Agenda

Coverage for care overview

Health insurance customer protections

New Health Insurance Marketplace

How will Medicaid change?

What does it mean for our state?

Call to action

50 million Americans Uninsured (2009)

Financing Mental Health Care

Source: Garfield (2011) Mental Health Financing in the US: A PrimerKaiser Commission on Medicaid and the Uninsured

Coverage for CareFederal/State Programs

• Medicaid: – Health finance program for the poor– Only covers some lower income people– Broad array of community mental health services– Does not cover inpatient care age 22 – 64

• Children’s Health Insurance Program (CHIP)• Children not covered by Medicaid 100% - 200% FPL• May or may not offer full range of Medicaid services

Coverage for CareFederal Programs

• Medicare: – Seniors, people who received SSDI for >24 months– Limited array of mental health services– Medicaid beneficiaries with very low incomes may

also qualify for Medicaid (dual-eligibles)

• Veterans/Military: – VA health care: limited eligibility, but wide array of

mental health services – TRICARE resembles private insurance

Coverage for Care State and Local Public Systems• State and county mental health authorities• Serve people who fall through the cracks• Provide services not covered by Medicaid

Private Health Insurance• Employer sponsored or purchased by individual/family• Varied benefits• Mental health parity requirements vary• Limited array of mental health benefits typical • Wider provider network

New Consumer Protections

Since 2010• Youth up to age 26 covered on

parent’s health plan• Children no denial for pre-

existing conditions• No lifetime limits on benefits• Temporary high-risk pools• Rescission: Cannot drop for

intense service need • Appeals process for denials• Medical Loss Ratio: 80-85% spent

on direct care

2014 and forward, Individual & small group plans• Essential health benefits (EHB) • MH/BH/SUD parity required• No denial for pre-existing

conditions• No annual limits• Guaranteed coverage• Rates can only differ based on:

– Age, geographic area, tobacco use, family size

• User friendly benefits statement

9

“My 21 year old daughter has had

major depression since she was a

child. We were very worried about

health insurance when she wanted

to leave home. Now she can stay

on our health plan until she is 26.”

The new health law allows parents

to keep adult children on their plan

until age 26.

Uninsured Adults with Mental Illness

US: Total of 45.6 million adults with mental illness

Source: SAMHSA, National Survey of Drug Use and Health, 2011

New Coverage Options

• Health Insurance Marketplace: private coverage• Individuals• Small Employers (SHOP)

• Medicaid expansion: 0 -138% FPL

• Parity required: 62M Americans Benefit– All individual and small group plans – All Medicaid Alternative Benefit Plans (Medicaid expansion)

– Traditional Medicaid managed care plans

Health Insurance Marketplace= Health Insurance Exchange

Goals: Good health coverage at affordable cost

•Regulates:

“Qualified Health Plans”

“Essential Health Benefits”

•Rates Qualified Health Plans

•Unified online application for exchange, Medicaid, CHIP

•Toll-free telephone hotline

•Website to compare health plan information

•Standardized format to present health benefit options

•Electronic calculator to figure of coverage

Qualified Health Plans (QHP)

Only Qualified Health Plans allowed in

Health Insurance Marketplaces

– Must provide Essential Health Benefits

– Insurer must meet requirements:

• In good standing with the State

• Offers at least:

– One silver and

– One gold plan

• Offers the same premium for qualified health

plans inside and outside the Marketplace

Source: Illinois Department of Insurance

Health Insurance Marketplace Incentives

• INDIVIDUALS

– Tax Credits for Premium Subsidies

– Cost-Sharing Subsidies

– Reduced OOP limits, annual cap

$6,350 (premium + deductible)

• SMALL BUSINESS

– Small business Health Options

Program (SHOP)

– Help small employers enroll

employees in qualified health plans

– Small Business Tax Credit

• Individual: 2014 forward, greater of…– 2014: $95 or 1% household income– 2015: $325 or 2% household income– 2016 and beyond: $695 or 2.5% household income

• Employer: 2015 forward – Applies to employers with 50 or more employees– Penalties from $2,000 to $3,000 per employee, – If employer fails to offer coverage or offers bare bones coverage

• Exempted: • Below tax filing threshold (Single, $10K, Jointly $20,000)• Religious reasons• Tribal member• Undocumented immigrant• Incarcerated• If no plan is less than 8% annual household income

Individual & Employer Penalties

Who Should Apply?• 85% of Americans already have health coverage that meets

ACA requirements – no need to apply– Private insurance– Medicare– Medicaid– VA benefits

• 15% may want to apply– Uninsured– Underinsured

• High health costs– Premiums, deductibles, out of pocket costs

• High health needs– Care you need is not covered

Essential Health BenefitsOutpatient clinic services

Emergency services

Hospital care

Maternity, newborn care

Mental health, behavioral health, substance use care

Prescription drugs

Rehabilitative & habilitative services

Laboratory services

Children’s services, dental & vision care

Wellness, disease management

Benefit Continuity

Essential Benefits Package

Source: Sommers, B.D. & Rosenbaum, S. (2011). Health Affairs. Presented by S Fields, NAMI 2011.

The new health law requires Medicaid expansion and

health insurance marketplace plans to provide medication

and lab work, but advocacy is needed.

“I had a 4.0 GPA in school but I

dropped out after my insurance

stopped covering my medication. I

started hanging out with the wrong

crowd and self-medicating just to get

away from the pain and confusion.

Now I’m trying to get back on track,

but every day is a struggle.”

Expanded Medicaid Eligibility

• The Affordable Care Act provides a second chance in states that expand

Medicaid. Anyone with an income below 138 % FPL can enroll in Medicaid

and get treatment. It is also easier to return to work because private

insurance with mental health benefits will be available.

• NEW DONUT HOLE! In states that do not expand Medicaid people with

incomes below 100 percent FPL will not get federal financial help to

buy a private plan.

“I was married and working, but

stopped taking my medications

because I didn’t feel sick. Things went

downhill fast. My wife left me, I lost my

job and had to move back in with my

parents.”

Medicaid ExpansionAny uninsured ≤ 138% FPL

– 100% federal match for newly Medicaid eligible: 2014 – 2016

– Reduced gradually to 90% federal match, 2020 forward• Source: Kaiser Family Foundation

http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/#note-1

Question:Do the new rules help me get Medicaid?Answer:IF your state expands Medicaid and IF your income is at or below 138% of Federal Poverty Level, then yes. 

Eligibility and Financial AssistanceFamily Size 100% FPL 138% FPL

1 $11,490 $15,856

2 $15,510 $21,404

3 $19,530 $26,951

4 $23,550 $32,499

Family Size 100% 400%

1 $11,490 $45,960

2 $15,510 $62,040

3 $19,530 $78,120

4 $23,550 $94,200

Question:Are you eligible for government help buying insurance?Answer:The government will help pay part of premiums and out-of-pocket costs for people with incomes between 100 percent and 400 percent of the federal poverty level.

The Marketplace is OPENEnroll TODAY

www.healthcare.gov

• Enrollment assistance - 24/7 call center– Toll free: 1-800-318-2596 – TTY/TDD: 1-855-889-4325 for assistance– English, Spanish, 150 languages

In-State Update

Call to Action • Contact your legislator today! Call or email!

– Visit state legislature website for contact information– Schedule a visit in the district

• ASK:– Health care coverage will help people with mental

illness recover and contribute to their communities.• Can I count on your support to expand good,

affordable health coverage to all households with incomes from 0 to 138 percent of poverty?

• Can I count on you to advocate for mental health coverage on par with medical/surgical care?

Presenter nameTitle

Contact information