Paul N. Samuels , Legal Action Center - PowerPoint Presentation

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Paul N. Samuels, Legal Action Center March 29, 2017

Medicaid Coverage for Opioid Treatment:

Benefits for StatesSlide2

The Old Model: Grants and Client Fees

Unlike Rest of Health Care: Federal Block Grant, State Appropriations and Clients Fees

Disadvantages:

Highly Dependent on Political EnvironmentHighly Dependent on Economic EnvironmentStatic: Doesn’t Grow with Need or DemandAdvantages:???????? (Familiarity)

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The New Model: Medicaid, Commercial Insurance and Parity

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Parity required for most commercial insurance (large group and exchange) and Medicaid managed care and expansion

ACA private insurance enrollment: +12.7 million enrolleesMedicaid plus Medicaid expansion:Most states provide Medicaid reimbursement to OTPs28 states and DC have elected to expand their Medicaid population (Federal government pays

enhanced match

for

expansion population—100%

through 2016

, 90% in 2019 and

beyond)Slide4

The New Model: Medicaid, Commercial Insurance and Parity (cont’d)

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Advantages:

Funding flows with rest of health careSince Medicaid an entitlement, funding increases with need/demandIncreased Medicaid funding frees up block grant and state appropriations for other (hopefully SUD) needsParity requires much better coverage for SUDDisadvantages/Challenges:Providers need to be able to bill and otherwise complyPayors have to work with OTPsSlide5

Mental Health and Substance Use Disorder Parity

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Mental Health Parity and Addiction Equity Act requires parity for SUD and MH with other medical conditions in:

Financial requirements Quantitative treatment limitations Non-quantitative treatment limitationsApplies to traditional Medicaid if managed care, all Medicaid expansion (managed care and fee-for-service), and most commercial insuranceSlide6

Required Coverage of SUD and MH Services under the Affordable Care Act

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The ACA dramatically improves

coverage for and access to substance use disorder (SUD) and mental health (MH) servicesUnder the ACA, SUD and MH services are essential health benefits which must be covered at parity (Mental Health Parity and Addiction Equity Act) with other covered medical benefits

Successful advocacy by Coalition for Whole Health and others Slide7

Current Health Care Reform Debate

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Much of the current structure, but not all, is being debated now, including:

Will Medicaid expansion continue?Will SUD and MH coverage continue to be an “Essential Health Benefit” that must be covered at parity with other illnesses?Opioid epidemic a major issue in the discussionParity for Medicaid managed care will remain the lawCMS has stated it will provide states more flexibilitySlide8

Using Medicaid to Expand Access to Care for People in the

Criminal

Justice System

8Huge opportunitiesRecognition of the potential for cost-savings and improvement of health and criminal justice outcomesRange of options to improve coverage and access around the countryCoverage for SUD and MH care at parityGreat opportunity for many newly Medicaid-eligible individuals who are justice-involved but also significant work in states not currently expanding their Medicaid populationSlide9

Criminal Justice Opportunities: Seamless Medicaid Coverage

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Medicaid can be suspended during incarceration

The federal government (CMS) has encouraged states to suspend not terminate Medicaid States that suspend Medicaid upon an individual’s incarceration:CA, CO, FL, IA, MD, MN, NY, NC, OH, OR, TX, WAThe enhanced federal Medicaid share in expansion states presents an even greater opportunity for cost-savingsReforming state policies to promote seamless Medicaid coverage will significantly help with continuity of care into the communitySlide10

Medicaid, Incarcerated Beneficiaries, and the Inpatient Exclusion

Medicaid can pay for services when the incarcerated individual is a “patient in a medical institution”

When they’ve been admitted as an

inpatient in a community-based hospital, nursing facility, juvenile psychiatric facility, or intermediate care facility for at least 24 hoursAll medically necessary Medicaid covered services provided to that individual while admitted can be billed to MedicaidFederal Medicaid dollars can pay for these services if the state’s policies allow for that

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State Cost-Savings by Billing Medicaid for Inpatient Care

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States that bill Medicaid for inpatient care:

AR, CA, CO, DE, LA, MI, MS, NE, NY, NC, OK, PA, VT, WAA number of states have recognized the huge potential for cost savings when they bill for inpatient careNorth Carolina saved $10 million in the first year (2011)California saved about $31 million in FY 2013New York estimated in 2012 that it could save $20 million annually if the state billed Medicaid for eligible inpatient careCSG Justice Center brief:https://csgjusticecenter.org/wp-content/uploads/2013/12/ACA-Medicaid-Expansion-Policy-Brief.pdf

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Medicaid Eligibility and Enrollment for Justice-Involved Individuals

Although federal rules prohibit payment for services for incarcerated

individuals,

this has no effect on Medicaid eligibility or enrollmentThere is no federal prohibition against screening for eligibility and enrolling during incarcerationHHS has clarified “corrections department employees…are not precluded from serving as an authorized representative of incarcerated individuals for purposes of submitting a (Medicaid) application on such an individual’s behalf”Enrollment can and should happen at all stages of justice system involvement

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Health Homes and the Criminal Justice

System

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Twenty-six states (and DC) have an approved Health Home State Plan Amendment or are working with CMS toward approvalIncludes ten states that are not currently expanding their Medicaid populationNew York is working to include justice-involved individuals through their initiativeRhode Island is focusing on substance use disorders, including opioid use disordersSlide14

Benefits of Using Medicaid for Opioid Medication-Assisted Treatment

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Better Health Outcomes: Reduced drug use

Better Public Safety Outcomes: Reduced recidivism and incarcerationReduced Health Care Costs: Washington State study findings that costs of SUD treatment offset by health care savings in first year and overall savings in subsequent yearsSlide15

Maximizing the Opportunities Before

Us

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Critical need for payors, regulators and providers to work closely together: State Medicaid agency, the SSAs for SUD and MH, and OTPsHuge interest in criminal justice system – drug courts and other community courts, jails, prisons, reentry and community supervision programs – in better engaging with the SUD and MH service provider network

Goal: Expand care by learning from early adopters, sharing best practices, and shaping existing models to work for each systemSlide16

We Are Here to Help

Legal Action Center

www.lac.org

(212) 243-1313

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