Adult Behavioral Health Benefits in Medicaid and the Marketplace

Introduction
  1. Substance Abuse and Mental Health Services Administration (SAMHSA), Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings at 12 (2013), available at http://www.samhsa.gov/data/sites/default/files/NSDUHmhfr2013/NSDUHmhfr2013.pdf.

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  2. Id. at 50.

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  3. Id.

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  4. Mark TL, Levit KR, Yee T, and Chow CM, “Spending on mental and substance use disorders projected to grow more slowly than all health spending through 2020.” 33 Health Affairs 1407-15 (Aug. 2014), available at http://content.healthaffairs.org/content/33/8/1407.abstract?sid=1e1a3e1e-7024-4836-bfab-bc68f1f32277.

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  5. Kaiser Commission on Medicaid and the Uninsured, The Role of Medicaid for People with Behavioral Health Conditions at 2 (Nov. 2012), available at https://www.kff.org/health-reform/fact-sheet/the-role-of-medicaid-for-adults-with/.

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  6. Substance Abuse and Mental Health Services Administration (SAMHSA), Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings at 24 (2013), available at http://www.samhsa.gov/data/sites/default/files/NSDUHmhfr2013/NSDUHmhfr2013.pdf.

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  7. Substance Abuse and Mental Health Services Administration (SAMHSA), Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings at 93 (2013), available at http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf.

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  8. Kaiser Commission on Medicaid and the Uninsured, The Role of Medicaid for People with Behavioral Health Conditions at 2 (Nov. 2012), available at at https://www.kff.org/health-reform/fact-sheet/the-role-of-medicaid-for-adults-with/.

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  9. Id. (internal citation omitted).

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  10. One study predicted that Medicaid enrollment for non-elderly adults with SMI would nearly double with implementation of the ACA’s expansion (estimated 24.5% of Medicaid beneficiaries in 2019, compared to 12.8% in 2006), with 31% of previously uninsured adults with SMI becoming newly eligible for Medicaid. However, this study pre-dates the Supreme Court’s ruling on the ACA’s constitutionality, which effectively made implementation of the Medicaid expansion a state option (Kaiser Commission on Medicaid and the Uninsured, A Guide to the Supreme Court’s Decision on the ACA’s Medicaid Expansion (Aug. 1, 2012), available at https://www.kff.org/health-reform/issue-brief/a-guide-to-the-supreme-courts-decision/).   To date, 30 states (including DC) have implemented the ACA’s Medicaid expansion (Kaiser Commission on Medicaid and the Uninsured, Status of State Action on the Medicaid Expansion Decision (April 29, 2015), available at https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/). The same study predicted that 28% of previously uninsured adults with SMI would become eligible for private insurance under the ACA. Rachel Garfield, Judith Lave, and Julie Donohue, Health Reform and the Scope of Benefits for Mental Health and Substance Use Disorder Services, 61 Psychiatric Services, 1081-1086 (Nov. 2010).

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Background
  1. Medicaid beneficiaries from birth through age 21 qualify for comprehensive coverage, including behavioral health services, under the mandatory Early Periodic Screening Diagnosis and Treatment benefit. 42. U.S.C. § § 1396a(a)(43), 1396d(r)(5).

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  2. Cf. 42 C.F.R. § § 440.210, 440.220.

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  3. 42 U.S.C. § 1396a(a)(1); 1396d(a); see generally Kaiser Commission on Medicaid and the Uninsured, Medicaid Enrollment and Expenditures by Federal Core Requirements and State Options (Jan. 2012), available at https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-and-expenditures-by-federal-core/. States also may provide behavioral health services through § 1915(c) home and community-based services waivers, which are outside the scope of this analysis.

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  4. CMS recently proposed that states may make capitation payments to MCOs and PIHPs for enrollees receiving services of no more than 15 days per month in an IMD that is an inpatient hospital facility or sub-acute facility providing crisis residential services. Proposed 42 C.F.R. § 438.3(u). CMS proposes this change in the capitated managed care context to address difficulties with beneficiary access to short-term inpatient behavioral health treatment and to recognize managed care plans’ flexibility in providing care in alternate settings in lieu of those covered by statute. 80 Fed. Reg. _____ (June 1, 2015), available at https://federalregister.gov/a/2015-12965.

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  5. See, e.g., SAMHSA, Medicaid Handbook: Interface with Behavioral Health Services at 3-5 (2013), available at http://store.samhsa.gov/shin/content/SMA13-4773/SMA13-4773_Mod1.pdf.

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  6. Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY 2011 MSIS and CMS-64 reports. 2010 data was used for FL, KS, ME, MD, MT, NM, NJ, OK, TX, and UT and then adjusted to 2011 spending levels.

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  7. 42 U.S.C. § 1396a(k)(1). The statute uses the former terminology, “benchmark benefits.” In its July 2013 final rule, CMS began using the term “ABP.” 78 Fed. Reg. 42160 (July 15, 2013); see generally 42 U.S.C. § 1396u-7; 42 C.F.R. § § 440.300-440.390.

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  8. 42 C.F.R. § 440.345(d).

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  9. 42 U.S.C. § 1396a(k)(1); 42 C.F.R. § 440.320. Technically, beneficiaries in the new adult expansion group who meet an ABP exemption “must be given the option of an Alternative Benefit Plan that includes all benefits available under the approved State plan” instead of being required to receive the ABP that the state has selected for the expansion group. 42 C.F.R. § 440.315.

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  10. 42 C.F.R. § 440.315(f).

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  11. HHS, Office of the Assistance Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy, How the Affordable Care Act Can Support Employment for People with Mental Illness at 3 (May 2014), available at http://www.aspe.hhs.gov/daltcp/reports/2014/ACAmiesIB.cfm.

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  12. 42 C.F.R. § 440.345(c); see also CMS, State Health Official Letter re: Application of the Mental Health Parity and Addiction Equity Act to Medicaid MCOs, CHIP, and Alternative Benefit (Benchmark) Plans (Jan. 16, 2013), available at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-001.pdf.

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  13. CMS, State Health Official Letter re: Application of the Mental Health Parity and Addiction Equity Act to Medicaid MCOs, CHIP, and Alternative Benefit (Benchmark) Plans (Jan. 16, 2013), available at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-001.pdf.

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  14. 80 Fed. Reg. 19420 (April 10, 2015), available at. https://www.federalregister.gov/articles/2015/04/10/2015-08135/medicaid-and-childrens-health-insurance-programs-mental-health-parity-and-addiction-equity-act-of; see also Kaiser Commission on Medicaid and the Uninsured, Behavioral Health Parity and Medicaid (forthcoming, 2015).

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  15. 45 C.F.R. § 147.150(a); see also 42 U.S.C. § 18022(b).

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  16. 45 C.F.R. § 156.100.

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  17. 45 C.F.R. § 156.100(a).

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  18. 45 C.F.R. § 147.160; see also ACA § 1311(j).

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Project Overview
  1. See Kaiser Commission on Medicaid and the Uninsured, Mental Health Financing in the United States: A Primer at 3 (April 2011), available at https://www.kff.org/medicaid/report/mental-health-financing-in-the-united-states/.

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  2. See, e.g., Kaiser Commission on Medicaid and the Uninsured, Benefits and Cost-Sharing for Working People with Disabilities in Medicaid and the Marketplace (Oct. 2014), available at https://www.kff.org/medicaid/issue-brief/benefits-and-cost-sharing-for-working-people-with-disabilities-in-medicaid-and-the-marketplace/.

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Methodology
  1. This measure was selected due to the availability of subsidies.

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Appendix B: Additional Information on Study States’ Medicaid Programs
  1. Arizona Health Care Cost Containment System, Medical Policy Manual, ch. 300, Policy 310, p. 310-2.

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  2. CMS, Special Terms and Conditions, Arizona Health Care Cost Containment System Section 1115 Demonstration at 11, available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/az/Health-Care-Cost-Containment-System/az-hccc-stc-10012011-09302016-amended-042013.pdf.

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  3. CMS, Letter to Tom Betlach, Director, AHCCCS (April 1, 2014) and State Plan Amendment AZ-14-0006, available at www.medicaid.gov.

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  4. Colorado Dep’t of Health Care Pol’y & Financing, Community Behavioral Health Services Program, available at http://www.colorado.gov/cs/Satellite?c=Page&cid=1212398231156&pagename=HCPR%2FHCPFLayout; Colorado Medical Assistance Program, Colorado 1500 Specialty Manuals at p. 5, available at http://www.colorado.gov/cs/Satellite?c=Document_C&childpagename=HCPF%2FDcoument_C%2FHCPFAddLink&cid-1210237704667&pagename=HCPFWrapper.

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  5. CMS, Colorado SPA CO-13-0055, (February 10, 2014), available at medicaid.gov.

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  6. CMS, Letter to Susan E. Birch, Executive Director, Dep’t of Health Care Pol’y and Financing (Feb. 10, 2014) and SPA CO-13-0055, available at www.medicaid.gov.

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  7. See http://www.ctbhp.com/about.htm.

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  8. See, e.g., http://www.ctbhp.com/providers/covrdsrvcs/CTBHP_Covered_Services.pdf.

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  9. See http://innovation.cms.gov/initiatives/MIPCD/MIPDC-The-States-Awarded.html.

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  10. Connecticut SPA 14-008, available at www.medicaid.gov.

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  11. Id. at 7.

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  12. Michigan Dep’t of Comm’y Health, Medicaid Provider Manual: Mental Health/Substance Abuse, p. 3-4 (April 1, 2014), available at http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf.

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  13. Michigan Dep’t of Comm’y Health Medicaid Provider Manual: Medicaid Health Plans, p. 7 (April 1, 2014), available at http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf.). Medicaid health plans are required to cover inpatient hospitalization due to complications of a substance use disorder, where substance use is a secondary diagnosis. Id. at 8.

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  14. Id. at 8.

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  15. Id. at 1.

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  16. CMS, Michigan SPA 14-0001 (April 30, 2014), available at www.medicaid.gov.

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