mental health policy - the affordablle care act and mental health

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Mental Health Policy IIThe Affordable Care Act

Building an Effective Community Support System

05/03/2023 Jane Addams College of Social Work - Mental Health Policy II

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Patient Protection and Affordable Care Act (P.L. 111-148)


• Requires most U.S. citizens and legal residents to have health insurance or impose a phased-in tax penalty (2014 – $95; 2016 - $695 - $2,085) .

• Creates state-based health benefit exchanges through which individuals cane purchase coverage.

• Cost-sharing credits available to individuals/families with income between 133-400% of the federal poverty level ($15,860 for individual, $21,400 for couple).

• Separate exchanges created for small businesses (SHOP).

• Require employers to pay penalties for employees who receive tax credits through the exchanges (to discourage this).

• Impose new regulations on health plans in the Exchanges and in the individual and small business markets.


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Medicaid Expansion under ACA


• Expand Medicaid to all non-Medicare eligible individuals under 65 (children, pregnant women, parents, and adults without dependent children) with modified gross adjusted incomes up to 133% FPL (sometimes 138% FPL because of a 5% “forgiveness”).

• Guarantee a benchmark benefit package (Alternative Benefit Plans or APBs) that is equivalent to health benefits available on the Exchange.

• All ABPs must include the same ten “essential health benefit” (EHB) categories established by the ACA that Marketplace health plans must include.


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Medicaid Expansion – Parity Provisions


• ABPs must provide parity between physical health and mental health.

• Insurers are prohibited from capping annual and lifetime spending for mental health and addictions treatment at levels below the caps imposed for physical health treatment.

• Mental health and addictions services will be required as essential benefits in the state exchanges.


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• Approximately 60% of individuals with disabilities who are dually eligible for Medicare and Medicaid have a mental illness.

• These individuals face elevated barriers to integrated care because they must navigate two complicated insurance systems.

• The ACA addresses this issue with the establishment of a new office within the HHS that has integration of these two benefit programs as its focus.

• Formally established in December 2010, the Federal Coordinated Health Care Office will monitor progress and provide technical assistance to states, health plans, and physicians to develop more integrated programs of care.


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• The ACA expands an existing SAMHSA program, allocating an additional $50 million in grants for coordinated and integrated services through the co-location of primary and specialty care in existing community-based behavioral health settings.

• These demonstration projects will generate valuable information regarding best practices for primary care colocation that can be used by practitioners who are working to integrate systems in years to come.

• In 2013 and 2014, Medicaid payments for fee-for-service and managed care for primary care were increased to the Medicare reimbursement levels, which represents a mean increase of approximately 33% across the states


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• Federal gov’t pays 100% of the expansion (for newly qualified beneficiaries) through 2016 and then phases down to 90% by 2020 and beyond.

• Increase Medicaid payments in fee-for-service and managed care for primary care services provided by primary care doctors (family medicine, general internal medicine or pediatric medicine) to 100% of the Medicare payment rates for 2013 and 2014.

• States will receive 100% federal financing for the increased payment rates.


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A June 28, 2012 Supreme Court decision (National Federation of Independent Business (NFIB) v. Sebelius) made Medicaid expansion optional for states. .


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SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated September 1, 2015.http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

WY WI*

WV

WA

VA

VT

UT

TX

TN

SD

SC

RI PA*

OR

OK

OH

ND

NC

NY

NM

NJ

NH*

NV NE

MT**

MO

MS

MN

MI*MA

MD

ME

LA

KY KS

IA* IN* IL

ID

HI

GA

FL

DC

DE

CT

CO CA

AR*AZ

AK

AL

Adopted (31 States including DC)

Adoption Under Discussion (1 State)

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

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Current Medicaid Expansion Enrollment in Illinois (August 2015):


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Current Medicaid Expansion Enrollment in Illinois (August 2015):


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Navigators, In-Person Counselors, Certified Application Agents


• A Community Partner is any organization or agency that assists or supports Illinoisans in need in accessing supportive benefits. Community Partners in ABE include organizations certified as Illinois Navigators, In-Person Counselors and Certified Application Agents.

• Community partners can help individuals complete their own application or make computers available for individuals to complete their own applications.


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Health Homes under ACA


• Health homes for people with chronic conditions. The ACA provides states with a new option (described in section 2703) to reform the delivery system for beneficiaries with chronic conditions by providing “health home” services and authorizes a temporary 90% federal match rate for these services.

• To qualify for health home funding states must develop a model that is focused on beneficiaries with at least two chronic conditions; one condition and at risk of developing another; or at least one serious and persistent mental health condition.

• Health home providers will integrate and coordinate all primary, acute, behavioral health and long term services and supports to treat the “whole- person” across the lifespan.


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Health Homes under ACA


States have flexibility to determine eligible health home providers. Health home providers can be:

• A designated provider: May be a physician, clinical/group practice, rural health clinic, community health center, community mental health center, home health agency, pediatrician, OB/GYN, or other provider.

• A team of health professionals: May include physicians, nurse care coordinators, nutritionists, social workers, behavioral health professionals, and can be free-standing, virtual, hospital-based, or a community mental health center.

• A health team: Must include medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral health providers, chiropractics, licensed complementary and alternative practitioners.


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Health Insurance Exchanges


• The ACA calls for the creation of state-based American Health Benefit Exchanges and Small Business Health Options Program (SHOP) Exchanges, administered by a governmental agency or non-profit organization, through which individuals and small businesses with up to 100 employees can purchase qualified coverage.

• Permit states to allow businesses with more than 100 employees to purchase coverage in the SHOP Exchange beginning in 2017.

• Restrict access to coverage through the Exchanges to U.S. citizens and legal immigrants who are not incarcerated.

• Enrollment (for most individuals) is restricted to open-enrollment periods (Nov. 15 2014 – Feb. 15, 2015).


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• Marketplace enrollment is currently open only for individuals who have gone through a qualifying life event - such as a marriage, job change, birth of a baby, or other change. Those who qualify are eligible for a Special Enrollment Period, or SEP. The SEP lasts for 60 days in the Marketplace after the marriage or other life event. The SHOP Marketplace and Medicaid are open for enrollment year round.

• Illinois enrolled 349,487 through the Illinois Health Insurance Marketplace (GetCoveredIllinois) through February 2015.

• Insurers submit plans to the Illinois Department of Insurance to be considered for inclusion in the Marketplace.


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Creates four benefit categories of plans plus a separate catastrophic plan to be offered through the Exchange, and in the individual and small group markets:

• Bronze plan represents minimum creditable coverage and provides the essential health benefits, cover 60% of the benefit costs of the plan, with an out-of-pocket limit equal to the Health Savings Account (HSA) current law limit ($5,950 for individuals and $11,900 for families in 2010);

• Silver plan provides the essential health benefits, covers 70% of the benefit costs of the plan, with the HSA out-of-pocket limits;


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• Gold plan provides the essential health benefits, covers 80% of the benefit costs of the plan, with the HSA out-of-pocket limits;

• Platinum plan provides the essential health benefits, covers 90% of the benefit costs of the plan, with the HSA out-of-pocket limits;

• Catastrophic plan available to those up to age 30 or to those who are exempt from the mandate to purchase coverage and provides catastrophic coverage only with the coverage level set at the HSA current law levels except that prevention benefits and coverage for three primary care visits would be exempt from the deductible. This plan is only available in the individual market.


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The Illinois Health Insurance Exchange



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Essential Benefits


By law, every qualified health plan (QHP) on the Marketplace must include:• Outpatient services, like services or tests done at a medical center or doctor’s

office that do not require you to stay overnight.

• Emergency services, like medical care given to treat a sudden or unexpected illness in an emergency to keep you from getting worse.

• Hospitalization, like services, tests or surgery that require you to stay the night in the hospital.

• Maternity and newborn care, like services during pregnancy and after your baby is delivered, including breastfeeding.

• Mental health and substance use disorder services, including behavioral health treatment, like services that improve your mental well-being or treat a mental illness or substance use problem.


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Essential Benefits


• Prescription drugs

• Habilitative and Rehabilitative services and devices, like physical therapy, which helps you recover skills that you lost because you were hurt or disabled, or helps you develop and maintain the skills you need.

• Laboratory services

• Preventative and wellness services and chronic disease management like check-ups and screenings to help you stay healthy, and services to improve your quality of life by preventing or lowering the effect of a disease. This includes monitoring and educating you about your treatment.


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Essential Benefits


• Pediatric care, including medical, dental and vision care for children.

• Dental coverage available through the Marketplace at an additional cost.


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The ACA and Immigrants


Undocumented immigrants (139,000 in Illinois?):

• Unable to buy private health insurance in exchange and ineligible for federal financial help.

• Exempt from individual mandate.

• Remain ineligible for Medicaid.

• Can purchase private insurance.

• Can get emergency healthcare and at FQHC community agencies.


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Federally Qualified Healthcare Centers


• Healthcare center is an all-encompassing term for federally qualified healthcare centers (FQHCs) and FQHC look-alikes; they are a key component of the health care safety net that provided care to more than 20 million Americans in 2011.

• Health centers (FQHCs and FQHC look-alikes), provide comprehensive primary health, oral health, mental health/substance abuse services, and enabling services. Health center is an all-encompassing term for a diverse range of public and nonprofit organizations and programs that provide primary care services.

• Those that receive federal grant funding are known as Section 330 grantees, which include FQHCs. FQHC look-alikes meet the same requirements as FQHCs but do not receive federal grant funding.


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The Federal Health Center Program supports four types of health centers:

Federally qualified health centers—Section 330 (e), which serve a variety of medically underserved populations and areas.

Migrant health centers –Section 330 (g), which provide care to migrant and seasonal agricultural workers and their families in a culturally sensitive way.

Health care for the homeless programs–Section 330 (h), which reach out to homeless individuals and families to provide primary care, substance abuse, and mental health services.

Public housing primary care programs—Section 330 (i), which are located in public housing communities and serve their residents.


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• Health centers, supported by the Health Resources and Services Administration (HRSA), treated approximately 21.7 million people in 2013, sixty‐two percent of whom are members of ethnic and minority groups. Thirty‐five percent have no health insurance; thirty‐two percent are children.

• By definition, FQHCs must provide care in medically underserved areas and to medically underserved populations (MUA/MUP).


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• The ACA has positioned health centers to play a crucial role in the future health care environment by establishing the Community Health Center Fund that provides $11 billion over a 5 year period for the operation, expansion, and construction of health centers throughout the Nation. $9.5 billion is targeted to:

• Support ongoing health center operations. • Create new health center sites in medically underserved areas. • Expand preventive and primary health care services, including oral

health, behavioral health, pharmacy, and/or enabling services, at existing health center sites.

• $1.5 billion will support major construction and renovation projects at community health centers nationwide.


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• Health centers are required by law to provide services to all people, regardless of ability to pay. The uninsured are charged for services on a board-approved sliding-fee scale, which is based on a patient’s family income and size.

• Health centers are financed through a mix of Medicaid and Medicare reimbursements (with different payment methodologies), direct patient revenue, other third-party payers (private insurers), state funding, local funding, philanthropic organizations, and grant funding from the Bureau of Primary Health Care (BPHC) of HRSA of the U.S. Department of Health and Human Services (HHS).

• The single largest source of funding is Medicaid.


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Further detail:



Roadmap of the ACA in Illinois for people with mental health issues: https://www.youtube.com/watch?v=SjLfnOf7j8o

Illinois Health Matters (source for Illinois policy on health reform including ACA and FQHC):http://illinoishealthmatters.org/

Reading on Chicago Mental Health and Public Health is posted on Blackboard.

https://www.youtube.com/watch?v=SjLfnOf7j8o

https://www.youtube.com/watch?v=SjLfnOf7j8o