Increase access to care for individuals and families, including criminal justice-involved populations, many of whom may be newly-eligible for Medi-Cal.  70 – 80% of AB 109 population under county supervision are in need of mental health or substance use disorder services. Increase public and private sector reimbursement of mental health and substance use disorder treatment services.  Currently, more than three-quarters of the funding for SUD treatment services comes from public sources, compared to less than half for all other health care. Reduce drain on state and county budgets due to private sector cost shift.

Ensure access to all ACA essential health benefits and levels of care, including intensive outpatient, partial hospitalization, and residential. From CMHDA-CADPAAC Health Reform Principles: “Mental health and substance use disorder systems must be equity partners with physical health care systems. Parity between mental health and substance use disorder and other medical systems and services must be realized at every level.” Parity Regulatory Issues: Clarity is still needed about how parity requirements apply to the EHB, and what the process is to supplement inadequate coverage.

The final rule needs to be clear on what the enforcement mechanism is to hold plans accountable if they don’t comply with parity. Although the proposed rule re-states the non-discrimination provisions of the ACA, the rule does not identify a standard to determine whether the coverage provided complies with the law. There needs to be a clearly-defined process to bring discriminatory benefit design or implementation into compliance with parity provisions. Disclosure of medical criteria used to make benefit determinations is necessary.  Without disclosure beneficiaries are unable to see if their plan complies with parity.

Non-quantitative treatment limits  Need definition of “clinically recognized standard of care.” Scope of service  Some plans are excluding levels of care.  Some payers still defy parity law with “fail-first” and concurrent reviews, requiring that patients fail in outpatient treatment before being approved for inpatient treatment, and calling for frequent reports from providers justifying continued treatment and pushing for discharge.  Cost-containment measures appear to be applied more stringently for MH/SUD than for medical/surgical benefits.  Medical management techniques and medical necessity criteria for MH/SUD services are often defined in a way that is more restrictive than for medical/surgical services.

The County Alcohol and Drug Program Administrators' Association of California (CADPAAC) is a non-profit association comprised of the designated county alcohol and drug program administrators representing the 58 counties within California. CADPAAC is dedicated to the reduction of individual and community problems related to the use of alcohol and other drugs. For further information, or questions regarding this presentation, contact: Thomas Renfree Executive Director, CADPAAC