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AMCHP State Public Health Autism Resource Center TA Call December 21, 2011 Meg Comeau, MHA Boston University School of Public Health
AMCHP State Public Health Autism Resource Center TA Call
December 21, 2011
Meg Comeau, MHA
Boston University School of Public Health
The Catalyst Center: Who are we?
• Funded by the Maternal and Child Health Bureau
• A project of the Health and Disability Working Group at the Boston University School of Public Health
• The National Center dedicated to the MCHB outcome measure: “…all children and youth with special health care needs have access to adequate health insurance coverage and financing”.
We are your friendly neighborhood health care financing policy wonks*!
*policy wonk: a person who studies or develops strategies and policies; especially one who has a keen interest in and aptitude for technical details
http://en.wiktionary.org/wiki/policy_wonk
What do we do?
• Provide technical assistance on health care financing policy and practice
• Conduct policy research to identify and evaluate financing innovations
• Create resources (educational products like policy briefs and webinars)
• Connect those interested in working together to address complex financing issues
What can’t we do?
•No direct advocacy or lobbying•No benefits counseling for individual families
Children with Autism and Autism Spectrum Disorders:
The Numbers
Out of all children with special health care needs, 5.4% of them have autism or an ASD (approximately 544,181)
Almost half (44.1%) have four or more co-existing health conditions
Unless otherwise noted, statistics in this presentation are from the Child and Adolescent Health Measurement Initiative. 2005/06 National Survey of Children with Special Health Care Needs, Data Resource Center for Child and Adolescent Health website. Retrieved 3/24/11 from www.cshcndata.org
Coverage Options for Autism/ASD Services
•Private Insurance–State Mandated Benefits
•Medicaid –Buy-in Programs and Waivers
•Provisions related to private and public coverage in Federal Health Care Reform (ACA)
State Mandated Benefits
• Mandated benefits are state laws requiring private insurance companies to cover specific care/services
• Self-funded (sometimes called ERISA) plans are exempt from state mandated benefits – approximately 50-60% of private insurance is through self-funded plans
• The devil is in the details – variation from state to state in what is actually covered
According to Autism Speaks, 29 states have passed Autism insurance reform laws
Retrieved 12/20/11 fromhttp://www.autismvotes.org/site/c.frKNI3PCImE/b.3909861/k.B9DF/State_Initiatives.htm
To learn more about state-specific mandated benefit laws for autism services:
Frequently Asked Questions About the State Autism Insurance Reform Laws at http://www.autismvotes.org/site/c.frKNI3PCImE/b.5216007/k.EE12/Resources.htm
Medicaid 101
•Public benefit program that covers low income/disabled people •Generally offers a more comprehensive benefit package with lower cost-sharing than CHIP or private insurance (EPSDT for children)•Can serve as a ‘wrap’ to fill in gaps in private coverage•Sometimes called the “children’s health insurance safety net”
Some ways to expand coverage for and close gaps in autism servicesthrough Medicaid• Medicaid buy-in program created through
a waiver
• Medicaid buy-in program created through the Family Opportunity Act
• Create HCBS waiver programs or increase the number of slots within existing waivers
• TEFRA state plan option/Katie Beckett waivers
Medicaid buy-in programs created through a waiver
Example: The Massachusetts CommonHealth program
Families can ‘buy in to’ Medicaid coverage for a child:•With a ‘severe disability’ – SSI criteria•Full Medicaid coverage if uninsured•Supplemental coverage if privately insured
The Massachusetts CommonHealth program
• No limit on family income
• Premium schedule based on a sliding scale
The Family Opportunity Act’s Medicaid Buy-in Option
Part of the 2005 Deficit Reduction ActNot a waiver; state plan option
Families can ‘buy-in’ to Medicaid coverage
for a child:• With a ‘severe disability’ – SSI criteria• Full Medicaid coverage if uninsured• Supplemental coverage if privately insured
• Limit on family income: must be below 300% of FPL (AGI)
• Premiums may be charged and there is a limit on how high they can be
• States may provide premium assistance to help families purchase private coverage
FOA provisions
Medicaid Waivers, Part 1• “Waives” certain federal rules: allows
states to offer different benefits to specific populations, disregard income limits, more....
• Can include a more expansive list of services/supports than state plan offers (not just medical care – goal is to keep people out of institutional care)
Medicaid Waivers, Part 2•Approximately 30 states have waivers that serve children/people with autism (either specifically or as part of a larger ID/DD population)
•Cost neutrality = waiting lists
•The devil is in the details – variability across states with regard to what is covered exactly and who is eligible
Resource for state Medicaid waivers
• New CMS website – www.Medicaid.gov At the bottom of the homepage, click on the
“Waivers” section
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/Waivers.html
TEFRA state plan option
• TEFRA state plan option: requires institutional level of care (ILC) but parental income is not counted
• Covers ‘medically necessary’ care
• Cost neutrality does not apply – generally means no waiting list
Relevant provisions in ACA for children with Autism/ASD• Prohibition on pre-existing condition exclusions• Guaranteed issue and guaranteed renewal
• Prohibition against rescission of coverage
• Removal of lifetime and annual benefit caps• Cost-sharing limits• Essential benefits in Exchange plans and
individual/small group market include:– Mental and behavioral health services– Habilitative and rehabilitative therapies
ACA – the devil is in the details
• Many of the consumer protection provisions will provide relief for many of the gaps in the current system of financing care for children with autism/ASD and their families
• Not every provision applies to every plan – grandfathered and self-funded plans are exempt from some provisions
• Many provisions roll out over time (2010-2014)
Essential benefitsEssential benefits
Goes into effect: January 1, Goes into effect: January 1, 20142014
Section 1302Section 1302
ACA requires that individual ACA requires that individual and small group plans and small group plans (whether offered through the (whether offered through the Exchange or not) include Exchange or not) include “essential benefits”. Any “essential benefits”. Any plan to be offered through plan to be offered through the Exchange must include the Exchange must include the essential benefits. the essential benefits.
Plans covering large Plans covering large groups (100 or more groups (100 or more employees) and employees) and grandfathered plans are grandfathered plans are exempt, as are self-funded exempt, as are self-funded plans. plans.
The essential health benefit categories under ACA include:
•Ambulatory care•Emergency services•Hospitalization•Laboratory services•Maternity and newborn care•Pediatric services, including oral and vision care•Preventative and wellness services, and chronic disease management •Rehabilitative and habilitative services and devices•Prescription drugs•Mental health and substance abuse services; including behavioral health
Bulletin from HHS – how EHB will be defined• HHS issued a pre-regulatory bulletin on
12/16/11, describing their plan for how the EHB will be defined
• Instead of one standard benefit package for all state Exchanges and individual/small group market plans, HHS will allow states to choose one of the following four to use as a benchmark plan:
The four options:
•Any of the three largest small-group plans in the state by enrollment;
•Any of the three largest state employee health plans by enrollment;
• Any of the three largest federal employee health benefits program plan options by enrollment; or
•The largest insured commercial non-Medicaid HMO plan operating in the state
Immediate questions
• What if a state doesn’t choose a benchmark plan?• The default plan will be the largest small-group plan in
the state.
• Have the categories of benefits changed?– No, states will still have to ensure that benefits
under all 10 categories are included in their choice of benchmark plan. If categories are missing, the state must add them.
More immediate questions
• What will be the impact on state mandated benefits?– ACA requires states to pay for benefits
mandated by state law that are not included under the 10 benefit categories.
– But the bulletin proposes a two year transition period (2014-2015) during which states that select a benchmark plan that include more comprehensive benefits will not have to pay the additional cost.
Is this a good thing? Well…..
• It could be good….– Might reduce opposition to ACA by acknowledging
the need/desire for state flexibility vs. federal mandate
– Might allow states to choose a more comprehensive plan since they will no longer be on the hook for the cost of the + benefits
– Will allow states to move forward in their Exchange planning more efficiently than previously – they are no longer waiting for HHS to make decisions about a standard
Is this a good thing? Well…..
• It might not be….– Continued variation among states– Will this perpetuate existing gaps in coverage for
children with ASD/DD?– Strong consumer protections and transparency
will need to be ensured– Still no guidance from HHS on co-pays,
deductibles, other cost-sharing
What can you do to stay informed? (The shameless plug portion of the presentation….)
• Sign up for quarterly Catalyst Center e-newsletter, Week in Review, product/activity announcements
• Read our policy briefs, participate in webinars, etc. Ask us TA questions!
• Partner with advocacy/consumer groups – lend your voice and expertise to theirs
• Comment on federal regulations as they come out
One resource to help: The Affordable Care Act: a side-by-side comparison of major provisions and their implications for CYSHCN
Another resource…The Affordable Care Act and Children with Special Health Care Needs: An Analysis and Steps for State Policymakers
Download both along with other ACA-related materials atwww.catalystctr.org
Questions and Discussion
For more information, contact
Meg Comeau, MHA
The Catalyst Center
Boston University School of Public Health
617-638-1936
www.catalystctr.org
