1. Coverage for
Care,
What’s at Stake?

2. Agenda Coverage for care overview
Health insurance customer protections
New Health Insurance Marketplace
How will Medicaid change?
What does it mean for our state?
Call to action

3. 50 million Americans Uninsured (2009)

4. Financing Mental Health Care
Source: Garfield (2011) Mental Health Financing in the US: A Primer
Kaiser Commission on Medicaid and the Uninsured

5. Coverage for Care Federal/State Programs
Medicaid:
Health finance program for the poor
Only covers some lower income people
Broad array of community mental health services
Does not cover inpatient care age 22 – 64
Children’s Health Insurance Program (CHIP)
Children not covered by Medicaid 100% - 200% FPL
May or may not offer full range of Medicaid services

6. Coverage for Care Federal Programs
Medicare:
Seniors, people who received SSDI for >24 months
Limited array of mental health services
Medicaid beneficiaries with very low incomes may also qualify for Medicaid (dual-eligibles)
Veterans/Military:
VA health care: limited eligibility, but wide array of mental health services
TRICARE resembles private insurance

7. Coverage for Care State and Local Public Systems
State and county mental health authorities
Serve people who fall through the cracks
Provide services not covered by Medicaid

8. Private Health Insurance
Employer sponsored or purchased by individual/family
Varied benefits
Mental health parity requirements vary
Limited array of mental health benefits typical
Wider provider network

9. New Health Insurance Rules Protect Customers
Children can’t be rejected for health coverage due to pre-existing conditions
Youth up to age 26 can be covered on parent’s health plan
No lifetime limits on benefits
Temporary high-risk pools
Plans may not withdraw coverage for getting sick
Appeals process for denials
Plans must spend 80-85% on direct care
System is fragmented, poorly coordinated.
Availability and quality of services vary from community to community.
Mental health system exists outside the mainstream health care system.
People living with serious mental illness die, on average, 25 years younger than the rest of the population.
Care is often not available until crisis occurs.
Cuts to public mental health services are compounding the crisis for youth and adults.

10. “My 21 year old daughter has had major depression since she was a child. We were very worried about health insurance when she wanted to leave home. Now she can stay on our health plan until she is 26.” The new health law allows parents to keep adult children on their plan until age 26.

11. Uninsured Adults with Mental Illness
US: Total of 45.6 million adults with mental illness
Source: SAMHSA, National Survey of Drug Use and Health, 2011

12. New Coverage Options Health Insurance Marketplace: private coverage
Individuals
Small Employers (SHOP)
Medicaid expansion: % FPL
Parity required:
All individual and small group plans
All Medicaid benchmark plans
Traditional Medicaid managed care plans
Care coordination/ integration strategies

13. Health Insurance Marketplace = Health Insurance Exchange
Goals: Good health coverage at affordable cost
Regulates:
“Qualified Health Plans”
“Essential Health Benefits”
Rates Qualified Health Plans
Unified online application for exchange, Medicaid, CHIP
Toll-free telephone hotline
Website to compare health plan information
Standardized format to present health benefit options
Electronic calculator to figure actual cost of coverage
Source: Mass Health Connector

14. Qualified Health Plans (QHP)
Only Qualified Health Plans allowed in Health Insurance Marketplaces
Must provide Essential Health Benefits
Insurer must meet requirements:
In good standing with the State
Offers at least:
One silver and
One gold plan
Offers the same premium for qualified health plans inside and outside the Exchange
Source: Illinois Department of Insurance

15. Health Insurance Marketplace Incentives
INDIVIDUALS
Tax Credits for Premium Subsidies
Cost-Sharing Subsidies
Reduced OOP limits, annual cap $6,350 (premium + deductible)
SMALL BUSINESS
Small business Health Options Program (SHOP)
Help small employers enroll employees in qualified health plans
Small Business Tax Credit
INDIVIDUALS. An Exchange must facilitate the purchase and sale of qualified health plans in the individual market.
Tax Credits for Premium Subsidies
Cost-Sharing Subsidies
Reduced OOP limits
SMALL BUSINESS. A State that establishes an Exchange must also provide for the establishment of a Small Business Health Options Program (SHOP Exchange) to assist qualified small employers in facilitating the enrollment of their employees in qualified health plans offered in the small group market.
Small Business Tax Credit

16. Individual & Employer Mandates
Individual responsibility to buy insurance
Penalties of $95 in 2014,
$325 in 2015,
$695 in 2016, OR
Percent of household income
1% in 2014,
2% in 2015 and
2.5% in 2016 and beyond
Exempts individuals below the tax filing threshold
Employer penalties Beginning in 2015
Applies to employers with 50 or more employees
Penalties from $2,000 to $3,000 per employee,
If employer fails to offer coverage or offers bare bones coverage

17. Eligibility and Financial Assistance
Question: Do the new rules help me get Medicaid?
Answer: IF your state expands Medicaid and IF your income is at or below 138% of Federal Poverty Level, then yes. 
Family Size
100% FPL
138% FPL 1
$11,490
$15,856 2
$15,510
$21,404 3
$19,530
$26,951 4
$23,550
$32,499
Question: Are you eligible for government help buying insurance?
Answer: The government will help pay part of premiums and out-of-pocket costs for people with incomes between 100 percent and 400 percent of the federal poverty level.
Family Size
100%
400% 1
$11,490
$45,960 2
$15,510
$62,040 3
$19,530
$78,120 4
$23,550
$94,200

18. Essential Health Benefits
Outpatient clinic services
Emergency services
Hospital care
Maternity, newborn care
Mental health, behavioral health, substance use care
Prescription drugs
Rehabilitative & habilitative services
Laboratory services
Children’s services, dental & vision care
Wellness, disease management

19. Benefit Continuity Essential Benefits Package
Source: Sommers, B.D. & Rosenbaum, S. (2011). Health Affairs. Presented by S Fields, NAMI 2011.

20. “I had a 4.0 GPA in school but I dropped out after my insurance stopped covering my medication. I started hanging out with the wrong crowd and self-medicating just to get away from the pain and confusion. Now I’m trying to get back on track, but every day is a struggle.”
The new health law requires Medicaid expansion and health insurance marketplace plans to provide medication and lab work, but advocacy is needed.

21. Expanded Medicaid Eligibility
Pregnant women
Infants/Children
Families with dependent children
Aged, Blind, Disabled
Assets and other income
Now
Categorical Financial Criteria
Families ithdependent children
AgedDisabled
Infants/Children
Single adults under 65:
Incomes up to 138% of the Federal Poverty Level
2014 Financial Criteria Only

22. “I was married and working, but stopped taking my medications because I didn’t feel sick. Things went downhill fast. My wife left me, I lost my job and had to move back in with my parents.”
The new health law will provide a second chance in states that expand Medicaid. Anyone with an income is below 138 % FPL will be able to enroll in Medicaid and get treatment. It will also be easier to return to work and get private insurance.
NEW DONUT HOLE? In states that do not expand Medicaid will people with incomes below 100 percent FPL will get federal financial help to buy a private plan?

23. Medicaid Expansion Any uninsured ≤ 138% FPL
100% federal match for newly Medicaid eligible: 2014 – 2016
Reduced gradually to 90% federal match, 2020 forward
Source: The Advisory Board Company, July 26, 2013

24. In-State Update

25. Prepare NOW for New Coverage www.healthcare.gov
Enrollment assistance - 24/7 call center
Toll free:
TTY/TDD: for assistance
English, Spanish, 150 languages

26. Call to Action Contact your legislator today! Call or email! ASK:
To find their contact information: [link]
Schedule a visit in the district
ASK:
Health care coverage will help people with mental illness recover and contribute to their communities.
Can I count on your support to expand good, affordable health coverage to all households with incomes from 0 to 138 percent of poverty?
Can I count on you to advocate for mental health coverage on par with medical/surgical care?

27. QUESTIONS? Thank you! Presenter name Title
Contact information