The ACA and ADTC

Kirstin Frescoln Facilitated Community Solutions

the ACA

the ACA

Objectives• Understand the common features of the ACA in

both Medicaid expansion and non-expansion states and State versus Federal exchanges

• Identify critical aspects of the ACA and how these impact Adult DTC operations and participants

• Know where to find more information about the ACA in your state or county

• Know who you should engage to help shape the insurance (Medicaid and Private) coverage available to your ADTC participants

ACA TimelineMarch 23, 2010 Patient Protection and Affordable Care Act a.k.a. ACA or Obamacare, signed into lawMarch 28, 2012 US Supreme Court rules that states not required to expand Medicaid coverageMarch 31, 2014 Open enrollment for Health Insurance Marketplace endedNovember 15, 2014 – February 15, 2015Open enrollment for Health Insurance Marketplace

Medicaid Expansion

10 Essential Benefits1. Ambulatory patient services2. Emergency services3. Hospitalization4. Maternity and newborn care5. Mental health and substance use disorder services,

including behavioral health treatment6. Prescription drugs7. Rehabilitative and habilitative services and devices 8. Laboratory services9. Preventive and wellness services and chronic disease

management10.Pediatric services, including oral and vision care

ACA Patient Protections

• Expanded insurance coverage through Medicaid expansion and Federal subsidies to make health insurance and treatment more affordable

• Guaranteed 10 Essential Benefits• Eliminated discriminatory insurance practices

that allowed denial of coverage based on pre-existing conditions

10 Essential Benefits1. Ambulatory patient services2. Emergency services3. Hospitalization4. Maternity and newborn care5. Mental health and substance use disorder services,

including behavioral health treatment6. Prescription drugs7. Rehabilitative and habilitative services and devices 8. Laboratory services9. Preventive and wellness services and chronic disease

management10.Pediatric services, including oral and vision care

Mental Health Parity and Addiction Equity Act

Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)• Increase access and reduce discriminatory practices

associated with mental health and substance use/abuse/dependence treatment

• Parity means that the substance use and mental health benefits covered by the plan must be covered in a manner that is no more restrictive than that of other covered medical health care benefits

• ACA closed “loop holes” in MHPAEA by extending requirements of parity law to all health care plans

Mental Health Parity and Addiction Equity Act

Implementation of parity is a work in progress

Defined by Federal government however…• How that will be negotiated in each state (or

county) probably not fully determined until later this year

• Clarification of what this means and how this should be implemented is likely to be decided in future years and through the courts

Expanded Coverage• Those states that have expanded Medicaid

coverage now may include adults 18 to 65 with incomes up to 138% (about $27,000 for a family of 3) of the Federal Poverty Level (FPL).

• Federal subsidies are available to help individuals pay for coverage if their income falls between 100-400% FPL (in Medicaid expansion and non-expansion states).

Medicaid• Healthcare coverage for particular categories of

people who are at or below 100% of the FPL• Coverage of benefits in Medicaid is determined by

the state division of medical assistance (or its equivalent) in its state plan, within the framework required by federal law

• Generally low-income – disabled adults, children (CHIP) and families, pregnant women, long-term care recipients, others as determined by each state

Medicaid Expansion• The ACA provided federal funds to expand

Medicaid coverage to individuals up to 138% of the federal poverty level

• Expansion extends Medicaid eligibility to all parents and other adults up to the new Medicaid limit

• Recommended development of Alternative Benefit Plans within Medicaid that extended coverage to populations not previously eligible such as non-disabled adult males

Medicaid Expansion Gap

• Individuals who are not members of a specific Medicaid covered category

• Gap is wider in those states that did not expand Medicaid coverage but may exist in expansion states depending on populations (not) covered

• Individuals who are not covered by Medicaid and who do not have incomes high enough to qualify for tax credits and subsides to purchase insurance coverage on the Exchange

Key Agencies/Individuals

• Single State AgencyOversees the state’s substance use/abuse/ dependency and mental health treatment

• Division of Medical Assistance (or equivalent)Oversees the state’s Medicaid and CHIP plans

• State Insurance CommissionerOversees certain private insurance coverage and ensures compliance with state insurance laws

Single State Agency• Oversees the state’s substance use/abuse/

dependency and mental health treatment• In some states, administers Drug Courts• Manages how the state’s Substance Abuse

Prevention and Treatment Block Grant funds are prioritized and expended

• Works with the state’s Medicaid offices and Insurance Commissioner to define substance use/abuse/ dependency and mental health treatment coverage

• Helps define and implement Parity Act

Division of Medical Assistance

• Define who and what is covered by Medicaid in each state within the framework of federal law

• In Medicaid expansion state, determine who and what is covered in the alternative benefit plans

Insurance Commissioner

• Ensures the benefit plans submitted by insurance companies meet state laws and benefit requirements

• Broad or narrow interpretation may affect what services and medications are included in plans

• For example, how parity is interpreted and enforced could affect which, if any, medication-assisted therapy drugs are covered  in your state  

• Different plans will have different coverage - BCBS may include only one drug while Kaiser might cover 10 and both could technically meet the requirements of the laws

So what does all this mean to you, your drug court operations, and your participants?!?

Change

Medical Necessity• Focus on clinical definitions of medical necessity

And…

• Focus on payers' definitions of medical necessity

How will your team ensure that your Drug Court participants are able to access and pay for clinically necessary treatment?

Residential Treatment• Residential treatment is not required for most

drugs (e.g., alcohol and benzodiazepines require medically supervised detoxification, opioids do not)

• Medicaid can not pay for residential treatment in facilities with more than 16 beds

How will your team ensure that your participants are able to access and pay for residential treatment when it is needed?

Medicaid Billing• In order to become a Medicaid provider,

treatment agencies must meet a variety of federal and state regulations

• Medicaid billing is complex

• Reimbursement is usually delayed

How will you help your treatment providers transition to Medicaid billing?

More Provider Choice• More people with insurance (private and

Medicaid) means that more providers may decide it is economically advantageous to provide treatment in your area

• Some of these providers may not be experienced in treating high-risk/high-needs Drug Court participants

• More providers means that you will have to make accommodations to your Drug Court policies, procedures and written materials

Less Provider Choice• Changes in Medicaid and private insurance may

result in a reduction in treatment providers in your area

• The ACA includes a “network adequacy” standard that was intended to protect (primarily rural) areas from a contraction in the number of qualified treatment providers

• Federally Qualified Health Centers (FQHC) are stepping in to provide mental health and substance use/abuse/dependency treatment in some rural areas

Responding to Changes in Providers

Find out about all the substance use/abuse/dependency treatment providers in your area

– what are their strengths? - which would be highly-qualified to treat your participants?

Know which are Medicaid providers and which are “preferred providers” on the most common private insurance plans in your area

Make changes to your policies and procedures to accommodate these provider changes

Substance Abuse Prevention and Treatment Block Grant

• SAMHSA block grant funds are noncompetitive grant dollars provided to all states based on a formula determined by Congress that takes into account population and other factors

• Typically used to provide substance use/abuse/ dependence treatment to high-needs populations such as justice-involved populations and others who may not otherwise have access to treatment coverage

• Managed by the Single State Agency

Substance Abuse Prevention and Treatment Block Grant

• States may be able to reapportion Block Grant funds for other treatment uses such as:

- pay treatment providers to participate in staffings- expand the number of participants you serve- provide enhanced complimentary care - offer medications not on the formulary- provide access to recovery management programs- pay for residential care

Substance Abuse Prevention and Treatment Block Grant

Know what your state’s Substance Abuse Prevention and Treatment Block Grant is used to cover

Find out if there are new opportunities for the Block Grant to expand treatment coverage

Talk with your state’s Single State Agencies about the needs of your Drug Court and participants and work to ensure the Block Grant continues to serve the needs of your Drug Court and participants

Parity• All insurance plans should now manage mental

health and substance use/abuse/dependency treatment in the exact same way they do primary medical and surgical care

What does that mean?!?!• Determinations of medical necessity should

be the same as medical/surgical care• Co-pays, maximum benefits, and treatment

duration should be determined in the same way as medical/surgical care

ParityAnd probably some problems

• Determinations of medical necessity are not always without controversy for medical/surgical care

• Co-pays, maximum benefits, and treatment duration for medical/surgical care are not always optimal

• The people who understand medical/surgical care generally don’t often understand mental health/substance abuse care and vice versa

ParityThe interpretation and implementation of parity will be determined over the next several years by your:

- Single State Agency- Medicaid Agency- Insurance Commissioner- Courts

Parity Find out how parity is being interpreted by staff at

your Single State Agency, Medicaid, and Insurance Commissioner

Determine how the most commonly accessed insurance plans are defining parity

Educate everyone about what parity means and why it is so important

Advocate for changes if necessary

Defining Coverage• New insurance plans• New providers• New laws

You and your Drug Court team will need to actively seek out and share information

Top Ten Actions10. Maximize the number of justice-involved individuals receiving Medicaid or insurance coverage

Talk with others in your state or jurisdiction about what they are doing to increase the number of justice-involved individuals enrolled in health care coverage

Consider how you or your Drug Court can contribute

Top Ten Actions9. Ensure continued access to high-quality treatment

Strengthen existing relationships with the highly qualified treatment providers

Build new relationships with all treatment and health plan providers operating in your area and serving your Drug Court participants

Support your treatment providers as they navigate the many changes and regulations associated with the ACA and Parity Act

Top Ten Actions8. Communicate with your Medicaid office, Insurance Commissioner, and others in your state implementing and overseeing health reform

Educate these officials about what Drug Courts do, the health care needs of the population you serve, and the kinds of treatment coverage that best serves this high-need, high-cost population

Engage officials in dialogue about how the Ten Essential Health Benefits, Parity Act, and nondiscrimination aspects of the ACA are being interpreted and implemented in your county and state

Top Ten Actions7. Understand medical necessity and how it affects Drug Court operations

Create or update treatment plans with the full continuum of treatment as recommended in the Adult Drug Court Best Practice Standards

Learn how your typical Drug Court treatment plan might meet or be challenged to meet clinical definitions of medical necessity and how these are likely to intersect or diverge from Medicaid or insurance company definitions of medical necessity

Talk with Medicaid, insurance plan administrators, and your treatment providers about how Medicaid and insurance plans can pay for Drug Court services provided to your participants

Top Ten Actions6. Communicate with your Single State Agency

Maintain active communication with officials at your Single State Agency about your Drug Court’s needs and the kinds of treatment coverage that best serves your participants

Discuss with your Single State Agency how the ACA (and resultant Medicaid and insurance changes) affect or could affect your Drug Court operations and participants

Top Ten Actions5. Determine how your state’s substance abuse prevention and mental health block grants may be affected

Talk with officials in your state’s substance abuse and mental health care agency

Find out how the state’s SAMHSA block grant funds are currently designated

What changes, if any, are planned because of the implementation of the ACA?

Top Ten Actions4. Understand what the Parity Act means in your state or jurisdiction

Get informed about parity by talking with and monitoring updates provided by your Single State Agency and others in your state and nationally that are working on parity

Talk to those who are involved in making decisions about how Drug Courts operate and the health care needs of the population you serve

Invite officials to observe your Drug Court to see how Drug Courts are a perfect example of why mental health and substance use/abuse/dependence treatment parity is so important

Top Ten Actions3. Learn more about Medicaid coverage and alternative benefit plans (if applicable) in your state

Review state-level documents to determine who is covered by Medicaid and Medicaid expansion and share the results with your Drug Court team

Top Ten Actions2. Get Educated

Learn everything you can about what the ACA is (and is not).

Find out how implementation of the ACA in your state affects your Drug Court operations and participants.

Participate in the many opportunities to learn more about the ACA and criminal justice populations through the available literature, web resources, webinars, and trainings provided by federal, state, and nonprofit groups.

Top Ten Actions2. Get Educated

Talk to your treatment partners and other agencies serving your Drug Court population about how they are preparing for and adjusting to the ACA.

Meet with your Drug Court team to identify what opportunities and challenges might be specific to your jurisdiction.

Make a plan to get ahead of the challenges and leverage the opportunities.

Top Ten Actions1. Be an educator

Share what you have learned with your Drug Court Team

Talk to both traditional and nontraditional partners about how Drug Courts operate, the population you serve, and the Drug Court participants’ complex treatment needs

Help shape access to care for your Drug Court population by educating those who are making decisions about ACA interpretation and implementation of what your Drug Court does, what it needs, and how it helps the community

Resources

Visit the NDCRC ACA resource link at http://www.ndcrc.org/ACA

Thank You