ACA Eligibility and Enrollment Changes: Implications and Opportunities for Behavioral Health Providers Stephanie McCladdie SAMHSA Regional Administrator

ACA Eligibility and Enrollment Changes: Implications and Opportunities for Behavioral Health Providers

Stephanie McCladdie

SAMHSA Regional Administrator

DHHS Region IV

FADAA Community Health and Wellness Conference

April 22, 2013

Current Picture of Eligibility

• Medicaid (as of January 1, 2013)*• Pregnant women (40 States at or above 185% FPL)• Disabled adults (11 States more restrictive than SSI)• Parents (1996 welfare income eligibility +

waivers/state funds – benefit limits/cost sharing = mixed picture) (only 18 States offer full Medicaid at poverty level)

• Low income, non-disabled, childless adults • 9 offer benefits equivalent to Medicaid (early ACA

option/waivers/state funds) (AZ, CO,CT, DE, DC, HI, MN, NY, and VT)

• 16 provide more limited benefits

Source: “Getting into Gear for 2014: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2012–2013” available at: http://www.kff.org/medicaid/upload/8401.pdf


• CHIP/Children in Medicaid• All states have expanded coverage (26 have options at or

above 250% FPL and only 4 less than 200% FPL)• CHIPRA allowed for significant improvements in eligibility

determination processes (express lane/presumptive eligibility)• 25 have exemption from 5-year lawfully-residing immigrant

wait due to CHIPRA• Medicare

• 65 years old or older or receiving SSI payments for 2 consecutive years

• State Exchanges• Massachusetts (premium subsidized up to 300% FPL)• Utah (no subsidies)

Enrollment Assistance Efforts

• 48 States offer in-person assistance in eligibility offices and/or toll-free hotline

• 47 states offer toll-free hotline • 3 5 states have out-stationed state eligibility

workers• 23 states have state-funded community-based

application assisters• 37 states have electronic online application in

Medicaid or CHIP• 28 states allow families to renew online (8 states

added this capability in 2012) • 36 states provide on line accounts


HEALTH COVERAGE IN 2014

Medicaid Exchange with Tax Credits

Exchange or Private

Plan

Income as a percent of the federal poverty level

0 133 400+

Coverage Options for Adults without Medicare or Employer-Based Coverage

A Continuum of Coverage – Everyone Fits Somewhere!

7

Data-driven Renewal for Continuous Coverage

Online Tool for Consumers to Easily Compare and Enroll in Health Plans

Modern, Data-driven Verification Systems

“No Wrong Door” Eligibility and Enrollment Model

Simple, Streamlined Application

A NEW WAY TO ENROLL IN COVERAGE

8

SIMPLE STREAMLINED APPLICATION PROCESS

NowDifferent applications for

different programsDenied? Back to the

drawing boardApplications often only

available on paper or as PDFs if online

In-person interview requirements

2014Regulations require a

single application as gateway to all coverage programs

Must be available online, by telephone through a call center, by mail, and in person

Interview requirements prohibited

9

Eligibility Determination Systems

ACA Consumer/Enrollment Assistance Activities

Consumer Assistance Grants • Employed directly by Medicaid agency or Exchange entity• Support state development of appeals assistance services and claims

dispute processes• Hiring and training for enrollment assistance outreach workers• Public outreach• http://www.healthcare.gov/news/factsheets/2010/10/capgrants-

states.html Marketplace Assisters • Employed directly by Medicaid agency or Exchange entity, or funded by

grant or contract to fulfill additional non-navigator assistance requirement• Can be financed by consumer assistance or establishment grants• Cannot take the place of Navigator program


Navigator program (2014)• Conduct public education activities to raise awareness of the availability of

qualified health plans • Distribute fair and impartial information about enrollment in qualified

health plans and the availability of premium tax credits • Facilitate enrollment in qualified health plans • Provide referrals to an office of health insurance consumer assistance or

ombudsman, or any other appropriate state agencies, for any enrollee with a grievance, complaint, or question regarding their health plan

• Provide information in a manner that is culturally and linguistically appropriate to the needs of the population served by the Exchange


Navigator program (2014)• Required for and financed by each Exchange• Strong conflict of interest standards• Restrictions on producer/broker licensure requirements• Privacy and security standards• Training and credentialing will be necessaryImplementation Update • FOA for FFE/SPE Navigators available NOW• At least 13 States engaged in public planning work (Feb. 27, 2013)

– AR, WA, WV, CA, CO, CT, DC, HI, MN, NV, OR, VT

• Some subsumed by broader assister program• Medicaid enrollment assistance questions raised

Persons Who Are Uninsured


2014 Projected Enrollment

Series10

5

10

15

Source: February 2013 CBO estimates

Mill

ions

Enroll at least 15 million people in new coverage options

}7 million in Exchange coverage

8 million in Medicaid or CHIP}16


Source: NSDUH

29%Individuals who are

uninsured with behavioral health

conditions71%Individuals who are uninsured

Data Sources

• National Survey on Drug Use and Health - Sponsored by SAMHSA - National and state estimates on prevalence of behavioral health conditions and treatment - 2008 - 2010 data - Approximately 67,500 interviews per year

• American Community Survey - Sponsored by the U.S. Bureau of the Census - National and State population estimates, including counts of uninsured by income level - 2010 data - Approximately 1.9 million persons in sample

18

Methods for Estimating Uninsured with M/SU Conditions by FPL

• From NSDUH, identified by State the number of uninsured persons aged 18-64 with income:

- Between 133% and 400% of the Federal poverty level (FPL) eligible for health insurance exchanges

- Less than 139% of the FPL eligible for Medicaid expansion

• Calculated NSDUH prevalence rates for serious mental illness (SMI) and substance use disorder (SUD) by State, for the above groups

• Applied SMI/SUD prevalence rates to American Community Survey counts of uninsured by State

19

Prevalence of Serious Mental Illness Among Adults Ages 18 – 64 by Current Medicaid Status and Eligibility for Medicaid Expansion

or Health Insurance Exchanges: Florida, US

20

CI = Confidence IntervalSources: 2008 - 2010 National Survey on Drug Use and Health (Revised March 2012)

2010 American Community Survey

11.7% 7.0% 6.0%9.0% 7.8% 5.2%0%

2%

4%

6%

8%

10%

12%

14%

Current Medicaid Population

(Florida: 852,351)FL CI: 6.2% - 12.8%

U.S. CI: 10.8% - 12.7%

Medicaid Expansion Population

(Florida: 536,304)FL CI: 5.5% - 10.9%U.S. CI: 6.3% - 7.7%

Health Insurance Exchange Population

(Florida: 688,995)FL CI: 3.5% - 7.6%

U.S. CI: 5.5% - 6.6%

Pre

vale

nce

Ra

te

National

Florida

Confidence Interval

I

Prevalence of Serious Psychological Distress Among Adults Ages 18 – 64 by Current Medicaid Status and Eligibility for Medicaid

Expansion or Health Insurance Exchanges: Florida, US

21



22.1% 14.9% 13.3%21.2% 15.9% 10.6%0%

5%

10%

15%

20%

25%

30%


(Florida: 852,351)FL CI: 16.8% - 26.2%U.S. CI: 21% - 23.2%


(Florida: 536,304)FL CI: 13% - 19.4%

U.S. CI: 14% - 15.9%


(Florida: 688,995)FL CI: 7.9% - 14%

U.S. CI: 12.5% - 14.2%

Pre

vale

nce

Rat

e

National

Florida

Confidence Interval

I

Prevalence of Substance Use Disorders Among Adults Ages 18 – 64 by Current Medicaid Status and Eligibility for Medicaid

Expansion or Health Insurance Exchanges: Florida, US

22



12.4% 14.2% 14.6%12.2% 11.5% 13.7%0%

2%

4%

6%

8%

10%

12%

14%

16%

18%


(Florida: 852,351)FL CI: 8.8% - 16.5%

U.S. CI: 11.5% - 13.3%


(Florida: 536,304)FL CI: 9.1% - 14.5%

U.S. CI: 13.2% - 15.2%


(Florida: 688,995)FL CI: 11% - 17%

U.S. CI: 13.7% - 15.6%

Pre

vale

nce

Rat

e

National

Florida

Confidence Interval

I

Prevalence of Behavioral Conditions Among Health Insurance Exchange Population: Florida, US

23



6.0% 13.3% 14.6%5.2% 10.6% 13.7%0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Serious Mental Illness FL CI: 3.5% - 7.6%

U.S. CI: 5.5% - 6.6%

Serious Psychological Distress

FL CI: 7.9% - 14%U.S. CI: 12.5% - 14.2%

Substance Use Disorder

FL CI: 11% - 17%U.S. CI: 13.7% - 15.6%

Pre

vale

nce

Rat

e

Uninsured Adults Ages 18 - 64 with Incomes Between 133- 399% of the Federal Poverty Level (Florida: 1,688,995)

National

Florida

Confidence Interval

I

Prevalence of Behavioral Conditions Among Medicaid Expansion Population: Florida, US

24



7.0% 14.9% 14.2%7.8% 15.9% 11.5%0%

5%

10%

15%

20%

25%

Serious Mental Illness FL CI: 5.5% - 10.9%U.S. CI: 6.3% - 7.7%

Serious Psychological Distress

FL CI: 13% - 19.4%U.S. CI: 14% - 15.9%

Substance Use Disorder

FL CI: 9.1% - 14.5%U.S. CI: 13.2% - 15.2%

Pre

vale

nce

Rat

e

Uninsured Adults Ages 18-64 with Incomes < 139% of the Federal Poverty Level (Florida: 1,536,304)

National

Florida

Confidence Interval

I

Methods for Estimating Population Characteristics

• From NSDUH, calculated the national prevalence rates for SMI, serious psychological distress (SPD), and SUD by income group with demographic populations of interest (e.g., uninsured non-Hispanic whites with income <138% FPL with SMI)

• Multiplied national prevalence rate by the ACS’ State population by income group with this demographic characteristic (e.g., national % of uninsured 18-34 year olds with income <138% FPL with SMI * ACS State number of 18-34 year olds with income <138% FPL)

• Calculated the percent distribution with condition in the State across demographic groups such as race, age, and education (e.g., percent with SMI with < high school, high school, or college education)

25

Characteristics of 18-64 Year-Olds with a Serious Mental Illness (SMI) Projected in Medicaid Expansion Population*

26

Most common characteristics of persons with SMI in Medicaid expansion population in Florida are:

• Female

• Non-Hispanic White

• High School Graduate

* Population with income less than 139% of the Federal Poverty Level and uninsured

National Florida Female 61% 61% Age 18-34 53% 49% Race/Ethnicity Non-Hispanic White 66% 62% Non-Hispanic Black 13% 18% Other 5% 3% Hispanic 16% 18% Education < High School 26% 24% High School Graduate 38% 40% College 37% 37%

Sources: 2008 - 2010 National Survey on Drug Use and Health (Revised March 2012) 2010 American Community Survey

Characteristics of 18-64 Year-Olds with a Substance Use Disorder (SUD) Projected in Medicaid Expansion Population*

27

Most common characteristics of persons with SUD in Medicaid expansion population in Florida are:

• Male

• Non-Hispanic White or Hispanic

* Population with income less than 139% of the Federal Poverty Level and uninsured

National Florida Male 75% 76% Age 18-34 63% 58% Race/Ethnicity Non-Hispanic White 51% 45% Non-Hispanic Black 20% 26% Other 4% 2% Hispanic 25% 27% Education < High School 37% 34% High School Graduate 32% 34% College 31% 31%


Characteristics of 18-64 Year-Olds with a Serious Mental Illness (SMI) Projected in Health Insurance Exchange*

28

Most common characteristics of persons with SMI in exchange population in Florida are:

• Female


• College Graduate

* Population with income from 133% to 399% of the Federal Poverty Level and uninsured

National Florida Female 60% 62% Age 18-34 57% 53% Race/Ethnicity Non-Hispanic White 68% 64% Non-Hispanic Black 10% 12% Other 5% 3% Hispanic 17% 21% Education < High School 18% 14% High School Graduate 38% 38% College 44% 47%


Characteristics of 18-64 Year-Olds with a Substance Use Disorder (SUD) Projected in Health Insurance Exchange*

29

Most common characteristics of persons with SUD in exchange population in Florida are:

• Male

• 18-34 years old


* Population with income from 133% to 399% of the Federal Poverty Level and uninsured

National Florida Male 73% 72% Age 18-34 69% 66% Race/Ethnicity Non-Hispanic White 52% 46% Non-Hispanic Black 14% 17% Other 5% 3% Hispanic 29% 34% Education < High School 26% 22% High School Graduate 38% 39% College 36% 39%


Enrollment and Behavioral Health

• In MA, 20-30% of patients seeking acute services are uninsured (in a state where 97% of population as a whole is insured).*

• In MA, 20-25% of acute service presentations are uninsured and most of these are young men 18-25 years old.*

• In MA, half of patients with MH and SUD conditions in focus groups were avoidably disenrolled at least once from their health insurance in the past year.*

• In ME, 10% of Maine residents but more than 31% of substance abuse treatment clients uninsured.**

*Source: Substance Abuse and Mental Health Services Administration. Enrollment and Disenrollment in Subsidized Health Insurance: Lessons Learned in Massachusetts. November 2011.

** Source: National Association of State Alcohol and Drug Abuse Directors, Inc. Effects of State Health Reform on Substance Abuse Services in Main, Massachusetts, and Vermont. Considerations for Implementation of the Patient Protection and Affordable Care Act (PPACA). June 2010.

3

SAMHSA Enrollment Coalitions Initiative

• Collaborate with national organizations whose members/constituents interact regularly with individuals with mental health and/or substance use conditions to create and implement enrollment communication campaigns

• Promote and encourage the use of CMS materials • Provide training and technical assistance in

developing enrollment communication campaigns using these materials

• Provide training to design and implement enrollment assistance activities

• Channel feedback and evaluate success31

Supporting Intermediaries

• Intermediary

focused efforts formed

in five categories:

SAMHSA Enrollment Coalitions Initiative

• Supporting coalition groups in their commitment to promoting access to insurance for their constituents

• Inviting coalition groups to shape enrollment support policy, planning, training and materials development

• Providing leadership for other organizations

33

Three Stages of the Effort

SAMHSA and coalitions will create training and technical assistance to encourage enrollment of individuals with M/SUD

SAMHSA will work with coalition organizations to offer training to their members/ constituents to develop enrollment campaigns and provide enrollment assistance (two rounds of this stage)

Members/ Constituents will implement activities to motivate and assist their clients/ patients to enroll

34

Timeline

Laying the Groundwork• Coalition formation• Health insurance literacy

training and technical assistance

• February –May 2013

Preparing for Enrollment• Enrollment campaign

training• Enrollment assistance

training• June – September 2013

Enrolling Eligible Individuals

• Continuation of enrollment campaigns

• Enrollment assistance • October 2013 - March

2014

35

Key Takeaways

• High prevalence of substance abuse and mental health conditions among the uninsured

• 2014 will potentially bring coverage to 11 million individuals with substance abuse and or mental health conditions

• Significant changes are happening to eligibility and enrollment systems

• Substance abuse and mental health peer organizations must play an active role in outreach and enrollment

Providers Accepting Health Insurance Payments

SA TREATMENT FACILITIES ACCEPTANCE OF INSURANCE PAYMENTS *

4

*Source: NSATSS **Source: 2011 NCCBH BH Salary Survey

SOURCE OF FUNDS FOR CMHCS**

Provider Business Operations Learning Networks

• TA to help 900+ provider orgs/year in 5 areas of practice• Strategic business planning in an era of health reform• 3rd-party contract negotiations• 3rd-party billing and compliance• Health insurance eligibility determinations and

enrollment• Health information technology adoption

• Special focus on providers of peer & recovery support services & providers serving racial & ethnic minority and other vulnerable populations

• http://www.samhsa.gov/healthReform/BHbusiness.aspx

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http://www.samhsa.gov/healthReform/BHbusiness.aspx

http://www.samhsa.gov/healthReform/BHbusiness.aspx

Enrollment Resources

• Healthcare.gov• http://www.healthcare.gov/marketplace/index.html

• HHS Partners Resources• http://www.cms.gov/Outreach-and-Education/Outreac

h/HIMarketplace/index.html• SAMHSA Enrollment Webpage

• http://www.samhsa.gov/enrollment/• State Refor(u)m Exchange Decisions

• http://www.statereforum.org/node/10222• Enroll America Best Practices

• http://www.enrollamerica.org/best-practices-institute

http://www.healthcare.gov/marketplace/index.html

http://www.cms.gov/Outreach-and-Education/Outreach/HIMarketplace/index.html

http://www.cms.gov/Outreach-and-Education/Outreach/HIMarketplace/index.html

http://www.samhsa.gov/enrollment/

http://www.statereforum.org/node/10222

http://www.enrollamerica.org/best-practices-institute

Documents

ACA Eligibility and Enrollment Changes: Implications and Opportunities for Behavioral Health Providers Stephanie McCladdie SAMHSA Regional Administrator