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Annual Meeting Washington, DC July 27, 2014 Stuart Yael Gordon, J.D., NASMHPD Director, Policy and Health Care Reform Christy Malik, MSW, NASMHPD Senior.

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Presentation on theme: "Annual Meeting Washington, DC July 27, 2014 Stuart Yael Gordon, J.D., NASMHPD Director, Policy and Health Care Reform Christy Malik, MSW, NASMHPD Senior."— Presentation transcript:

1 Annual Meeting Washington, DC July 27, 2014 Stuart Yael Gordon, J.D., NASMHPD Director, Policy and Health Care Reform Christy Malik, MSW, NASMHPD Senior Policy Associate Justin Harding, J.D., NASMHPD Senior Policy Associate 1

2 2 1.Engage with SAMSHA and CMS in Ongoing Policy Discussions (Block Grant MOE, 5% Set Aside, HCBS, ACA Enrollment, behavioral health quality measures, provider access) 2.Engage with Congressional members and staff on draft legislative proposals, proposed amendments (mandatory AOT, CMHC grants) 3.Brief Congressional members, staff on MH and SA issues

3 3 4.Review & analyze Congressional legislation, collect NASMHPD member feedback, draft support or opposition letters 5.Review & analyze proposed regulations, notices, grant opportunities from SAMHSA, CMS (Medicaid, Medicare, CHIP), NIH, ACL, etc. 6.Notify NASMHPD members (particularly Financing and Medicaid Division) of legislative activity, agency policy initiatives, RFPs, grant opportunities.

4 7.Partner with other Public Official Associations, stakeholders in drafting correspondence, comments  with NAMD on 42 CFR Part 2  with National Council on need for transparent implementation of Excellence in Mental Health Act  Medicaid/Public Health Expert Group: ASTHO, NAMD, HRSA, CMS 4

5 8.Work with Stakeholder Coalitions to Develop Policy Positions:  Mental Health Liaison Group (MHLG): National Council, NAMI, both APAs, Bazelon, NASADAD, MHA, NAADAC, et al.  Coalition for Whole Health (CWH): jointly led by NACBHDD & LAC 5

6  NASMHPD staff sits on SAMHSA, CMS quarterly advisory groups. ◦Next CMS “Association of Associations” (NAMD, NASADAD, et al.) meeting July 30.  NASMHPD staff & members on SAMHSA workgroup drafting data set of client-level Block Grant performance measures.  SAMHSA sought feedback from NAMSHPD members on state early intervention programs in drafting guidance for FY2014 5% Early Intervention Mental Health Block Grant set aside. 6

7  CMS sought input from NASMHPD on HCBS in non-residential settings in drafting forthcoming guidance.  NASMHPD joins quarterly CMS calls on impacts of ACA and mental health parity on provider access.  NASMHPD works with other stakeholder to co- sponsor CMS and SAMHSA policy webinars. 7

8 1.Advocacy group composed of national organizations in the mental health and substance abuse disorders fields, and allied organizations 2.NASMHPD worked closely with CWH members on: o Letter to Senate Finance Committee on Medicare & Medicaid for individuals with MH & SUD o Comment letter on ACA §1557 nondiscrimination mandate o Comment letter on streamlined exchange application data elements 8

9  Implementation of a state advocacy survey ◦Goal of survey: collect state information for CMS and SAMHSA on status of health reform information and parity (state-specific difficulties, best practices)  332 responses from 42 states; highest response from NJ and IA  Of 253 responses, 83 respondents said their state has acted to make information available on MH/SUD coverage & benefits. ◦170 said their state has taken no action 9

10  Of 260 responses, 36 respondents said they were able to obtain information to determine if plans have adequate MH & SUD provider networks to ensure timely access.  219 of 346 respondents said they would like technical assistance on: ◦Implementing and monitoring parity ◦Medicaid expansion requirements related to MH & SU 10

11  Core themes from survey: ◦Transparency lacking ◦Non-Medicaid expansion states requesting info on expansion models ◦A need for education and technical assistance  CWH is collating data to provide state- specific information; final report to be released in fall. 11

12  Rep. Tim Murphy (R-PA) sought NASMHPD feedback on omnibus H.R. 3717, “Helping Families in Mental Health Crisis Act.”H.R. 3717 ◦NASMHPD suggested legislative language; later sent general letter commending elements, intent.  House GOP leaders announced in June bill would move forward only with “noncontroversial” provisions, but new version still not released. ◦Original version now has 93 co-sponsors, 32 Democrats (4 Dems w/drew sponsorship). 12

13  Rep. Murphy sought NASMHPD support for limitation on IMD exclusion permitting Medicaid reimbursement for inpatient care in facilities with average patient stay < 30 days. No NASMHPD consensus. Continuing to work with Rep. Murphy staff on question of support for IMD provisions. NASMHPD conveyed support for continued inclusion of state-operated psychiatric hospitals in IMD exclusion limitation provision. 13

14  Given omnibus nature of bill, former Rep. Patrick Kennedy formed a behavioral health work group to submit to Rep. Murphy’s staff modifications to controversial provisions, including: ◦Mandatory AOT as condition of Block Grant funding ◦Reduction of SAMHSA role ◦Narrowing of IMD exclusion ◦Reduction in funding for P&A, prohibition against lobbying by P&A providers 14

15  NASMHPD participated in workgroup deliberations, offered language on mental health parity for traditional Medicaid.  General consensus reached by work group & draft language forwarded. ◦Reduction in IMD exclusion limitation to <20 days ◦Making new Assistant Secretary responsible for coordinating policy across federal agencies; SAMHSA maintains day-to-day responsibilities.  No response from Rep. Murphy. 15

16  3-Year Demo testing partial limitation on IMD exclusion for free-standing private psychiatric facilities in 12 states*  Murphy holding July 30 hearing to tout results supportive of his IMD exclusion provisions.  December report to Congress : 16 * AL, CA, CT, DC, IL, MD, ME, MO, NC, RI, WA, WV

17  Murphy staff worked with staff for Reps. Ron Barber (AZ), Diana DeGette (CO), Grace Napolitano (CA), Paul Tonka (NY), & Doris Matsui (CA).  With no consensus reached on controversial issues, Dems introduced H.R. 4574, “Strengthening Mental Health in Our Communities Act of 2014”.H.R. 4574 ◦Focus—prevention & early intervention grant programs.  Didn’t include mandating AOT, limiting IMD exclusion, & reducing funding for P&A. 17

18  Up to 55 co-sponsors, all Dems, many of whom are also co-sponsors of Murphy bill.  NASMHPD sent Rep. Barber a letter commending elements & intent.  Rep. Murphy adamantly opposes combining bills.  Barber bill unlikely to move this year. 18

19  NASMHPD joined MHLG members on Capitol Hill in seeking continuation of set-aside funding for early intervention programs & funding for Mental Health First Aid, P&A, Suicide Prevention.  SAMHSA budget requested continuation of 5% set- aside in FY2014 into FY2015.  Senate Appropriations Subcommittee held 15- minute June 10 markup of $157B Labor-HHS budget with CMS/SAMHSA funding. 19

20  Subcommittee voice vote approval w/o amdmts.  Full Committee markup never held since GOP wanted anti-ACA amdmts added. Bill stalls.  Text of bill posted July 24 FYI: ◦$1.078,975B for mental health services, $6.8M less than FY2014, but $12.14M more than requested by Administration ◦5% set aside for early intervention continued ◦$2.14B for substance use treatment services, $38.6M less than FY2014, but $22.75M more than requested. 20

21  In House, Labor-HHS bill only agency appropriations bill not to move out of House Appropriations Subcommittee.  2nd Senate measure stalls after Republican attempts to amend in unrelated ACA amendment:  Justice-Commerce-Transportation-Agriculture “minibus” with money for MIOTRCA, Veterans Courts, Mental Health Courts, Drug Courts, and increased funding for guns record-check system.  Likely final outcome: Continuing Resolution for FY2015, passed in September 2014; extended in lame duck. 21

22  Sens. Bernie Sanders’/John McCain’s Senate Veterans Administration reform bill (S. 2450) is still being “reconciled” with Rep. Jeff Miller’s H.R. 4810. ◦Both give VA Administrator greater power to hire, fire SES. ◦Both require VA to pay for outside medical care for veterans not able to get prompt treatment or living > 40 miles from VA facility.  Latter is Sen. Udall bill provision which NASMHPD supported. 22

23  Senate Bill would: ◦Authorize VA to lease private facilities in 17 states & PR. ◦Mandate report on wait time for mental health services, recommendations on staffing in mental health clinics.  CBO est. costs of $50B/year ◦House wants “pay for”, but has only been able to find offsets for some provisions. Senate not seeking offsets. 23

24  Final Mental Health Parity Regulations published November 13, 2013 for private insurance, Medicaid MCOs, CHIP, and Medicaid alternative benefit plans ◦Awaiting promised regulations for traditional Medicaid. Some state agencies are beginning to circumvent parity regulations - ex. Autism benefits. 24

25  Two upcoming NASMHPD activities, both derived from the SAMHSA “Coalition” Technical Assistance contract. Webinar on “The Scope and Magnitude of Mental Health Parity”, in conjunction with NAMI, in the late summer. A webinar and document, intended for use by SMHA’s, being developed by NASMHPD and The Implementation Group, will focus on parity best practices and strategies for states across parity implementation. 25

26  Proposed Medicare Part D regulations for CY 2015 would have eliminated protected class for antidepressants in 2015, antipsychotics in 2016.  NASMHPD response—drafted by members, based on previous Medical Directors Council White Paper—recognized distinctive needs of mental health patients & distinctive characteristics of mental health drugs while noting need for government to control use and costs.  Universal opposition, acrimonious Congressional hearing led to CMS withdrawal March 10. 26

27  Final HCBS regulations published in January after several revisions. Took effect March 17.  Rules apply to §1915(c) and (k) HCBS waivers as well as §1915(i) State Plan Option HCBS.  Regulations retain 2012 proposed bans against citing services in, on grounds of, or adjacent to public NFs, IMDs, ICF/IID, or hospitals but allow citing in, on grounds of, or adjacent to private institutions & on grounds of or adjacent to public institutions if presumption is overcome.  CMS held webinars for NASMHPD members, staff. 27

28  Setting must be integrated in and supporting full access to greater community, including opportunities for:  Employment in competitive integrated settings  Engagement in community life  Control of personal resources  Services in community  States have 5 years to comply, must file transition plan by March 16, 2015. 28

29  States applying for or renewing waivers before that date must comply or file transition plans at time of application. ◦Requirements apply to non-residential services as well as residential services.  CMS held conference call with NASMHPD members to get feedback for additional guidance on non-residential HCBS services. 29

30  Webinar featured CMS speakers explaining the rule.the rule ◦Slides. Webinar replay. The webinar was largely focused on the provider perspective, the big takeaways for SMHAs is that:SlidesWebinar replay The Conditions of Participation are currently applicable only to CMHCs that bill for Medicare (and by definition offer partial hospitalization services). 30

31  The Conditions of Participation may subsequently apply to other types of CMHCs should the state voluntarily adopt the Conditions. CMS warns this is common.  Commissioners should reach out to their Medicaid agencies, providers to discuss state rules adoption. 31

32  SAMHSA held June 11 full-day “listening session” seeking stakeholder input on updating regulations on disclosure of patient-identifiable substance use treatment information.  SAMHSA acknowledged: ◦Significant changes in 25 years since regulations were adopted, including new integrated care models and HIT. ◦Substance use treatment no longer primarily conducted by specialty treatment providers, coordination of care now an issue. 32

33  2,500 signed up to participate, most by phone.  NASMHPD staff attended listening session in person.  Covered topics included:  Applicability of 42 CFR Part 2  Consent requirements  Re-disclosure and medical emergency provisions  Quality Service Organization (QSO) provision  Research  Electronic prescribing and prescription drug monitoring programs (PDMPs) 33

34  Witnesses for and against repeal cited stigma of substance use as justification for and against separate restrictions.  Opponents of repeal cited threat to safety of domestic violence victims.  Proponents for repeal cited need to facilitate care coordination.  Written comments were accepted until June 25. 34

35  NASMHPD workgroup of Medical Directors and Financing and Medicaid Division and staff worked with National Association of Medicaid Directors (NAMD) members and staff to draft comments.  Comment letter acknowledged need to protect substance abuse treatment information, but urged repeal, with exception of restrictions on disclosure in criminal investigations and procedures, to align with HIPAA restrictions imposed for other providers. 35

36  House Energy and Commerce sought comments, until July 22, on “digital healthcare ecosystem.”  Senate Finance is seeking comments, due August 12, on ideas to improve data transparency  NASMHPD, NAMD are independently filing comments incorporating joint 42 CFR Part 2 comments, but also addressing own member concerns. 36

37  NASMHPD comments—drafted with input from Financing and Medicaid Division, Medical Directors—also address: ◦Need to open Medicaid, Medicare EHR incentives to behavioral health providers. ◦Need to align State and Federal telehealth standards. ◦Need to improve Medicaid access to Medicare records. 37

38  Late 2013: CMS announces moratorium on provider Medicare appeals which, by law, must have disposition in 90 days.  OMHA (Office of Medicare Hearings and Appeals) told 800 witnesses and attendees at February 12, 2014 hearing that: o Delays attributable to paper-based system, increased demand, and over-lawyering. OMHA staff cannot walk the halls or use offices or conference rooms due to paper volume. 38

39  OMHA also told attendees: o Recovery Audit Program mandated by Congress added to backlog. o Beneficiary appeals in theory first, but 4-month backlog before OMHA opens mail, assigns appeal to ALJ.  OMHA caseload increased 545% between FY2011 and FY2013.  8 to 10 year backlog. 39

40 40

41  OMHA receives a year's appeals every 4 to 6 weeks, and has 800,000 appeals pending (there were a mere 357,000 in January).  ALJ teams operating at record efficiency levels: ◦Will 7 additional ALJ teams August 25, ◦But on July 10 th Chief ALJ Judge Griswold told House Oversight Health Subcommittee that the new ALJ teams (72K cases/year) are unlikely to cure the backlog, and that more funds are needed.  Griswold suggested using funds recovered by Recovery Audit Contractors. 26

42  OMHA to start electronic filing by Summer 2015.  On June 30, Chief ALJ Judge Griswold announced piloted options of: 1.mediation via “facilitated settlement conferences” 2.resolution through statistical sampling, extrapolation  OMHA meeting regularly with CMS on ways to reduce the number of Medicare claim appeals below the ALJ level.  American Hospital Association sued OMHA in May. 42

43  May 22 nd Advisory Council Meeting. Council almost exclusively comprised of researchers.  Issued new strategic plan.  Re-organizing – part of HHS-wide re-organization. Adding a new digital division (Rdoc) as well.  Pleased with their digital presence – Twitter, etc…  Trying to remain connected with various initiatives, including parity, gun violence, and block grant (esp. 5% set aside for early intervention) issues. 43

44  Project RAISE may be new model for research. 17 years typically vs. 17 weeks for RAISE. But efficacy study for RAISE is still ongoing.  Lengthy discussion of data privacy concerns, including how some hospitals have automatic data sharing for research, provider records, treating MI same as other diseases.  NIMH says it cannot require data sharing, but can opt to not work with non-sharing entities. Emphasized leveraging funding. 44

45  NIMH considering redesign of research, bifurcating data and analysis. One entity would gather, one do the “good science”.  NIMH, Advisory Council worried a failure to train providers properly in fidelity—so treatment is accurate to the model—may result in insurers, CMS denying payment, bypassing (or violating) parity, ACA.  Council also discussed how Medicare Hospital Readmission penalties could change research, services. IOM is researching how to measure success. 45

46  Special Enrollment Periods (SEPs), continued Medicaid enrollment throughout year  Planning October 2014 outreach for 2015  Consumer education on how to use benefits  Narrow networks – New regulations coming 46

47  Subsidies in Federal exchange: Halbig v. Burwell (D.C. Ct. of Appeals) vs. King v. Burwell (4 th Cir. Ct. of Appeals) ◦Who: Multiple courts considering issue, including these two Federal Courts of Appeals ◦What: No immediate impact. If upheld on appeal, D.C. decision would strike all subsidies in states using Federal Exchange, affect both individual and employer mandates. ◦Why: D.C. Circuit used classic legislative interpretation to differentiate between federal and state exchanges. NOT federalism. ◦Next: Further appeals. 47

48  The NASMHPD Government Relations Team is here for you. Whether it be Federal legislation, regulations, or agency action: ◦If you need to know, call us. ◦If you want to be heard, call us. ◦If you’ve got a cool idea on Federal policy you want to vet, call us. ◦If you just need to vent about the Feds, call us.  or 703-682-7552  or 703-682-5184  or 703-682-5182 48

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