1. ACA, Realignment of EPSDT, Parity, Mild/Moderate to HMOs It’s a Whole new world, Or is it?
Rusty Selix
California Council of
Community
Mental Health Agencies
CMHACY 2014

2. ACA and MH Federal Parity
MediCal 100% FFP for low income adults not already eligible through disability or children
Includes TAY – foster care graduates
Eliminates pre existing conditions as barrier to private insurance
Healthy families to MediCal
Full parity for all plans- SUD MediCal

3. MediCal Managed Care Expanded
Covers whatever is medically necessary but does not meet county mental health standard of potential functional impairment (for adults)
Children slightly broader
Medication Management/ Mild/moderate
Plans have formed modest networks
Medicare rates - enough for others
without our members in most counties
Santa Clara providers included at county rates

4. MOUs between counties and plans
Establish screening, assessment, referrals
Right now can vary by county
State and plan standardization likely soon
No one falls between the cracks
One or the other must provide the care
Could have disputes over payments
More will ask plans for care
County responsibilities unchanged

5. Screening and Assessment
No current state requirement for kids
Screening tools by plans and counties
Assessment by MH professional by either
generally by plan
Plan either provides or refers
Referral to county then to provider
Provider authorization from plan or county

6. Higher Costs Under Counties
Commercial contracts have lower overhead
Less documentation required
Other states have similar pattern
Plans still must meet CMS Medicaid rules
State oversight different – what can we learn
State and counties have added requirements
Providers can set up separate corporation

7. Future Structural Changes?
No one is proposing an end to carve out
CMS letter based on audits and lack of action
Service Integration under current financing
Need to learn how plans comply with CMS on billing with much lower costs
Federal Financing structure could change from fee for service to capitation
Might require competitive bidding on all services

8. Goal of Seamless Integration
Screening in primary care
For adults includes SBIRT and PHQ-2
Children nothing required yet
EPSDT Performance Outcomes to address
Evaluation by health plan
Referrals, co-location or warm hand off
Who will be missed?
What are issues and challenges?

9. End Fail First System?
People currently in public mental health system get referred after hitting a bottom
Special ed, child welfare, juv. justice, hospital
Substantial functional impairment at intake
Almost always SED condition that has been present and diagnosable for years
Mental Health system itself can’t change this

10. Help at First Possible Sign
School mental health partnerships can identify and support all children
Get help years before they need special ed
Primary care and ER see almost everyone
Universal screening and coordination can identify mental illnesses early in their onset
More people will be referred for care
Less disability and less long term costs

11. Nearly All Will Meet County Criteria – my belief
Most common MH treatment is prescription for anti –depressant by primary care MD
Most so called mild – moderate will not result in a referral to MH professional
Most of MH by plans will be medication management for ADHD
I could be wrong

12. Realignment Formula Adjustments
EPSDT and Alcohol & Drug are sub allocation entitlements inside Behavioral Health Account of 2011 Realignment
For future years total growth is adjusted by spending on those programs and each county’s share of growth is adjusted by its utilization of those funds
State still needs to clarify so counties don’t think $$ are capped –letter promised soon
When will state do the allocations?

13. State HHS call to Patrick Gardner
Mike Wilkening Undersecretary called
Closing in on a decision expected in next few days
Memorialized in ACIN - letter to counties
Reimburse counties out of this year's growth account for net expenditures above the total allocation for behavioral sub account programs.  
Expect letter to address considerations for future growth allocations that include:
incentives for EPSDT investment and improving access and performance, probably tied to the POS process.

14. Realignment Growth is Growing
MH share of growth was limited until child welfare got $200 million of growth
Will be met in two years instead of 3
MH will get larger share of growth from 14-15
First call on growth to satisfy net growth in EPSDT and Alcohol & Drug
Reduce base for underspending counties
Unclear about adult MediCal
Rest to counties by formula

15. Katie A and Realignment
Implementation starting
$$ were included in realignment
Part of EPSDT
Questions about funding adequacy
Possible augmentation through claim/suit under Prop 30 if it is viewed as new mandate

16. EPSDT Outcomes Subject matter experts meeting regularly
First phase uses existing data
After that a choice between developing priority additional data like Adult System of Care or build something more comprehensive statewide
Special Katie A requirements
Screening and referral elements

17. Excellence in Mental Health Act
Just passed Congress and signed into law
Part of Medicare payment for MDs law
Creates FQBHC funding intended to approximate federal status for FQHCs
States to get 90% FFP for outpatient MH and SUD for SED/SMI for 2 years
Details through 2015 regs and 2016 plans
Could be worth $$ Billions in California
Efforts to make permanent and nationwide

18. Many Terms need to be defined
Can a county be an FQBHC or must certification be for each specific location
What is Serious Mental Illness
What services are covered
Inpatient and residential excluded
Must serve all on sliding scale
does that include undocumented immigrants?

19. Future full of hope and possibility
Screening and early identification seems certain to become a norm
TAY can keep MediCal
Funding picture brighter
Outcomes will improve care
Address paperwork burden?
Coordination and integration growing
Primary Care + Schools + Alcohol and Drug
Opportunity to serve whole family

20. Contact Information
Rusty Selix
ext. 0 or cell
Michele Peterson
ext. 111 or cell