View this presentation. - National Association of State Mental Health

John R. Kasich, Governor
Tracy J. Plouck, Director
We Have Medicaid Expansion! Now What?
NASMHPD Commissioners Meeting
July 29, 2014
Tracy J. Plouck, Director, Ohio Dept. of Mental Health & Addiction Services
1. Ohio’s behavioral health system background
2. Ohio’s Medicaid expansion story
3. What does Medicaid expansion mean for
4. OhioMHAS stakeholder relationships
5. The road toward carve-in
6. Questions
• Local planning for public behavioral health services
within Ohio’s 88 counties is the statutory
responsibility of 53 ADAMH boards
• Boards generate $350 million+ in local levies for
behavioral health services, but ~10 of the ADAMH
boards have no levy revenue
• Historically, boards used federal, state & local funds
to buy inpatient and community services (both
Medicaid and non-Medicaid)
• In 2012, the state “elevated” non-federal Medicaid
match responsibility to the state level, thereby freeing
the boards of that increasing financial responsibility
• Some boards appreciated this relief and others
were upset because it undercut local control
• In 2012, the state also assumed 100% funding
responsibility for state hospital bed days (previously,
boards paid for civil days and state paid for forensic)
• Board response was mixed
• Prior to January 2014, Ohio Medicaid covered
individuals with disabilities to 64% FPL, with spend
down from 300% FPL (209b state)
• Medicaid managed care covers most enrollees, but
excludes individuals on waiver, spend down, or long
term institutional settings
• Behavioral health services are carved out of Medicaid
managed care
02/04/2013: Governor John R. Kasich announces that he supports extending
Medicaid for Ohio citizens
04/09/2013: GOP-led Ohio House drops Medicaid plan from the budget
07/01/2013: Gov. Kasich signs the budget, vetoes block of Medicaid expansion
09/07/2013: Petition to put Medicaid expansion on ballot is certified
09/22/2013: Ohio Medicaid Director asks the State Controlling Board for
permission to extend Medicaid
10/21/2013: Controlling Board votes 5-2 in favor of expanding Medicaid
12/28/2013: The Supreme Court of Ohio upholds Medicaid expansion by
rejecting a challenge to the Controlling Board’s authority to
expand Medicaid
01/01/2014: Ohioans at or below 138% of the federal poverty level now qualify
and can apply for Medicaid coverage
Number of Ohio county residents who are uninsured
with income below 138% of poverty
(593,912 statewide in 2010)
Source: U.S. Census, Small Area Health Insurance Estimates (2010)
• SFY 15 estimates for these
NEW enrollees who are
previously uninsured &
known to MH/AOD system:
o Medicaid mental health
& addiction services =
$75 million
o Physical health care
services = $482 million
As a result of Medicaid enrollment, an estimated $70
million annually in local ADAMH board spending may be
redirected to other critical service gaps such as housing,
prevention, peer services or addressing waiting lists.
• General Assembly did not endorse Medicaid,
but did recognize challenges in our system
• Appropriated $50 million/year for FYs 14/15,
discretionary spending by ADAMH boards
• $30 million – mental health
• $17.5 million – addiction services
• $2.5 million – drug court & MAT pilots
• Advocates heralded this infusion AND
subsequent Medicaid expansion as affirmation
• The new $47.5 million went to ADAMH boards
to spend as they saw fit in order to address
local priorities
• As OhioMHAS released allocation guidelines
related to the $47.5 million appropriation, we
underscored that this could change because
Medicaid was still our highest priority
• Ohio Benefits went from no contract to a
functioning system (via nine major releases) in
one year
• Over 1 million people have applied for
Medicaid via Ohio Benefits
• Nearly 60% of those applied via the self
service portal
• Ohio is building capacity in this system for
other social services benefits
• We cross the finish line and begin a new race!
• Outreach is robust
• Online approach is great for people who are
computer literate
• Our providers scramble to hire/borrow county
workers who are trained in the new system
• New system works as programmed but there
are some human workforce glitches…
• Backlogs begin/increase at some county offices
• Confusion, worker shortages, union issues
• Different interpretations of how to apply rules
• Some places tell people to apply via paper
application (!!!)
• Enrollment reports exist but are not publicly
available at first
• Technical assistance is location-specific
• Some reluctance to issue statewide clarification
• Ohio Department of Rehabilitation & Correction
seeks to get offenders enrolled in Medicaid
prior to release so that card can be available
as person is leaving prison
• Progress slow; hope to have one of the 30 prisons
pilot this in October 2014
• Jails & community-based correctional facilities
clamor for the same opportunity but are
further back in line
• Ohio’s 6 state hospitals had 7,000+ admissions
in SFY 14
• We have workers (often peers) who are
assisting patients to enroll
• Compliments our longstanding efforts to
expedite SSI/SSDI enrollment for patients
• We anticipate that this will enable us to
significantly impact our discharge medication
costs AND improve continuity of care
• In March 2014 the Kasich Administration
proposed legislation to redirect the $47.5
million that was discretionary for ADAMH board
use in FY 14
• Logic was that Medicaid expansion will free up
an annualized $70 million in board budgets
and these resources should be re-programmed
to address other system gaps that transcend
individual jurisdictions
Gaps in care
crisis and
housing**, $21.6
prevention, $1.5
Prevention, $5.0
Residential State
housing, $5.0***
Payroll for
dockets, $4.4
residential, $1.5
• All stakeholders except ADAMH boards
endorsed the Governor’s proposal
• Boards lobbied General Assembly to continue
discretionary uses
• Argued that Medicaid enrollment wasn’t
going well; added that Medicaid payments
do not go through the boards
• Emphasized local control
• Boards’ lobbying efforts were undercut
• Advocacy from others
• Medicaid enrollment reports released
• Administrative spending decisions of some
boards received media attention
• Ultimately, Governor’s proposal was supported,
with a few tweaks
• Anecdotally, AOD
providers are seeing
significant increased
service demand and
some are already
hiring additional
• IMD concerns are
obstructing some
provider expansion
• Ohio’s ICDS demonstration went live July 2014
• Coding alignment activity underway between
behavioral health and the rest of Medicaid
• Hoping to see our system reflected in SIM
• Carve-in discussion on the horizon
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