Issue Brief: Health Care Reform

The Health Care Reform Law: A Summary of Provisions and Advocacy Strategies for Behavioral Health Advocates

Passed on March 23, 2010, The Patient Protection and Affordable Care Act (ACA) (Pub.L. 111-148) is expected to expand health care coverage to an additional 32 million citizens and legal immigrants by 2019 through a combination of state-based private insurance exchanges and a Medicaid expansion. In addition, the new law includes a number of reforms to curb harmful insurance company practices as well as provisions to slow the growth of health care costs and improve quality of care.

Expanding Coverage

The new law will greatly expand access to health care coverage including mental health care and substance use treatment primarily through the following provisions:

• An individual mandate requires most individuals to obtain insurance. ACA includes tax penalties for those who do not comply and exceptions for financial hardship and religious objections. The individual mandate is required to ensure healthy individuals obtain insurance, making the pooling the risks of healthy and riskier participants.
• Premium and cost-sharing subsidies were included to reduce the cost of health insurance for those with incomes up to 400% of the federal poverty level ($43,000 for individuals and $88,000 for family of four).
• ACA includes penalties for employers with more than 50 employees that do not offer health insurance coverage and have at least one employee who receives a subsidy to access coverage.
• Small businesses with no more than 25 employees and average annual wages of less than $50,000 will receive tax credits for their insurance costs. Tax-exempt small businesses are also eligible for these credits.
• The law requires coverage of dependent children up to age 26 for all individual and group policies - effective six months after enactment (September 23, 2010).

State Exchanges

The Affordable Care Act requires the establishment of state-based health plan "Exchanges" by January 1, 2014 through which individuals and small businesses can purchase coverage with pooled risk and thus lower premiums. States are to create "American Health Benefit Exchanges" and "Small Business Health Options Program (SHOP) Exchanges" to be administered by a governmental agency or non-profit organization through which small businesses (up to 100 employees) and individuals can purchase insurance.

Mental health care and addiction treatment are included on the list of essential benefits that must be covered in new plans offered to the uninsured through the exchanges. These benefits (and others on essential list including rehabilitative services, prescription drugs, preventive services, etc) will be further defined by the Secretary and include opportunities for public comment.

The Mental Health Parity and Addiction Equity Act is expanded to apply to health insurance plans offered to small businesses and individuals. individuals. For more information on the components of MHPAEA, please see MHA's parity information.

Medicaid Expansion

In 2014, Medicaid will expand to 133% of the federal poverty level ($14,404 for individuals; $29,327 for families of four) regardless of traditional eligibility categories (thus including childless adults). Those newly eligible for Medicaid through the expansion will not receive regular Medicaid benefits - instead benefits modeled on private insurance packages.

But a mandate that the mental health and substance use benefits that are required of plans offered through the Exchanges will apply to those newly eligible for Medicaid through the expansion. The federal parity requirements will also apply to those newly eligible for Medicaid.

Enhanced federal funding for those newly eligible for Medicaid: starts at 100 % federal and phases down to 90% federal by 2020.

States have the option to expand Medicaid (with regular match) to childless adults beginning April 1, 2010. To date, Connecticut and DC have opted to expand their Medicaid programs early. Minnesota is also likely to opt to expand their Medicaid program to 133% of the federal poverty level in early 2011.

Other Medicaid Changes

State maintenance of effort requirement directs states to maintain their eligibility levels for adults until the Secretary of HHS deems the exchanges to be fully operational (expected 2014) and for children in Medicaid and CHIP through September 2019. (This MOE does not apply to benefit levels.)

Existing Medicaid state plan option for covering home and community-based services is expanded to include individuals with higher incomes and to cover more services.

The Children's Health Insurance Program is maintained until 2019 at least and funded through 2015.

Primary care providers will receive increased Medicaid payment rates to 100% of Medicare rates for 2013 and 2014.

Private Insurance Market Reforms

Preexisting condition exclusions are prohibited in all plans starting in 2014 for adults and six months after enactment (September 23, 2010) for children. Insurers must accept every employer and individual that applies - guaranteed issue and renewability - beginning in 2014.

Beginning in 2014, premiums may no longer be based on health status - instead only age, tobacco use, geographic area, and family size.

Lifetime caps on the dollar value of benefits are prohibited in all plans starting six months after enactment and annual limits are restricted (as determined by the Secretary) until 2014 and prohibited after that.

All plans are required to cover preventive services within six months after enactment (September 23, 2010).

The Secretary is directed to establish a temporary high risk insurance pool within 90 days of enactment to provide coverage to people with preexisting conditions unable to access coverage. Individuals in the high risk pool will be transitioned into the state exchanges in 2014, when they are established and insurers are no longer able to discriminate based on preexisting conditions.

Improvements to Care Coordination

A new Medicaid state plan option has been established to permit Medicaid enrollees with at least two chronic conditions or at least one serious mental health condition to designate a provider (which could be a community mental health center) as a health home. This option will be subject to 90% federal funding for two years, effective in January 2011.

A new grant program has been established to support co-location of primary and specialty care services in community-based mental and behavioral health settings. Another grant program will be available to fund community health teams to support primary care practices with interdisciplinary resources including access to mental health and addiction treatment specialists.

A new program has been set up at HHS to develop, test, and disseminate shared decision-making tools to facilitate collaboration between patients, caregivers, and clinicians and incorporation of patient preferences and values into treatment decisions.

ACA establishes a new office within CMS to better integrate Medicare and Medicaid benefits for dual eligibles and improve coordination between the federal government and states.

Prevention

A National Prevention, Health Promotion, and Public Health Council has been established to coordinate federal activities and develop a national strategy. Headed by the Surgeon General, the Council is gaining input from stakeholders in developing the strategy.

ACA established a Prevention and Public Health Fund with significant funding ($7 billion for FY 2010 through 2015 and $2 billion each year after that) for prevention and public health programs.

A new community transformation grant program will be established to support delivery of community-based prevention and wellness services.

Home visitation will be promoted with $1.5 billion in grant funding for early childhood home visitation programs.

ACA sets up a new grant program to fund school-based health clinics - $50 million for each fiscal year 2010 through 2013 - with explicit direction that clinics are to include mental health and substance use assessments, treatment and referrals.

Provisions in the new law give employers more flexibility to lower premiums or offer other incentives for employees who participate in wellness programs. Grants are also authorized for small employers that establish wellness programs.

New annual wellness visit benefit is authorized for Medicare beneficiaries- providing comprehensive health risk assessment and creation of personal prevention plan. Additionally, Medicare is directed to cover preventive services approved by US Preventive Services Task Force (USPSTF) and without cost-sharing. Depression screening is an approved service by the USPSTF.

Federal Medicaid funding will be increased by one percentage point for states that cover immunizations and preventive services endorsed by USPSTF for adults with no cost-sharing, including depression screening.

Incentives will be established in Medicaid for beneficiaries to complete healthy lifestyle programs.

Other Provisions of Interest to the Behavioral Health Community

Postpartum Depression: ACA funds a new federal initiative to combat postpartum depression through a public education campaign and a new grant program to provide medical and support services for individuals with or at risk of postpartum conditions.

Centers of Excellence on Depression: A grant program was established to develop innovative interventions through services research.

Medicaid Coverage of Psychiatric Hospitals: This demonstration program will allow Medicaid coverage of private inpatient psychiatric facilities (i.e., IMDs). $75 million is available for 5 years.

Closing the Medicare Part D doughnut hole: ACA makes available a $250 rebate for Medicare beneficiaries in the coverage gap in 2010, and phases out the gap by 2020. Drug companies are to provide a 50% discount for brand-name medications filled in the gap beginning in 2011.

Comparative Effectiveness Research: New independent Patient-Centered Outcomes Research Institute was established to prioritize and fund comparative effectiveness research.

Workforce: ACA included a number of new education and training grants and loan repayment programs targeted to mental health and addiction treatment providers (particularly pediatric and child and adolescent specialists). Programs to educate primary care providers about integration of mental and physical health, chronic disease management, treating vulnerable populations including individuals with mental health or substance use conditions were also included.

ACA directs the Secretary to develop new conditions of participation in Medicare for community mental health centers to address fraudulent activity regarding partial hospitalization.

Funding for community health centers is increased to $11 billion between FY 2011 and 2015.

CLASS Act: This provision establishes a national, voluntary long term care insurance program providing cash benefit to purchase non-medical services and supports necessary to maintain community living.

Community First Choice Option: ACA establishes a new state option in Medicaid to provide community-based attendant supports and services for individuals with disabilities who would otherwise require institutional care including in institutions for mental diseases.

ACA requires removal of benzodiazepines and barbiturates from list of medications states may exclude from Medicaid coverage.

Major State Responsibilities

States are to create "American Health Benefit Exchanges" and "Small Business Health Options Program (SHOP) Exchanges" to be administered by a governmental agency or non-profit organization through which small businesses (up to 100 employees) and individuals can purchase insurance.

Grants will be made available to states for establishing the Exchanges - amounts to be specified by the Secretary of HHS.

Federal government will contract with insurers to offer at least two multi-state plans in each Exchange but states can require benefits in addition to the essential benefits package be provided to enrollees of a multi-state qualified health plan offered in such state.

States can enter "health care choice compacts" with other states to pool individual market plans but these plans would be subject to the laws and regulations (including consumer protection standards) of the purchaser's home state.

An additional $30 million in grants is available to states to establish and operate offices of health insurance consumer assistance and ombudsman offices. States must collect data and report on the types of problems encountered by consumers.

The temporary high risk pool may be carried out through contracts with the states or nonprofits.

States are responsible for enrolling newly eligible beneficiaries into Medicaid no later than Jan 2014 and states have the option to expand enrollment as early as 2011.

States are directed to maintain current Medicaid and CHIP eligibility levels for children until 2019 and for adults until Exchanges are operational.

States are directed to simplify enrollment processes for Medicaid and CHIP and conduct outreach to educate and enroll vulnerable populations into Medicaid or CHIP including individuals with mental health or substance use conditions as well as facilitate enrollment in Exchange plans and subsidy programs for those found not eligible for Medicaid or CHIP.

Advocacy Engagement at the State Level

The Affordable Care Act presents an opportunity for advocacy by state advocates to improve access to insurance benefits and behavioral health services that are needed and have long been denied many Americans. MHA encourages its affiliates and community partners to engage with state, federal and private sector decision makers to ensure that ACA is implemented robustly and the behavioral health provisions contained in the law improve the lives of individuals living with mental illnesses. To that end, MHA has developed general principles and characteristics that should be considered in developing a modern behavioral health system.

Major Principles of a Modern Behavioral Health System

Mental Health America represents the experiences and needs of consumers and families who too often endure chronic barriers to accessing high-quality, culturally and linguistically competent, adequately-financed community-based services and supports. MHA encourages advocates and decision makers to support innovative approaches to increasing access to care and improving the quality of health care delivery. A modern behavioral health system must embody these major principles:

• Coverage should include prevention, early-intervention, treatment, and rehabilitation services, and offer a full range of services to address the continuum of behavioral health needs for consumers experiencing mild to severe illnesses.
• All services provided should be seamlessly integrated with primary care, with the focus on the consumer as the center of the health care system. Recovery-oriented systems that operate within a shared decision-making framework must provide adequate reimbursement and flexible staffing so that consumers will have time to work with their clinicians in developing a meaningful treatment plan reflecting their goals and accommodating the acuity of their illness. We see the health/medical home as the core element in the engagement of consumers in a recovery-oriented system. The health home will be the entity promoting the seamless integration of behavioral health into primary care and will provide access to the array of appropriate behavioral health services.
• A wide range of services should be available for people based on a range of acuity, disability, and engagement levels. The degree of disability and the need for long-term vs. acute care services, as well as the consumer's goals, should dictate the services rendered. While the needs and goals of many individuals with behavioral health needs can be addressed by basic services offered within the health home, individuals with enduring disabilities or with mental illnesses that do not respond to primary care services should have available more intensive services that will likely be afforded outside (but closely coordinated with) the health home.

Access

Access to services is critical if a modern behavioral health system is to achieve its goal of reaching individuals and families. Accessibility can be achieved through the following steps:

• Providing integrated services within the health home model will allow for better identification and access to behavioral health services and management of co-morbid illnesses.
• Recognizing the high prevalence of co-occurring mental health and general health conditions, behavioral health services and supports should be available as an essential component of any disease management program.
• Plans must cover services provided in locations where individuals routinely frequent in order to reduce barriers, identify needs, and engage individuals in care as early as possible. School-based clinics and workplace health services should be considered reimbursable providers.
• Longer-term, more intensive care for illnesses that are proving to be more disabling should be easily accessed from the health home, and coordination with primary care/health home should be systematic and on-going. Individuals should also be able to move out of more intensive services and into support services when they are no longer in need of the longer-term services.
• A graduated set of services contingent up on the need of the individual must be available. A wide spectrum of services to support the continuum of severity of behavioral health needs should be provided.
• Families should be viewed as an insured unit, so services available to the parent to support the treatment of a child with a mental health condition can be covered. For instance, parenting supports to teach a parent to cope with the special needs of their child should be reimbursable, even though the parent is the recipient of the service and the child is the beneficiary of the service.
• Communication and integration between the children's health system and the adult health system will promote seamless delivery of behavioral health services and supports that are developmentally appropriate for the individual.
• To eliminate behavioral health disparities and the resulting burden, policies and practices should incorporate and be responsive to cultural pathways related to problem identification, help-seeking patterns, referrals, diagnosis and treatment preferences.

Research

There is a significant body of research that powerfully argues for the implementation of effective interventions to prevent the onset and reduce the rate of mental health and substance use conditions, particularly among children. To ensure these strategies are a priority:

• Evidence-based interventions focused on the prevention of mental health and substance use conditions should be part of any benefit package. We have overwhelming evidence pointing to both targeted and broad interventions that can prevent mental health and substance use disorders and promote mental health and wellness.
• Many of the preventive services for children are targeted at supporting the parent in raising a healthy child. As is the case in providing treatment services to the parent for the benefit of the child, preventive interventions that are delivered to the parent with the goal of developing a healthy child should be reimbursable.
• Screening for mental health and substance use conditions should be a basic element of practice within the health home and specialty settings. Competent staff should be available to screen and further assess as indicated in order to promote early intervention and provide the most appropriate service for the level of need and goals of the individual.

Recovery

Mental Health America is committed to the notion that every individual with a mental health or substance use condition can recover. A modern behavioral health system must provide supports and promote services and systems that facilitate the recovery of people with mental health and substance use conditions so every person with an illness can live a meaningful live in their community. To achieve this critical goal:

• The modern mental health system should operate within a framework of shared decision-making. Adequate time should be available for an individual to work with her provider to select the recovery services that are most appropriate for her goals.
• Individuals will develop their own recovery plan with the goal of community integration and engagement in roles that are meaningful to each person. Services should support community integration with a full range of activities, including employment, education, and family and civic participation.
• For individuals with significant disability and longer term care needs, the definition of what is medically necessary should be expanded to ensure that the wide array of services and supports that help consumers integrate into the larger society are accessible. This may occur through assertive, accountable case management systems or within a disease management plan for persons with significant rehabilitation needs.
• Younger adults will have special and different recovery needs than older adults. A special emphasis for them is likely engaging in education and vocational services that will assist them in becoming self-sufficient and integrated in the community. Early, accessible recovery services for younger adults will likely mitigate large long-term direct and indirect costs for individuals who are not engaged in the workforce and have few social supports in the community.

Available Services in the Essential Benefit Package

The federal government will create a floor of essential benefits that must be included in the expanded Medicaid benefits and the state health insurance exchanges. State will be allowed to provide coverage above those basic levels established by the Secretary. MHA urges its affiliates and partners to advocate on both the federal and state level for a robust essential benefit package in order to ensure that the new benefits are meaningful and address the needs of individuals with mental illnesses.

Services should be available and provided in such a way that individuals can move through the system and access various benefits based on their level of need and personal goals. The services fall into four major categories; traditional services, psychosocial rehabilitation services, preventative services, and ancillary services. All of the services listed should be coordinated with one another so, for example, crisis services are provided on a short-term basis and link to longer term medication, case management, and peer support services to support recovery.

Traditional Mental Health Services

• Inpatient Services (including residential services for children, detox and other services for individuals with substance use conditions)
• Medication Services
• Psychotherapy Services
• Case Management Services
• Crisis Intervention Services
• Screening, Assessment and Treatment Planning

Inpatient Services (including residential services for children, detox and other services for individuals with substance use conditions)

Psychosocial Rehabilitation Services

• Individual and Group Rehabilitation services
• Supported Employment
• Supported Education
• Life Supports (housing, access to transportation, life skills)
• Financial Planning/Money Management
• Peer Support Services

Preventative Services

• Screening and Early Intervention
• Targeted Prevention
• Wellness and Health Promotion Services

Ancillary Services

• Respite care for family members
• Consultation between health care providers

Advocacy Strategies

In order to realize the true potential of the new health reform law and ensure that the modern behavioral health system is developed in an appropriate way to serve the needs of individuals with mental illnesses, state and local advocates must monitor and be engaged in the implementation process. Different states will utilize different strategies for implementing the law and determining the ways the Medicaid expansion and health insurance exchange will be put into operation. Below are a few tips for engaging in process in your state so behavioral health is adequately represented in the process:

• Identify, join or create coalitions of voluntary health organizations and provider organizations from various conditions in order to advocate for the views of mental health and substance use consumers and providers.
• Advocate for benefit plans that will be developed for the expanded Medicaid population to include robust mental health and substance abuse services.
• Advocate for robust mental health and substance abuse services as essential benefits for the Exchanges, as these will be the basis for the essential benefits in the Medicaid expansion plans.
• Offer consultant services to legislators, the state insurance commissioner, health department, Medicaid director, mental health and substance use authority, and governor's office to provide feedback and advice regarding the interests of the behavioral health community.

For more information on advocacy strategies, please see MHA's Health Reform Strategy Brief.