1. National Health Reform State Level Issues for NAMI Consideration Presented by Technical Assistance Collaborative, Inc. July 8, 2011

2. Planning and Implementation Issues at the State Level 1.Outreach to and enrollment of the currently uninsured “Expansion” populations 2.Enrollment Issues for “Excluded” individuals 3.Models for physical health – behavioral health integration – march of the ACOs 4.Ongoing roles for state MH and SA Authorities

3. BEGINNING IN 2014: 32 MILLION MORE AMERICANS WILL BE INSURED 4-6 mil Commercial Insurance Medicaid 6-10 Million have MH/SUD Needs 3 Source: SAMHSA 3

4. Coverage Opportunities 90-95 percent will have opportunity to be covered by Medicaid or through Insurance Exchanges 4 Source: SAMHSA 4 Persons served by state Substance Abuse authority Persons served by state Mental Health authority

5. Outreach and Enrollment of Uninsured Populations Some people with mental and substance use disorders are difficult to reach and engage, and frequently also experience the most stigma and discrimination In Massachusetts, which already has 96% of the population insured, over 20% of people presenting for substance abuse services are still uninsured Many of the uninsured single adults are not connected: not to family; not to permanent place of employment; not to primary care physician or clinic. Poverty is one reason people become unconnected, but there are a myriad of other reasons

6. Outreach and Engagement To be effective with outreach and enrollment, it will be necessary to start where the people are: emergency departments; health centers; FQHCs; food banks; homeless shelters; job banks; libraries; etc. Family networks such as NAMI can be very effective in getting the word out to otherwise unconnected people Remember: not everyone wants to access behavioral health services through the public mental health and substance abuse service systems: many different outreach strategies and access portals will be needed States must develop detailed outreach and enrollment plans and develop simplified automated systems for people to enroll. NAMI and other advocates should be fully involved in the design and implementation of these strategies and systems

7. Medicaid Enrollment for “Medically Frail Individuals and other “Excluded” Populations Most of the expansion population will be enrolled into “Benchmark” plans Benchmark plans, including plans offered through the exchanges as well as under Medicaid, will have Parity level benefits for MH and SA services (inpatient and outpatient) States are not permitted to automatically enroll “medically frail” Individuals into benchmark plans: there individuals may opt to enroll in regular Medicaid or into a benchmark plan

8. Enrollment The definition of “medically frail” includes people with mental illness or substance abuse or co-occurring disorders States will have some latitude to establish criteria for the “exclusion” population – It is not clear yet how this will be done In some states, and for some people, enrolling in regular Medicaid will provide a more robust set of benefits, perhaps including rehab option, case management, personal care, etc. However, remember that parity applies only to health plans (both public and private) and not to traditional fee for service Medicaid

9. Enrollment States will also continue to define what services will be covered in basic fee for service plans Thus, in some states and for some individuals enrollment in regular fee for service Medicaid could result in a benefit plan that does not meet parity Plus, in some states, the expansion population is likely to be enrolled in managed care plans which may or may not be well coordinated with specialty or carve-out behavioral health plans

10. Enrollment If a state decides to enroll the expansion population into managed care plans, it will have to decide what behavioral health services may be “carved out” and how coordination with traditional specialty mental health and substance abuse services will be assured NAMI affiliates at the state level should be fully informed and involved as states plan for these changes and make these decisions. Affiliates should also be prepared to provide accurate information and advice to individuals and families about what choices they have as they enroll in Medicaid.

11. Models for Physical Health Integration: March of the ACOs SAMHSA demonstrations – 53 sites and TA Center HRSA grants to over 100 FQHCs: 67% of FQHCs provide MH and SA services CMS Health Homes –State Plan Option CMS – 10 state Medicare-Medicaid dual eligible demonstration with a focus on integrated care Many different models for integration are being tried in different state and local jurisdictions NAMI already knows that it must be fully involved in these activities to make sure people with serious mental illness are well represented

12. Concerns about Accountable Care Organizations (ACOs) A lot is happening behind the scenes Many large hospital systems and their affiliated physician group practices and outpatient clinics are already working to become ACOs – there could be large financial incentives to “wrap up” as much of the business as possible – with large enrolled population and in-house provider network they can be financially successful

13. Concerns about Accountable Care Organizations (ACOs) Where do traditional MH and SA providers fit into this model? (Note that all members of ACOs will have to have electronic health record capability) What will be the financial incentives for large ACO’s to enroll adults with serious mental illness and children with serious emotional disturbance? How will states with specialty MH plans (carve- outs) assure access to ACOs for coordinated care for people with serious mental illness?

14. Emerging Roles for State MH and SA Authorities If Medicaid (and Medicare) are 95% of the funding, and almost everyone has health insurance with parity benefits, what will state MH and SA authorities, and their regional/County counterparts, have to do? What types of funding will the MH and SA Authorities continue to have control over or access to for prudent purchasing of best practice services? What happens to trusted MH and SA system providers that receive virtually all their revenues from Medicaid and/or move under the administrative umbrella of Health Homes or ACOs? The federal MH and SA Block Grants are going to be more focused on coordination with Medicaid, not just on spending Block Grant dollars for generic services for priority populations. How can states exert the maximum influence with relatively few dollars?

15. Emerging Roles for State MH and SA Authorities SAMHSA Administrator Pam Hyde: “Be the experts!” Participate in state Medicaid and health reform implementation planning Participate in managed care purchasing/contracting Exercise leadership in BH system quality management and oversight Bring good data and well-grounded expertise to the table Lead effective advocacy coalitions Use state and Block Grant dollars prudently and strategically Prioritize funding and leadership related to non-medical services – Housing – Employment – Community Integration – Informal and peer supports – Forensic MH