1 AFFORDABLE CARE ACT UPDATE & EXPANSION OF MENTAL HEALTH SEMINAR
2 Paul Jaconette Chief Operating Officer CenCal Health
3 Progress of Medi-Cal Expansion How is enrollment going? Approx. # of adults receiving CenCal Health eligibility: 1,400 in January (500 in SB and 900 in SLO County) 3,300 February (1,350 in SB and 1,950 in SLO County) Potential 6,500 individuals in CalFresh eligible (both Counties) Patients being fast tracked. State FFS Medi-Cal eligible initially and then CenCal Health eligible (processing backlog at DSS). Enrollment above projections. Good news = patients enrolled. Bad news = specialty access for FFS Medi-Cal members. Who is assisting? Certified Enrollment Counselors and Department of Social Services are working quickly to enroll patients
4 Enrollment in Covered CA How is it going? January (state-wide): 728,410 enrollment (85% eligible for subsidies) January (state-wide) 1.5M enrolled in Medi-Cal What type of coverage? Patients eligible for a subsidy (federal government) selected the Silver Plan 67% of the time Patients not eligible for a subsidy selected the lowest cost selected Bronze, Silver, Platinum and Gold Plans (depending on the cost sharing they preferred in deductible/copay ratio) Covered CA campaigns bringing awareness Over 3,000 patients eligible for traditional Medi-Cal in January and February (6,000 total) both Counties enrolled in CenCal Health
5 Up Next What to expect in the future? Additional services for Medi-Cal members, including Mental Health and Substance Use Disorder Services Integration of Mental and Physical Health services Why is this so important? What services are available? Who will be providing them?
6 The Impact of Mental Illness A major impact on an individual s overall health status and quality of life. Estimated that, on average, people with serious mental illness die 25 years earlier than the general population. Unaddressed mental illness impacts overall health care costs. For Medi-Cal patients with chronic conditions, health care costs are up to 75% higher w/ mental illness. National Association of State Mental Health Program Directors, Morbidity and Mortality in People with Serious Mental Illness (October 2006). Cynthia Boyd et al., Clarifying Multimorbidity Patterns to Improve Targeting and Delivery of Clinical Services for Medicaid Populations, Center for Health Care Strategies (December 2010)
7 Prevalence of Mental Illness in CA In California, about 16% of adult population (more than 4 million people) have mental health care needs. Of those, 1 million adults have a severe mental illness that impairs their daily functioning. About 4% of the population has conditions that are severely disabling and 7% are seriously emotionally disturbed. Significantly higher %s in lower income populations. Human Services Research Institute, Technical Assistance Collaborative, and Charles Holzer, California Mental Health Prevalence Estimates (February 2012), accessed January 30, 2013,
8 Prevalence in Low Income Populations
9 Profound Lack of Coverage A large proportion of Californians lack access to mental health services and may now be eligible. According to the CA Health Interview Survey, less than half of California adults with mental health needs received treatment. Of those who did, less than one-quarter reported that the treatment met their needs. Of the respondents with mental health needs who were uninsured, 69% received no treatment at all. UCLA Center for Health Policy Research, Half a Million Uninsured California Adults with Mental Health Needs Are Eligible for Health Coverage Expansions (November 2012).
10 Is Health Coverage Available? Until passage of 2008 federal Mental Health Parity and Addiction Equity (MHPAE) Act, private health insurance coverage for mental health benefits was significantly more limited than coverage for medical and surgical benefits. Historically, even Medicare required higher cost sharing for mental health services than for medical services.
11 Historical Medi-Cal Coverage In 1991, CA transferred financial and administrative responsibility for mental health programs to Counties. (Carve Out) Public mental health services in CA have been delivered through county systems that operate separately from other publicly funded health care services. (Severe Conditions) Medi-Cal beneficiaries with less severe mental health conditions face significant gaps both in coverage and in access to services. Technical Assistance Collaborative, California Mental Health and Substance Use Needs Assessment.
12 Mental Health and the ACA Under ACA, health plans in Covered CA must cover 10 Essential Health Benefits, including mental health and substance use disorder services. These services must be provided at parity with medical and surgical benefits, in accordance with the 2008 federal Mental Health Parity Act. Benefits to Medi-Cal patients also must meet these requirements, offering mild to moderate coverage. Kirsten Beronio et al., ASPE Issue Brief: Affordable Care Act Expands Mental Health and Substance Use Disorder Benefits and Federal Parity Protections for 62 Million Americans, US Department of Health and Human Services (February 20, 2013).
13 Why CenCal Health? Ensuring access to coordinated mental health and physical health services is imperative to improving population health outcomes.
14 Expansion of Behavioral Health CenCal Health now offers mental health services for eligible Medi-Cal members: Services for the severely and chronically ill will continue to be provided through County Mental Health Departments Psychological services for less severe disorders are covered by CenCal Health (Individual/Group Psychotherapy/Counseling Services, Psych Medication Consults, Testing) Expanded substance abuse services available through County Programs
16 New Partner: The Holman Group CenCal Health partnered with The Holman Group to administer the new mental health benefits on our behalf The Holman Group, based out of Northridge, CA, is a well-established Managed Behavioral Health Organization Arranges for quality mental health services. Holman has developed a contracted network of mental health providers available -- now. Holman offers these services to CenCal Health members and provides support to PCPs.
17 How do patients get access? CenCal Health will continue to cover outpatient lab, supplies and drugs (excluding anti-psychotic drugs) through our lab and pharmacy network. We will also cover mental health services within the scope of PCP practice. Services for mild to moderate conditions will be provided through The Holman Group s provider network. PCPs may refer members for mental health services by accessing Holman Group 24 hours a day, 365 days a year via their toll-free number (800) Members may also self refer by calling directly.
18 How are services arranged? The Holman Group will conduct initial screening and then Arrange for face-to-face assessment w/ mental provider or refer to another appropriate resource or Coordinate with County Mental Health for Specialty Mental Health services on the PCP s behalf if member has severe mental illness. No defined limits on # of visits w/ mental health provider. Benefits are provided based on the level of care needed to make progress towards treatment goals. Note: Couples counseling or family counseling for relational problems are not covered. Medi-Medi members have Medicare Insurance as Primary (seek care through Medicare benefit first)
19 A different type of referral No RAF necessary, just the call Regulations that govern sharing of information related to mental health services more restrictive If PCP needs psychiatric medical consult, information provided over the phone If PCP calls Holman to refer and treat with LCSW/MFT, very little information can be shared (no progress notes) Remember: Patients must agree to seek treatment If PCP and Psychiatrist are co-managing patient, info. on treatment, medication, necessary labs can be shared. CenCal working with Holman to get info. on our website
20 Liz Santillan, Provider Relations Supervisor Jenny Sanchez, Quality Improvement Coordinator
21 Who we are? For over 35 years, Holman has been providing the most comprehensive services in the least restrictive setting We hold one of the oldest specialty behavioral health Knox-Keene licenses in the mental health and substance abuse in CA.
22 What do we offer? Holman s Behavioral Health Benefits Administration Services include the facilitation of all levels of care, including: Individual/group mental health evaluation, screening, testing and brief treatment (psychotherapy) Crisis Intervention and Crisis Stabilization Psychological testing when clinically indicated to evaluate a mental health condition Outpatient services for the purposes of monitoring drug therapy Outpatient services that include lab work, drugs, and supplies Psychiatric consultation Referrals to Other Medi-Cal/Community/County Resources
23 About Holman Holman Healthcare Advisors are compassionate licensed professionals, Range from masters level to psychiatrists who ensure that the appropriate level of treatment is authorized and that the member is progressing. Holman s care management team consists of two Medical Directors and outpatient and inpatient health care advisors.
24 Provider Network The Holman Group has a dynamic global provider network with over 36,000 licensed clinicians. Network providers, accessible to program participants, are licensed professionals experienced in counseling people of all ages and ethnic groups on a full spectrum of issues. Our therapists offer up-to-date therapeutic approaches, such as Cognitive-Behavioral and Solution-Focused therapies.
25 We know what a comforting feeling it is to know that there is someone available every hour of every day of the year. That s why we have the following features in place which set us apart from similar organizations, but, most importantly, keep our members feeling safe is our Nationwide toll-free number with access to Crisis Intervention 24 hours a day, 365 days a year. Provides after-hours services via a Medical Answering service with access to one of our licensed counselors who are on call to assist in crisis situations.
26 Our Member Count 500,000+
27 County of San Luis Obispo Behavioral Health Department Greg Vickery, LMFT Behavioral Health Quality Support Team Division Manager & Compliance Officer
28 Target Population Welfare & Institutions Code Adults with Serious Mental Illness (SMI) ( Serious = severe & persistent) Included diagnosis Substantial functional impairment or imminent risk of decompensation Disabled to the degree public assistance, services or entitlements would be required
29 Target Population Welfare & Institutions Code Seriously Emotionally Disturbed (SED) Youth Included diagnosis Substantial functional impairment in two areas (self-care, school, family, community) And Risk of or removed from home Or Impairments x 6 months or 1 year w/o treatment Or Psychotic features, suicide risk, violence risk
30 Medical Necessity CCR, Title 9,
31 Specialty Mental Health Services Specialty Mental Health Services Medication Support Therapy Case Management & Rehabilitation Services Day Treatment/Day Rehabilitation Crisis Intervention Crisis Stabilization/Crisis Residential (Coming soon!) Adult Residential Treatment Psychiatric Inpatient/Psychiatric Health Facility (PHF) Therapeutic Behavioral Services (TBS) Katie A services: Intensive Care Coordination (ICC) In Home Behavioral Services (IHBS)
32 To access mental health services, or for immediate help, such as Mobile Crisis Services, call (24 hours/7 days a week)