Medicaid in the Era of Health Care Reform

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Medicaid in the Era of Health Care Reform

Presented by:

SAMHSA SOAR Technical Assistance CenterPolicy Research Associates, Inc.

Under contract to:

Substance Abuse and Mental Health Services AdministrationU.S. Department of Health and Human Services

Webinar Instructions Question instructions Muting Recording availability Downloading documents Evaluation

SOAR Training

2-day Stepping Stones to Recovery training

www.prainc.com/soar Find your State

Agenda The Increasing Importance of SOAR

Programs– Deborah Dennis, SAMHSA SOAR Technical Assistance Center

The Affordable Care Act and You– Sue Augustus, Health and Disability Advocates, Chicago, IL

Financial Support for Medicaid Enrollment– Steve Day, Technical Assistance Collaborative, Boston, MA

SOAR and Medicaid Administrative Claiming– Deborah Dennis, SAMHSA SOAR Technical Assistance Center

Questions and Answers

The Increasing Importance of SOAR Programs

Deborah Dennis

SAMHSA SOAR Technical Assistance Center

Policy Research Associates, Inc.

Benefits are Essential

SSI/SSDI = crucial income Medicaid/Medicare = vital healthcare

– Ending homelessness– Improving health outcomes– Supporting recovery

How will SOAR change?

Affordable Care Act brings expanded access to Medicaid

SSI/SSDI remain as crucial income supports

SOAR providers can continue their work and help with outreach for the Medicaid Expansion population

The Affordable Care Act and You

Sue Augustus

Health and Disability Advocates

Chicago, IL

Affordable Care Act (ACA) Major provisions affecting low income

populations:– Medicaid Expansion to 133% FPL for Childless

Adults– Establishment of State Health Care Exchanges

and Premium Tax Subsidies up to 400% FPL– Individual Mandate Requires taxpayers to pay a

penalty if they do not purchase insurance– Ban on lifetime limits, pre-existing conditions,

gender and health rating, and rescissions– Coverage for dependent children up to age 26– Medicare Part D Donut Hole Closing

Medicaid Expansion

New Adult Group for Childless Adults No need to meet disability criteria or be

eligible for SSI New income methodology under MAGI No asset test

ACA- Additional Provisions

Real Time Enrollment and Data Matching

Streamlined Citizenship/Identification Documentation

Proposed regulations set forth guidance to states on how to integrate new Medicaid with traditional Medicaid

Between Now and 2014 – What SOAR Case Managers Can Do

Although many of the individuals you currently serve will be eligible for Medicaid on 1/1/14, SOAR is important now:– There are still almost 2 years until 2014 – getting

people SSI and Medicaid remains critical– The Medicaid program that currently exists may

provide more benefits, especially in mental health, than the “new” “Essential Health Benefits” Medicaid that your State may adopt

SSI and Medicaid Remember that in some states establishing

eligibility for SSI does not automatically make people eligible for Medicaid

SOAR case managers are likely already addressing the need for separate applications in these 11 states:– Connecticut, Hawaii, Illinois, Indiana, Minnesota,

Missouri, New Hampshire, North Dakota, Ohio, Oklahoma, and Virginia

2014 and Beyond On 1/1/14, individuals will not automatically be

enrolled – they will still have to apply for Medicaid SOAR case managers will be especially poised to

help individuals who are homeless to enroll; The health care reform law only provides access

to Medicaid; income supports, such as SSI and SSDI are critical for safe and stable housing, which in turn lead to better health outcomes

Other ACA Changes That Can Impact People who are Homeless

Health Homes for Individuals with Chronic Conditions– “Health home model of service delivery” encompasses all the

medical, behavioral health and social supports and services needed by a beneficiary with chronic conditions;

– The chronic conditions described in the Act include a mental health condition, a substance use disorder, asthma, diabetes, heart disease, and being overweight, as evidenced by a body mass index over 25

– Health home services are defined as “comprehensive and timely high quality services

Health Home Services Comprehensive care management

Care coordination and health promotion

Comprehensive transitional care from inpatient to other settings, including appropriate follow-up

Individual and family support, which includes authorized representatives

Referral to community and social support services, if relevant

The use of health information technology to link services, as feasible and appropriate

Get Involved SOAR Case Managers can improve client health

outcomes and be a part of Health Homes

Every State is in a different place – find out what your State Medicaid agency is doing on ACA implementation

Talk to your State legislators and Medicaid agency staff about how SOAR can be a partner in health care reform efforts

Talk to your local Community Mental Health Clinics, FQHCs and hospitals about their plans for care coordination - SOAR should be a part of it.

Financial Support for Medicaid Enrollment

Steve Day

Technical Assistance Collaborative

Boston, MA

Medicaid Expansion: Issues and ChoicesWhat are essential benefits & benchmark plans? Each state will define a benchmark plan benefit design for both Medicaid

and for the Health Insurance exchanges

The benchmark plan will be equal to typical commercial insurance and/or state employee benefits in that state

Must provide coverage for essential benefits, which include mental health and substance use services

States will have some latitude to define these essential services, but must conform to the federal parity law

Most will probably include some combination of outpatient, inpatient and pharmacy services

Less likely to include case management, rehabilitation option, home health, and other in-home or community support services

Medicaid Enrollment Most new Medicaid enrollees will be eligible to receive

benefits defined in the benchmark plan for each state

However, states may not automatically enroll people who are “medically frail” in benchmark plans

– States will define types of people considered medically frail

– This can include people with serious mental illness, substance use disorders, and/or co-occurring conditions

– People who are defined by each state as medically frail may be entitled to receive the complete Medicaid benefit package in that state’s Medicaid plan; not just the benchmark benefit

Differences in Benefits

As noted earlier, in some states the benchmark benefit will be more generous than the regular Medicaid state plan benefit

– This is most likely to be true for substance use services, which are not well covered in many state Medicaid plans

Managed Care Plans

Many states will be enrolling the newly eligible Medicaid expansion population into managed care plans

– New enrollees will likely have to select from among several managed care plans

– If they do not select a particular plan, they will likely be assigned to a managed care plan

What Can You Do? Pay attention to what your state defines as the essential

benefit benchmark plan for new Medicaid enrollees

Assist potential enrollees to make informed choices about:

– Whether they could make a case to be defined as medically frail and thereby access the complete Medicaid benefit

– Whether they might receive better benefits by enrolling in the state’s benchmark plan

– If applicable, which managed care plan should they select?

Financial Support for Enrollment

Medicaid administrative claiming

– Some SOAR case managers may be located in public or non-profit agencies that already do Medicaid administrative claiming

• FQHCs and Community Health Centers

• Community Mental Health Centers

• Public facilities

• State or county government

Federally Qualified Health Centers

Some FQHCs may be able to cover costs of Medicaid referral and application activities for uninsured people

– This typically does not cover the costs of assisting people with SSI applications, appeals, etc.

Outreach/Engagement Every state will have an outreach/engagement plan to

enroll uninsured people in Medicaid and Health Insurance Exchanges

– Contracting with community agencies

– Payment is unclear for outreach and enrollment activities

SOAR case managers:

– Have skills/experience that could be beneficial to states, particularly for uninsured single adults that have no other connection to services (e.g. people who are homeless or at risk)

– Could provide useful training/consultation to state/county agencies engaged in system-wide outreach/engagement efforts

SOAR and Medicaid Administrative Claiming

Deborah Dennis

SAMHSA SOAR Technical Assistance Center

Policy Research Associates, Inc.

Medicaid Eligibility Specialists State of Georgia SOAR Project 2010- SOAR benefits specialists in each state

operated hospitals 2011- Converted to Medicaid eligibility specialists Collaboration between Department of Community

Health (DCH) and Department of Behavioral Health and Developmental Disabilities (DBHDD)

Refocusing Positions

Assist with SSI/Medicaid for individuals:

– Discharged from the state hospitals

– Crisis stabilization units

– Living in the community

Single Point of Contact at State for:

– Policy/fidelity, trainings/certifications, supervision, data reporting, coordination

Funding Positions Medicaid Administrative Claiming

The Centers for Medicare and Medicaid Services (CMS) principals that guide this can be found at Section 1903(a)(7) of the Social Security Act

Implementation of administrative claiming guidelines can be found at 42 CFR 430.1 and 42 CFR 431.15.

CMS allows administrative costs including:– Medicaid eligibility determinations

– Medicaid outreach

Allowable Activities CMS outlines facilitating Medicaid eligibility

activities to include: – Explaining eligibility rules

– Verifying eligibility

– Assisting individuals in completing applications

– Gathering information related to eligibility

– Assisting families in gathering documentation

– Supplying necessary eligibility forms

– Referring individuals to local assistance offices to make application

Questions and Answers

Facilitators:SAMHSA SOAR Technical Assistance Center

Policy Research Associates, Inc.

For More Information on SOAR

Visit the SOAR website at www.prainc.com/soar

Or contact:

SAMHSA SOAR TA Center

Policy Research Associates, Inc.Delmar, NY

518-439-7415soar@prainc.com