2. 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

3. 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

4. Current Picture of Eligibility 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)

5. 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

6. Current Picture of Eligibility

7. HEALTH COVERAGE IN 2014 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

8. 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

9. SIMPLE STREAMLINED APPLICATION PROCESS Now  Different applications for different programs  Denied? Back to the drawing board  Applications often only available on paper or as PDFs if online  In-person interview requirements 2014  Regulations 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

10. Eligibility Determination Systems

11. 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

12. ACA Consumer/Enrollment Assistance Activities 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

13. ACA Consumer/Enrollment Assistance Activities 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 necessary Implementation 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

14. Persons Who Are Uninsured

16. 2014 Projected Enrollment Source: February 2013 CBO estimates Millions Enroll at least 15 million people in new coverage options } 7 million in Exchange coverage 8 million in Medicaid or CHIP } 16

17. Persons Who Are Uninsured Source: NSDUH 29% Individuals who are uninsured with behavioral health conditions 71% Individuals who are uninsured

18. 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

19. 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

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

21. 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 CI = Confidence Interval Sources: 2008 - 2010 National Survey on Drug Use and Health (Revised March 2012) 2010 American Community Survey

22. 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 CI = Confidence Interval Sources: 2008 - 2010 National Survey on Drug Use and Health (Revised March 2012) 2010 American Community Survey

23. Prevalence of Behavioral Conditions Among Health Insurance Exchange Population: Florida, US 23 CI = Confidence Interval Sources: 2008 - 2010 National Survey on Drug Use and Health (Revised March 2012) 2010 American Community Survey

24. Prevalence of Behavioral Conditions Among Medicaid Expansion Population: Florida, US 24 CI = Confidence Interval Sources: 2008 - 2010 National Survey on Drug Use and Health (Revised March 2012) 2010 American Community Survey

25. 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

26. 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 NationalFlorida Female61% Age 18-3453%49% Race/Ethnicity Non-Hispanic White66%62% Non-Hispanic Black13%18% Other5%3% Hispanic16%18% Education < High School26%24% High School Graduate38%40% College37% Sources: 2008 - 2010 National Survey on Drug Use and Health (Revised March 2012) 2010 American Community Survey

27. 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 NationalFlorida Male75%76% Age 18-3463%58% Race/Ethnicity Non-Hispanic White51%45% Non-Hispanic Black20%26% Other4%2% Hispanic25%27% Education < High School37%34% High School Graduate32%34% College31% Sources: 2008 - 2010 National Survey on Drug Use and Health (Revised March 2012) 2010 American Community Survey

28. 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 Non-Hispanic White or Hispanic College Graduate * Population with income from 133% to 399% of the Federal Poverty Level and uninsured NationalFlorida Female60%62% Age 18-3457%53% Race/Ethnicity Non-Hispanic White68%64% Non-Hispanic Black10%12% Other5%3% Hispanic17%21% Education < High School18%14% High School Graduate38% College44%47% Sources: 2008 - 2010 National Survey on Drug Use and Health (Revised March 2012) 2010 American Community Survey

29. 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 Non-Hispanic White or Hispanic * Population with income from 133% to 399% of the Federal Poverty Level and uninsured NationalFlorida Male73%72% Age 18-3469%66% Race/Ethnicity Non-Hispanic White52%46% Non-Hispanic Black14%17% Other5%3% Hispanic29%34% Education < High School26%22% High School Graduate38%39% College36%39% Sources: 2008 - 2010 National Survey on Drug Use and Health (Revised March 2012) 2010 American Community Survey

30. 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

31. 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 success 31

32. Supporting Intermediaries Intermediary focused efforts formed in five categories:

33. 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

34. 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

35. 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

36. 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

37. 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 **

38. 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.a spxhttp://www.samhsa.gov/healthReform/BHbusiness.a spx 38

39. Enrollment Resources Healthcare.gov http://www.healthcare.gov/marketplace/index.html HHS Partners Resources http://www.cms.gov/Outreach-and- Education/Outreach/HIMarketplace/index.htmlhttp://www.cms.gov/Outreach-and- Education/Outreach/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