1. Mental Health and SUD: Opportunities in Health Reform
Barbara Edwards, Director
Disabled and Elderly Health Programs Group
Center for Medicaid, CHIP, and Survey & Certification
Centers for Medicare & Medicaid Services
October 14, 2010

2. CMCS and Behavioral Health
Medicaid is the largest payer for mental health services in the United States
In 2007, Medicaid funding comprised 58% of State Mental Health Agency revenues for community mental health services
Comprehensive services available through Medicaid; many are optional under Medicaid so state’s have considerable flexibility in benefit design
DEHPG – responsible for most services and programs that are used to provide community based MH/SUD services – Rx, TCM.Rehab, 1915 b, c waivers

3. Medicaid MH/SA Service Users
Source: SAMHSA

4. Medicaid Expenditures for MH/SA Service Users
People with MH and SUD are more likely to have other costly physical health conditions than medicaid enrollees who don’t have MH or SUD
Source: SAMHSA

5. MH/SUD: DEHPG Goals
Federal policy supports the offer of effective services and supports
Improved integration of physical and behavioral health care
Person-centered, consumer-directed care that supports successful community integration
Improved accountability and program integrity to assure Medicaid is a reliable funding option

6. A System of Coverage
Medicaid/
CHIP
Exchange
Employer Coverage

7. Affordable Care Act: Sources of Coverage Under Age 65 (2019)
24m
51m
22m
25m
159m
16 million newly covered by Medicaid; eligibility to 133% fpl
Not a “safety net” but a full partner in assuring coverage for all
Eligible = enrolled
Essential to make a system out of different components to achieve coverage, quality and cost containment objectives
Source: Congressional Budget Office, March 2010

8. New Paradigm
Not a “safety net” but a full partner in assuring coverage for all
Eligible = enrolled
Essential to make a system out of different components to achieve coverage, quality and cost containment objectives 8

9. Newly Eligible Individuals
An estimated 5.4 million people that are currently uninsured with a MH/SUD problem would gain coverage under the ACA
50% of those individuals likely to be served Medicaid.
Donohue J, R Garfield, and J Lave, “The Impact of
Expanded Health Insurance Coverage on Individuals with
Mental Illnesses and Substance Abuse Disorders”
ASPE Report April 2010.

10. Benefit Design Issues
The new Medicaid expansion population must receive benchmark or benchmark-equivalent coverage
Benchmark plans: comparable to Federal Employee Blue Cross/Blue Shield Health Benefits, State’s employee health insurance plan, or State’s largest commercial HMO plan
Benchmark equivalent: Actuarially equivalent to above plans

11. ACA and Benchmark Plans
In 2014, benchmark and benchmark equivalent plans must begin providing at least “essential health benefits” (section 1302 (b))
“Mental health and substance use disorder services, including behavioral health treatment” are included as a category within “essential health benefits”
MHPAEA/MH Parity applies
Secretary will issue guidance

12. Medicaid for ABD
New eligibility option not available to those eligible for SSI or those 65 years of age and older
New benchmark plan does not change state options regarding “traditional” Medicaid, including ABD

13. ACA: Medicaid Behavioral Health
Provides new state plan and grant opportunities that include opportunities to address mental health and/or substance use disorder
Implementation teams within CMCS seek to engage stakeholders
Engagement strategies vary, based on topic, timetable

14. ACA: Medicaid Behavioral Health
1915 (i) – waiver-like services offered under State Plan Option ( )
Can target populations
Adds additional service, income options
Extends and expands Money Follow the Person
Enhanced FMAP available through 2016
Enables a new solicitation
“additional services and supports”

15. ACA: Medicaid Behavioral Health
Health home, chronic conditions ( )
MH, SUD are conditions that are eligible
Enhanced FMAP for 8 quarters
State/SAMHSA collaboration
Community First Choice ( )
Enhanced FMAP for Community attendant services
Balancing Incentives Program ( )
Enhanced FMAP for HCBS for 5 years
Care coordination, transition assistance, linkages to non-medical as well as medical services
Community First Choice ( )
Community attendant services
For individuals not yet at an institutional level of care (below 150% FPL)
Enhanced FMAP
Balancing Incentives Program ( )
Enhanced FMAP for HCBS for 5 years
5% increase for states with community LTC $ < 25%
2% increase for states with community LTC $ < 50%

16. Non-ACA Priority Provisions
MHPAEA/Mental Health Parity - applies to Medicaid managed care plans (MCOs), CHIP State Plans, and benchmark plans
Targeted Case Management option – final regulations
Rehabilitation option
The Parity law specifically applies to CHIP but lacks a parallel reference to Medicaid. Does require that Medicaid MCP must comply. CMS is considering how to issue additional guidance since this construct appears to raise questions. We welcome hearing from stakeholders regarding specific questions.

17. Opportunity for System Transformation
This is a time of unprecedented opportunity to transform the system of care for individuals with disabilities
CMS’ new Administrator, Dr. Donald Berwick, M.D., has articulated how this transformation can be achieved…

18. The “Triple Aim”
Population
Health
Experience
Of Care
Per Capita
Cost

19. The Foundation for a Redesigned Service System for Individuals with Chronic Conditions
Person Centered
Individual Control
Integration
Quality

20. Person Centered Person centered plans of care
Individuals and people important to them
Functional assessments
Individual’s experience of care

21. Individual Control Choice
Self-direction through both waivers and state plan options
EHR
Education, Information

22. Quality CHIPRA and Adult Quality Measures
Quality Improvement Program development
Quality reporting imbedded in new HCBS services

23. Integration Single entry point/no wrong door (ADRC funding)
Models of integration
primary, acute, LTC
behavioral health and physical health
Medicare and Medicaid

24. “Good and Modern” CMCS is very interested in SAMHSA’s initiative
Looking for new opportunities to collaborate to encourage effective Medicaid coverage and services