today’s Discussion • A. SAMHSA and Leading Change • B. Health Coverage, Medicaid/CHIP and Behavioral Health • C. SAMHSA Block Grants • D. SAMHSA Response to Public Health Crises: Medication-Assisted Treatment (MAT) and Opioids • E. Enhancing Partnerships and Collaboration Slide 2 A. SAMSHA Leading Change 2.0-Strategic Plan Slide 3 1 7/26/2016 A. Leading Change 2.0 • Six Strategic Initiative areas: Health Care and Health Systems Integration (HCHSI); Prevention; Trauma and Justice; Recovery Support; Health Information Technology; Workforce Development • For HCHSI Goals include fostering integration, providing support to states on Medicare and Medicaid and financing mechanisms, supporting parity, increasing “coverage and access for those in need” Slide 4 B. Health Coverage: Reasons for Not Receiving Mental Health Services in the Past Year among Adults Aged 18 or Older with a Perceived Unmet Need for Mental Health Care Who Did Not Receive Mental Health Services, by Mental Illness Status: Percentages, 2014 AMI-any mental illness SMI-serious mental illness Slide 5 B. Health Coverage: Reasons for Not Receiving Illicit Drug Use Treatment or Alcohol Use Treatment among People Aged 12 or Older Who Felt They Needed Treatment: Percentages, 2011-2014 Combined Slide 6 2 7/26/2016 B. Background: Health Coverage • Total coverage: 49% employer-based; 19% Medicaid, 13% Medicare, 10% uninsured; 6% non-group (e.g., Marketplace); 2% other public. About 32.3 million non-elderly (ages 18-64) Americans total lack health insurance. Total US Population: 316 million • Up to 15.9 million of 32.3 million non-elderly uninsured eligible for Medicaid and the Marketplaces. Of these, about half eligible for Marketplace (tax credits)(22 percent) or Medicaid/CHIP (28%) • Others ineligible due to immigration status (15 percent), income (12 percent), employer-sponsored insurance offer (15 percent) or coverage gap in non-expansion states (9 percent) • 2.9 million in coverage gap Slide 7 B. ACA insurance coverage • 20 million uninsured adults have gained health coverage incl. Medicaid and the Marketplace between October 2013-Feb. 2016 (individuals may move between coverage options) • Estimated 8.9 million non-elderly white adults, 3 million African-Americans, 4 million Hispanics have gained coverage • Uninsured rate drop from 20.3 percent to 11.5 percent as of first quarter 2016 • 2.3 million young adults gain coverage due to provisions allowing adults 19-25 to remain on parent/guardian coverage through age 26 • More than half of uninsured are persons of color, including African-Americans (14 percent) and Hispanics (34 percent) • Uninsurance rate declined 18.2 percent to 10.1 percent in Medicaid expansion states; 23.4 to 16.1 percent in non- expansion states Slide 8 B. Background: Medicaid • Medicaid is a Joint State-Federal Entitlement program- anyone meeting eligibility requirements can enroll • Federal participation/federal medical assistance percentage (FMAP) ranges from 50 percent to 74 percent for each state • 72.5 million total now enrolled in Medicaid and Children’s Health Insurance Program • Children’s Health Insurance Program (CHIP)- established 1997, now covers roughly 8.1 million low-income children above cut- off for Medicaid. 35 million children in Medicaid/CHIP. • About 15 million person increase in enrollment since Oct. 2013 • Increase in enrollment of 35 percent (~12.7 million) in Medicaid expansion states vs. 11 percent (~2 .26 million) in non- expansion states Slide 9 3 7/26/2016 B. Medicaid Expansion Status Source: NASHP/RWJF As of May 2016: 19 states are not expanding Medicaid to cover those up to 138% of the Federal Poverty Level; 26 states (including D.C.) are expanding, 6 are using alternative expansion strategies Slide 10 B. Medicaid and Behavioral Health • Represents roughly 30 percent of total mental health spending (est. $179 billion as of 2014) • Represents roughly 25 percent of total substance use disorder spending (est. $31 billion as of 2014) • As many as 20 percent of Medicaid beneficiaries have a behavioral health diagnosis • 3 million children in Medicaid for reasons other than disability and child welfare had a behavioral health diagnosis • Persons with behavioral health diagnoses represent a high portion of Medicaid expenditures (at least 2-3 times higher expenditures than those without such diagnoses); High prevalence of comorbidities such as heart diseases, diabetes, smoking • Role in supportive housing, helping homeless persons • Role of collaborative chronic care approaches, some with peer specialist roles • Carve-out managed care models that promote specialization and accountability versus carve-in models that promote integrated care • Opportunities at state level to provide input on contracts with MCOs Slide 11 B. Background: Medicaid and Mental Health (MH) Spending Slide 12 4 7/26/2016 B. Background: Medicaid and Substance Use Disorder (SUD) Spending Slide 13 B. Coverage gap-Medicaid expansion •Medicaid expansion may increase access to services •Expansion may help meet mental health/substance abuse needs •Supports rural hospitals and others serving indigent •ASPE/SAMHSA-cite study in 2016 brief; “low-income adults with serious mental illness are 30% more likely to receive treatment if they have Medicaid coverage.” • SAMHSA estimate-of 5.3 million persons with behavioral health disorder (any mental illness or substance use disorder) potentially eligible for Medicaid expansion, more than 2.6 million live in states that have not expanded Medicaid/undecided •Reduced income and racial/ethnicity disparities in coverage •Medicaid expansion can help reduce out-of-pocket spending for mental health services and other needs •Linked to reduced expenses in criminal justice and disability costs and improved employment productivity Slide 14 B. Opportunities for Impact- CMS Regulations • Medicaid Parity Regulation-Medicaid Managed Care, Children’s Health Insurance Program and Alternative Benefit Plans (Final, March 2016) • Medicaid and Children's Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, and Revisions Related to Third Party Liability (Final, May 2016) • Proposed Rule: Medicare and Medicaid Programs; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies (Nov. 2015) • Final Rule: Mechanized Claims Processing and Information Retrieval Systems (December 2015): Following ACA, HHS provided additional funds for improved Medicaid eligibility and enrollment systems. Funding will now be extended. • Final Rule with Comment Period: Methods for Assuring Access to Covered Medicaid Services (Nov. 2015): Access Monitoring Review Plans must address key areas: primary care, physician specialists, behavioral health, pre- and post- natal obstetrics (including labor and delivery), and home health services; input from stakeholders on rate changes and access. • Opportunities: Review Federal Register and Regulations.gov Slide 15 5 7/26/2016 B. Mental Health Parity and Addiction Equity Act (2008) • ASPE estimated ACA will expand parity protection for 30 million with existing coverage for mental health/substance use disorders and provide new protections for 32 million • 2013 Commercial Parity regulation- applies to non-Federal governmental plans with more than 100 employees, group health plans of private employers with more than 50 employees and individual market health plans • Medicaid Parity Regulation-Medicaid Managed Care, Children’s Health Insurance Program and Alternative Benefit Plans (Final March 2016, Proposed April 2015) • Rule estimated by CMS to impact 23 million enrolled in Medicaid managed care, children’s health insurance program and alternative benefit plans • Medicaid parity and commercial plans as closely aligned as feasible • Medical/surgical and MH/SUD services classified in four areas inpatient, outpatient, pharmacy and emergency areas of classification (includes long-term care services) • Improve availability of medical necessity criteria • Applies parity to both quantitative limits (e.g., visit limits) and non-quantitative treatment limitations(e.g., prior authorization, medical necessity) • Includes examples to improve understanding and compliance • SAMHSA working with stakeholders to identify public and private coverage parity gaps and develop parity outreach materials Slide 16 Parity • White House Mental Health and Substance Use Disorder Parity Task Force- report to President due Oct. 2016 • Includes HHS, Labor, Justice, VA, DOD • Listening sessions held April-June • Public can provide comments • See http://www.hhs.gov/about/ agencies/advisory-committees/parity/ Slide 17 B. Medicaid Managed Care • More than 70 percent of Medicaid enrollees now are served by managed care arrangements compared to 8 percent in 1992 • “45.9 million (or 73.5 percent of all Medicaid beneficiaries) accessed part or all of their Medicaid benefits through Medicaid managed care” in FY 2013 • Expansion of Medicaid managed long-term services and supports (20 states compared to 8 in 2004) • 4.3 million children enrolled in CHIP (or about 81 percent of all separate CHIP beneficiaries) enrolled in MCOs in FY 2013 • Medicaid and Children's Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, and Revisions Related to Third Party Liability (Proposed