1. Mental Health Parity, the ACA, & Californians with Mental Health Challenges

2. What this training will cover I.Stigma Faced by People with Mental Health Disabilities II.Overview of Mental Health Parity –Existing Federal & State Laws III.Overview of the Affordable Care Act – New Federal and State Laws IV.Intersection of Parity & ACA in California V.How the Laws Can Reduce Stigma and Discrimination

3. Stigma

4. Stigma faced by people with mental health challenges Stigma refers to attitudes and beliefs that lead people to reject, avoid, or fear those they perceive as being different.

5. Discrimination faced by people with mental health challenges Unjust deprivation of rights and opportunities due to stigma - exclusion or marginalization of people - denial of equal health / insurance benefit - less chance of full participation in life

6. What is mental health parity?

7. Parity ends disparity or unequal physical and mental health insurance coverage Parity = Equality

8. Examples of No Parity Equality of Copayments 1. Different levels of co pays are banned 2. $15 for outpatient physical health visit 3. $20 for outpatient mental health visit Equal Treatment Lengths 1.Different levels of an treatment limits are banned 2.21 inpatient days for mental health care 3.30 inpatient days for physical health care

9. California Mental Health Parity Act Health care plans issued, amended or renewed on or after July 1, 2000 provide coverage for the diagnosis and treatment of specified mental health conditions under the same terms and conditions applied to other medical conditions. Cal. Health & Safety Code § 1374.72(a)

10. People protected under CA parity -Children with serious emotional disturbances -People with serious mental illnesses (SMI), which are defined to include: schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorders, panic disorder, obsessive-compulsive disorder, pervasive developmental disorder or autism, anorexia nervosa, bulimia nervosa Cal. Health & Safety Code § 1374.72(d)

11. Equal terms and conditions Include but not limited to the following: 1.maximum lifetime benefits 2.copayments 3.individual and family deductibles. Cal. Health & Safety Code § 1374.72(c)

12. Benefits that must be provided Include: 1.outpatient services 2.inpatient hospital services 3.partial hospital services 4.prescription drugs, if the plan contract includes coverage for prescription drugs. Cal. Health & Safety Code § 1374.72(b)

13. All “medically necessary” treatment 9 th Circuit found that California parity law requires that a health plan provide all “medically necessary treatment” for “severe mental illnesses,” such as: residential care for an individual with anorexia Harlick v. Blue Shield of California 686 F.3d 699 (2012)

14. Federal parity law Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008

15. Federal parity regulations Equal financial requirements and treatment limitations between mental health / substance abuse disorder benefits and medical/surgical benefits. See: 26 CFR Pt. 54 (DOT), 29 CFR pt 2590 (DOL), 45 CFR Pt 146 (DHHS), Federal Register, Vol 78, No.219 68240-68296 (Nov. 13, 2013) [Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008]

16. Equal terms and conditions -Quantitative: co-pay, deductibles, number of visits, lifetime caps -Non-quantitative: utilization review, formulary design, step therapy See: 26 CFR Pt. 54 (DOT), 29 CFR pt 2590 (DOL), 45 CFR Pt 146 (DHHS), Federal Register, Vol 75, No.21 5410-5451 (Feb. 2, 2010) [interim final rules under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008]

17. CA & Federal Parity Laws CAFederal Specified DiagnosesYN Specified BenefitsYN Federal parity law requires equality if any mental health or substance use disorder benefits are covered.

18. Federal parity: 6 benefit classes 1.inpatient, in-network 2.inpatient, out-of-network 3.outpatient, in-network 4.outpatient, out-of-network 5.emergency care 6.prescription drugs. See: Federal Register Vol. 75, No. 21 5413

19. Benefit coverage by federal parity Coverage provided for mental health and substance abuse disorder benefits in each classification in which medical/surgical coverage is provided. See: Federal Register Vol. 75, No. 21 5413

20. Do federal parity rules define inpatient, outpatient or emergency care? No. Fed parity regulations say plan terms defining benefits must be consistent with generally recognized standards of medical practice. Plan must apply terms uniformly. See: Federal Register Vol. 75, No. 21 5413-5414

21. What is the Affordable Care Act (ACA)?

22. The Patient Protection & Affordable Care Act of 2010 (ACA) = “Obama-Care”

23. What are the goals of the Affordable Care Act?

24. Goal 1: Strengthen Health Care Objective A: More secure coverage for those insured & extend affordable coverage to uninsured Objective B: Improve healthcare quality and patient safety Objective C: Emphasize primary and preventive care linked with community prevention services Objective D: Reduce the growth of healthcare costs while promoting high-value, effective care Objective E: Ensure access to quality, culturally competent care for vulnerable populations Objective F: Promote the adoption and meaningful use of health information technology Source: http://www.hhs.gov/secretary/about/goal1.html [includes other goals]http://www.hhs.gov/secretary/about/goal1.html

25. How does ACA extend affordable coverage to the uninsured?

26. 1. Public Medicaid (Medi-Cal in California) Expansion 2. Private Plans on health insurance “Exchanges” a.Individual Mandate b.Employer Mandate

27. Will Medi-Cal expand?

28. California plans to increase Medi-Cal eligibility to single, childless adults up to 138% of federal poverty level Source: Committee No. 1 Health & Human Services, Assembly Budget Committee (3/6/13) at: http://abgt.assembly.ca.gov/sites/abgt.assembly.ca.gov/files/March%206%20- %20Affordable%20Care%20Act%20Medi-Cal%20Expansion.pdf http://abgt.assembly.ca.gov/sites/abgt.assembly.ca.gov/files/March%206%20- %20Affordable%20Care%20Act%20Medi-Cal%20Expansion.pdf

29. Benefits of Medi-Cal Expansion 1. Insure over 1 million Californians 2.100% fed $ for 3 yrs, then over 4 yrs up to 10% state match 3.More insured people improves public health for all in CA 4.Infuses millions, possibly billions, of fed $ in CA 5.Insure more people nationally = market stability & cost control Source: Committee No. 1 Health & Human Services, Assembly Budget Committee (3/6/13)

30. What are health insurance Exchanges?

31. What are Health Insurance Exchanges? Organizations set up to help individuals and small businesses purchase health insurance policies “Covered California” is the exchange in CA

32. What is the individual mandate? Most Americans must get health coverage Penalty phased in 2014 through 2016 Exempts certain individuals

33. What is the employer mandate? ACA responsibilities apply to employers with 50 + employees Penalty for failure to offer minimum essential coverage to employees Implementation in 2015

34. Other ACA provisions include 1.Subsidies 2.Pre-existing condition coverage 3.People under age 26 covered on parental insurance Source: http://www.hhs.gov/secretary/about/goal1.htmlhttp://www.hhs.gov/secretary/about/goal1.html

35. Intersection of Mental Health Parity & the ACA for Californians with Mental Health Challenges

36. ACA Plans must comply with federal parity law & provide 10 “essential health benefits”

37. Essential benefits 1.Ambulatory 2.Emergency 3.Hospitalization 4.Maternity and newborn care 5.Mental health and substance use disorder services 6.Prescription drugs 7.Rehabilitative & habilitative 8.Laboratory 9.Preventative, wellness, chronic disease management 10.Pediatric services, including oral and vision care See http://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.htmlhttp://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.html

38. California has adopted Kaiser HMO Plan as benchmark Includes following mental health coverage: –Outpatient mental health services –Inpatient hospital and intensive psychiatric treatment programs (includes crisis residential treatment)

39. CA benchmark coverage Services are for the diagnosis or treatment of Mental Disorders…identified as a "mental disorder" in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM) that results in clinically significant distress or impairment of mental, emotional, or behavioral functioning. Kaiser Small Group HMO Plan 1637, Plan 30-N, p.33 (Aug. 15, 2011)

40. Medi-Cal Expansion 1.Provide same array of mental health services to individuals currently eligible: Specialty Mental Health Services 2.Provide benchmark /10 essential health benefits

41. Parity & ACA can reduce stigma and discrimination “Stigma is the most formidable obstacle to progress in the arena of mental illness and health.”

42. Prevention & Wellness Care 1.Help people recognize early signs 2.Connect with support and services 3.Improved Outcomes - a.Reduce homelessness b. Increase employment c. Avoid unnecessary criminal justice involvement and hospitalization

43. Rehabilitation & Recovery 1.Individualized Services 2.Peer Support 3.Self-Help or Consumer-run Services 4.Cultural & Linguistic Competence 5.Improved Outcomes - a.Help people attain their goals b.Support living in most integrated setting

44. Policy Paper on Recovery-Focused Hospital Diversion & Aftercare 1.Best practices on pathways to home & community services 2.Cost and quality analysis of model crisis alternatives to hospitalization 3.Recovery-based policy recommendations 4.Coordination between private plans and the public mental health system

45. Alternatives to Acute Hospital -Outreach / Prevention -Crisis Lines / Crisis Clinics -Mobile Crisis Intervention -Crisis Stabilization Units / Urgent Care Units -Crisis Residential Treatment Facilities -Crisis Respite -Integrated Services –Full Service Partnership (FSP) –Assertive Community Treatment (ACT) –Wraparound –System of Care

46. Disclaimer This area of the law is rapidly developing. These provisions are not intended to include all federal and state laws, regulations, policy directives or other relevant references. Further legal research is required. The intent here is to provide a general overview of these topics.

47. Disability Rights California is funded by a variety of sources, for a complete list of funders, go to http://www.disabilityrightsca.org/ Documents/ListofGrantsAndContracts.html.

48. CalMHSA The California Mental Health Services Authority (CalMHSA) is an organization of county governments working to improve mental health outcomes for individuals, families and communities. Prevention and Early Intervention programs implemented by CalMHSA are funded by counties through the voter-approved Mental Health Services Act (Prop 63). Prop. 63 provides the funding and framework needed to expand mental health services to previously underserved populations and all of California’s diverse communities.