Maryland’s Public Behavioral Health

Care System – Changes on the

Horizon

Susan Jenkins October 2013

• Over 47 million non-elderly Americans were uninsured in 2012.  

• Decreasing the number of uninsured is a key goal of the Affordable Care Act (ACA), which will provide Medicaid or subsidized coverage to qualifying individuals with incomes up to 400% of poverty beginning in 2014.

Affordable Care Act (ACA) goal: reduce the number of uninsured

• One-quarter (25%) of uninsured adults go without needed care each year due to cost.

• The uninsured are less likely than those with insurance to receive preventive care and services for major health conditions and chronic diseases.  (Kaiser Foundation)

The lack of insurance impacts access to health care

• to millions of currently uninsured people through the expansion of Medicaid eligibility and establishment of Health Insurance Marketplaces in 2014,

• and also will help people maintain coverage and make private insurance affordable and accessible.

The ACA will expand coverage…

• Young adults stay on their parents’ health plans to age 26

• No lifetime or annual limits on essential health benefits for children and adults (1/1/2014)

• No pre-existing condition exclusions (for adults beginning 1/1/2014)

• Expanded Medicaid coverage for former foster youth up to age 26

• Preventive care without co-pays or deductibles• No pre-authorization for ER • Seniors get help with their prescription drugs

Affordable Care Act

• Governor O’Malley, Lt Governor Brown, Secretary Sharfstein, Deputies Charles Milligan and Gayle Jordan-Randolph, MD have been leaders in Maryland for health care reform and the ACA.

• The Maryland Legislature has also been supportive and partnered in these efforts.

Maryland has embraced Health Care Reform and the ACA

• Lower Per Capita Costs

• Improved Outcomes

• Better Patient Experience…

Triple Aim

• ACA requires all small group and non-group insurance policies sold inside and outside Exchange beginning 1/1/14 to cover minimum set of “essential health benefits (EHB).”

• EHB must cover ten benefit categories including mental health & substance use disorder services, prescription drugs;

• Health Care Reform Coordinating Council (HCRCC) reviewed the options.

Essential Health Benefits

• Maryland’s largest small group plan will be the State’s benchmark;

• GEHA (Government Employees Health Association) is a self-insured, not-for-profit association providing health plans to federal employees.

• The federal GEHA behavioral health benefit will be the behavioral health benefit in Maryland’s benchmark plan.

Behavioral Health Benefit

• Maryland Health Connection is the new marketplace opened October 2013.

• Make insurance company comparisons and determine eligibility for financial assistance (tax credits) to reduce the cost of monthly insurance premiums.

• A single, streamlined application will determine eligibility for Medicaid or private insurance.

• Consumer assistance will also be available through the call center or in-person throughout the state in Local Health Departments, Departments of Social Services and a network of consumer assistance organizations known as “Connector Entities.”

www.marylandhealthconnection.gov

• ADAA and MHA to reorganize into a single Behavioral Health Administration – July 1, 2014

• One Administrative Services Organization (ASO) will manage Behavioral Health Administration benefits for Medicaid Recipients and uninsured - July1, 2015

• New integrated Behavioral Health regulations

• Accreditation instead of certification by OHCQ based on regulations

Changes Planned To the PBHS

Services - Assessment, Individual Counseling, Group Counseling, Opioid Maintenance Therapy, Intensive Outpatient

◦ Current: MA patients are paid by MCO◦ Current: Uninsured patients are paid by grant funds◦ Current: Provider submits data in SMART◦ Current: authorizations by MCO (MA Patients)◦ Current: Provider bills MCO (MA Patients)

◦ Future: Paid by ASO (MA and uninsured)◦ Future: Provider will submit data to ASO ◦ Future: ASO authorizes services◦ Future: Provider will bill ASO

Outpatient Treatment Services

Levels III.7 (medically monitored intensive), III.5 (clinically managed high intensity), III.3 (clinically managed medium intensity ),and III.1(halfway house - clinically managed low intensity)

Current: Paid by grant funds Current: Jurisdiction authorizes service Current: Provider submits data in SMART

Future: Jurisdiction’s choice - Paid by grant funds OR by ASO

Future: If jurisdiction chooses to have residential service paid by ASO, provider bills ASO

Future: Provider will submit data to ASO and ASO will authorize service

Future: Jurisdiction submits data to ASO

Residential Treatment Services

Services - Care Coordination, Continuing Care Recovery Checkups, Recovery Housing, Recovery Community Center Activities, Recovery Coaching

Current: Paid by grant funds Current: Jurisdiction authorizes service Current: Provider submits data in SMART

Potential: Paid by grant funds Potential: Provider will submit all data to ASO Potential: For Care Coordination, Continuing

Care, and Recovery Coaching, ASO will authorize service

Recovery Services

• The Behavioral Health Administration will establish the requirements for a service

• The service provider will provide information to the ASO that allows the ASO to evaluate whether the prospective service recipient meets the established requirements

• The ASO will either approve or disapprove the service

Authorization for Services