The Affordable Care Act & Mental HealthBy Joyce Cripps, MSA

Partners in Change: Psychological & Community Services, PLC

Partners in Change720 W. Wackerly, Ste. 11Midland, MI 48640

Introduction to the ACAKaiser Health News 2013

Partners in Change720 W. Wackerly, Ste. 11Midland, MI 48640

• 60% of adults and 70% of children in the United States do not receive mental health services. This is often due to poor coverage, if any, by private insurers.

• Since the passing of the Patient Protection and Affordable Care Act (ACA), mental health and drug treatment are one of the “10 essential health benefits” that all insurers must offer (Braverman, 2013).

The 10 Essential Health Benefits

• Wellness & disease management• Prescription drugs• Hospitalization• Laboratory services• Emergency services• Maternity & newborn care• Children’s care, dental & vision• Rehabilitation & habilitation• Mental, behavioral health & substance use

care• Outpatient clinic services

– The Patient Protection and Affordable Care Act (PPACA). http://healthcare.gov/law/full

Partners in Change720 W. Wackerly, Ste. 11Midland, MI 48640

6 Ways the ACA is Changing Mental Health

1.Pre-existing conditions are now covered.

2.Insurance plans must offer parity of mental and physical health coverage.

A. Mental Health Parity and Addiction Equality Act will now be actively enforced by the ACA

3. There are limits on out-of-pocket spending.A. ACA limits out-of-pocket amounts to $6,350 for individuals and

$12,700 for families. Currently, 1/3 of plans available on the “individual market have out-of-pocket costs exceeding that limit,” (Braverman, 2013).

Partners in Change720 W. Wackerly, Ste. 11Midland, MI 48640

6 Ways the ACA is Changing Mental Health

4. Insurers must cover prescription drugs.

5. More people are getting treatment.A. Insurers began covering mental health treatment in 2011, and the

number of people seeking this type of coverage soared. This is expected to increase as people become aware of coverage under the ACA (Braverman, 2013).

6. The already strained system isn’t keeping up.A. There are only enough psychiatrists in the U.S. to meet the needs

of 53% of those who need services. This number is much smaller in rural areas of the country (Braverman, 2013).

Partners in Change720 W. Wackerly, Ste. 11Midland, MI 48640

• The Mental Health Parity and Addiction Act was signed by President Bush in 2008.– This requires insurers to treat mental illness the same way they treat

physical illness. – The law was written to present better access to mental health care, but

the law has lacked enforcement.

• The ACA is now forcing insurance companies to charge patients the same co-pay regardless of the type of care. Deductibles and doctors visits would also be comparable (Christensen, 2013).

Partners in Change720 W. Wackerly, Ste. 11Midland, MI 48640

Why are these changes important?• Serious mental illness cost the U.S. $193.2 billion in lost

earnings in 2012– Also the leading cause of disability in the U.S.

• There were over 7.6 million ER visits for mental health conditions in 2007, 1 in 8 of these visits were by an uninsured person.

• There is a disproportionate amount of youths and adults incarcerated due to an undiagnosed mental illness (NAMI, 2013)

Partners in Change720 W. Wackerly, Ste. 11Midland, MI 48640

What does this mean for providers?• The ACA had changed how the government will enforce

actions against “fraud, waste, and abuse of federally funded health care programs such as Medicare and Medicaid,” (Nguyen, 2010).

• Section 6401 of the ACA “requires providers and suppliers to implement compliance programs as a condition of enrollment in federally funded health care programs such as Medicare, Medicaid, and the Children's Health Insurance Program (CHIP),” (Nguyen, 2010).

Partners in Change720 W. Wackerly, Ste. 11Midland, MI 48640

What should a compliance program look like?

• Accountability– Should be value-based and outcome-oriented.– Incorporate “administrative safeguards and other

technologies to detect inappropriate claims as well as affiliations with individual clinicians that have been de-barred, de-licensed, or otherwise excluded from federally funded health care programs,” (Nguyen, 2010).

Partners in Change720 W. Wackerly, Ste. 11Midland, MI 48640

What should a compliance program look like?

• Transparency– Must have the correct systems in place to allow for

new requirements for data compilation, reporting and analysis for accuracy and completeness.

– Must be compliant with HIPPA and Health Information Technology for Clinical and Economic Health (HITECH) Acts.

• Many states have strict requirements to protect the confidentiality of psychiatric medical information (Nguyen, 2010).

Partners in Change720 W. Wackerly, Ste. 11Midland, MI 48640

What should a compliance program look like?

• Quality– The Federal government has declared that Quality is

integral to reimbursement from insurance providers.– Providers must not falsify or provide substandard

care to patients with reimbursement from Medicare or Medicaid

• This would involve a of risk being investigated by the FCA (False Claims Act).

– Should include adopting evidence-based practice guidelines, improve clinical documentation practices, and capture and report quality data.

Partners in Change720 W. Wackerly, Ste. 11Midland, MI 48640

How should mental health providers prepare?

• Establish top-down, company wide culture of compliance and ethics with the following:– Written policies and procedures– Standards of conduct– Education and targeted training– Ongoing auditing and monitoring– Open reporting channels– Focus on preventing and detecting fraud and abuse– Appropriate disciplinary action for noncompliance

• (Nguyen, 2010)

Partners in Change720 W. Wackerly, Ste. 11Midland, MI 48640

How can providers reinvent standard of care?

• Implement new ways of evaluating and improving financial and organizational tools.– Will decrease poor quality and high cost of mental health

services.

• Providers will be able to be more responsive to clients with serious mental illness and chronic illness.– This would include incorporating mental health care to

patients using long-term care or health homes (Mechanic, 2012)

Partners in Change720 W. Wackerly, Ste. 11Midland, MI 48640

How can providers reinvent standard of care?

• Better able to coordinate Medicaid behavioral services with social service and housing programs.– This will prevent and manage homelessness for people with a

serious mental illness (Mechanic, 2012).

• Providers can focus more attention on substance abuse problems and mental health problems with each client.

• The ACA has established new ways to implement evidence-based treatments, like supported employment, that have commonly been neglected (Mechanic, 2012).- Implementation of these treatments can be difficult, but the

ACA can help providers overcome these barriers (Mechanic, 2012).

Partners in Change720 W. Wackerly, Ste. 11Midland, MI 48640

• Establishing compliance programs will ready the clinic for upcoming changes.

• Providers can reinvent the standard of care for mental health patients.

• Will be able to offer behavioral mental health services to more clients.

• There will be a shortage of providers, which means there will be opportunity to increase number of patients.

Partners in Change720 W. Wackerly, Ste. 11Midland, MI 48640

References• Braverman, B. (2013, November 26). 6 ways obamacare is changing mental health

coverage. The Fiscal Times. Retrieved from: http://www.thefiscaltimes.com/Articles/2013/11/26/6-Ways-Obamacare-Changing-Mental-Health-Coverage

• Christensen, J. (2013, November 08). Feds boosting mental health treatment, access. CNN Health. Retrieved from: http://www.cnn.com/2013/11/08/health/hhs-mental-health/

• Mechanic, D. (2012). Seizing opportunities under the affordable care act for transforming the mental and behavioral health system. Health Affairs, 31(2), 376-82. Retrieved from http://0-search.proquest.com.catalog.lib.cmich.edu/docview/921992809?accountid=10181

• NAMI (2013, March). Mental health and the uninsured. National Alliance on Mental Health. Retrieved from: http://www.nami.org/Content/NavigationMenu/Inform_Yourself/About_Public_Policy/Issue_Spotlights/Health_Care_Reform/ACA-FactSheet9-MedicaidandMH.pdf

• Nguyen, D. (2010). The health care reform bill: Compliance implications for behavioral and mental health services. Journal of Health Care Compliance, 12(4), 11-14,61. Retrieved from http://0-search.proquest.com.catalog.lib.cmich.edu/docview/614004596?accountid=10181