Agenda
 Coverage for care overview
 Health insurance customer protections
 New Health Insurance Marketplace
 How will Medicaid change?
 What does it mean for our state?
 Call to action
50 million Americans Uninsured (2009)
Financing Mental Health Care
Other federal
5%
Medicaid
27%
Other state
and local
18%
Out of
pocket
12%
Medicare
8%
Other private
3%
Private
insurance
27%
Source: Garfield (2011) Mental Health Financing in the US: A Primer
Kaiser Commission on Medicaid and the Uninsured
Coverage for Care
Federal/State Programs
• Medicaid:
–
–
–
–
Health finance program for the poor
Only covers some lower income people
Broad array of community mental health services
Does not cover inpatient care age 22 – 64
• Children’s Health Insurance Program (CHIP)
• Children not covered by Medicaid 100% - 200% FPL
• May or may not offer full range of Medicaid services
Coverage for Care
Federal Programs
• Medicare:
– Seniors, people who received SSDI for >24 months
– Limited array of mental health services
– Medicaid beneficiaries with very low incomes may
also qualify for Medicaid (dual-eligibles)
• Veterans/Military:
– VA health care: limited eligibility, but wide array of
mental health services
– TRICARE resembles private insurance
Coverage for Care
State and Local Public Systems
• State and county mental health authorities
• Serve people who fall through the cracks
• Provide services not covered by Medicaid
Private Health Insurance
•
•
•
•
•
Employer sponsored or purchased by individual/family
Varied benefits
Mental health parity requirements vary
Limited array of mental health benefits typical
Wider provider network
New Health Insurance Rules
Protect Customers
• Children can’t be rejected for health coverage due to
pre-existing conditions
• Youth up to age 26 can be covered on parent’s health plan
• No lifetime limits on benefits
• Temporary high-risk pools
• Plans may not withdraw coverage
getting sick
• Appeals process for denials
• Plans must spend 80-85% on direct care
for
“My 21 year old daughter has had
major depression since she was a
child. We were very worried about
health insurance when she wanted
to leave home. Now she can stay
on our health plan until she is 26.”
The new health law allows parents
to keep adult children on their plan
until age 26.
Uninsured Adults with Mental Illness
Uninsured
11 million
24%
Covered
34.5 million
76%
US: Total of 45.6 million adults with mental illness
Source: SAMHSA, National Survey of Drug Use and Health, 2011
New Coverage Options
• Health Insurance Marketplace: private coverage
• Individuals
• Small Employers (SHOP)
• Medicaid expansion: 0 -138% FPL
• Parity required:
– All individual and small group plans
– All Medicaid benchmark plans
– Traditional Medicaid managed care plans
• Care coordination/ integration strategies
Health Insurance Marketplace
= Health Insurance Exchange
Goals: Good health coverage at affordable cost
• Regulates:
“Qualified Health Plans”
“Essential Health Benefits”
• Rates Qualified Health Plans
Source: Mass Health Connector www.mahealthconnector.org/
• Unified online application for exchange, Medicaid, CHIP
• Toll-free telephone hotline
• Website to compare health plan information
• Standardized format to present health benefit options
• Electronic calculator to figure actual cost of coverage
Qualified Health Plans (QHP)
Only Qualified Health Plans allowed in
Health Insurance Marketplaces
– Must provide Essential Health Benefits
– Insurer must meet requirements:
• In good standing with the State
• Offers at least:
– One silver and
– One gold plan
• Offers the same premium for qualified health
plans inside and outside the Exchange
Source: Illinois Department of Insurance
Health Insurance Marketplace Incentives
• INDIVIDUALS
– Tax Credits for Premium Subsidies
– Cost-Sharing Subsidies
– Reduced OOP limits, annual cap $6,350
(premium + deductible)
• SMALL BUSINESS
– Small business Health Options Program
(SHOP)
– Help small employers enroll employees
in qualified health plans
– Small Business Tax Credit
Individual & Employer Mandates
• Individual responsibility to buy insurance
– Penalties of $95 in 2014,
• $325 in 2015,
• $695 in 2016, OR
– Percent of household income
• 1% in 2014,
• 2% in 2015 and
• 2.5% in 2016 and beyond
– Exempts individuals below the tax filing threshold
• Employer penalties Beginning in 2015
– Applies to employers with 50 or more employees
– Penalties from $2,000 to $3,000 per employee,
– If employer fails to offer coverage or offers bare bones coverage
Eligibility and Financial Assistance
Question:
Do the new rules help me get Medicaid?
Answer:
IF your state expands Medicaid and IF
your income is at or below 138% of
Federal Poverty Level, then yes.
Question:
Are you eligible for government help
buying insurance?
Answer:
The government will help pay part of
premiums and out-of-pocket costs for
people with incomes between 100
percent and 400 percent of the federal
poverty level.
Family Size
100% FPL
138% FPL
1
$11,490
$15,856
2
$15,510
$21,404
3
$19,530
$26,951
4
$23,550
$32,499
Family Size
100%
400%
1
$11,490
$45,960
2
$15,510
$62,040
3
$19,530
$78,120
4
$23,550
$94,200
Essential Health Benefits
 Outpatient clinic services
 Prescription drugs
 Emergency services
 Rehabilitative &
habilitative services
 Hospital care
 Maternity, newborn care
 Mental health, behavioral
health, substance use
care
 Laboratory services
 Children’s services,
dental & vision care
 Wellness, disease
management
Benefit Continuity
Essential
Benefits
Package
Source: Sommers, B.D. & Rosenbaum, S. (2011). Health Affairs.
Presented by S Fields, NAMI 2011.
“I had a 4.0 GPA in school but I
dropped out after my insurance
stopped covering my medication. I
started hanging out with the wrong
crowd and self-medicating just to get
away from the pain and confusion.
Now I’m trying to get back on track,
but every day is a struggle.”
The new health law requires Medicaid expansion and
health insurance marketplace plans to provide medication
and lab work, but advocacy is needed.
Expanded Medicaid Eligibility
Now
Categorical
+ Financial
Criteria
•
•
•
•
•
Pregnant women
Infants/Children
Families with dependent children
Aged, Blind, Disabled
Assets and other income
2014
Financial
Criteria Only
•Single adults under 65:
•Incomes up to 138% of
the Federal Poverty Level
• Ag
ed
Dis
abl
ed
• Fa
mil
Infants/Children ies
ith
de
pe
nd
ent
chil
dre
n
“I was married and working, but
stopped taking my medications
because I didn’t feel sick. Things went
downhill fast. My wife left me, I lost my
job and had to move back in with my
parents.”
•
The new health law will provide a second chance in states that expand
Medicaid. Anyone with an income is below 138 % FPL will be able to enroll
in Medicaid and get treatment. It will also be easier to return to work and
get private insurance.
•
NEW DONUT HOLE? In states that do not expand Medicaid will people with
incomes below 100 percent FPL will get federal financial help to buy a
private plan?
Medicaid Expansion
Any uninsured ≤ 138% FPL
– 100% federal match for newly Medicaid eligible: 2014 – 2016
– Reduced gradually to 90% federal match, 2020 forward
Source: The Advisory Board Company, July 26, 2013
In-State Update
Prepare NOW for New Coverage
www.healthcare.gov
• Enrollment assistance - 24/7 call center
– Toll free: 1-800-318-2596
– TTY/TDD: 1-855-889-4325 for assistance
– English, Spanish, 150 languages
Call to Action
• Contact your legislator today! Call or email!
– To find their contact information: [link]
– Schedule a visit in the district
• ASK:
– Health care coverage will help people with mental
illness recover and contribute to their communities.
– Can I count on your support to expand good,
affordable health coverage to all households with
incomes from 0 to 138 percent of poverty?
– Can I count on you to advocate for mental health
coverage on par with medical/surgical care?
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