mental health parity, the aca, & californians with mental health challenges

Mental Health Parity, the ACA, & Californians with Mental

Health Challenges

What this training will coverI. Stigma Faced by People with Mental Health

DisabilitiesII. Overview of Mental Health Parity –Existing

Federal & State LawsIII. Overview of the Affordable Care Act – New

Federal and State LawsIV. Intersection of Parity & ACA in CaliforniaV. How the Laws Can Reduce Stigma and

Discrimination

Stigma

Stigma faced by people with mental health challenges

Stigma refers to attitudes and beliefs that lead people to reject, avoid, or fear those they perceive as being different.

Discrimination faced by people with mental health challenges

Unjust deprivation of rights and opportunities due to stigma - exclusion or marginalization of people- denial of equal health / insurance benefit- less chance of full participation in life

What is mental health parity?

Parity ends disparity or unequal physical and mental health insurance coverage

Parity = Equality

Examples of No Parity

Equality of Copayments

1. Different levels of co pays are banned

2. $15 for outpatient physical health visit

3. $20 for outpatient mental health visit

Equal Treatment Lengths1. Different levels of an

treatment limits are banned

2. 21 inpatient days for mental health care

3. 30 inpatient days for physical health care

California Mental HealthParity Act

Health care plans issued, amended or renewed on or after July 1, 2000 provide coverage for the diagnosis and treatment of specified mental health conditions under the same terms and conditions applied to other medical conditions.

Cal. Health & Safety Code § 1374.72(a)

People protected under CA parity

- Children with serious emotional disturbances- People with serious mental illnesses (SMI),

which are defined to include: schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorders, panic disorder, obsessive-compulsive disorder, pervasive developmental disorder or autism, anorexia nervosa, bulimia nervosa

Cal. Health & Safety Code § 1374.72(d)

Equal terms and conditions Include but not limited to the following:1. maximum lifetime benefits2. copayments3. individual and family deductibles.Cal. Health & Safety Code § 1374.72(c)

Benefits that must be provided

Include: 1. outpatient services2. inpatient hospital services3. partial hospital services4. prescription drugs, if the plan contract

includes coverage for prescription drugs.Cal. Health & Safety Code § 1374.72(b)

All “medically necessary” treatment

9th Circuit found that California parity law requires that a health plan provide all “medically necessary treatment” for “severe mental illnesses,” such as: residential care for an individual with anorexiaHarlick v. Blue Shield of California 686 F.3d 699 (2012)

Federal parity lawPaul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008

Federal parity regulationsEqual financial requirements and treatment limitations between mental health / substance abuse disorder benefits and medical/surgical benefits.

See: 26 CFR Pt. 54 (DOT), 29 CFR pt 2590 (DOL), 45 CFR Pt 146 (DHHS), Federal Register, Vol 78, No.219 68240-68296 (Nov. 13, 2013) [Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008]

Equal terms and conditions- Quantitative: co-pay, deductibles, number

of visits, lifetime caps- Non-quantitative: utilization review,

formulary design, step therapy

See: 26 CFR Pt. 54 (DOT), 29 CFR pt 2590 (DOL), 45 CFR Pt 146 (DHHS), Federal Register, Vol 75, No.21 5410-5451 (Feb. 2, 2010) [interim final rules under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008]

CA & Federal Parity LawsCA Federal

Specified Diagnoses Y NSpecified Benefits Y N

Federal parity law requires equality if any mental health or substance use disorder benefits are covered.

Federal parity: 6 benefit classes

1. inpatient, in-network2. inpatient, out-of-network3. outpatient, in-network4. outpatient, out-of-network5. emergency care6. prescription drugs. See: Federal Register Vol. 75, No. 21 5413

Benefit coverageby federal parity

Coverage provided for mental health and substance abuse disorder benefits in each classification in which medical/surgical coverage is provided.

See: Federal Register Vol. 75, No. 21 5413

Do federal parity rules define inpatient, outpatient or emergency care?

No. Fed parity regulations say plan terms defining benefits must be consistent with generally recognized standards of medical practice. Plan must apply terms uniformly.

See: Federal Register Vol. 75, No. 21 5413-5414

What is the Affordable Care Act (ACA)?

The Patient Protection & Affordable Care Act of 2010 (ACA) = “Obama-Care”

What are the goals of the Affordable Care Act?

Goal 1: Strengthen Health Care

Objective A: More secure coverage for those insured & extend affordable coverage to uninsuredObjective B: Improve healthcare quality and patient safetyObjective C: Emphasize primary and preventive care linked with community prevention servicesObjective D: Reduce the growth of healthcare costs while promoting high-value, effective careObjective E: Ensure access to quality, culturally competent care for vulnerable populationsObjective F: Promote the adoption and meaningful use of health information technology

Source: http://www.hhs.gov/secretary/about/goal1.html [includes other goals]

How does ACA extend affordable coverage to the uninsured?

How does ACA extend affordable coverage to the uninsured?

1. Public Medicaid (Medi-Cal in California) Expansion2. Private Plans on health insurance

“Exchanges”a. Individual Mandateb. Employer Mandate

Will Medi-Cal expand?

California plans to increase Medi-Cal eligibility to single, childless adults up to 138% of federal poverty level

Source: Committee No. 1 Health & Human Services, Assembly Budget Committee (3/6/13) at: http://abgt.assembly.ca.gov/sites/abgt.assembly.ca.gov/files/March%206%20-%20Affordable%20Care%20Act%20Medi-Cal%20Expansion.pdf

Benefits of Medi-Cal Expansion 1. Insure over 1 million Californians

2. 100% fed $ for 3 yrs, then over 4 yrs up to 10% state match

3. More insured people improves public health for all in CA

4. Infuses millions, possibly billions, of fed $ in CA

5. Insure more people nationally = market stability & cost control

Source: Committee No. 1 Health & Human Services, Assembly Budget Committee (3/6/13)

What are health insurance Exchanges?

What are Health Insurance Exchanges?

Organizations set up to help individuals and small businesses purchase health insurance policies

“Covered California” is the exchange in CA

What is the individual mandate?

Most Americans must get health coverage

Penalty phased in 2014 through 2016

Exempts certain individuals

What is the employer mandate?

ACA responsibilities apply to employers with 50 + employees

Penalty for failure to offer minimum essential coverage to employees

Implementation in 2015

Other ACA provisions include

1. Subsidies2. Pre-existing condition coverage3. People under age 26 covered on

parental insuranceSource: http://www.hhs.gov/secretary/about/goal1.html

Intersection of Mental Health Parity & the ACA for Californians with Mental Health

Challenges

ACA Plans must comply with federal parity law & provide 10 “essential health benefits”

Essential benefits1. Ambulatory2. Emergency3. Hospitalization4. Maternity and newborn care5. Mental health and substance use disorder services6. Prescription drugs7. Rehabilitative & habilitative8. Laboratory9. Preventative, wellness, chronic disease management10. Pediatric services, including oral and vision care

See http://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.html

California has adopted Kaiser HMO Plan as benchmark

Includes following mental health coverage:– Outpatient mental health services– Inpatient hospital and intensive psychiatric

treatment programs (includes crisis residential treatment)

CA benchmark coverageServices are for the diagnosis or treatment of Mental Disorders…identified as a "mental disorder" in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM) that results in clinically significant distress or impairment of mental, emotional, or behavioral functioning.

Kaiser Small Group HMO Plan 1637, Plan 30-N, p.33 (Aug. 15, 2011)

Medi-Cal Expansion1. Provide same array of mental health

services to individuals currently eligible: Specialty Mental Health Services

2. Provide benchmark /10 essential health benefits

Parity & ACA can reduce stigma and discrimination

“Stigma is the most formidable obstacle to progress in the arena

of mental illness and health.”

Prevention & Wellness Care1. Help people recognize early signs2. Connect with support and services3. Improved Outcomes -

a. Reduce homelessnessb. Increase employmentc. Avoid unnecessary criminal justice

involvement and hospitalization

Rehabilitation & Recovery 1. Individualized Services2. Peer Support3. Self-Help or Consumer-run Services4. Cultural & Linguistic Competence5. Improved Outcomes -

a. Help people attain their goalsb. Support living in most integrated setting

Policy Paper on Recovery-Focused Hospital Diversion & Aftercare

1. Best practices on pathways to home & community services

2. Cost and quality analysis of model crisis alternatives to hospitalization

3. Recovery-based policy recommendations4. Coordination between private plans and

the public mental health system

Alternatives to Acute Hospital - Outreach / Prevention- Crisis Lines / Crisis Clinics- Mobile Crisis Intervention- Crisis Stabilization Units / Urgent Care Units- Crisis Residential Treatment Facilities- Crisis Respite- Integrated Services

– Full Service Partnership (FSP)– Assertive Community Treatment (ACT)– Wraparound– System of Care

DisclaimerThis area of the law is rapidly developing. These provisions are not intended to include all federal and state laws, regulations, policy directives or other relevant references. Further legal research is required. The intent here is to provide a general overview of these topics.

Disability Rights California isfunded by a variety of sources, for a

complete list of funders, go to http://www.disabilityrightsca.org/

Documents/ListofGrantsAndContracts.html.

CalMHSA

The California Mental Health Services Authority (CalMHSA) is an organization of county governments working to improve mental health outcomes for individuals, families and communities. Prevention and Early Intervention programs implemented by CalMHSA are funded by counties through the voter-approved Mental Health Services Act (Prop 63). Prop. 63 provides the funding and framework needed to expand mental health services to previously underserved populations and all of California’s diverse communities.