Health Reform: Understanding and Navigating the Affordable Care Act

Transcription

1 Health Reform: Understanding and Navigating the Affordable Care Act Prepared for The National Association of Drug Court Professionals 19 th Annual Training Conference July 14, 2013 Prepared by Supported by The Robert Wood Johnson Foundation

2 The COCHS Approach: Public Safety and Community Health Public safety and public health systems are intertwined. Similarly, the health of the justice-involved population is intertwined with the health of the general population. Connecting health care in the criminal justice system to health care in the greater community preserves the investments jurisdictions make in their vulnerable justiceinvolved populations. 2

3 Health Reform The Patient Protection and Affordable Care Act (ACA) expands health coverage to millions of previously uninsured Americans, creating access to needed services for many for the first time. Many of the newly insured will be justice-involved, and the dramatic increase in treatment resources could have a major impact on the criminal justice system. 3

4 Health Reform Most if not all of the services utilized by Drug Courts could be financed through the ACA s coverage expansions. By harnessing the opportunities presented by the ACA, Drug Court professionals could reduce costs for jurisdictions while simultaneously expanding their efforts to reduce crime and help people lead drug-free lives. 4

5 Presentation Overview 1. Health Reform Why Health Reform Matters for Criminal Justice 3. The Role of Health Information Technology 4. Eligibility and Enrollment 5. Defining Benefits 6. What Works in Behavioral Health Treatment 7. Putting it all Together: Steps for Drug Court Professionals to Capitalize on Health Reform 5

6 1. Health Reform 101 6

7 The Patient Protection and Affordable Care Act: Establishes an individual mandate. Requires each state to have a health insurance exchange (aka marketplace). Expands eligibility for federally subsidized coverage to qualified adults, many of whom may be justice-involved. Provides enhanced Medicaid funding for the expansion population. Establishes essential health benefits (EHBs), which include mental health and substance use disorder benefits. Requires parity between somatic and behavioral health coverage. Ushers in numerous other insurance reforms. 7

8 The Individual Mandate Beginning in 2014 individuals will be required to have health coverage. The IRS will enforce the mandate. There will be exemptions for individuals unable to find affordable coverage and other groups. 8

9 Health Insurance Exchanges Every state will be required to have an exchange. Exchanges educate consumers about their plan options and allow consumers to purchase coverage from qualified health plans (QHPs). Exchanges can be state operated, federally operated, or statefederal partnership. 9

10 Expanded Coverage A. The ACA allows qualified individuals to enroll in federally subsidized QHPs offered through the exchanges. B. The ACA allows the expansion of Medicaid at state option to cover millions of society s most vulnerable individuals. QHP and Medicaid expansion coverage begins January 2014 with applications available October Up to 32 million Americans will be newly covered. 10

11 Enhanced Medicaid Funding States that expand Medicaid will receive federal funding for services provided to the expansion population to the tune of: 100% in % in % in % in % in 2020 and beyond 11

12 Essential Health 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

13 Parity The ACA extends the requirements of the 2008 Mental Health Parity and Addiction Equity Act to millions of Americans, including those who will be newly eligible for coverage. These requirements aim to ensure that when coverage for mental health and substance use conditions is provided, it is generally comparable to coverage for medical and surgical care. - U.S. Department of Health and Human Services 13

14 Other Insurance Reforms Additional insurance reforms in the ACA include: Prohibition on exclusions based on pre-existing conditions. No annual or lifetime limits on coverage. Coverage of preventive services at no cost. 14

15 2. Why Health Reform Matters for Criminal Justice 15

16 Health Status of Justice-Involved Individuals Individuals in jail are disproportionately young, male, persons of color, and poor. They have high rates of health problems (chronic and infectious disease, injuries), psychiatric disorders, and substance use disorders (SUDs). 80% of individuals in jail with chronic medical conditions have not received treatment in the community prior to arrest. 16

17 Release from Prison A High Risk of Death for Former Inmates A 2007 study reported overall increased mortality rates for former inmates in Washington State: 3.5x greater than the general population. Mortality was the highest during the first two weeks after release: 12.5x greater than the general population. The study found a high incidence of death due to: overdose, HIV, homicide, motor vehicle accidents, cancer, liver disease. Binswanger, Ingrid A., Stern, Marc. Deyo, Riahard A. Heagerty, Patrick J. Cheadle, Allen. Elmore, Joann G. and Thomas Koepsell. New England Journal of Medicine, 356: January

18 Characteristics of the Justice-Involved Population Comparing the incidence of disease among the general population with the criminal justice population: Condition Substance Use Disorder 1:2 Mental Health Disorder 1:2 Co-Occurring MH/SU Disorder 1:2 Tuberculosis 1:5 Sexually Transmitted Infections 1:2 Hepatitis C 1:4 HIV/AIDS 1:48 Gen l : CJ Pop *Correctional population numbers came from: Taxman et al. (2007), supplemented by information on federal prisoners, probationers, and parolees from the Bureau of Justice Statistics Prisoners in 2007 and Probation and Parole in 2007 (available at *Offender health status numbers came from: Taxman, F., Cropsey, K., & Gallagher, C. (under review). 18

19 Jails as Behavioral Health Care Providers Jails have become de facto behavioral health providers in many communities, a role for which they are not adequately equipped to meet the need. A 2009 study estimated the current prevalence of serious mental illness among adult jail inmates to be 15% for males and 31% for females. Among jail detainees with a diagnosed mental illness, 75% of women and 72% of men have a co-occurring substance use disorder. 19

20 Jails as Behavioral Health Care Providers The ADAM II 2011 Report Over 60% of arrestees in all sites tested positive for at least one drug in their system, and few reported having received outpatient drug or alcohol treatment in the prior year less than 10% in 8 of the 10 sites. 13% - 38% of arrestees tested positive for multiple substances. 13% - 30% of arrestees said they had been arrested two or more times in the prior year. 20

21 Uninsured Few people in jail or prison today are enrolled in Medicaid because they have not been eligible as single, childless adults. Currently, 90% of detainees have no health insurance upon release from jail. 21

22 Massachusetts Uninsured According to a recent NASADAD study, less than 3% of Massachusetts residents are uninsured, but the uninsured residents are likely to have elevated rates of chronic SUDs. In fact, approximately 22% of the admissions for publicly funded SAT in MA in 2009 were uninsured. The uninsured population was disproportionately low-income and young adult, Black, and Hispanic, characteristics that mirror the demographics of the jail-involved population. 22

23 Jails Community NOT Prison Nationally, only about 4% of jail admissions result in sentences to prison. Or, in other terms... 96% of jail detainees and inmates return directly to the community from jail, along with their often untreated health conditions. COCHS mantra: The health of the justice-involved population is intertwined with the health of the general population. Connecting health care in the criminal justice system to health care in the greater community preserves the investments jurisdictions make in their vulnerable justice-involved populations. 23

24 Washington State: The Mancuso Effect Reduced Crime / Improved Health & Safety When chemical dependency treatment was offered to very low income adults a population that included many individuals with histories of justice-involvement research found: improved physical and mental health, and significant cost savings in health care. reduced crime and recidivism, and correlated savings to crime victims and criminal justice systems. 24

25 Washington State: The Mancuso Effect Reduced Crime / Improved Health & Safety The next two slides illustrate the savings reported by Dr. David Mancuso, Senior Research Supervisor, Department of Social and Health Services. Mancuso, D, Felver, B. Bending the Health Care Cost Curve by Expanding Alcohol/Drug Treatment, Washington State DSHS Research and Data Analysis Division, RDA Report 4.81 (Sept 2010). Mancuso, D, Felver, B. Providing chemical dependency treatment to low-income adults results in significant public safety benefits, Washington State DSHS Research and Data Analysis Division, Report (Feb 2009). Mancuso, D, Felver, B. Health Care Reform, Medicaid Expansion and Access to Alcohol/Drug Treatment: Opportunities for Disability Prevention, DSHS, RDA Report 4.84 (Oct 2004). 25

26 Arrests decline significantly after alcohol/drug treatment Decline in the number of arrests in the year following treatment relative to untreated comparison group 18% DECLINE 17% DECLINE 33% DECLINE April

27 Alcohol/drug treatment impacts: Medical Costs April

28 Alcohol/drug treatment impacts: Criminal justice costs Criminal justice impacts make the economics of alcohol/drug treatment for low-income adults attractive: 1. Criminal justice system cost savings Disability Lifeline: $ 1.16 in benefits per dollar of cost ADATSA: $ 0.69 in benefits per dollar of cost Other low-income: $ 1.06 in benefits per dollar of cost 2. Overall savings: criminal justice system and crime victims Disability Lifeline: $ 2.83 in benefits per dollar of cost ADATSA: $ 1.69 in benefits per dollar of cost Other low-income: $ 2.58 in benefits per dollar of cost 28

29 The Economics of Treating the Justice-Involved Population Without access to care, many justice-involved individuals will be frequent flyers of emergency room services, inpatient psychiatric services in the community, and jail health services. From a fiscal perspective, it will be in the interest of state and local jurisdictions to offer effective behavioral health treatment to justice-involved individuals. 29

30 3. The Role of Health Information Technology 30

31 HITECH HITECH and Health Reform (a double tsunami) EHRs Meaningful Use (MU) State HIE Cooperative Agreement Program Health Reform ACOs (pay for performance) Health Insurance Exchanges (HIX) Medicaid Expansion Pending Disposition 31

32 Health Information Exchange (the bridge) The goal is to make sure that information will follow the patient, wherever and whenever it is needed and regardless of vendor or geographical boundaries. ONC chief Farzad Mostashari, MD Most of the initiatives and policies of HITECH and ACA involve or are predicated on the idea of exchanging health data. 32

33 Health Information Exchange (what exactly is HIE?) HIE provides the capability to electronically move clinical information among disparate health care information systems while maintaining the meaning of the information being exchanged. HIE (noun): organization (HIOs, RHIOs) HIE (verb): technology exchanging data 33

34 HIE and Jails Today (islands apart) 10 million unique admissions 34

35 Unseen Health Care in Jails Intake Sick Call Release 35

36 HIE and Jails of the Future (islands bridged) 10 million unique admissions 36

37 Obstacles Counties have budgetary constraints Jail infrastructure existing EHR? HIE availability HIE sustainability Interoperability standards Technology is still very new 37

38 Consent? HIPAA Law allows for access to health records of an inmate if jail officials determine that the health of an inmate could impact the safety, security or good order of the institution. However: if state or local law is stricter than HIPAA, the stricter state or local law applies. However: the HIE organization may have its own standards and decide not to permit the HIE in the jail if consent is not obtained. 38

39 42 CFR Part 2 Substance Abuse Treatment Records Patient s written consent is required for disclosure including: The name or title of the individual or the name of the organization to which disclosure is to be made. How much and what kind of information is to be disclosed. A statement that the consent is subject to revocation at any time. The date, event or condition upon which the consent will expire if not revoked before. Some HIEs will not include SA records ONC Data Segmentation initiatives 39

40 HIEs & Jails Implementations New York City Multnomah County, OR Camden, NJ 40

41 4. Eligibility and Enrollment 41

42 A. Eligibility Individuals must be uninsured to qualify for Medicaid and QHP premium subsidies. Additional eligibility criteria include: Income Citizenship status 42

43 Income: Medicaid In Medicaid expansion states, Medicaid will be newly available to non-elderly adults with income up to 138% FPL, regardless of health status, gender, or parental status. COCHS estimates that about 2/3 of the jail-involved population will be eligible for Medicaid under the expansion, creating access to health care for many individuals for the first time. 43

44 Income: Exchange QHPs Individuals with income from 138% - 405% FPL will be able to purchase QHPs with federal premium subsidies through the health insurance exchanges. COCHS estimates that about 1/3 of the jail-involved population will be eligible for premium subsidies to buy QHPs through the exchanges. 44

45 Citizenship and Identity The Deficit Reduction Act of 2006 made documented proof of citizenship (or qualified alien status) and identity a requirement for Medicaid eligibility. This requirement extends to Medicaid expansion populations. Citizenship and identity must be verified for QHP premium subsidy eligibility as well. These requirements could present challenges for justiceinvolved individuals. 45

46 Medicaid Eligibility and Coverage for Justice-Involved Justice-involved individuals residing in the community (e.g., on probation/parole, participating in Drug Court, under pretrial supervision) can be eligible for Medicaid and can receive coverage. Medicaid coverage is not currently available for individuals in jail or prison, but individuals who are otherwise eligible retain their eligibility while in jail or prison. 46

47 QHP Eligibility and Coverage for Justice-Involved Regarding QHPs available through health insurance exchanges, the ACA specifies that: [a]n individual shall not be treated as a qualified individual if, at the time of enrollment, the individual is incarcerated, other than incarceration pending the disposition of charges. This means that, subject to the requirements of health plans, individuals may be able to newly enroll or maintain existing coverage through a QHP while incarcerated while pending disposition of charges. 47

48 B. Enrollment Single application Federal data hub Authorized representatives Various models for enrolling justice-involved individuals Medicaid Administrative Activities claiming 48

49 Single Application Individuals will be able to apply for Medicaid and QHPs through a single application. Application will be available online, in-person, over phone, i.e., a no wrong door approach. Application for Medicaid and QHPs opens in October

50 Federal Data Hub The federal government will establish an electronic service, the data hub, that states can use to obtain or verify eligibility information. Information will be available from the Social Security Administration, the Department of Treasury, and other third party sources. Information available through the data hub could include income, citizenship status, identity, etc. States must use the data hub if the necessary information is available rather than requesting the information from applicants. 50

51 Authorized Representatives An individual can designate an authorized representative, or A-Rep, to manage the enrollment process on his or her behalf. Designating an A-Rep generally requires the beneficiary s signature. Public safety professionals could act as A-Reps for individuals under various forms of criminal justice supervision. 51

52 Various Models for Enrolling Justice-Involved Populations Population of data fields through existing databases, as in Connecticut. Authority for state or county to act as authorized representative without requiring signature, as in California. Eligibility workers stationed in correctional settings, as in Maryland. Community-based organization assists with application at jail intake, as in Cook County, IL. 52

53 Connecticut Model The Department of Social Services has collaborated with the Department of Corrections. The Medicaid application populates with data from the Department of Corrections database. Enrollment is targeted to begin upon discharge. 53

54 California Model California SB 92 (2011) allows the California Department of Corrections and Rehabilitation to act on behalf of a state prison inmate for purposes of applying for or determining Medicaid eligibility, without requiring the participation of the inmate. Pending legislation would grant counties a similar authority with respect to individuals in jails. 54

55 Maryland Model Medicaid eligibility workers are stationed at correctional facilities. Eligibility workers assist inmates with applications prior to release. Enrollment is targeted to begin upon discharge. 55

56 Cook County Model A community-based organization has a contract with the Cook County Health and Hospital System to assist justice-involved individuals with enrollment. Application assistance begins at jail intake. Enrollment is targeted to begin upon discharge. 56

57 Medicaid Administrative Activities Claiming Through Medicaid Administrative Activities (MAA) claiming, states and counties can receive federal reimbursement for activities that are necessary for the proper and efficient administration of the state Medicaid plan. Medicaid outreach, application assistance, and nonemergency transportation are potentially eligible. Public safety personnel are potentially eligible for MAA. Activities can be eligible for 75% or 50% federal reimbursement. 57

58 Medicaid Administrative Activities Claiming The 75% reimbursement is available for activities related to maintenance and operation of new Medicaid eligibility systems. Eligible activities include: Intake Acceptance Eligibility determination Outputs Ongoing case maintenance activities Customer service Maintenance of routine updates 58

59 5. Defining Benefits 59

60 States Define Benefits within Federal Guidelines For QHPs, states select a commercial benchmark plan that meets EHB requirements. QHPs must offer coverage at least equivalent to the benchmark plan. For Medicaid expansion, states create one or more Alternative Benefit Plans (ABPs) for the expansion population. ABPs must cover the 10 EHBs. 60

61 State Flexibility Through QHP commercial benchmark plan selection and the adoption of Medicaid ABPs, states have flexibility to create benefit packages that cover crucial behavioral health services. For example, in California the Medicaid ABP will include: Day treatment Intensive outpatient treatment Individual and group chemical dependency counseling Medical treatment for withdrawal symptoms Methadone maintenance Transitional residential recovery services 61

62 6. What Works in Behavioral Health Treatment 62

63 Evidence-Based Risk Reduction What the criminal justice literature teaches us: Various forms of cognitive behavioral therapy are crucial Time is of the essence There are services that are proven to reduce morbidity, mortality, and for individuals with histories of justiceinvolvement recidivism. 63

64 What Works Harm Reduction Medication Behavioral Health Treatment Other Services Needed For Success Komaromy M, What Works in Addiction Treatment, PowerPoint presentation, April 12,

65 Infection prevention Syringe exchange Harm Reduction Overdose death prevention Naloxone reduces opioid overdose deaths Komaromy M, What Works in Addiction Treatment, PowerPoint presentation, April 12,

66 Alcohol addiction medication Naltrexone Acamprosate Topiramate Disulfiram Medication Opioid addiction medication Injectable naltrexone Opioid agonists (methadone, buprenorphine) Komaromy M, What Works in Addiction Treatment, PowerPoint presentation, April 12,

67 Methadone Opioid Agonist Medications Buprenorphine As effective as moderate-dose methadone Reduces overdose death Administered by any trained physician Office-based, by prescription Safe, almost impossible to overdose Likely very long term treatment Komaromy M, What Works in Addiction Treatment, PowerPoint presentation, April 12,

68 Behavioral Health Interventions Essential for more complex patients injection drug users, individuals with co-occurring disorders, and individuals with justice-system involvement. Key Modalities: Motivational interviewing, cognitive behavioral therapies (MRT, REBT, etc.), therapeutic communities, contingency management, Community Reinforcement Approach. Komaromy M, What Works in Addiction Treatment, PowerPoint presentation, April 12, 2013; Taxman FS, Benefit Needs for Criminal Justice Involved Individuals, PowerPoint presentation, April 12,

69 Other Services Needed for Success Individuals involved with the criminal justice system with behavioral health disorders could benefit from additional services, such as: Pre-vocational training, supported employment, career planning, problem solving skills, self-help, social skills, adaptive skills, anger management, etc. Analogous supportive services are often provided to individuals with developmental disabilities through habilitative services benefits. Komaromy M, What Works in Addiction Treatment, PowerPoint presentation, April 12, 2013; Taxman FS, Benefit Needs for Criminal Justice Involved Individuals, PowerPoint presentation, April 12,

70 7. Putting it all Together: Steps for Drug Court Professionals to Capitalize on Health Reform 70

71 The ACA represents an unprecedented opportunity for jurisdictions to conserve scarce local funds by tapping into federal health care resources. Treatment ordered by Drug Courts could be financed by Medicaid and QHPs if clients are enrolled and if services and providers meet insurers requirements. What follows is a guide for taking a Drug Court client through the steps necessary to capitalize on the ACA s opportunities. 71

72 Steps Does the client already have coverage through Medicaid or a QHP? If no: 1. Determine whether your agency claims MAA. If not, consider contacting the state or county agency in charge of MAA claiming to discuss reimbursement opportunities for Medicaid outreach and application assistance. 2. Consider assisting the client in applying for Medicaid or a QHP. 72

73 Steps Does the client already have coverage through Medicaid or a QHP? If yes: 1. Determine what managed care organization the client belongs to (for clients enrolled in QHPs and Medicaid clients in states with Medicaid managed care). 2. Determine whether behavioral health is carved out. 3. Determine what benefits are included in the client s health insurance. 73

74 Steps 4. Determine how your Drug Court program relates to the client s benefits. Are the services utilized by your jurisdiction s Drug Court covered by the client s insurance? Are there additional services not currently being utilized by your jurisdiction s Drug Court that could be covered through the client s insurance? 5. Analyze local providers with respect to the client s insurance. Are the providers in the client s insurance network? 74

75 Steps 6. Determine whether the client has an assessment, diagnosis, and treatment plan approved by the primary care provider. Determine whether the treatment plan documents medically necessary services. Determine how those services compare to the court s plan. Adjust the court s plan as necessary. (Note: Medicaid clients cannot be required to pay for Medicaid covered services.) 7. Determine whether the client has given permission for data sharing between the provider and the court. 75

76 Questions? Mike DuBose Ben Butler Steve Rosenberg 76