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Health Care Reform and

Parity-An Overview

Nassau County Heroin Treatment Task ForceTracie M. Gardner

Director of NYS PolicyDecember 7, 2012

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Legal and Policy Advocacy for people with

addiction histories, criminal records, and HIV/AIDS Fighting discrimination Advocating for the expansion of services and

resources Co-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. H

Helped to create NY Coalition for Whole Health

Legal Action Center

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Landmark victories in health coverage for

substance use disorders and mental health Mental Health Parity and Addiction Equity Act

prohibits discrimination The Affordable Care Act (ACA) aims to expand

SUD care dramatically by requiring coverage at parity in both health insurance exchanges and Medicaid expansion

Parity and Health Care Reform: A Time of

Tremendous Opportunity

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The 10 required categories of service:

1. Ambulatory Services2. Prescription Drugs3. Emergency Services4. Rehabilitative and Habilitative Services and

Devices 5. Maternity and Newborn Care6. Laboratory Services7. Mental Health and Substance Use Disorder

Services8. Preventive & Wellness Services and Chronic

Disease Management9. Hospitalization 10. Pediatric Services

Essential Health Benefits

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EHB will have a direct impact on over 70

million Americans Where the EHB is required, parity is required ACA improves on the federal parity law:

SUD/MH benefits required and must be provided at parity

Essential Health Benefits

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The 10 EHB categories are in statute: HHS

giving states strong role with no federal EHB definition

For States that do not choose, largest small group is default

BUT states must ensure parity! So: States will have lots of flexibility, But must

include SUD at parity, But will have lots of flexibility

Essential Health Benefits—who decides the specifics?

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Advocacy extremely important to take

advantage of this extraordinary opportunity:

1. Evaluate the benchmark plan2. Ensure compliance with Parity3. Identify what is not included

NY chose Oxford as its benchmark plan

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We need to ensure that NY’s essential health

benefit addresses: Long-term recovery and a chronic care approach Include full continuum of prevention, treatment,

habilitation and rehabilitation Residential treatment when appropriate Prescribed medications when appropriate,

including all approved medications for SUD/MH

NY chose Oxford as its benchmark plan

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Expansion to everyone below 133% FPL, including

childless adults for the first time in most states Approximately 16 million new enrollees Enormous opportunity to close treatment gap: Huge

Opportunity for Criminal Justice population States will also be deciding benefits for Medicaid

expansion: Must meet EHB and parity requirements, similar “benchmarking” process for Medicaid expansion as with EHB

Federal government to pay enhanced match rate for expansion population: eventually 90% in all states

Other Issues Related to Health Care reform: Medicaid expansion

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Competitive State-based marketplaces for

small employers and individuals to pool risk and purchase insurance

Plans will have to meet EHB and parity requirements and other consumer protections

Plans will have to maintain an adequate network of providers, including SUD/MH providers, to ensure all services are accessible without unreasonable delay

Other Issues Related to Health Care reform: Health

Insurance Exchanges

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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.

Important ACA Implementation activities

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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.

Important ACA Implementation activities

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Inclusion of addiction in integrated care

initiatives: Health homes and accountable care organizations

Inclusion of substance use prevention in chronic disease prevention initiatives

Identification of the addiction service workforce as part of the health workforce

Other important ACA implementation activities

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Recognition that ACA coverage provisions do not

go into effect until 2014 and will take years to fully implement

Likely some SUD services will not be covered in some states and not everyone in need will be insured: especially true for criminal justice system

Huge need for continued strong federal funding before the ACA is fully implemented and beyond

Need strong and united advocacy in Washington and states

Protecting SUD Safety Net Funding

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Insurers are prohibited from refusing to cover SUD

treatment that they cover for other medical/surgical conditions

Discrimination in quantitative and non quantitative limitations PROHIBITED

Insurers 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.

Parity Requirements

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Danger of discrimination by insurers: Refusal

to cover assessments or treatment ordered by court or other CJ agency

Eliminate Discrimination

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Meaningful Use—Incentivizing 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

Other important developments (outside of ACA and parity):

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BHOs at the MRT Behavioral Health Subcommittee

October 18, 2012 Meeting http://www.health.ny.gov/health_care/medicaid/redesign/docs/bh_bene_man_care_ppt.pdf

Behavioral Health Subcommittee recommendations• Managed 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 roles

Other important developments (outside of

ACA and parity):