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
OhioMHAS?
4. OhioMHAS stakeholder relationships
5. The road toward carve-in
6. Questions
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• 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)
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• 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
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• 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
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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
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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)
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• 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
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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.
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• 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
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• 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
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• 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
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• 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…
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• 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
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• 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
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• 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
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• 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
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Gaps in care
emphasizing
crisis and
housing**, $21.6
SAPT-related
prevention, $1.5
Statewide
Prevention, $5.0
Residential State
Supplement
program
improvements,
$7.5
Recovery
housing, $5.0***
Payroll for
specialty
dockets, $4.4
SAPT-related
women's
network/
residential, $1.5
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• 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
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• 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
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• Anecdotally, AOD
providers are seeing
significant increased
service demand and
some are already
hiring additional
workers
• IMD concerns are
obstructing some
provider expansion
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• 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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