
Introduction on Current Medicaid Program – Financing and Impact

Impact of New Medicaid Expansion Program in Addressing the Needs of
Uninsured Individuals with Mental Illness




Expanding Health Insurance Coverage & Increasing Access to Services
Redesigning the System
Facilitating Integration
Improving Quality and Health Information Technology

Action Steps for Advocacy Organizations on Medicaid Expansion

Action Steps on Maximizing Enrollment
2
Financing


Current Medicaid – Each state receives federal matching $$ (50%-76%) and varies
considerably by state.
Medicaid Expansion – Federal match at 100% from 2014 to 2016 and levels off to 90 percent
in 2020.
Eligibility


Current Medicaid – Federal law requires states to cover certain “categories” like children and
women who are pregnant.
Medicaid Expansion – State residents with incomes below 138% of the FPL are eligible for
coverage.
Benefits


Current Medicaid – Federal law requires states to provide a minimum benefit package for
adults and children and can provide optional services such as mental health services and
dental care.
Medicaid Expansion – State must provide an “essential health benefits” package that includes
“mental health and substance abuse services, including behavioral health treatment.”
Benefits must be at parity based on MHPAEA.
3
Transformative Impacts of Medicaid Expansion
on Addressing the Needs of Uninsured
People with Mental Illness
4

Purely monetary estimates of the new Medicaid expansion ignore the potential
benefits to improved access to affordable health care for millions of people with a
mental illness who are without health insurance.

ACA was enacted to address the magnitude of the uninsured problem in the U.S -about 50 million people are uninsured in the U.S.

In the absence of the new Medicaid expansion in their state, millions of lower- &
moderate-income adults will be left without an affordable coverage option and
continue to face the health and financial consequences of going uninsured.

There are several cascading events or transitions in which improved health status
and quality care can be achieved for currently uninsured persons with mental
illness who are eligible under the expansion initiative. A failure to take advantage
of the Medicaid expansion option will represent lost opportunities in 10 key areas.
5

States hit hard by the recent economic recession – fresh in the minds of
governors and state legislatures.

State policy-makers concerned about new state implementation costs under
the Medicaid expansion, and overall costs to federal government.

Fear of “risk and bait” under the new Medicaid expansion program. Fear
underscored by recent debate on dealing with the “fiscal cliff.”

Concerns of increased enrollment under the current Medicaid program
known as “Woodwork” or the “Welcome Mat” effect.

Those opposed to expansion see it as unnecessary government action.

Most consequential state Medicaid decision since 1966.
6
7

1. Expanding health insurance coverage to millions of uninsured people with
mental health (MH) conditions – or at risk of developing such illnesses.

2. Increasing health insurance mental health and medical benefits through the
implementation of an “essential health benefits” package, which includes “mental
health, substance abuse and behavioral services” that Americans will receive
through the Medicaid expansion and state health insurance marketplaces.

3. Providing mental health benefits at “parity” which means that mental health
coverage and benefits must have similar provisions as medical services.

4. Growing the country’s mental health workforce by encouraging new medical
and related personnel to enter the mental health field through new incentive
programs.

5. Reinventing and redesigning state mental health systems by enabling states
and federal agencies to test and evaluate improved financial and organizational
tools, in order to address the fragmentation of mental health services that lead to
poor quality and high cost.
8

6. Promoting early screening & intervention of mental illness for children &
young adults – and adults – and referring individuals to the right providers; to
effectively reduce the burden of disease on children, their families & communities.

7. Integrating mental health care into primary and health care services, as we
have an opportunity to address this long-standing problem because many people
with these conditions will now have health insurance coverage.

8. Integrating mental health and substance abuse services which has been a
persistent deterrent to appropriate care, but the Medicaid expansion provides
numerous opportunities to better address this issue.

9. Implementing evidence-based treatments and support services, that
contribute to high levels of social functioning and recovery but are often not used
in the care of people suffering from mental health conditions.

10. Insuring that services and programs are person-centered and support
health, recovery and resilience and healing for individuals and their families who
experience mental health disorders.
9

NASMHPD has estimated that nearly 14 million currently uninsured Americans
who have a mental illness – from serious to moderate conditions – will be eligible
for health insurance coverage through the new Medicaid expansion and state health
insurance exchanges between 2014 and 2019.

Between 2014 and 2019, a full Medicaid expansion effort will provide health
insurance coverage to 17 million people with incomes less than 138 percent of the
federal poverty level (FPL) who were previously uninsured.

About 40 percent of this group – or 6.6 million individuals – with serious or
moderate mental illnesses who are currently uninsured will obtain health insurance
through the new Medicaid expansion program between 2014 and 2019.

As a result of the Medicaid health insurance expansion, researchers estimated
significantly reduced mortality for people who were previously uninsured and
improved health status for people with mental illness, as well as overall enhanced
productivity.
10
New Medicaid Expansion
Figure 6
Note: CI = Confidence Interval
11

In addition to the coverage impact of the new Medicaid expansion,
6.8 million uninsured people with a mental illness will also gain
health insurance coverage though the implementation of state health
insurance exchanges under the ACA, out of nearly 22 million
projected newly-insured people between 2014 and 2019.

We believe the combined effect of the Medicaid expansion and the
health insurance exchanges will begin to reverse what has been a
withering in public investment in mental health in the 21st century.

Expanded Medicaid eligibility creates a way for lower-income and
other uninsured individuals to obtain health insurance – but also
makes a number of changes to how the mental health and health
care systems can better operate through delivery reforms.
12
State Health Insurance Marketplaces
Figure 7
Note: CI = Confidence Interval
13

ACA requires the inclusion of medical benefits and mental health and substance
use treatment services in the list of the 10 essential health benefits (EHBs) that
qualified health plans must offer to participate in state health insurance
exchanges, and essentially provided through the new Medicaid expansion effort.

EHBs must include items and services within at least the following 10 categories:
mental health and substance use disorder services, including behavioral health
treatment, ambulatory patient services; emergency services; hospitalization;
maternity and newborn care; prescription drugs; rehabilitative and habilitative
services and devices; laboratory services; preventive and wellness services and
chronic disease management; and pediatric services, including oral and vision care.

The law also allows states to extend Medicaid coverage, including all benefits and
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) requirements,
to foster children who have aged out of the foster care system, up to the age of 26
beginning in 2014.
14

The Mental Health Parity and Addiction Equity Act (MHPAEA) of
2008 prohibits financial requirements and treatment limitations for
mental health and substance abuse benefits in group health plans
from being more restrictive than those placed on medical and
surgical benefits.

The parity provisions also will apply to the new expanded Medicaid
programs, as well as to Medicaid managed care programs, and under
the state health insurance exchanges.

Most importantly, the ACA requires the inclusion of mental health
and substance use treatment services in the list of the 10 essential
benefits that insurance exchanges must offer, and as a consequence
provided through the Medicaid expansion.
15

We recognize that at this time, there is insufficient capacity and coordination in
the current system to adequately serve the newly-eligible population with
mental health needs under Medicaid expansion and the ACA.

A major area of concern is having enough providers to ensure access to mental
health services.

Effectively serving newly-eligible children and adults who may be
experiencing the first signs of a mental health condition and have immediate
needs, calls for building capacity in the current mental health system.

The Medicaid expansion will force the issue as integrated care for MH and PC
services is gaining momentum.

And when it comes to children, it makes perfect sense –critical shortage of MH
providers and nearly all children visit the PC setting.
16
There are several reasons why the Medicaid Expansion has made reinventing and improving
mental health more likely now if states pursue the expansion initiative. Following are some
examples of opportunities that the states build on:

First, the Medicaid expansion provisions will enable states and federal agencies to test and
evaluate improved financial and organizational tools in order to address the fragmentation of
mental health services that lead to poor quality and high cost.

Second, many provisions, such as health homes, are directed toward chronic disease
comorbidities. These provisions make it possible for care providers to be more responsive to
clients who not only have serious mental illnesses, but also have other serious chronic
diseases or disease risks.

Third, provisions in the new law allow providers to better coordinate Medicaid mental health
services with social service and housing programs that seek to prevent and manage
homelessness among people with serious mental illnesses.

Fourth, by extending the concepts of treatment and related supportive care to such entities as
health homes, Medicaid provisions provide new pathways for incorporating evidence-based
treatments, such as supported employment, that are commonly neglected.
17

It’s all about prevention! Medicaid expansion promotes the prevention and early
identification of both health care and mental health problems, thereby allowing for
early intervention, which can effectively reduce the burden of disease on children,
their families and communities.

The Medicaid expansion, the current Medicaid program and other ACA coverage
expansions, will facilitate identification of mental illness at a young age due to
increased access to key screening services.

Moreover, children could begin therapy, even without a specific diagnosis that can
be difficult to determine for many adolescents. The critically important goal is to
reduce the chances that a serious diagnosis will develop later.

The Medicaid expansion could begin to allow comprehensive pediatric practices
and children’s mental health programs to bill for parent training and support for
behavioral management, as well as reimburse pediatric and child mental health
programs for care coordination with schools and other agencies. Care coordination
could be more effective than layering on additional treatments.
18

Several reports of the Institute of Medicine (IOM) over the last decade
have documented the strength of the science base related to preventing
mental health disorders and promoting emotional well-being.

Children and adults with serious mental illnesses are at great risk for many
preventable co-occurring diseases, such as childhood obesity and diabetes.
Increased access to services that can prevent these illnesses greatly
improve the lives of children and families.

Some states have already announced they are going to participate in the
new Medicaid expansion effort and are beginning to undertake programs to
better identify the early signs of mental illness in young people, and refer
children to effective treatment programs.
19

A major challenge for the next decade is to integrate basic MH care into primary care.
Most Americans with mental health conditions get no treatment for these problems. We
also know that more people are treated for mental illnesses by their family physician or
other primary care practitioner than by MH specialists. The problem is that we have
many unmet needs while many specialty MH programs are at capacity.

We have an opportunity in the new expansion effort to address this problem because
many people with these conditions will now have coverage that includes MH care and
because practical ways to deliver basic MH care in PC settings are now well established.

There is considerably less stigma in visits to primary care. People with a chronic illness
like diabetes that also have depression, have health care costs at least 50% percent
higher. Improving basic MH care in the PC setting is a huge need & opportunity.

This all will not occur automatically. MH care within PC today is often inadequate. It
can be done well – improving health and reducing costs – but barriers must be
addressed. Payments and supports for basic MH care in PC are often lacking, so less
than 15% of the people with depression in PC get adequate care.
20

Lack of integration between MH & SA treatment has been a persistent deterrent to
appropriate care, but expansion provides opportunities to address this issue.

The new expansion effort encourages the use of preventive services and substance
abuse education, evaluation, and treatment, and it allows providers treating people
with mental illnesses to pay more attention and receive payments to SA problems.

Expansion enables a transformation in the management of SA, whether occurring
along with mental illness or as a condition in its own right.

Expansion does this through a “whole person” perspective focusing on the
integration of services, as well as by encouraging coordination through health
homes, & collaborative teams & services.

Medicaid expansion provides a major opportunity for greater collaboration
and shared responsibility by requiring MH and SA services be incorporated
into current/emerging clinical models funded by the ACA.
21

Evidence-based treatments that contribute to high levels of social functioning and
recovery often are not used in the care of people suffering from mental health
conditions. Individuals must be involved in meaningful daily activities for them to
avoid restlessness, isolation, boredom, and lack of self-regard.

CMS established a Medicare-Medicaid Coordination Office in an effort to ensure
“full access to seamless, high quality care and to make the system as cost-effective
as possible” for the dual-eligible population. The goal is to create new approaches
to care coordination.

Addressing the risk of homelessness and victimization & providing stable housing
are critical to effective & efficient long-term management of serious mental
illness.

Lifelong disability for people with mental illness is usually unnecessary. While
many of the worst outcomes of serious mental illness (e.g. homelessness, comorbid
medical illness, incarceration) are receiving increased attention, we are still failing
systematically to help people escape poverty and disability.
22

A modern mental health system should include a structure in which all
holistic outcomes, measures and indicators of health are collected, stored
and shared with the individual who has a mental illness, and all of the
providers who are associated with care of the individual.

The development of interoperable, integrated electronic health records will
be necessary, as will community-wide indicators of MH and SA disorders
in order to improve coordination and quality of care.

Medicaid expansion has the potential to afford uninsured people with
a mental illness greatly expanded access to MH and SA treatment in an
integrated and community-based setting, with a person-centered
treatment focus.
23
24

The best way to reduce mental illness and stigma is through better access
to health coverage and timely, effective services. Eliminating access
barriers involves fully implementing the new expansion initiative.

Advocates need to provide guidance to state decision makers on the
incentives built into the expansion to improve health and well-being of
individuals with mental illness.

Medicaid expansion can help accelerate the creation of a strong
infrastructure of community-based services.

Simply put: The new expansion effort will save lives,
improve the quality of life, and improve the health status
for millions of uninsured people with mental illness.
25

In light of the Newtown, CT and Aurora, CO incidents, state officials
should constantly hear messages around the need for:
 Early screening, identification and intervention; and
 Access to a full array of effective services and supports.

When both of these care delivery issues are adequately addressed, it
improves outcomes, and reduces the need to serve children and young
adults in high-end, high-utilization, and more costly, settings.

M.E.: Key policy vehicle to address children’s MH service delivery issues.

How will you improve access to effective MH services for children and
young adults living with mental illness? Half of all mental illness occurs
by age 14 and three-quarters by age 24, yet many of our youth don’t have
access to the most effective MH services.
26
he Waterfall ffect ascading
Impact of Medicaid xpansion on
tate u ets (in Billions of Dollars
Figure 1
2014-2023). State Budget Gains in #1- #4
and #7 are for 2014-2019 only.
1. State
Budget Gains
from
Increased
Federal
Spending on
Existing
Medicaid
Enrollees
1
$66
2. Budget Gains
from Increased
Federal
Spending on
Coverage for
Adults > 138%
of FPL Currently
Covered by
Waivers
$69
-
1
2.
2
3. Budget
Gains from
Reduced State
Spending on
Uncompensated Care
$85
4. Budget
Gains from
Increased
Federal
Spending on
Behavioral
Health
Services
$39
5. Budget
Gains from
Better Care
Coord. of
Dual
Eligibles
(2014-2023)
$34
6. Budget
Gains on
Medicaid
Drug
Rebates
$8
7. Budget
Gains in
Out-Years of
Medicaid
Expansion
from20202023
$76
All budget gains related to Medicaid Expansion referenced in this figure are for acute care costs only (e.g., physician costs not included).
Budget gains due to maintenance of effort, transferring eligibility for special categories of adults (e.g., individuals with breast cancer) and shifting
costs to insurance exchanges for “medically needy” adults.
27
Table 1 – Urban Institute
Worst- and Best-Case Scenarios for State Budget Effects
of Key Provisions of the Affordable Care Act: 2014-2019 (in Billions)
State Budget Gains
Worst-case Scenario in Gains
Best-case Scenario in Gains
Uncompensated Care Gains
+$42.6
+$85.1
Mental Health Gains
+$19.9
+$39.7
Table 2 – NASMHPD-NRI
FY2009 to FY2012 Total $4.6 Billion in Cuts*
Year
Average
Median
Minimum
Maximum
Total
FY 2009
(39 States)
$36,849,116
$13,226,000
$0
$554,003,000
$1,216,020,843
FY 2010
(38 States)
$29,123,575
$12,300,000
$0
$213,591,000
$1,019,325,136
FY 2011
(36 States)
$35,294,953
$0
$132,000,000
$1,270,618,291
FY 2012
(31 States)
$28,074,541
$9,040,000
$0
$242,500,000
$842,236,221
FY 2013
(15 States)
$17,709,032
$13,700,000
$0
$82,000,000
$247,926,447
*Note: Results based on 41 State Mental Health Authorities Reporting Winter 2011-2012. NASMHPD-NRI
28

The Medicaid expansion will replace billions of state and local dollars that are
funded on mental health services, with new federal Medicaid monies.

Advocates should promote through several communications that a significant
portion of the new federal dollars for MH services be used to re-strengthen
state systems & begin to restore harmful cutbacks as an initial priority.

Due to severe state cutbacks over the last four years, individuals with a mental
illness who are uninsured often only receive basic, state-funded public MH care
services and of limited duration, and often these services are crisis-oriented.

With the new expansion, states can redirect funds from jails, prisons, and crisisdriven services, such as traditional homeless shelters and hospital emergency
departments into supportive, permanent housing and evidence-based treatment.

We should invest in upstream community-based initiatives that will result in
budget and quality of care gains over the long run.
29
Figure 3 – Kaiser Commission on Medicaid & the Uninsured, Flow of Medicaid Dollars
Federal Medicaid
Matching DollarsInjection of new
Money
State Medicaid Dollars
Direct
Effect
s
Health Care Services
JOBS
Vendors
(ex. Medicaid Supply Firms)
Employee Income
Consumer Goods
and Services
Indirect
Effects
Induced
Effects
Taxes
3030

The impact of the Medicaid expansion on state budgets is substantial.
Overall, states will see over $300 billion in budget gains between 2014 and
2023 that will add to their surpluses or significantly reduce budget deficits.

It is estimated that the federal government could spend nearly $900 billion
in states through the Medicaid expansion effort from 2014 to 2019.

The new Medicaid expansion and the ACA is a good deal for states,
businesses and their citizens – and promotes entrepreneurship.

Several studies show that the new Medicaid expansion program will
increase jobs an the state’s tax base.

States that choose not to opt in to the expansion will see their tax
dollars go to other states that expand coverage.
31
32

Extent to which the promise of the ACA/Medicaid expansion is fulfilled depends in large part
on how many people actually avail themselves of the new coverage options. Rate of Medicaid
enrollment among currently eligible adults averages only 62% across the states.

In recognition of specific types of problems and challenges, legislation and regulations
envision a streamlined process for enrolling Americans into either Medicaid or private plans
through the exchanges. A series of enrollment regs have been finalized by CMS.

ACA lays out a number of interrelated strategies for streamlining enrollment process,
coordinating across programs & helping people learn about options.

Efforts at streamlining enrollment are vital not only for individuals and families in need of
coverage and care, but also for the U.S. health care mental health safety-net system.

Now is the time to find out what your state is planning and to urge state officials to take
maximum advantage of the opportunity to modernize systems.
33
A NEW WAY TO ENROLL IN COVERAGE
Simple, Streamlined Application
34
“No Wrong Door” Eligibility and Enrollment Model
Modern, Data-Driven Verification Systems
Online Tool for Consumers to Easily Compare and Enroll in Health Plans
Data-Driven Renewal for Continuous Coverage
34

States will be required to use a single, streamlined application
form. And collect the data needed for enrollment in Medicaid &
exchanges, & to coordinate enrollment across various options.

The goal is to ensure that there is, as many experts describe
it, "no wrong door" for an applicant.

Regardless of the system individuals use or the program they
start off applying for, they will be screened for eligibility under
all available options & enrolled in the correct one.
35

Data-driven eligibility. One of the most important things that a new IT system must
support is a true data-driven eligibility system. The system needs to establish real-time
connections with a range of federal, state, and private databases that contain information
relevant to eligibility for exchange coverage, Basic Health, Medicaid, and CHIP.

Coordination between health coverage programs. It is also critically important that
the exchange, Medicaid, and other health programs coordinate their eligibility processes.

A centralize “my account” feature. Enrollees should have access to their coverage
enrollment information online & by phone. This will allow them to easily see which
coverage each member of the household is enrolled in and what assistance they are
eligible to receive.

Coordination with other human services programs. An additional consideration
when designing the data-driven, integrated eligibility system will be whether and how to
integrate eligibility for other human services programs, like SNAP and TANF.
36
Navigator programs are a required component of exchange consumer assistance. At a
minimum, each entity that is selected to be a navigator must do the following:





1. Maintain expertise in and conduct outreach and public education on the health
coverage options and financial assistance that are provided through the exchange.
2. Distribute accurate & impartial information about the full range of coverage options
that are available through the exchange and public programs.
3. Facilitate enrollment in qualified health plans through the exchange.
4. Make referrals to health insurance consumer assistance or ombudsman programs and
to state agencies for help with grievances, complaints, appeals.
5. Provide information and services in a manner that is culturally and linguistically
appropriate and accessible to people with disabilities.
Selecting Navigators
 Entities that exchanges select to become navigators must include at least 1 communitybased and consumer-focused nonprofit & at least 1 other type of public or private entity.
37

Secure adequate & sustainable funding for navigator programs.

Establish a central source to provide tech support for navigators.

Provide formal mechanisms for communication and data sharing among
navigators, the exchange, and state agencies.

Create seamless referral system among entities providing consumer
assistance.

Work with navigator entities to develop data collection requirements that
enable the exchange to evaluate navigator performance. Ensure that
outreach & public education strategies that are used by the exchange and
navigator programs are consistent & coordinated.

Provide contact information for the navigator program in all outreach and
public education materials.
38
Convene—or strengthen—state and local coalitions.


An effort of this magnitude will require a partnership among many different stakeholders.
Many diverse voices should be at the table, including you, hospitals; community health
centers and safety-net providers; doctors other providers; consumer groups; groups
representing communities of color; health insurance plans; business community; etc.
Groups can work together to establish an outreach strategy that leverages the strengths and
connections each partner brings.
Encourage the state to invest in outreach.


There is no federal funding explicitly earmarked for outreach, but states can include funding
for outreach in their Exchange Establishment Grant requests.
Stakeholders should urge their states to develop a plan for outreach this year and to include
significant resources in their grant requests to accomplish this task.
Identify segments of the uninsured to target.


The uninsured MH population may require different messages and different outreach
strategies.
In order to develop the most effective outreach campaign, it will be important to know who
the uninsured with mental illness are in your state & pick segments of that population to
target in an outreach campaign.
39








Issue #1 – Will the online application and consumer web-based services
be easy to use?
Issue 2 – How will the website facilitate access to personalized help from
the call center, navigators, or other assisters?
Issue 3 – How will the IT system use electronic data sources to verify
eligibility in real-time?
Issue 4 – How will the IT infrastructure coordinate coverage seamlessly
between an exchange, Medicaid, and CHIP?
Issue 5 – Will the web-based services help consumers compare, make an
informed selection and enroll in a health plan of their choice?
Issue 6 – How will the system help people maintain and renew coverage?
Issue 7 – How will the system protect the privacy and confidentiality of
personal information?
Issue 8 – Does the system provide clear information about grievance and
appeal procedures and incorporate due process protections?
40
41

NASMHPD Report on “The Waterfall Effect: Transformative Impacts of Medicaid
Expansion on States”

Fact Sheet

Talking Points

FAQs

Recommendations and Actions to Begin Restoring State MH Funding

Workforce Issues

Guidance on Outreach and Enrollment, IT Systems, Navigators
*All materials can be accessed on our website at www.nasmhpd.org
42
THANK YOU FOR THE OPPORTUNITY!
Follow up questions, and for any additional
information on Medicaid expansion and health care
reform, please contact Joel Miller at:
joel.miller@nasmhpd.org, or at 703-739-9333
43