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Implementing the Affordable Care Act in
Massachusetts – What’s at Stake for
People Living with Serious Mental illness
and Their Families
Andrew Sperling
Director of Legislative Advocacy
NAMI National
andrew@nami.org
October 19, 2013
The Divisive Politics of the ACA
• Despite the resolution of the 2012 election, the
future of the ACA still dominates the national
political debate
• Sharp divisions between, and within, the major
political parties
• The end of the government shutdown is unlikely to
resolve this debate
• Registration and plan enrollment challenges on the
state run and federally facilitated Exchanges are
likely to continue
• Plan enrollment is not effective until January 2014
and initial enrollment will run through 2014
Federal Structure of the ACA
• Individual mandate with penalties, the greater of:
– $95 in 2014, $325 in 2015, $695 in 2016, OR
– % of household income (1% in 2014, 2% in 2015 and 2.5% in
2016 and beyond)
– Exempts individuals below the tax filing threshold and those
otherwise eligible for Medicaid expansion
• Employer mandate – Penalizes employers with 50 or more workers
that do not offer affordable coverage
– Companies that fail to offer coverage and have employees
receiving subsidies in the exchange must pay $2,000 per
employee
– Companies that offer coverage but have employees in the
exchange must pay $3,000 per employee
– Enforcement of penalties delayed until 2015
Insurance Market Reforms
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Since September 2010:
– Bar on pre-existing condition exclusions for children under 19
– Prohibition on coverage rescissions months
– Family coverage for dependents up to age 26
– No lifetime limits on coverage
Starting in 2014:
– Prohibition on pre-existing condition exclusions
– Restrictions to severely limit the use of health status, gender and age in
determining premium rates
– Requirements for guaranteed issue and guaranteed renewal of coverage in the
individual and small group markets
– New restrictions on annual and lifetime limits in insurance plans, with greater
accountability for “grandfathered” plans (prohibiting caps after 2014 and a
requirement for covering preventive services with no cost sharing after 2018)
– New restrictions on medical loss ratio (requiring plans to dedicate a fixed % of
premium dollars to care)
– Greater transparency, accountability and notice requirements for health plans
seeking to increase premiums on enrollees
Subsidies for Coverage Expansion
• Below 138% of FPL (about $14,500 for a single
individual in 2013) eligible for Medicaid expansion IF
your state elects the option – expansion was made
optional by the Supreme Court in 2012
– 17 million Americans meet this criteria, 5.2 million are
in states not currently electing to expand Medicaid
• Between 138% and 400% of FPL premium tax
credits are available (as limit on premium as a % of
income)
– Cost sharing subsidies available up to 250% of FPL
(reduced maximum annual cost sharing limitation)
Qualified Health Plans
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Qualified Health Plans (QHPs) will be available to individuals and small
employers in the Exchange
The Exchange will:
– Set standards for QHPs
– Certify participating plans, and
– Rank plans from bronze to platinum to indicate what level of coverage
the plan offers
QHPs must:
– Provide “Essential Health Benefits” (EHBs)
– Ensure sufficient choice of providers
– Be accountable for performance on clinical quality measures and patient satisfaction
– Implement a quality improvement strategy
– Provide accurate and standardized consumer information
4 “metal” levels
– Bronze – covers 60% of actuarial value of benefits
– Silver – covers 70% of actuarial value of benefits
– Gold – covers 80% of actuarial value of benefits
– Platinum – covers 90% of actuarial value of benefits
– Catastrophic – high-deductible plan for individuals up to age 30 or individuals exempted from
the mandate to purchase coverage
Essential Health Benefits
• 10 required benefit categories: ambulatory, emergency,
hospitalization, maternity/newborn, mental health and
substance use disorder services, prescription drugs,
rehabilitative/habilitative, laboratory,
preventive/wellness/chronic disease management,
pediatric services (including oral and vision)
• Separate regulations have been issued for EHB
requirements in the Exchanges and Medicaid expansion
• States were allowed to select a state “benchmark”
standard for EHB from within their current market (MA
chose Blue Cross-Blue Shield HMO Blue)
• Major concerns remain with the limited requirements for
prescription drug coverage – coverage can be limited to
as few as a single drug in each therapeutic class
Mental Health Specific Provisions
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Parity requirement in state-based exchanges (Section 1311) – all plans
offered through exchanges must comply with the Domenici-Wellstone
Mental Health Parity and Addiction Equity Act of 2008
Medicaid 1915(i) plan option – Allows targeting of different benefit packages
for targeted populations (e.g., serious mental illness) and specific services
(e.g., supported employment, ACT teams, supportive services in housing,
transportation, etc.), with no cost neutrality requirement
Medicaid emergency psychiatric demonstration project (Section 2707) –
Lifts IMD restrictions for emergency acute care – 13 states selected
Medicaid “medical home” option (Section 2703) – Available through a plan
amendment with 90% FMAP (no waiver required) to target care
coordination for individuals with:
– at least two chronic conditions, or
– one chronic condition and risk of another, or
– at least one serious mental health condition
– currently underway in 15 states
Implementation in Massachusetts
• On April 12, 2006 former Governor Romney signed comprehensive
reform legislation into law
• Commonwealth Care imposed an individual mandate and
subsidized coverage for individuals and families up to 300% of FPL
• Commonwealth Choice enables those not eligible for
Commonwealth Care to shop and purchase coverage through the
Massachusetts Connector
• In 2010, Business Express program launched for small employers
• As of August 2013 – 254,000 individuals enrolled through the
Connector, 207,000 through Commonwealth Care
• In 2012, Governor Patrick signed legislation authorizing the Health
Connector to be authorized as a state-based Exchange under the
ACA
Implementation in Massachusetts
• Consumer Assistance and Outreach
• 10 organizations designated to serve as Navigators
• Online portal for the Connector
– www.mahealthconnector.org
• Registration and enrollment through a single webbased portal
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MAGI screen (Modified Adjusted Gross Income)
Clearance through the federal “HUB”
Why the first two weeks have been challenging
This week’s budget agreement will tighten rules on
income verification
Implementation in Massachusetts
• Navigator program for the small group and individual
markets
• SHOP Marketplace and “Sub-connectors” for small
businesses
• Basic Health Program (BHP) authorized in June
2012 for optional coverage for adults between 139%
and 200% of FPL with wrap around premiums and
cost sharing subsidies
• Common IT system for the Commonwealth Care
Connector, Medicaid, CHIP
Medicaid Expansion in Massachusetts
• Expanded eligibility began in 2006
• The remaining 108,000 uninsured individuals will be eligible for the
Health Connector in 2014
• Eligibility up to 138% of FPL – about $15,856 for a single adult – no
asset test!!
• MAGI screen process much simpler than current application and
income/asset verification process – continuous eligibility throughout
the year
• “Medically frail” are to be screened to an enhanced benefit program
similar to existing Medicaid
• Primary Adult Care (PAC) program ends on December 31, 2013
• 100% FMAP through 2017 and then 90% thereafter
• Pre-existing mandatory eligibility categories stay in the “old”
Medicaid program
– Concerns about a future two-tiered Medicaid program
More information
• www.healthcare.gov
• www.mahealthconnector.org
• http://www.nami.org/Template.
cfm?Section=Health_Care_Re
form