Drug Crisis on LI: Current Challenges and Future Solutions

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Health Care Reform and Parity-An OverviewNassau County Heroin Treatment Task ForceTracie M. Gardner Director of NYS PolicyDecember 7, 2012Legal and Policy Advocacy for people with addiction histories, criminal records, and HIV/AIDSFighting discriminationAdvocating for the expansion of services and resourcesCo-Chair on national level of the Coalition for Whole Health, over 100 national, state and local members advocating for strong ACA implementation for MH/SUD. HHelped to create NY Coalition for Whole Health

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Legal Action Center

Have on call lawyers to provide drag and alcohol programs with information technical assistance on these and other issues such as confidentiality.2Landmark victories in health coverage for substance use disorders and mental health Mental Health Parity and Addiction Equity Act prohibits discriminationThe Affordable Care Act (ACA) aims to expand SUD care dramatically by requiring coverage at parity in both health insurance exchanges and Medicaid expansion

3Parity and Health Care Reform: A Time of Tremendous Opportunity

Greater understanding of addiction as treatable chronic health conditionBipartisan and Predates Fed HCRBipartisan support for SUD/MH coverageLots of opportunity with or without ACA

3The 10 required categories of service:

Ambulatory ServicesPrescription DrugsEmergency ServicesRehabilitative and Habilitative Services and Devices Maternity and Newborn CareLaboratory ServicesMental Health and Substance Use Disorder ServicesPreventive & Wellness Services and Chronic Disease ManagementHospitalization Pediatric Services

4Essential Health Benefits

The ACA will require certain health coverage to meet minimum requirements, including benefit requirements, beginning in 2014. While the SUD/MH category itself is important, SUD/MH touches, and must be addressed, in most of the 10 categoriesEssential Health Benefits (including SUD and MH) must be offered:By private insurance plans participating in the health insurance exchangesBy non-grandfathered individual and small group plans outside the exchangesTo newly-eligible Medicaid enrollees, including childless adultsLarge group plans and traditional Medicaid do not need to meet EHB requirements

4EHB will have a direct impact on over 70 million AmericansWhere the EHB is required, parity is requiredACA improves on the federal parity law:SUD/MH benefits required and must be provided at parity

5Essential Health Benefits

Extension to individual and small group plansSuccess due to bipartisan support and collaborative efforts among government, providers and advocates

5The 10 EHB categories are in statute: HHS giving states strong role with no federal EHB definitionFor States that do not choose, largest small group is defaultBUT states must ensure parity!So: States will have lots of flexibility, But must include SUD at parity, But will have lots of flexibility

6Essential Health Benefitswho decides the specifics?

HHS allowing States to benchmark to one of ten options:One of the states three largest small group plans One of the three largest FEHBP plansOne of the three largest State-employee plansThe largest HMO in the State

6Advocacy extremely important to take advantage of this extraordinary opportunity:Evaluate the benchmark planEnsure compliance with ParityIdentify what is not included

7NY chose Oxford as its benchmark plan

We need to evaluate NYs base-benchmark plan to determine whether the scope of SUD and MH services covered is comparable with services covered for other illness, and meets with additional requirements of the parity law and the essential health benefit provisions of the ACAWe need to determining whether the financial requirements, and quantitative and treatment limitations imposed on the base benchmark plans SUD and MH benefits are more restrictive than those applied to other medical/surgical benefits and therefore in violation of the parity requirements of the ACAWe need to identify Identifying SUD and MH services that arent covered in the base-benchmark plan and providing legal arguments for their inclusion

7We need to ensure that NYs essential health benefit addresses:Long-term recovery and a chronic care approachInclude full continuum of prevention, treatment, habilitation and rehabilitationResidential treatment when appropriatePrescribed medications when appropriate, including all approved medications for SUD/MH

8NY chose Oxford as its benchmark plan

Expansion to everyone below 133% FPL, including childless adults for the first time in most statesApproximately 16 million new enrolleesEnormous opportunity to close treatment gap: Huge Opportunity for Criminal Justice populationStates will also be deciding benefits for Medicaid expansion: Must meet EHB and parity requirements, similar benchmarking process for Medicaid expansion as with EHBFederal government to pay enhanced match rate for expansion population: eventually 90% in all states

9Other Issues Related to Health Care reform: Medicaid expansionCompetitive State-based marketplaces for small employers and individuals to pool risk and purchase insurancePlans will have to meet EHB and parity requirements and other consumer protectionsPlans will have to maintain an adequate network of providers, including SUD/MH providers, to ensure all services are accessible without unreasonable delay

10Other Issues Related to Health Care reform: Health Insurance Exchanges

There are several provisions in the proposed rule on Essential Health Benefits that we like, including the following:The proposed regulations make clear that the requirements of the Mental Health Parity and Addiction Equity Act apply in the context of the EHB.We support allowing states the flexibility to choose the base benchmark option that works best for them while still retaining the state mandates that were in place at the end of last year, as state benefit mandates are important to provide stronger protections to consumers. We support expanding the number of prescription drugs that the EHB will offer to include what will likely be a wider range of covered medications. 11Important ACA Implementation activities

We'll be finishing the comments for CWH in next week or so and then collecting signatures from as many groups as possible and submitting them to HHS plus urging as many as possible to submit their own similar comments.12Important ACA Implementation activitiesInclusion of addiction in integrated care initiatives: Health homes and accountable care organizationsInclusion of substance use prevention in chronic disease prevention initiativesIdentification of the addiction service workforce as part of the health workforce

13Other important ACA implementation activities

Recognition that ACA coverage provisions do not go into effect until 2014 and will take years to fully implementLikely some SUD services will not be covered in some states and not everyone in need will be insured: especially true for criminal justice systemHuge need for continued strong federal funding before the ACA is fully implemented and beyondNeed strong and united advocacy in Washington and states

14Protecting SUD Safety Net Funding

Insurers are prohibited from refusing to cover SUD treatment that they cover for other medical/surgical conditionsDiscrimination in quantitative and non quantitative limitations PROHIBITEDInsurers are prohibited from providing poorer coverage for SUD than they provide for other medical/surgical conditions: Insurers cannot charge more or allow fewer visits for MAT than comparable medical/surgical conditions, and cannot use more restrictive utilization review, managed care, etc.

15Parity Requirements

Danger of discrimination by insurers: Refusal to cover assessments or treatment ordered by court or other CJ agency

16Eliminate Discrimination

Meaningful UseIncentivizing EHR systems to incorporate our data

On November 7, 2012 The Office of the National Coordinator for Health IT (ONC), released a Request for Comments (RFC) regarding the Stage 3 Definition of Meaningful Use of Electronic Health Records (EHRs). There are a number of topics within this RFC that are of importance to the behavioral health community including consent management in electronic health information exchange and access to prescription drug monitoring program data http://www.healthit.gov/sites/default/files/hitpc_stage3_rfc_final.pdf

17Other important developments (outside of ACA and parity):

17BHOs at the MRT Behavioral Health SubcommitteeOctober 18, 2012 Meeting http://www.health.ny.gov/health_care/medicaid/redesign/docs/bh_bene_man_care_ppt.pdfBehavioral Health Subcommittee recommendationsManaged care approaches using risk-bearing SNPs and/or BHOs should be developed. In NYC, full-benefit SNPs should be developed to include mental health, physical health, and substance abuse populations.SNPs/BHOs should be given responsibilities to pay for inpatient care at State psychiatric hospitals and to coordinate discharge planning. This will help reduce incentive for BHOs/SNPs to institutionalize people in State psychiatric hospitals.Advance the core principle that manage care approaches for people with behavioral health care needs should assist enrollees in recovery and in functioning in meaningful life roles18Other important developments (outside of ACA and parity):