Agenda
Coverage for care overview
Health insurance customer protections
New Health Insurance Marketplace
How will Medicaid change?
What does it mean for our state?
Call to action
Financing Mental Health Care
Source: Garfield (2011) Mental Health Financing in the US: A PrimerKaiser Commission on Medicaid and the Uninsured
Coverage for CareFederal/State Programs
• Medicaid: – Health finance program for the poor– Only covers some lower income people– Broad array of community mental health services– Does not cover inpatient care age 22 – 64
• Children’s Health Insurance Program (CHIP)• Children not covered by Medicaid 100% - 200% FPL• May or may not offer full range of Medicaid services
Coverage for CareFederal Programs
• Medicare: – Seniors, people who received SSDI for >24 months– Limited array of mental health services– Medicaid beneficiaries with very low incomes may
also qualify for Medicaid (dual-eligibles)
• Veterans/Military: – VA health care: limited eligibility, but wide array of
mental health services – TRICARE resembles private insurance
Coverage for Care State and Local Public Systems• State and county mental health authorities• Serve people who fall through the cracks• Provide services not covered by Medicaid
Private Health Insurance• Employer sponsored or purchased by individual/family• Varied benefits• Mental health parity requirements vary• Limited array of mental health benefits typical • Wider provider network
New Consumer Protections
Since 2010• Youth up to age 26 covered on
parent’s health plan• Children no denial for pre-
existing conditions• No lifetime limits on benefits• Temporary high-risk pools• Rescission: Cannot drop for
intense service need • Appeals process for denials• Medical Loss Ratio: 80-85% spent
on direct care
2014 and forward, Individual & small group plans• Essential health benefits (EHB) • MH/BH/SUD parity required• No denial for pre-existing
conditions• No annual limits• Guaranteed coverage• Rates can only differ based on:
– Age, geographic area, tobacco use, family size
• User friendly benefits statement
9
“My 21 year old daughter has had
major depression since she was a
child. We were very worried about
health insurance when she wanted
to leave home. Now she can stay
on our health plan until she is 26.”
The new health law allows parents
to keep adult children on their plan
until age 26.
Uninsured Adults with Mental Illness
US: Total of 45.6 million adults with mental illness
Source: SAMHSA, National Survey of Drug Use and Health, 2011
New Coverage Options
• Health Insurance Marketplace: private coverage• Individuals• Small Employers (SHOP)
• Medicaid expansion: 0 -138% FPL
• Parity required: 62M Americans Benefit– All individual and small group plans – All Medicaid Alternative Benefit Plans (Medicaid expansion)
– Traditional Medicaid managed care plans
Health Insurance Marketplace= Health Insurance Exchange
Goals: Good health coverage at affordable cost
•Regulates:
“Qualified Health Plans”
“Essential Health Benefits”
•Rates Qualified Health Plans
•Unified online application for exchange, Medicaid, CHIP
•Toll-free telephone hotline
•Website to compare health plan information
•Standardized format to present health benefit options
•Electronic calculator to figure of coverage
Qualified Health Plans (QHP)
Only Qualified Health Plans allowed in
Health Insurance Marketplaces
– Must provide Essential Health Benefits
– Insurer must meet requirements:
• In good standing with the State
• Offers at least:
– One silver and
– One gold plan
• Offers the same premium for qualified health
plans inside and outside the Marketplace
Source: Illinois Department of Insurance
Health Insurance Marketplace Incentives
• INDIVIDUALS
– Tax Credits for Premium Subsidies
– Cost-Sharing Subsidies
– Reduced OOP limits, annual cap
$6,350 (premium + deductible)
• SMALL BUSINESS
– Small business Health Options
Program (SHOP)
– Help small employers enroll
employees in qualified health plans
– Small Business Tax Credit
• Individual: 2014 forward, greater of…– 2014: $95 or 1% household income– 2015: $325 or 2% household income– 2016 and beyond: $695 or 2.5% household income
• Employer: 2015 forward – Applies to employers with 50 or more employees– Penalties from $2,000 to $3,000 per employee, – If employer fails to offer coverage or offers bare bones coverage
• Exempted: • Below tax filing threshold (Single, $10K, Jointly $20,000)• Religious reasons• Tribal member• Undocumented immigrant• Incarcerated• If no plan is less than 8% annual household income
Individual & Employer Penalties
Who Should Apply?• 85% of Americans already have health coverage that meets
ACA requirements – no need to apply– Private insurance– Medicare– Medicaid– VA benefits
• 15% may want to apply– Uninsured– Underinsured
• High health costs– Premiums, deductibles, out of pocket costs
• High health needs– Care you need is not covered
Essential Health BenefitsOutpatient clinic services
Emergency services
Hospital care
Maternity, newborn care
Mental health, behavioral health, substance use care
Prescription drugs
Rehabilitative & habilitative services
Laboratory services
Children’s services, dental & vision care
Wellness, disease management
Benefit Continuity
Essential Benefits Package
Source: Sommers, B.D. & Rosenbaum, S. (2011). Health Affairs. Presented by S Fields, NAMI 2011.
The new health law requires Medicaid expansion and
health insurance marketplace plans to provide medication
and lab work, but advocacy is needed.
“I had a 4.0 GPA in school but I
dropped out after my insurance
stopped covering my medication. I
started hanging out with the wrong
crowd and self-medicating just to get
away from the pain and confusion.
Now I’m trying to get back on track,
but every day is a struggle.”
• The Affordable Care Act provides a second chance in states that expand
Medicaid. Anyone with an income below 138 % FPL can enroll in Medicaid
and get treatment. It is also easier to return to work because private
insurance with mental health benefits will be available.
• NEW DONUT HOLE! In states that do not expand Medicaid people with
incomes below 100 percent FPL will not get federal financial help to
buy a private plan.
“I was married and working, but
stopped taking my medications
because I didn’t feel sick. Things went
downhill fast. My wife left me, I lost my
job and had to move back in with my
parents.”
Medicaid ExpansionAny uninsured ≤ 138% FPL
– 100% federal match for newly Medicaid eligible: 2014 – 2016
– Reduced gradually to 90% federal match, 2020 forward• Source: Kaiser Family Foundation
http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/#note-1
Question:Do the new rules help me get Medicaid?Answer:IF your state expands Medicaid and IF your income is at or below 138% of Federal Poverty Level, then yes.
Eligibility and Financial AssistanceFamily Size 100% FPL 138% FPL
1 $11,490 $15,856
2 $15,510 $21,404
3 $19,530 $26,951
4 $23,550 $32,499
Family Size 100% 400%
1 $11,490 $45,960
2 $15,510 $62,040
3 $19,530 $78,120
4 $23,550 $94,200
Question:Are you eligible for government help buying insurance?Answer:The government will help pay part of premiums and out-of-pocket costs for people with incomes between 100 percent and 400 percent of the federal poverty level.
The Marketplace is OPENEnroll TODAY
www.healthcare.gov
• Enrollment assistance - 24/7 call center– Toll free: 1-800-318-2596 – TTY/TDD: 1-855-889-4325 for assistance– English, Spanish, 150 languages
Call to Action • Contact your legislator today! Call or email!
– Visit state legislature website for contact information– Schedule a visit in the district
• ASK:– Health care coverage will help people with mental
illness recover and contribute to their communities.• Can I count on your support to expand good,
affordable health coverage to all households with incomes from 0 to 138 percent of poverty?
• Can I count on you to advocate for mental health coverage on par with medical/surgical care?