How Will the Affordable Care Act Affect Your Program? Gabrielle de la Guéronnière, Legal Action Center
JMHCP Grantee Meeting, February 28, 2013
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Legal Action Center/National HIRE Network Advocacy for people with addiction histories,
criminal records, and HIV/AIDS
Federal policy work advocating for the expansion of
services and resources for people with addiction histories, criminal records, and HIV/AIDS Staff and coordinate activity for the Coalition for Whole Health
Fighting discrimination: eliminating legal and policy
barriers in place for people with addiction histories and criminal records
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Health Reform: What happens next? Initiatives of particular importance for people
in the criminal justice system
Expanding coverage for services Medicaid expansion Health insurance exchange activity Improving access to care Essential Health Benefits process Eligibility and enrollment work
How to ensure you have a meaningful role in
the process
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Ways the Federal Health Care Law Seeks to Increase Coverage: Expanding Medicaid Expanding Medicaid eligibility: Expansion to everyone below 133% FPL, including
childless adults for the first time in most states Potential of 16 million new enrollees around the country Huge opportunity for criminal justice-involved individuals to get
coverage
Federal government to pay enhanced match rate for
expansion population—100% for 2014 -2016, 90% in 2019 and beyond
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Status of the Medicaid Expansion Nationally U.S. Supreme Court decision made the Medicaid
expansion optional Where the states stand today: Governors of 14 states have said they won’t expand (AL, GA, ID, IA, LA,
ME, MS, NC, OK, PA, SC, SD, TX, WI) 2 states are leaning toward not expanding (NE, WY) 24 states and DC will be participating
http://www.advisory.com/DailyBriefing/2012/11/09/
MedicaidMap#lightbox/1/ Power of federal dollars as a big incentive… Coverage expansion begins on January 1, 2014; ongoing 5
work by CMS to work with the states
Ways the Federal Health Care Law Seeks to Increase Coverage: Expanding Medicaid Defining Medicaid benefits: Will “benchmark” to the benefit list from the BCBS plan in FEHBP, a state employee plan, largest HMO in the state, benchmark-equivalent, or Secretary-approved coverage States have considerable flexibility Multiple benchmark plans possible for different
populations Regardless of the benefit benchmark, MH and SUD benefits required to be covered at parity with other health care benefits 6
Expanding Medicaid: Specific considerations for the criminal justice community Prohibition on federal Medicaid reimbursement for health
care provided in jail or prison remains Need to get every eligible individual enrolled in Medicaid now even more important Suspending not terminating Medicaid enrollment while an
individual is incarcerated—no requirement to terminate, federal policy encouraging suspension Provision of the “inmate exclusion” that allows for federal reimbursement for health care provided in certain community settings—significant opportunity for State savings Continuity of care when individuals return to the community from incarceration and connection to recidivism 7
Expanding Medicaid: What are the key education steps? Continued education of state and federal policy-makers
about barriers to health care for criminal justice-involved individuals Suspension not termination Medicaid policies and their impact
on reentry programming in your state Ongoing work at the state level with the Medicaid
Directors Ensuring comprehensive MH and SUD coverage at parity Engaging in Medicaid Health Home work 8
Ways the Federal Health Care Law Seeks to Increase Coverage: Expanding Private Insurance Creation of Health Insurance Exchanges Competitive state-based marketplaces for small
employers and individuals to pool risk and purchase insurance Sliding scale tax credits to purchase insurance 20 million people expected to be covered by private
plans operating in the HIEs Large plans can start to come in in 2017
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Requirements for Plans in Health Insurance Exchanges Plans will have to meet Qualified Health Plan and
various consumer protective-requirements (including Essential Health Benefits requirements) Plans will have to maintain a sufficient network of providers, including MH/SUD providers, to ensure all services are accessible without unreasonable delay Above requirements will apply regardless of whether
the exchange is run by the state and/or the federal government 10
Ways the Federal Health Care Law Seeks to Increase Coverage: Expanding Private Insurance Three Exchange Options for States State-run exchanges Federally facilitated exchanges State-federal partnerships; states can choose to
oversee: Consumer outreach and/or Plan management activities
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Ways the Federal Health Care Law Seeks to Increase Coverage: Expanding Private Insurance Deadlines to notify the feds about choice of exchange
have passed 16 states and DC will run their own exchanges 7 states will partner with the feds to run their exchanges 27 states will have federally facilitated exchanges
http://www.avalerehealth.net/news/spotlight/
20130215_Exchange_Progress_Map.pdf Feds have released exchange guidance on each of these
options, more is expected Exchanges should be fully operational by open enrollment in October; coverage begins in January 2014 12
Health Insurance Exchanges: What are the key education steps? Educating state and federal decision-makers about exchange
policies that would ensure that the needs of people in the criminal justice system are best met Requiring exchanges to conduct strong outreach and education
activities Enforcement of EHB and other strong consumer protections Enforcement of network adequacy standards Ensuring that coverage is easily accessible Ensuring that governing boards and other advisory bodies include people with expertise on MH, SUD, other chronic conditions, and criminal justice involvement 13
Current Focus of Work to Expand Coverage for Care: Defining the Essential Health Benefits The federal health care law requires certain health coverage
to meet minimum requirements beginning in 2014. The 10 required categories in the Essential Health Benefit are: Ambulatory Services
Prescription Drugs
Emergency Services
Rehabilitative and Habilitative Services and Devices
Maternity and Newborn Care
Laboratory Services
Mental Health and Substance Use Preventive & Wellness Services Disorder Services, including and Chronic Disease behavioral health treatment Management 14
Hospitalization
Pediatric Services
Essential Health Benefits (cont’d) The Essential Health Benefits (EHB), including
SUD and MH services, must be offered: By private insurance plans participating in the health insurance exchanges By non-grandfathered individual and small group plans outside the exchanges To newly-eligible Medicaid enrollees, including childless adults Large group plans and “traditional” Medicaid do not need to meet EHB requirements
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Essential Health Benefits: Who decides the specifics? The 10 EHB categories, including the MH/SUD
category, are not defined in the ACA Continuum of care for MH and SUD is not
defined Which of the services you provide will be reimbursable under the ACA? Last year, the federal Department of HHS set
out a framework for defining the EHB Strong State role, no federal definition of EHB 16
Essential Health Benefits: What choices have states faced? States could “benchmark” to benefit list of one of ten
types of health insurance plans For states that did not choose, benefit list from state’s largest small group is default 28 states (and DC) have picked a benchmark plan 19 states and DC picked small group plans 5 states picked the HMO plan 3 states picked state employee plans 23 states did not pick or defaulted to the state’s largest small group plan 17
Essential Health Benefits: What Protections Does the Law Afford? EHB must cover each of the ten essential health benefit
categories (including the MH and SUD category) If a category is missing it must be substituted with that category from
another benchmark plan option
Coverage must comply with parity requirements of
MHPAEA Must not be more restrictive than the scope of coverage for
other medical/surgical benefits provided by the plan Scope of services discussed in MHPAEA’s Interim Final Rule If plan doesn’t comply with parity, coverage must be brought into compliance 18
Essential Health Benefits: What Protections Does the Law Afford? Coverage must meet non-discrimination requirements Benefits cannot be designed in a way that discriminates
against people because of age, disability or expected length of life EHB must address the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups Coverage must look like “typical employer coverage” The Secretary of HHS must certify that each state’s benchmark plan meets the above coverage requirements 19
Essential Health Benefits Process: What are the next federal steps? Final EHB rule for commercial plans was issued last week Consistent with previous guidance Does include strong clarifying language that coverage that
doesn’t meet MH/SUD parity requirements will have to be brought into compliance and that states will not be held financially responsible Final EHB rule for Medicaid expansion plans is expected in
April Final MH/SUD parity rule is expected in May Secretary of HHS will certify state benchmark plans 20
Next Steps for the States on EHB Determining the status of work on the EHB in your state;
where is the locus of activity? http://www.statereforum.org/analyses/state-progress-onessential-health-benefits What does the EHB benchmark plan coverage look like? Identifying gaps in coverage Determining which consumer-protective provisions of the ACA would be most helpful to use to fill in those gaps Educating state decision-makers about the need to supplement poor coverage to bring it into compliance with the law
Emphasizing that supplementing coverage will not bring additional
state costs
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Eligibility and Enrollment Work Huge focus in the Obama administration Single streamlined application process Instituting consumer-friendly eligibility determination
policies Work at the federal level and in states to update eligibility
determination systems and policies Work to determine which outreach and enrollment assistance activities are most effective Particular focus on meeting the needs of harder to serve populations 22
Getting Ready for Improved Access: What are the next steps? Weigh in as decisions are made to simplify eligibility
determinations and to institute effective enrollment practices Determine your agency’s role and interaction with
Navigators, Assisters and Certified Application Counselors Huge value MH/SUD, reentry service providers and peer specialists bring to the table Looking out for funding opportunities to help with
this work 23
Questions and Discussion? Gabrielle de la Guéronnière gdelagueronniere@lac-dc.org www.lac.org www.coalitionforwholehealth.org/resources-for-local-advocates/
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