View this presentation. - National Association of State Mental Health

Annual Meeting
Washington, DC
July 27, 2014
Stuart Yael Gordon, J.D., NASMHPD Director, Policy and
Health Care Reform
Christy Malik, MSW, NASMHPD Senior Policy Associate
Justin Harding, J.D., NASMHPD Senior Policy Associate
1. Engage with SAMSHA and CMS in Ongoing Policy
Discussions (Block Grant MOE, 5% Set Aside,
HCBS, ACA Enrollment, behavioral health quality
measures, provider access)
2. Engage with Congressional members and staff on
draft legislative proposals, proposed
amendments (mandatory AOT, CMHC grants)
3. Brief Congressional members, staff on MH and
SA issues
4. Review & analyze Congressional legislation,
collect NASMHPD member feedback, draft
support or opposition letters
5. Review & analyze proposed regulations, notices,
grant opportunities from SAMHSA, CMS
(Medicaid, Medicare, CHIP), NIH, ACL, etc.
6. Notify NASMHPD members (particularly
Financing and Medicaid Division) of legislative
activity, agency policy initiatives, RFPs, grant
7. Partner with other Public Official Associations,
stakeholders in drafting correspondence, comments
 with NAMD on 42 CFR Part 2
 with National Council on need for transparent
implementation of Excellence in Mental Health Act
 Medicaid/Public Health Expert Group: ASTHO,
8. Work with Stakeholder Coalitions to Develop Policy
 Mental Health Liaison Group (MHLG): National
Council, NAMI, both APAs, Bazelon, NASADAD,
MHA, NAADAC, et al.
Coalition for Whole Health (CWH): jointly led by
NASMHPD staff sits on SAMHSA, CMS quarterly
advisory groups.
◦ Next CMS “Association of Associations” (NAMD,
NASADAD, et al.) meeting July 30.
NASMHPD staff & members on SAMHSA
workgroup drafting data set of client-level Block
Grant performance measures.
SAMHSA sought feedback from NAMSHPD
members on state early intervention programs in
drafting guidance for FY2014 5% Early
Intervention Mental Health Block Grant set aside.
CMS sought input from NASMHPD on HCBS in
non-residential settings in drafting forthcoming
NASMHPD joins quarterly CMS calls on impacts of
ACA and mental health parity on provider access.
NASMHPD works with other stakeholder to cosponsor CMS and SAMHSA policy webinars.
1. Advocacy group composed of national
organizations in the mental health and substance
abuse disorders fields, and allied organizations
2. NASMHPD worked closely with CWH members on:
o Letter to Senate Finance Committee on Medicare
& Medicaid for individuals with MH & SUD
o Comment letter on ACA §1557 nondiscrimination
o Comment letter on streamlined exchange
application data elements
Implementation of a state advocacy survey
◦ Goal of survey: collect state information for CMS
and SAMHSA on status of health reform
information and parity (state-specific difficulties,
best practices)
332 responses from 42 states; highest response
from NJ and IA
Of 253 responses, 83 respondents said their state
has acted to make information available on MH/SUD
coverage & benefits.
◦ 170 said their state has taken no action
Of 260 responses, 36 respondents said they were
able to obtain information to determine if plans have
adequate MH & SUD provider networks to ensure
timely access.
219 of 346 respondents said they would like technical
assistance on:
◦ Implementing and monitoring parity
◦ Medicaid expansion requirements related to MH & SU
Core themes from survey:
◦ Transparency lacking
◦ Non-Medicaid expansion states requesting
info on expansion models
◦ A need for education and technical
CWH is collating data to provide statespecific information; final report to be
released in fall.
Rep. Tim Murphy (R-PA) sought NASMHPD feedback
on omnibus H.R. 3717, “Helping Families in Mental
Health Crisis Act.”
◦ NASMHPD suggested legislative language; later sent
general letter commending elements, intent.
House GOP leaders announced in June bill would
move forward only with “noncontroversial” provisions,
but new version still not released.
◦ Original version now has 93 co-sponsors, 32
(4 Dems w/drew sponsorship).
Rep. Murphy sought NASMHPD support for limitation
on IMD exclusion permitting Medicaid reimbursement
for inpatient care in facilities with average patient stay
< 30 days.
• No NASMHPD consensus. Continuing to work with
Rep. Murphy staff on question of support for IMD
• NASMHPD conveyed support for continued
inclusion of state-operated psychiatric hospitals in
IMD exclusion limitation provision.
Given omnibus nature of bill, former Rep. Patrick
Kennedy formed a behavioral health work group
to submit to Rep. Murphy’s staff modifications to
controversial provisions, including:
◦ Mandatory AOT as condition of Block Grant
◦ Reduction of SAMHSA role
◦ Narrowing of IMD exclusion
◦ Reduction in funding for P&A, prohibition
against lobbying by P&A providers
NASMHPD participated in workgroup
deliberations, offered language on mental
health parity for traditional Medicaid.
General consensus reached by work group &
draft language forwarded.
◦ Reduction in IMD exclusion limitation to <20
◦ Making new Assistant Secretary responsible for
coordinating policy across federal agencies;
SAMHSA maintains day-to-day responsibilities.
No response from Rep. Murphy.
3-Year Demo testing partial limitation on IMD
exclusion for free-standing private psychiatric
facilities in 12 states*
Murphy holding July 30 hearing to tout results
supportive of his IMD exclusion provisions.
December report to Congress :
Murphy staff worked with staff for Reps. Ron Barber
(AZ), Diana DeGette (CO), Grace Napolitano (CA),
Paul Tonka (NY), & Doris Matsui (CA).
With no consensus reached on controversial issues,
Dems introduced H.R. 4574, “Strengthening Mental
Health in Our Communities Act of 2014”.
◦ Focus—prevention & early intervention grant
 Didn’t include mandating AOT, limiting IMD
exclusion, & reducing funding for P&A.
Up to 55 co-sponsors, all Dems, many of whom are
also co-sponsors of Murphy bill.
NASMHPD sent Rep. Barber a letter commending
elements & intent.
Rep. Murphy adamantly opposes combining bills.
Barber bill unlikely to move this year.
NASMHPD joined MHLG members on Capitol Hill in
seeking continuation of set-aside funding for early
intervention programs & funding for Mental Health
First Aid, P&A, Suicide Prevention.
SAMHSA budget requested continuation of 5% setaside in FY2014 into FY2015.
Senate Appropriations Subcommittee held 15minute June 10 markup of $157B Labor-HHS
budget with CMS/SAMHSA funding.
Subcommittee voice vote approval w/o amdmts.
Full Committee markup never held since GOP
wanted anti-ACA amdmts added. Bill stalls.
Text of bill posted July 24 FYI:
◦ $1.078,975B for mental health services, $6.8M less
than FY2014, but $12.14M more than requested by
◦ 5% set aside for early intervention continued
◦ $2.14B for substance use treatment services,
$38.6M less than FY2014, but $22.75M more
than requested.
In House, Labor-HHS bill only agency
appropriations bill not to move out of House
Appropriations Subcommittee.
2nd Senate measure stalls after Republican
attempts to amend in unrelated ACA amendment:
“minibus” with money for MIOTRCA, Veterans
Courts, Mental Health Courts, Drug Courts, and
increased funding for guns record-check system.
Likely final outcome: Continuing Resolution for
FY2015, passed in September 2014; extended in
lame duck.
Sens. Bernie Sanders’/John McCain’s Senate
Veterans Administration reform bill (S. 2450) is
still being “reconciled” with Rep. Jeff Miller’s H.R.
◦ Both give VA Administrator greater power to hire,
fire SES.
◦ Both require VA to pay for outside medical care
for veterans not able to get prompt treatment or
living > 40 miles from VA facility.
 Latter is Sen. Udall bill provision which
NASMHPD supported.
Senate Bill would:
◦ Authorize VA to lease private facilities in 17
states & PR.
◦ Mandate report on wait time for mental health
services, recommendations on staffing in mental
health clinics.
CBO est. costs of $50B/year
◦ House wants “pay for”, but has only been able to
find offsets for some provisions. Senate not
seeking offsets.
Final Mental Health Parity Regulations published
November 13, 2013 for private insurance,
Medicaid MCOs, CHIP, and Medicaid alternative
benefit plans
◦ Awaiting promised regulations for traditional
• Some state agencies are beginning to
circumvent parity regulations - ex. Autism
Two upcoming NASMHPD activities, both derived
from the SAMHSA “Coalition” Technical Assistance
• Webinar on “The Scope and Magnitude of
Mental Health Parity”, in conjunction with NAMI,
in the late summer.
• A webinar and document, intended for use by
SMHA’s, being developed by NASMHPD and The
Implementation Group, will focus on parity
best practices and strategies for states across
parity implementation.
Proposed Medicare Part D regulations for CY 2015
would have eliminated protected class for
antidepressants in 2015, antipsychotics in 2016.
NASMHPD response—drafted by members, based
on previous Medical Directors Council White
Paper—recognized distinctive needs of mental
health patients & distinctive characteristics of
mental health drugs while noting need for
government to control use and costs.
Universal opposition, acrimonious Congressional
hearing led to CMS withdrawal March 10.
Final HCBS regulations published in January after
several revisions. Took effect March 17.
Rules apply to §1915(c) and (k) HCBS waivers
as well as §1915(i) State Plan Option HCBS.
Regulations retain 2012 proposed bans against
citing services in, on grounds of, or adjacent to
public NFs, IMDs, ICF/IID, or hospitals but allow
citing in, on grounds of, or adjacent to private
institutions & on grounds of or adjacent to public
institutions if presumption is overcome.
CMS held webinars for NASMHPD members, staff.
Setting must be integrated in and supporting full
access to greater community, including
opportunities for:
 Employment in competitive integrated
 Engagement in community life
 Control of personal resources
 Services in community
States have 5 years to comply, must file
transition plan by March 16, 2015.
States applying for or renewing waivers before
that date must comply or file transition plans at
time of application.
◦ Requirements apply to non-residential services
as well as residential services.
CMS held conference call with NASMHPD
members to get feedback for additional guidance
on non-residential HCBS services.
Webinar featured CMS speakers explaining the
◦ Slides. Webinar replay. The webinar was largely
focused on the provider perspective, the big
takeaways for SMHAs is that:
The Conditions of Participation are currently
applicable only to CMHCs that bill for Medicare
(and by definition offer partial hospitalization
The Conditions of Participation may subsequently
apply to other types of CMHCs should the state
voluntarily adopt the Conditions. CMS warns this
is common.
Commissioners should reach out to their Medicaid
agencies, providers to discuss state rules
SAMHSA held June 11 full-day “listening session”
seeking stakeholder input on updating
regulations on disclosure of patient-identifiable
substance use treatment information.
SAMHSA acknowledged:
◦ Significant changes in 25 years since
regulations were adopted, including new
integrated care models and HIT.
◦ Substance use treatment no longer primarily
conducted by specialty treatment providers,
coordination of care now an issue.
2,500 signed up to participate, most by phone.
NASMHPD staff attended listening session in person.
Covered topics included:
Applicability of 42 CFR Part 2
Consent requirements
Re-disclosure and medical emergency provisions
Quality Service Organization (QSO) provision
Electronic prescribing and prescription drug
monitoring programs (PDMPs)
Witnesses for and against repeal cited stigma of
substance use as justification for and against
separate restrictions.
Opponents of repeal cited threat to safety of
domestic violence victims.
Proponents for repeal cited need to facilitate care
Written comments were accepted until June 25.
NASMHPD workgroup of Medical Directors and
Financing and Medicaid Division and staff worked
with National Association of Medicaid Directors
(NAMD) members and staff to draft comments.
Comment letter acknowledged need to protect
substance abuse treatment information, but
urged repeal, with exception of restrictions on
disclosure in criminal investigations and
procedures, to align with HIPAA restrictions
imposed for other providers.
House Energy and Commerce sought comments,
until July 22, on “digital healthcare ecosystem.”
Senate Finance is seeking comments, due August
12, on ideas to improve data transparency
NASMHPD, NAMD are independently filing
comments incorporating joint 42 CFR Part 2
comments, but also addressing own member
NASMHPD comments—drafted with input from
Financing and Medicaid Division, Medical
Directors—also address:
◦ Need to open Medicaid, Medicare EHR
incentives to behavioral health providers.
◦ Need to align State and Federal telehealth
◦ Need to improve Medicaid access to Medicare
Late 2013: CMS announces moratorium on
provider Medicare appeals which, by law, must
have disposition in 90 days.
OMHA (Office of Medicare Hearings and Appeals)
told 800 witnesses and attendees at February 12,
2014 hearing that:
Delays attributable to paper-based system,
increased demand, and over-lawyering. OMHA
staff cannot walk the halls or use offices or
conference rooms due to paper volume.
OMHA also told attendees:
Recovery Audit Program mandated by Congress
added to backlog.
Beneficiary appeals in theory first, but 4-month
backlog before OMHA opens mail, assigns
appeal to ALJ.
OMHA caseload increased 545% between FY2011
and FY2013.
8 to 10 year backlog.
OMHA receives a year's appeals every 4 to 6 weeks,
and has 800,000 appeals pending (there were a
mere 357,000 in January).
ALJ teams operating at record efficiency levels:
◦ Will 7 additional ALJ teams August 25,
◦ But on July 10th Chief ALJ Judge Griswold told
House Oversight Health Subcommittee that the
new ALJ teams (72K cases/year) are unlikely to
cure the backlog, and that more funds are needed.
Griswold suggested using funds recovered by
Recovery Audit Contractors.
OMHA to start electronic filing by Summer 2015.
On June 30, Chief ALJ Judge Griswold announced
piloted options of:
1. mediation via “facilitated settlement
2. resolution through statistical sampling,
OMHA meeting regularly with CMS on ways to
reduce the number of Medicare claim appeals
below the ALJ level.
American Hospital Association sued OMHA in May.
May 22nd Advisory Council Meeting. Council
almost exclusively comprised of researchers.
Issued new strategic plan.
Re-organizing – part of HHS-wide re-organization.
Adding a new digital division (Rdoc) as well.
Pleased with their digital presence – Twitter, etc…
Trying to remain connected with various
initiatives, including parity, gun violence, and
block grant (esp. 5% set aside for early
intervention) issues.
Project RAISE may be new model for research. 17
years typically vs. 17 weeks for RAISE. But efficacy
study for RAISE is still ongoing.
Lengthy discussion of data privacy concerns,
including how some hospitals have automatic
data sharing for research, provider records,
treating MI same as other diseases.
NIMH says it cannot require data sharing, but can
opt to not work with non-sharing entities.
Emphasized leveraging funding.
NIMH considering redesign of research, bifurcating
data and analysis. One entity would gather, one do
the “good science”.
NIMH, Advisory Council worried a failure to train
providers properly in fidelity—so treatment is
accurate to the model—may result in insurers,
CMS denying payment, bypassing (or violating)
parity, ACA.
Council also discussed how Medicare Hospital
Readmission penalties could change research,
services. IOM is researching how to measure
Special Enrollment Periods (SEPs),
continued Medicaid enrollment throughout
Planning October 2014 outreach for 2015
Consumer education on how to use
Narrow networks – New regulations
Subsidies in Federal exchange: Halbig v. Burwell
(D.C. Ct. of Appeals) vs. King v. Burwell (4th Cir.
Ct. of Appeals)
◦ Who: Multiple courts considering issue, including
these two Federal Courts of Appeals
◦ What: No immediate impact. If upheld on
appeal, D.C. decision would strike all subsidies
in states using Federal Exchange, affect both
individual and employer mandates.
◦ Why: D.C. Circuit used classic legislative
interpretation to differentiate between federal
and state exchanges. NOT federalism.
◦ Next: Further appeals.
The NASMHPD Government Relations Team is
here for you. Whether it be Federal legislation,
regulations, or agency action:
◦ If you need to know, call us.
◦ If you want to be heard, call us.
◦ If you’ve got a cool idea on Federal policy you
want to vet, call us.
◦ If you just need to vent about the Feds, call us.
[email protected] or 703-682-7552
[email protected] or 703-682-5184
[email protected] or 703-682-5182

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