MACPAC Study of Medicaid Behavioral Health

Washington Update
November 11, 2014
Stuart Yael Gordon, J.D., NASMHPD Director,
Policy and Health Care Reform
No Labor/HHS bill voted in House, Senate
Mikulski did post Senate bill not voted.
Continuing Resolution enacted September
17, expires December 11.
GOP split. Some want full omnibus passed
during lame duck, some want to extend CR
until March, then enact full budget.
House Appropriations will not release full
budget until days before CR expires.
House GOP leaders announced in June that bill would move
forward only with “noncontroversial” provisions (not
specified), but new version still not released.
Rep. Murphy continues to push for full passage.
◦ Cited Robin Williams’ August 12th suicide as evidence of
need for comprehensive reform.
Staff for House Energy and Commerce Chair Chairman Upton
has told us “disease-specific” bill cannot move without bipartisan consensus.
Original version now has 108 co-sponsors, 36 of whom are
Democrats (4 Dems w/drew as sponsors).
Bill likely will not move before end of post-election Lame Duck
session (historic median length 33 days, shortest 3 days,
longest 58 days).
Even if bill moves out of E&C Committee, unlikely there’s time to
pass full House.
Even if bill passes full House, Senate very unlikely to bring to
floor, but bill would be positioned for support in 114th Congress.
Budget C.R. will expire Dec. 11; either CR will be continued until
March 2015 or full budget will be enacted during Lame Duck.
With Republicans leading Senate, provisions of Murphy bill
could pass in early 2015 as part of Budget Reconciliation
Process requiring only simple majority vote of Senate (51
votes) rather than 60-vote super-majority.
Byrd Rule requires provisions in reconciliation bills to be
budgetary in nature (affecting revenue or spending.) Provision
that doesn’t produce a change in outlays or revenue is subject
to point of order that can be waived only with 60 votes.
H.R. 4574, “Strengthening Mental Health in Our
Communities Act of 2014”
Up to 63 co-sponsors, all Dems, many of whom are
also co-sponsors of Murphy bill.
Rep. Murphy adamantly opposes combining bills.
H.R. 4574 unlikely to move this year (even out of
committee), but is likely to return as Murphy
September 18, 2013, CMS finalizes methodology for allocating
FY2014 and FY2015 DSH reductions and promises separate
rulemaking for ensuing years.
Implementation delayed with Congressional delays …
◦ The Middle Class Tax Relief and Job Creation Act of 2012
extended reductions to FY2022.
◦ Sec. 1204 of Bipartisan Budget Act of 2013 delayed
implementation of the DSH payment cuts until FY2016 and
extended reductions through FY2023.
◦ Protecting Access to Medicare Act of 2014 delayed
reductions to FY2017 and extended reductions to FY2024.
Result: in FY2017, aggregate DSH reductions will total $1.8B,
rather than $500M originally scheduled for 1st year under ACA.
12 DSH bills, including one with sponsor (Baucus) gone, none
moving, all already outdated by 2014 doc fix (H.R. 4302).
Under H.R. 4302, Medicaid and CHIP Payment and Access
Commission (MACPAC) must report to Congress annually,
beginning February 1, 2016 on:
◦ Changes in the number of uninsured;
◦ Amount and sources of hospitals’ uncompensated care costs,
including costs resulting from unreimbursed and underreimbursed services, charity care, or bad debt;
◦ Identity of hospitals with high levels of uncompensated care
that provide access to essential community services for lowincome, uninsured, and vulnerable populations, including
trauma care and public health services.
◦ State-specific analyses of the relationship between the most
State DSH allotments and uncompensated care data.
Price Waterhouse Cooper released 9/3/14 report on admissions
and uncompensated care in for-profit hospitals, comparing
hospitals in 26 Medicaid expansion states (and D.C.) to those in
24 non-expansion states.
◦ 47% reduction in admissions of uninsured or self-paying
patients at the hospitals in expansion states in the first half of
Colorado Hospital Association (CHA) collects monthly financial
and volume data for 465 hospitals in 30 states across the
country in DATABANK. 15 states in database expanded Medicaid,
15 did not. June CHA Report found:
◦ When compared to the Q1 of FY 2013, there was a 30% drop
in average charity care per hospital across expansion states, to
$1.9M from $2.8M.
Proportion of charges by payer per group and
average charity care per hospital.
17-member MACPAC has 6 vacancies opening up January 1.
MACPAC, created in 2010, has never had representative
from Behavioral Health provider/consumer community.
NASMHPD forwarded PA Department of Public Welfare
nomination of PA Medical Director Dale Adair by Sept. 5
deadline, with our support.
◦ Nomination seconded in letter from 30+ members of D.C.’s
Mental Health Liaison Group and separate letter from APA.
October 30, MACPAC began examining role of behavioral
health in Medicaid, with eye toward two reports to Congress
in April, June 2015.
Issues touched on in the October 30 briefing and proposed for
future consideration by MACPAC members included:
◦ the high cost of treating individuals with behavioral health
◦ the prevalence and treatment of behavioral health disorders;
◦ the fact that in some states there may be three delivery
systems for behavioral health conditions;
◦ what is entailed in Medicaid coverage for mental illness and
substance use disorders;
◦ the sometimes conflicting responsibilities and eligibility
standards of federal and state agencies providing behavioral
health treatment—including HRSA, SAMHSA, DoE, and the
criminal justice system;
Issues proposed for consideration also included:
◦ Medicaid behavioral health carve-outs and the difficulties they
create, particularly where carve-out policies change
◦ barriers to service—including the IMD exclusion and provider
shortages—and state steps taken to address those barriers;
◦ how the IMD exclusion interacts with mental health parity and
Early Periodic Screening, Diagnosis, and Treatment (EPSDT)
◦ over-prescription of psychotropic drugs to some populations;
◦ abuse of opioids; and
◦ state approaches to integrating behavioral health and other
medical services, and how integration affects costs,
NASMHPD, National Association of Medicaid Directors
commended MACPAC on initiative.
◦ NAMD urged study of IMD exclusion.
◦ NAMSHPD urged study of role of peer support services
in maintaining access in mental health and substance
use treatment.
◦ ASPE said it is currently studying impact of health
homes, IMD exclusion demo, supported employment.
◦ PEW Research Center said it’s looking at
interrelationship between behavioral health and
 Regulations governing HCBS residential services published
January 16. Guidance on non-residential services
promised, still not published.
 “Association of Associations” (NAMD, NASUAD, NASDDDS,
NASMHPD) asked by CMS to help define service terms,
beginning with “prevocational services” and “adult day
services,” for inclusion in guidance on non-residential HCBS
services, with 8-week deadline.
Workgroups formed with representatives from each
Associations want to start with existing HCBS waiver
taxonomy, then modify as appropriate to reflect
appropriate sites, group-specific characteristics.
1. October 8: SAMHSA proposed to conduct a 61-
question Peer Support Worker core competencies
survey and telephone interviews to help SAMHSA
prepare people in recovery for the role of peer
worker and subsequently evaluate the job
performance of peer workers.
◦ SAMHSA would survey 100 workers and
interview 20.
 NASMHPD Feedback submitted by November
10 deadline: Sample far too small given that
33 states reimburse under Medicaid for peer
 8 state, 2 year demo under which CBHCs will be paid under a
prospective payment system (PPS) to provide behavioral health
services, and states reimbursed at 90% FMAP.
 Short turnaround for awarding of $25M in state planning grants
by January 1, 2016, so no formal regulations to be published.
SAMHSA, CMS will issue only guidance to states.
 November 12: All-Day Listening Session at SAMHSA and via
phone on draft guidance on implementation of Excellence in
Mental Health (“Section 223”) two-year CBHC grant program.
 SAMHSA drafting guidance for states to set CBHC certification
standards based on H.R. 4302 language. Two weeks for filing
written comments following Listening Session; November 26
 CMS drafting guidance on CBHC prospective payment system,
due by September 2015. CMS Listening Session to be held
November 20, virtually only.
24-hour crisis mental health services, including emergency
crisis intervention and crisis stabilization
Screening, assessment, and diagnosis, including risk
Patient-centered treatment planning
Outpatient mental health and substance use services
Outpatient clinic primary care screening and monitoring of key
health indicators and health risk.
Targeted case management
Psychiatric rehabilitation service
Peer support and counselor services, family supports
Services for veterans, armed forces members, particularly in
rural areas.
McConnell says he wants repeal of individual
mandate, 30-hour workweek for coverage.
Full repeal unlikely – Insurers would likely oppose
◦ Wellpoint enrollment up 1.68M, half are Medicaid
enrollees. Stock up 50%. Retooled as “utility”
◦ United Healthcare, which sat out 2014, all in for
◦ 57 more issuers in federal exchange. Total issuer
enrollment now 248.
Hearing still on in Federal Court of Appeals for
DC, scheduled for December 17.
Question: Can subsidies be provided to enrollees
through federally facilitated exchanges?
18 states just filed Amici brief in D.C. court:
◦ If two interpretations, court must accept least
◦ No notice to participating states of threat of loss
of subsidy – Constitutional violation
Challengers asking DC Court to dismiss.
SCOTUS expected to hear in March 2015, decide
in June.

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