The ACA and
ADTC
Kirstin Frescoln
Facilitated Community Solutions
the ACA
the ACA
Objectives
• Understand the common features of the ACA in
both Medicaid expansion and non-expansion states
and State versus Federal exchanges
• Identify critical aspects of the ACA and how these
impact Adult DTC operations and participants
• Know where to find more information about the
ACA in your state or county
• Know who you should engage to help shape the
insurance (Medicaid and Private) coverage
available to your ADTC participants
ACA Timeline
March 23, 2010
Patient Protection and Affordable Care Act a.k.a.
ACA or Obamacare, signed into law
March 28, 2012
US Supreme Court rules that states not required to
expand Medicaid coverage
March 31, 2014
Open enrollment for Health Insurance Marketplace
ended
November 15, 2014 – February 15, 2015
Open enrollment for Health Insurance Marketplace
Medicaid Expansion
10 Essential Benefits
1.
2.
3.
4.
5.
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
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
ACA Patient Protections
• Expanded insurance coverage through Medicaid
expansion and Federal subsidies to make health
insurance and treatment more affordable
• Guaranteed 10 Essential Benefits
• Eliminated discriminatory insurance practices that
allowed denial of coverage based on pre-existing
conditions
10 Essential Benefits
1.
2.
3.
4.
5.
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
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
Mental Health Parity and
Addiction Equity Act
Mental Health Parity and Addiction Equity Act of 2008
(MHPAEA)
• Increase access and reduce discriminatory
practices associated with mental health and
substance use/abuse/dependence treatment
• Parity means that the substance use and mental
health benefits covered by the plan must be
covered in a manner that is no more restrictive than
that of other covered medical health care benefits
• ACA closed “loop holes” in MHPAEA by extending
requirements of parity law to all health care plans
Mental Health Parity and
Addiction Equity Act
Implementation of parity is a work in progress
Defined by Federal government however…
• How that will be negotiated in each state (or
county) probably not fully determined until later this
year
• Clarification of what this means and how this should
be implemented is likely to be decided in future
years and through the courts
Expanded Coverage
• Those states that have expanded Medicaid
coverage now may include adults 18 to 65 with
incomes up to 138% (about $27,000 for a family of 3)
of the Federal Poverty Level (FPL).
• Federal subsidies are available to help individuals
pay for coverage if their income falls between 100400% FPL (in Medicaid expansion and nonexpansion states).
Medicaid
• Healthcare coverage for particular categories of
people who are at or below 100% of the FPL
• Coverage of benefits in Medicaid is determined by
the state division of medical assistance (or its
equivalent) in its state plan, within the framework
required by federal law
• Generally low-income – disabled adults, children
(CHIP) and families, pregnant women, long-term
care recipients, others as determined by each state
Medicaid Expansion
• The ACA provided federal funds to expand
Medicaid coverage to individuals up to 138% of the
federal poverty level
• Expansion extends Medicaid eligibility to all parents
and other adults up to the new Medicaid limit
• Recommended development of Alternative Benefit
Plans within Medicaid that extended coverage to
populations not previously eligible such as nondisabled adult males
Medicaid Expansion Gap
• Individuals who are not members of a specific
Medicaid covered category
• Gap is wider in those states that did not expand
Medicaid coverage but may exist in expansion
states depending on populations (not) covered
• Individuals who are not covered by Medicaid and
who do not have incomes high enough to qualify
for tax credits and subsides to purchase insurance
coverage on the Exchange
Key Agencies/Individuals
• Single State Agency
Oversees the state’s substance use/abuse/
dependency and mental health treatment
• Division of Medical Assistance (or equivalent)
Oversees the state’s Medicaid and CHIP plans
• State Insurance Commissioner
Oversees certain private insurance coverage
and ensures compliance with state insurance
laws
Single State Agency
• Oversees the state’s substance use/abuse/
dependency and mental health treatment
• In some states, administers Drug Courts
• Manages how the state’s Substance Abuse
Prevention and Treatment Block Grant funds are
prioritized and expended
• Works with the state’s Medicaid offices and
Insurance Commissioner to define substance
use/abuse/ dependency and mental health
treatment coverage
• Helps define and implement Parity Act
Division of Medical
Assistance
• Define who and what is covered by Medicaid in
each state within the framework of federal law
• In Medicaid expansion state, determine who and
what is covered in the alternative benefit plans
Insurance Commissioner
• Ensures the benefit plans submitted by insurance
companies meet state laws and benefit
requirements
• Broad or narrow interpretation may affect what
services and medications are included in plans
• For example, how parity is interpreted and enforced
could affect which, if any, medication-assisted
therapy drugs are covered in your state
• Different plans will have different coverage - BCBS
may include only one drug while Kaiser might cover
10 and both could technically meet the
requirements of the laws
So what does all this
mean to you, your drug
court operations, and
your participants?!?
Change
Medical Necessity
• Focus on clinical definitions of medical necessity
And…
• Focus on payers' definitions of medical necessity
 How will your team ensure that your Drug Court
participants are able to access and pay for
clinically necessary treatment?
Residential Treatment
• Residential treatment is not required for most drugs
(e.g., alcohol and benzodiazepines require
medically supervised detoxification, opioids do not)
• Medicaid can not pay for residential treatment in
facilities with more than 16 beds
 How will your team ensure that your participants are
able to access and pay for residential treatment
when it is needed?
Medicaid Billing
• In order to become a Medicaid provider, treatment
agencies must meet a variety of federal and state
regulations
• Medicaid billing is complex
• Reimbursement is usually delayed
 How will you help your treatment providers transition
to Medicaid billing?
More Provider Choice
• More people with insurance (private and Medicaid)
means that more providers may decide it is
economically advantageous to provide treatment
in your area
• Some of these providers may not be experienced in
treating high-risk/high-needs Drug Court
participants
• More providers means that you will have to make
accommodations to your Drug Court policies,
procedures and written materials
Less Provider Choice
• Changes in Medicaid and private insurance may
result in a reduction in treatment providers in your
area
• The ACA includes a “network adequacy” standard
that was intended to protect (primarily rural) areas
from a contraction in the number of qualified
treatment providers
• Federally Qualified Health Centers (FQHC) are
stepping in to provide mental health and substance
use/abuse/dependency treatment in some rural
areas
Responding to Changes in
Providers
 Find out about all the substance
use/abuse/dependency treatment providers in your
area
– what are their strengths?
- which would be highly-qualified to treat your
participants?
 Know which are Medicaid providers and which are
“preferred providers” on the most common private
insurance plans in your area
 Make changes to your policies and procedures to
accommodate these provider changes
Substance Abuse Prevention and
Treatment Block Grant
• SAMHSA block grant funds are noncompetitive
grant dollars provided to all states based on a
formula determined by Congress that takes into
account population and other factors
• Typically used to provide substance use/abuse/
dependence treatment to high-needs populations
such as justice-involved populations and others who
may not otherwise have access to treatment
coverage
• Managed by the Single State Agency
Substance Abuse Prevention and
Treatment Block Grant
• States may be able to reapportion Block Grant
funds for other treatment uses such as:
- pay treatment providers to participate in
staffings
- expand the number of participants you serve
- provide enhanced complimentary care
- offer medications not on the formulary
- provide access to recovery management
programs
- pay for residential care
Substance Abuse Prevention and
Treatment Block Grant
 Know what your state’s Substance Abuse
Prevention and Treatment Block Grant is used to
cover
 Find out if there are new opportunities for the Block
Grant to expand treatment coverage
 Talk with your state’s Single State Agencies about
the needs of your Drug Court and participants and
work to ensure the Block Grant continues to serve
the needs of your Drug Court and participants
Parity
• All insurance plans should now manage mental
health and substance use/abuse/dependency
treatment in the exact same way they do primary
medical and surgical care
What does that mean?!?!
• Determinations of medical necessity should be
the same as medical/surgical care
• Co-pays, maximum benefits, and treatment
duration should be determined in the same way
as medical/surgical care
Parity
And probably some problems
• Determinations of medical necessity are not always
without controversy for medical/surgical care
• Co-pays, maximum benefits, and treatment
duration for medical/surgical care are not always
optimal
• The people who understand medical/surgical care
generally don’t often understand mental
health/substance abuse care and vice versa
Parity
The interpretation and implementation of parity will be
determined over the next several years by your:
- Single State Agency
- Medicaid Agency
- Insurance Commissioner
- Courts
Parity
 Find out how parity is being interpreted by staff at
your Single State Agency, Medicaid, and Insurance
Commissioner
 Determine how the most commonly accessed
insurance plans are defining parity
 Educate everyone about what parity means and
why it is so important
 Advocate for changes if necessary
Defining Coverage
• New insurance plans
• New providers
• New laws
 You and your Drug Court team will need to actively
seek out and share information
Top Ten Actions
10. Maximize the number of justice-involved individuals
receiving Medicaid or insurance coverage
 Talk with others in your state or jurisdiction about
what they are doing to increase the number of
justice-involved individuals enrolled in health care
coverage
 Consider how you or your Drug Court can
contribute
Top Ten Actions
9. Ensure continued access to high-quality treatment
 Strengthen existing relationships with the highly
qualified treatment providers
 Build new relationships with all treatment and health
plan providers operating in your area and serving
your Drug Court participants
 Support your treatment providers as they navigate
the many changes and regulations associated with
the ACA and Parity Act
Top Ten Actions
8. Communicate with your Medicaid office, Insurance
Commissioner, and others in your state implementing and
overseeing health reform
 Educate these officials about what Drug Courts do, the
health care needs of the population you serve, and the
kinds of treatment coverage that best serves this highneed, high-cost population
 Engage officials in dialogue about how the Ten Essential
Health Benefits, Parity Act, and nondiscrimination
aspects of the ACA are being interpreted and
implemented in your county and state
Top Ten Actions
7. Understand medical necessity and how it affects Drug
Court operations
 Create or update treatment plans with the full
continuum of treatment as recommended in the Adult
Drug Court Best Practice Standards
 Learn how your typical Drug Court treatment plan might
meet or be challenged to meet clinical definitions of
medical necessity and how these are likely to intersect
or diverge from Medicaid or insurance company
definitions of medical necessity
 Talk with Medicaid, insurance plan administrators, and
your treatment providers about how Medicaid and
insurance plans can pay for Drug Court services
provided to your participants
Top Ten Actions
6. Communicate with your Single State Agency
 Maintain active communication with officials at
your Single State Agency about your Drug Court’s
needs and the kinds of treatment coverage that
best serves your participants
 Discuss with your Single State Agency how the ACA
(and resultant Medicaid and insurance changes)
affect or could affect your Drug Court operations
and participants
Top Ten Actions
5. Determine how your state’s substance abuse
prevention and mental health block grants may be
affected
 Talk with officials in your state’s substance abuse
and mental health care agency
 Find out how the state’s SAMHSA block grant funds
are currently designated
 What changes, if any, are planned because of the
implementation of the ACA?
Top Ten Actions
4. Understand what the Parity Act means in your state or
jurisdiction
 Get informed about parity by talking with and
monitoring updates provided by your Single State
Agency and others in your state and nationally that are
working on parity
 Talk to those who are involved in making decisions about
how Drug Courts operate and the health care needs of
the population you serve
 Invite officials to observe your Drug Court to see how
Drug Courts are a perfect example of why mental health
and substance use/abuse/dependence treatment
parity is so important
Top Ten Actions
3. Learn more about Medicaid coverage and
alternative benefit plans (if applicable) in your state
 Review state-level documents to determine who is
covered by Medicaid and Medicaid expansion and
share the results with your Drug Court team
Top Ten Actions
2. Get Educated
 Learn everything you can about what the ACA is
(and is not).
 Find out how implementation of the ACA in your
state affects your Drug Court operations and
participants.
 Participate in the many opportunities to learn more
about the ACA and criminal justice populations
through the available literature, web resources,
webinars, and trainings provided by federal, state,
and nonprofit groups.
Top Ten Actions
2. Get Educated
 Talk to your treatment partners and other agencies
serving your Drug Court population about how they
are preparing for and adjusting to the ACA.
 Meet with your Drug Court team to identify what
opportunities and challenges might be specific to
your jurisdiction.
 Make a plan to get ahead of the challenges and
leverage the opportunities.
Top Ten Actions
1. Be an educator
 Share what you have learned with your Drug Court
Team
 Talk to both traditional and nontraditional partners
about how Drug Courts operate, the population you
serve, and the Drug Court participants’ complex
treatment needs
 Help shape access to care for your Drug Court
population by educating those who are making
decisions about ACA interpretation and implementation
of what your Drug Court does, what it needs, and how it
helps the community
Resources
Visit the NDCRC ACA resource link
at http://www.ndcrc.org/ACA
Thank You