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The ACA and ADTC Kirstin Frescoln Facilitated Community Solutions.

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Presentation on theme: "The ACA and ADTC Kirstin Frescoln Facilitated Community Solutions."— Presentation transcript:

1 The ACA and ADTC Kirstin Frescoln Facilitated Community Solutions

2 the ACA

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5 Objectives Understand the common features of the ACA in both Medicaid expansion and non-expansion states and State versus Federal exchanges Identify critical aspects of the ACA and how these impact Adult DTC operations and participants Know where to find more information about the ACA in your state or county Know who you should engage to help shape the insurance (Medicaid and Private) coverage available to your ADTC participants

6 ACA Timeline March 23, 2010 Patient Protection and Affordable Care Act a.k.a. ACA or Obamacare, signed into law March 28, 2012 US Supreme Court rules that states not required to expand Medicaid coverage March 31, 2014 Open enrollment for Health Insurance Marketplace ended November 15, 2014 – February 15, 2015 Open enrollment for Health Insurance Marketplace

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8 Medicaid Expansion

9 10 Essential Benefits 1.Ambulatory patient services 2.Emergency services 3.Hospitalization 4.Maternity and newborn care 5.Mental health and substance use disorder services, including behavioral health treatment 6.Prescription drugs 7.Rehabilitative and habilitative services and devices 8.Laboratory services 9.Preventive and wellness services and chronic disease management 10.Pediatric services, including oral and vision care

10 ACA Patient Protections Expanded insurance coverage through Medicaid expansion and Federal subsidies to make health insurance and treatment more affordable Guaranteed 10 Essential Benefits Eliminated discriminatory insurance practices that allowed denial of coverage based on pre-existing conditions

11 10 Essential Benefits 1.Ambulatory patient services 2.Emergency services 3.Hospitalization 4.Maternity and newborn care 5.Mental health and substance use disorder services, including behavioral health treatment 6.Prescription drugs 7.Rehabilitative and habilitative services and devices 8.Laboratory services 9.Preventive and wellness services and chronic disease management 10.Pediatric services, including oral and vision care

12 Mental Health Parity and Addiction Equity Act Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) Increase access and reduce discriminatory practices associated with mental health and substance use/abuse/dependence treatment Parity means that the substance use and mental health benefits covered by the plan must be covered in a manner that is no more restrictive than that of other covered medical health care benefits ACA closed “loop holes” in MHPAEA by extending requirements of parity law to all health care plans

13 Mental Health Parity and Addiction Equity Act Implementation of parity is a work in progress Defined by Federal government however… How that will be negotiated in each state (or county) probably not fully determined until later this year Clarification of what this means and how this should be implemented is likely to be decided in future years and through the courts

14 Expanded Coverage Those states that have expanded Medicaid coverage now may include adults 18 to 65 with incomes up to 138% (about $27,000 for a family of 3) of the Federal Poverty Level (FPL). Federal subsidies are available to help individuals pay for coverage if their income falls between % FPL (in Medicaid expansion and non- expansion states).

15 Medicaid Healthcare coverage for particular categories of people who are at or below 100% of the FPL Coverage of benefits in Medicaid is determined by the state division of medical assistance (or its equivalent) in its state plan, within the framework required by federal law Generally low-income – disabled adults, children (CHIP) and families, pregnant women, long-term care recipients, others as determined by each state

16 Medicaid Expansion The ACA provided federal funds to expand Medicaid coverage to individuals up to 138% of the federal poverty level Expansion extends Medicaid eligibility to all parents and other adults up to the new Medicaid limit Recommended development of Alternative Benefit Plans within Medicaid that extended coverage to populations not previously eligible such as non- disabled adult males

17 Medicaid Expansion Gap Individuals who are not members of a specific Medicaid covered category Gap is wider in those states that did not expand Medicaid coverage but may exist in expansion states depending on populations (not) covered Individuals who are not covered by Medicaid and who do not have incomes high enough to qualify for tax credits and subsides to purchase insurance coverage on the Exchange

18 Key Agencies/Individuals Single State Agency Oversees the state’s substance use/abuse/ dependency and mental health treatment Division of Medical Assistance (or equivalent) Oversees the state’s Medicaid and CHIP plans State Insurance Commissioner Oversees certain private insurance coverage and ensures compliance with state insurance laws

19 Single State Agency Oversees the state’s substance use/abuse/ dependency and mental health treatment In some states, administers Drug Courts Manages how the state’s Substance Abuse Prevention and Treatment Block Grant funds are prioritized and expended Works with the state’s Medicaid offices and Insurance Commissioner to define substance use/abuse/ dependency and mental health treatment coverage Helps define and implement Parity Act

20 Division of Medical Assistance Define who and what is covered by Medicaid in each state within the framework of federal law In Medicaid expansion state, determine who and what is covered in the alternative benefit plans

21 Insurance Commissioner Ensures the benefit plans submitted by insurance companies meet state laws and benefit requirements Broad or narrow interpretation may affect what services and medications are included in plans For example, how parity is interpreted and enforced could affect which, if any, medication-assisted therapy drugs are covered in your state Different plans will have different coverage - BCBS may include only one drug while Kaiser might cover 10 and both could technically meet the requirements of the laws

22 So what does all this mean to you, your drug court operations, and your participants?!?

23 Change

24 Medical Necessity Focus on clinical definitions of medical necessity And… Focus on payers' definitions of medical necessity  How will your team ensure that your Drug Court participants are able to access and pay for clinically necessary treatment?

25 Residential Treatment Residential treatment is not required for most drugs (e.g., alcohol and benzodiazepines require medically supervised detoxification, opioids do not) Medicaid can not pay for residential treatment in facilities with more than 16 beds  How will your team ensure that your participants are able to access and pay for residential treatment when it is needed?

26 Medicaid Billing In order to become a Medicaid provider, treatment agencies must meet a variety of federal and state regulations Medicaid billing is complex Reimbursement is usually delayed  How will you help your treatment providers transition to Medicaid billing?

27 More Provider Choice More people with insurance (private and Medicaid) means that more providers may decide it is economically advantageous to provide treatment in your area Some of these providers may not be experienced in treating high-risk/high-needs Drug Court participants More providers means that you will have to make accommodations to your Drug Court policies, procedures and written materials

28 Less Provider Choice Changes in Medicaid and private insurance may result in a reduction in treatment providers in your area The ACA includes a “network adequacy” standard that was intended to protect (primarily rural) areas from a contraction in the number of qualified treatment providers Federally Qualified Health Centers (FQHC) are stepping in to provide mental health and substance use/abuse/dependency treatment in some rural areas

29 Responding to Changes in Providers  Find out about all the substance use/abuse/dependency treatment providers in your area – what are their strengths? - which would be highly-qualified to treat your participants?  Know which are Medicaid providers and which are “preferred providers” on the most common private insurance plans in your area  Make changes to your policies and procedures to accommodate these provider changes

30 Substance Abuse Prevention and Treatment Block Grant SAMHSA block grant funds are noncompetitive grant dollars provided to all states based on a formula determined by Congress that takes into account population and other factors Typically used to provide substance use/abuse/ dependence treatment to high-needs populations such as justice-involved populations and others who may not otherwise have access to treatment coverage Managed by the Single State Agency

31 Substance Abuse Prevention and Treatment Block Grant States may be able to reapportion Block Grant funds for other treatment uses such as: - pay treatment providers to participate in staffings - expand the number of participants you serve - provide enhanced complimentary care - offer medications not on the formulary - provide access to recovery management programs - pay for residential care

32 Substance Abuse Prevention and Treatment Block Grant  Know what your state’s Substance Abuse Prevention and Treatment Block Grant is used to cover  Find out if there are new opportunities for the Block Grant to expand treatment coverage  Talk with your state’s Single State Agencies about the needs of your Drug Court and participants and work to ensure the Block Grant continues to serve the needs of your Drug Court and participants

33 Parity All insurance plans should now manage mental health and substance use/abuse/dependency treatment in the exact same way they do primary medical and surgical care What does that mean?!?! Determinations of medical necessity should be the same as medical/surgical care Co-pays, maximum benefits, and treatment duration should be determined in the same way as medical/surgical care

34 Parity And probably some problems Determinations of medical necessity are not always without controversy for medical/surgical care Co-pays, maximum benefits, and treatment duration for medical/surgical care are not always optimal The people who understand medical/surgical care generally don’t often understand mental health/substance abuse care and vice versa

35 Parity The interpretation and implementation of parity will be determined over the next several years by your: - Single State Agency - Medicaid Agency - Insurance Commissioner - Courts

36 Parity  Find out how parity is being interpreted by staff at your Single State Agency, Medicaid, and Insurance Commissioner  Determine how the most commonly accessed insurance plans are defining parity  Educate everyone about what parity means and why it is so important  Advocate for changes if necessary

37 Defining Coverage New insurance plans New providers New laws  You and your Drug Court team will need to actively seek out and share information

38 Top Ten Actions 10. Maximize the number of justice-involved individuals receiving Medicaid or insurance coverage  Talk with others in your state or jurisdiction about what they are doing to increase the number of justice-involved individuals enrolled in health care coverage  Consider how you or your Drug Court can contribute

39 Top Ten Actions 9. Ensure continued access to high-quality treatment  Strengthen existing relationships with the highly qualified treatment providers  Build new relationships with all treatment and health plan providers operating in your area and serving your Drug Court participants  Support your treatment providers as they navigate the many changes and regulations associated with the ACA and Parity Act

40 Top Ten Actions 8. Communicate with your Medicaid office, Insurance Commissioner, and others in your state implementing and overseeing health reform  Educate these officials about what Drug Courts do, the health care needs of the population you serve, and the kinds of treatment coverage that best serves this high- need, high-cost population  Engage officials in dialogue about how the Ten Essential Health Benefits, Parity Act, and nondiscrimination aspects of the ACA are being interpreted and implemented in your county and state

41 Top Ten Actions 7. Understand medical necessity and how it affects Drug Court operations  Create or update treatment plans with the full continuum of treatment as recommended in the Adult Drug Court Best Practice Standards  Learn how your typical Drug Court treatment plan might meet or be challenged to meet clinical definitions of medical necessity and how these are likely to intersect or diverge from Medicaid or insurance company definitions of medical necessity  Talk with Medicaid, insurance plan administrators, and your treatment providers about how Medicaid and insurance plans can pay for Drug Court services provided to your participants

42 Top Ten Actions 6. Communicate with your Single State Agency  Maintain active communication with officials at your Single State Agency about your Drug Court’s needs and the kinds of treatment coverage that best serves your participants  Discuss with your Single State Agency how the ACA (and resultant Medicaid and insurance changes) affect or could affect your Drug Court operations and participants

43 Top Ten Actions 5. Determine how your state’s substance abuse prevention and mental health block grants may be affected  Talk with officials in your state’s substance abuse and mental health care agency  Find out how the state’s SAMHSA block grant funds are currently designated  What changes, if any, are planned because of the implementation of the ACA?

44 Top Ten Actions 4. Understand what the Parity Act means in your state or jurisdiction  Get informed about parity by talking with and monitoring updates provided by your Single State Agency and others in your state and nationally that are working on parity  Talk to those who are involved in making decisions about how Drug Courts operate and the health care needs of the population you serve  Invite officials to observe your Drug Court to see how Drug Courts are a perfect example of why mental health and substance use/abuse/dependence treatment parity is so important

45 Top Ten Actions 3. Learn more about Medicaid coverage and alternative benefit plans (if applicable) in your state  Review state-level documents to determine who is covered by Medicaid and Medicaid expansion and share the results with your Drug Court team

46 Top Ten Actions 2. Get Educated  Learn everything you can about what the ACA is (and is not).  Find out how implementation of the ACA in your state affects your Drug Court operations and participants.  Participate in the many opportunities to learn more about the ACA and criminal justice populations through the available literature, web resources, webinars, and trainings provided by federal, state, and nonprofit groups.

47 Top Ten Actions 2. Get Educated  Talk to your treatment partners and other agencies serving your Drug Court population about how they are preparing for and adjusting to the ACA.  Meet with your Drug Court team to identify what opportunities and challenges might be specific to your jurisdiction.  Make a plan to get ahead of the challenges and leverage the opportunities.

48 Top Ten Actions 1.Be an educator  Share what you have learned with your Drug Court Team  Talk to both traditional and nontraditional partners about how Drug Courts operate, the population you serve, and the Drug Court participants’ complex treatment needs  Help shape access to care for your Drug Court population by educating those who are making decisions about ACA interpretation and implementation of what your Drug Court does, what it needs, and how it helps the community

49 Resources Visit the NDCRC ACA resource link at

50 Thank You


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