Putting It All Together: Collaboration and Coordinated Care Workshop 11

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Session Format Jim Wotring, MSW: Director, National TA Center for Children’s Mental Health, Georgetown University; Collaboration Opportunities under the Affordable Care Act Linda Sagor, MD, MPD: University of Massachusetts Memorial FaCES (Foster Children Evaluation Services) Clinic Bill Bouska, MPA: Oregon Health Authority, Children's Mental Health System Manager Discussion, Questions and Peer Sharing

Collaboration Opportunities Under The Affordable Care Act Jim Wotring, MSW, Director National Technical Assistance Center for Children’s Mental Health, Georgetown University

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Affordable Care Act General Provisions

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY General Provisions Coverage of young adults to age 26 on their parents’ health insurance plans – starting 2010 The percentage of people ages who have any insurance coverage increased from 64% to 73% as of June This translates into 2.5 million additional young adults with coverage.

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY General Provisions State grants awarded to start Maternal, Infant, and Early Childhood Home Visiting Programs for vulnerable children. $88 million in 2010 and $225 million in 2011 to 49 states, DC, and 5 U.S. territories.

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY General Provisions Opportunities: Add mental health screening, early identification, and early intervention to home visiting programs. Add evidence-based interventions and referral pathways to behavioral health services. List of grant awardees is found at: evisiting.html. evisiting.html

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY General Provisions New Medicaid Options for States Young adults previously in foster care will qualify for Medicaid to age 25 beginning This will immediately effect about 20,000 young adults.

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY General Provisions Opportunity and Collaboration Ensure that services offered for young adults are appropriate to their behavioral health needs and provided using a system of care approach. Advocate with your state department of mental health to modify its State Medicaid Plan to change age and definitional criteria to allow young adults to have access to both child and adult State Plan services.

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Health Insurance Exchanges

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Health Insurance Exchanges An Exchange is a single place where an array of qualified health insurance plans are available for purchase by individuals and businesses. It is run by a governmental agency, state government/non-profit partnership, or nonprofit entity. Exchanges must be in place by Jan. 1, Exchanges must include both plans offered to individuals and a Small Business Health Options Program (SHOP).

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Health Insurance Exchanges Exchanges also will enroll individuals in CHIP, Medicaid, and Basic Health Plans. States can choose to establish an Exchange or default operations to the federal government. States have wide discretion in setting the standards, requirements, and rates for plans offered in the Exchange and for monitoring plans to ensure quality and hold down costs.

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Health Insurance Exchanges Exchange Health Plan Benefits Packages must offer essential benefits, including rehabilitative and habilitative services, and allows for additional mental health and addiction services. Exchanges will offer plans with different levels of benefits, deductibles, and co- pays.

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Health Insurance Exchanges Opportunity and Collaboration HHS Secretary established “benchmark” standards for health plans offered in Exchanges States can choose to establish an Exchange or default operations to the federal government Approximately 25 million more Americans will have coverage Exchanges will require new partnerships and expanded network of providers

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Medicaid and CHIP

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Medicaid 2014,15, and 16100% % % % 2020 and beyond90% Federal Medical Assistance Percentage (FMAP) for new eligible populations (incomes of 100% – 133% of poverty) increases: States can reduce their general fund costs for serving newly eligible populations.

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY CHIP States must maintain current eligibility levels for CHIP through Sept States receive performance incentive bonuses for increasing enrollment and simplifying eligibility. Beginning 2013, states will receive a 23% increase in the CHIP match rate through 2019.

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Medicaid and CHIP Opportunity and Collaboration More parents will have coverage for behavioral health services More providers will be needed, building capacity Significant amount of state general funds savings could be realized that could be used to fund other behavioral health services OR anything else States need to forge relationships with key advocates/agencies with a strong plan to use “savings”

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Medicaid 1915(i)

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Medicaid 1915(i) State Plan Amendments As of February 2012, eight states (Iowa, Nevada, Colorado, Washington, Wisconsin, Idaho, Louisiana and Oregon) have HHS-approved 1915(i) options in place. A number of these states have targeted expanded services to people with serious mental illnesses. Many more are considering implementing the option to serve people with serious mental illnesses. Bazelon Center for Mental Health Law, The Affordable Care Act at Year Two, March

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Medicaid 1915(i) Income eligibility is up to 150% of federal poverty level or 300% of the maximum SSI payment. Breaks the “eligibility link” between HCBS and institutional level of care currently required under a 1915(c) HCBS waiver. 1915(i) State Plan Amendment (SPA): States can amend their State Plans to offer HCBS as State Plan option benefits. Started in 2010: Unique type of State plan benefit with similarities to HCBS waivers Source: Kathy Poisal, Center for Medicare and Medicaid Services

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Medicaid 1915(i): Service Examples Case management Homemaker Home Health Aide Personal Care Adult Day Health HabilitationRespite Care Day treatment or Partial Hospitalization Psychosocial Rehab Clinic Services States can also offer “Other” services Source: Kathy Poisal, Center for Medicare and Medicaid Services

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Medicaid 1915(i): Eligibility Determined by an individualized evaluation of need e.g., individuals with the same condition may differ in Activities of Daily Living (ADL) May be functional criteria such as ADLs or use scores from the CAFAS or CANS to measure functioning. May include State-defined risk factors Needs-based criteria are not: descriptive characteristics of the person, or diagnosis population characteristics institutional levels of care

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Medicaid 1915(i): Population of Focus Example States can do one plan amendment with several target populations: Child or young adult in need of supportive services for activities of daily living (ADL) because he/she is not functioning in home, school, or community and is at eminent risk of removal from their home (risk factor). Age can be specified e.g Adult in need of supportive services for (ADL) because he/she is not functioning in the community and is at risk of psychiatric hospitalization (risk factor).

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Medicaid 1915(i) Opportunity and Collaboration States must provide services statewide, building capacity with key partnerships States must serve all children who meet their CMS approved 1915(i) population definition. However, states may identify a very specific population in order to limit their exposure. The 1915(i) SPA may be phased in over a five- year period, allowing states time for providers to develop new, flexible, home and community-based services.

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Medicaid Sec Health Homes

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Health Homes Medicaid Sec Health Homes States can choose to enroll Medicaid beneficiaries with chronic conditions into Health Homes through a State Plan Option to receive comprehensive, system of care services. As of February 2012, HHS approved Medicaid state plan amendments in three states (Missouri, New York and Rhode Island); 3 states (North Carolina, Oregon and Washington) are seeking approval; and 13 states have sought planning funds from the Centers for Medicare and Medicaid Services (CMS). Bazelon Center for Mental Health Law, The Affordable Care Act at Year Two, March

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Health Homes Health Homes can be established in community behavioral health or developmental disability organizations. January 1, % for certain services for two years. Funded by increased FMAP

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Health Homes Must provide for an individual’s primary care and disability-specific services needs in one location, and provide care management and coordination for all needed services. States may experiment with innovative payment methodologies, including case rates, inclusive salaries, and other mechanisms to save on costs of care. Health Homes must serve all ages, though a state can define specific enrollment criteria.

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Health Homes Waives comparability 1902(a)(10)(B) and statewideness 1902(a)(1) Medicaid eligible individuals must have : two or more chronic conditions one condition and the risk of developing another or at least one serious and persistent mental health condition The chronic conditions listed in statute include: mental health condition substance abuse disorder asthma diabetes heart disease being overweight (as evidenced by a BMI of > 25).

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Health Homes Three distinct types of providers can provide Health Home services: designated providers; a team of health care professionals; and a health team. Providers of health home services are required to report quality measures to the state as a condition for receiving payment. States are required to collect utilization, expenditure, and quality data for a federal interim survey and an independent evaluation.

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Health Homes Required Health Home services reimbursed at 90% federal FMAP are: Comprehensive Care Management; Care coordination; Health promotion; Comprehensive transitional care from inpatient to other settings; Individual and family support; Referral to community and social support services; and Use of health information technology, as feasible and appropriate.

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Health Homes Opportunity and Collaboration Children and youth with serious behavioral health problems and their families will be able to receive integrated care: both mind and body. Successful state systems of care and wraparound processes can serve as models for the design of Health Homes. Linkages and close partnerships to primary care health providers will be essential.

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY Citations and Resources This presentation utilized the following organization web-sites: Government Health Care Website National Council for Community Behavioral Healthcare The Arc The Kaiser Family Foundation The Robert Wood Johnson Foundation/George Washington Univ The Bazelon Center for Mental Health Law The federal Centers for Medicare and Medicaid

Jim Wotring