[NYAPRS Enews] CMS: Coverage, Service Design Opportunities for Individuals with BH Conditions

[Harvey Rosenthal]

Center for Medicaid and CHIP Services 

CMCS Informational Bulletin 

DATE: December 3, 2012 

FROM: Cindy Mann, Director Center for Medicaid and CHIP Services (CMCS) 

 

SUBJECT: Coverage and Service Design Opportunities for Individuals with
Mental Illness and Substance Use Disorders 

The purpose of this CMCS Informational Bulletin is to provide
information regarding services and good practices for individuals with a
behavioral health disorder1. The Centers for Medicare & Medicaid
Services (CMS) is encouraged with the increased interest by states to
develop effective strategies for developing benefit designs for this
population2. Many states have included behavioral health services for
these individuals in the state plans and various Medicaid managed care
waivers. 

More recently, states are considering or have taken advantages of new
opportunities offered through the health Home program, Money Follows the
Person program, Balancing Incentive Program and the revised section
1915(i) Home and Community Based Services state plan option. Looking
forward, states will have more opportunities to develop good benefit
design as a result of the Mental Health Parity and Addictions Equity Act
(MHPAEA) and benchmark plan for individuals in the Medicaid expansion
population. Given this interest, we are releasing a series of
Informational Bulletins that will provide additional information
regarding services and supports to meet the health, behavioral health
and long term services and support needs of individuals with mental
health or substance use disorders. 

 

Background 

There are several major drivers that are influencing CMS's decision to
develop this guidance regarding individuals with behavioral health
disorders. These drivers will impact state decisions to review and
revise their benefit design. 

* Medicaid is the largest payer for mental health services in the United
States, comprising 27 percent of all expenditures for mental health
services. As a result, Medicaid coverage policy can have a significant
impact on the health of this population as well as the quality and costs
of both health and behavioral health services. 

* Individuals with mental health disorders represent comprise almost 11
percent of the individuals enrolled in Medicaid and represent almost 30
percent of all Medicaid expenditures. It is anticipated that 14 percent
of the individuals who are uninsured and have incomes below 133 percent
of the Federal Poverty Line may have a substance use disorder3

* Individuals with a behavioral health disorder utilize significant
health care services. Nearly 12 million visits made to U.S. hospital
emergency departments in 2007 involved individuals with a mental
disorder, substance abuse problem, or both, according to News and
Numbers4, Agency for Healthcare Research and Quality. These visits
account for one in eight of the 95 million visits to emergency
departments by adults that year. Almost a quarter of hospital admissions
are associated with a mental or substance use disorder. 

* Access to Medicaid coverage can help beneficiaries get access to the
care and services they need for their substance use disorder, reduce ER
visits and hospital visits and better manage their condition. Providing
effective substance abuse treatment to Medicaid recipients have been
shown to offset their medical costs by 20 percent5. 

* Early identification and intervention of mental health and substance
use disorders are critical for children, youth and adults. Almost eight
percent of youth 12-17 in the Medicaid/CHIP program had a major
depressive disorder in 20096. This number is significantly higher for
youth in child welfare (18.1 percent). American Indian/Alaska Native
youth have almost three times the rate of suicide than the general
population. 

* Newly developed CMS policies and programs support states' efforts to
rebalance and reform their service delivery system, especially for
individuals with behavioral health issues. In addition, new policies
regarding home and community based settings will positively impact the
housing options for individuals with behavioral health conditions. These
policies and programs are in part a response to the United States
Department of Justice (DOJ) efforts under the American with Disabilities
Act to ensure meaningful community integration for people with
disabilities, and state compliance with the Supreme Court decision in
Olmstead vs. LC. 

* Recent legislation (the Children's Health Insurance Reauthorization
Act and section 2701 of the Affordable Care Act) requires the Secretary
to identify core quality measures to be used for children and adults
that participate in the CHIP and Medicaid program. Initial measures
include screening for depression and follow up after hospitalization for
mental illness. In addition, four key quality measurement projects are
currently underway in Home and Community Based Services (HCBS) programs.
The projects test a variety of measurement sets that address quality of
life, health, satisfaction, impact of program design, and system
balancing. 

 

Principles and Goals for Coverage of Individuals with Mental and
Substance Use Disorders 

There is a generally accepted set of principles regarding behavioral
health that may guide the development of new and existing services. We
believe that these general principles can apply to provision of
behavioral health services and cross the lifespan of individuals who
need and use these services. At a minimum, these principles recognize
that: 

* Identifying and treating mental illness and substance use disorders is
essential to improving overall health. 

* Services and programs should be person-centered and support health,
recovery and resilience for individuals and their families who
experience mental or substance use disorders. 

* Individuals and families should have choice and control over all
aspects of their life, including their mental health and substance use
disorder services. 

* Benefit designs should be cost effective and seek to reduce costs
across the health care system for unnecessary services. 

* Services should be of high quality and consistent with clinical
guidelines, evidence-based practices or consensus from the clinical and
consumer communities. 

* Services should maximize community integration. 

 

To effectively implement these principles, CMS has developed some
initial goals that will direct our internal work to support effective
benefit design for individuals with behavioral health disorders. These
goals include: 

* Effective use of screening for mental and substance use disorders,
including strategies to refer and effectively treat individuals with
these conditions. 

* Increased access to behavioral health services for persons with
serious and/or chronic disorders. 

* Improved integration of primary care and behavioral health, and in
some instances, long term services and support to obtain better health
outcomes for individuals with mental and substance use disorders. 

* Better availability of Evidenced Based Practices to enhance recovery
and resiliency and reduce barriers to social inclusion. 

* Strategic development, implementation and testing of new benefit
design and service delivery with models that are taken to scale. 

 

Resources for States 

CMS has identified existing and, in cooperation with our federal
partners, is developing new resources for states seeking to enhance
their efforts to address the service need of individuals with mental and
substance use disorders. These resources seek to support states in their
efforts to improve benefit design, comply with MHPAEA, develop community
integration strategies and coordinate behavioral health care with
primary care and other services. 

 

Supporting an Effective Benefit Design 

CMS is working closely with other federal partners including the
Administration on Children, Youth and Families (ACYF) and the Substance
Abuse and Mental Health Services Administration (SAMHSA) to identify
effective practices for individuals with behavioral health conditions.
Over the past several years, these agencies have developed guidance
regarding these practices. In November of 2011, ACYF, SAMHSA and CMS
disseminated a letter on the appropriate use of anti-psychotic
medication among children in foster care. This guidance offered expanded
opportunities to States to strengthen their systems for prescribing and
monitoring psychotropic medication use among children in foster care.
This guidance can be found at

http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD-11-23-11.p
df 

These three agencies coordinated a technical expert panel on effective
services and supports for children and youth in treatment foster care
settings. The recommendations from this panel will be available in 2013.

In 2010 SAMHSA released a brief describing a "good and modern" mental
health and substance abuse system. This document sought to provide
clarity to federal agencies (including CMS) that regulate or purchase
services for individuals with mental and substance use disorders and
offer guidance to agencies that are presently making decisions about
expanding services to these populations. This may be helpful in
rethinking or constructing a benefit design that includes good
practices. This guidance can be found at
http://www.samhsa.gov/healthReform/docs/good_and_modern_4_18_2011_508.pd
f. 

 

Mental Health Parity and Addiction Equity Act

CMS has released guidance to States regarding the Mental Health Parity
and Addiction Equity Act (MHPAEA). This State Health Official letter can
be found at
http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SHO110
409.pdf. 

Over the past several years the Departments of Labor, Treasury and
Health and Human Services have developed additional guidance regarding
MHPAEA. While focused on commercial group plans, it provides some useful
background information and additional guidance to clarify the 2010
MHPAEA regulations. The Department of Labor's Website also provides up
to the date information including a series of frequently asked questions
that provides additional guidance regarding parity:
http://www.dol.gov/ebsa/consumer_info_health.html. 

SAMHSA's Resource Guide: http://www.samhsa.gov/healthReform/parity also
provides information that may be helpful to understand MHPAEA.

 

Community Integration

CMS has taken several important steps to enhance efforts to integrate
individuals with disabilities, including individuals with a mental or
substance use disorders into home and community settings. In addition,
we are working closely with DOJ, and other HHS agencies to recommend
effective strategies for addressing issues related to the Supreme
Court's Olmstead ruling. This includes participation in SAMHSA's
Olmstead Policy meeting and offering technical assistance in cooperation
with the Department of Housing and Urban Development to states specific
to community integration. This technical assistance includes supporting
states to develop strategies to assure home and community-based services
are offered in settings that comport with the characteristics described
in the 1915(i) and Community First Choice (CFC) program. A description
of these characteristics can be found on page 105 of the Notice of
Proposed Rule Making for the CFC and 1915(i) program
https://s3.amazonaws.com/public-inspection.federalregister.gov/2012-1029
4.pdf. In addition, the DOJ provides an overview of the Olmstead ruling
and questions and answers regarding DOJ's integration enforcement
efforts at http://www.ada.gov/olmstead/q&a_olmstead.pdf. 

 

Integration of Physical and Behavioral Health 

Strategies to integrate primary care and behavioral health services are
paramount to improving the lives of individuals who suffer from
depression, addiction and other chronic diseases. In addition, better
coordination between hospitals, primary care and behavioral health
providers can address the increasing trend of individuals at risk of
suicide. There are many resources available that can improve the
coordination between primary and behavioral health care. For instance,
the Center for Health Care Strategies is the federal contractor
providing information and technical assistance to states in their
development of health homes and strategies for coordinating care for
Medicare and Medicaid beneficiaries. Additional information can be found
at http://www.integratedcareresourcecenter.com. 

 

Applicability for CMS Programs 

There are a variety of current and new coverage options that States may
use to cover behavioral health services. Traditionally States have
amended their Medicaid State Plans to make changes to their benefit
design. However, over the past several years, CMS has new authorities
that can also address the physical, behavioral and long term services
and supports needs for individuals living with a mental health and/or
substance use disorder. A brief description of options to cover these
individuals is presented available at
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Bene
fits/Mental-Health-Services-.html. 

 

Sequencing of Subsequent Bulletins 

Over the next year, CMS will distribute a series of informational
bulletins that will provide further information regarding service
coverage for individuals with mental illness and/or substance use
disorder. The series will address: 

* Prevention and early intervention of mental health conditions for
children, youth and adults. This will include information regarding
screens that can be used to identify the early onset of mental illness
(including conditions related to trauma and suicide) or substance use,
including strategies for enhancing states' efforts to comply with EPSDT
requirements. This bulletin will also discuss strategies for screening,
brief intervention and referral to treatment as well as other preventive
services recommended by the United States Prevention Services Task Force
regarding recommended screening to identify possible behavioral health
issues. 

* Adolescents and adults who use alcohol and illicit drugs. This
bulletin will provide information on services that have been recommended
by SAMHSA and other federal agencies to address individuals who need
short term treatment as well as individuals who have an addictive
disorder that need more long term services and supports. 

* Benefit design for children and adolescents with significant mental
health issues, including serious emotional disturbances. Information in
this bulletin will describe effective benefit design for individuals who
have acute mental health issues including exposure to trauma. The
bulletin will also include long term services and supports that have
been used in the 1915(c) HCBS, 1915(b) waiver programs and various CMS
demonstration including the Psychiatric Residential Treatment Facilities
Demonstration and Money Follows the Person. Another bulletin will
address the structure coverage and payment for the benefit category of
inpatient psychiatric hospital or facility services for individuals
under age 21 to ensure that children receiving this benefit obtain all
services necessary to meet their medical, psychological, social,
behavioral and developmental needs, as identified in a plan of care. 

* Service coverage for adults with a significant mental health
condition. This will include individuals who have a serious and
persistent mental illness, especially those individuals that have
significant health and mental health co-morbidities. 

 

We hope this information will be helpful. CMS is available to provide
technical assistance to States regarding the Medicaid program for
individuals with a behavioral health condition. Questions regarding this
guidance can be directed to John O'Brien at (410) 786-5529. We look
forward to continuing our work together.

 

http://content.govdelivery.com/attachments/USCMS/2012/12/03/file_attachm
ents/178580/CIB-12-03-2012.pdf 

 

-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://kilakwa.net/pipermail/nyaprs_kilakwa.net/attachments/20121204/c3787666/attachment.html>