Medicaid’s role in low income individuals access to mental health services

Medicaid plays a significant role in providing treatment for low income individuals with mental health conditions. Medicaid recipients usage of mental health services “is comparable to and sometimes greater” than usage among privately insured individuals, according to a Kaiser Family Foundation (KFF) analysis. In 2015, Medicaid covered 22 percent of nonelderly adults with mental illness and 26 percent of nonelderly adults with serious mental illness. KFF found that Medicaid coverage of mental health services is often more comprehensive than private insurance coverage.

Analysis Findings

The analysis (1) describes individuals with mental health conditions, and (2) compares the mental health needs and the receipt of services among individuals without insurance, with Medicaid, and with private insurance. KFF provided the following findings:

  • Characteristics of nonelderly adults with mental illness. Twenty percent of nonelderly adults have a mental illness. They are predominantly white, female, and under 50. Five percent have a serious mental illness. Most are employed (63 percent), but 4 in ten have low incomes and 22 percent are below poverty. In addition, nonelderly adults with mental illness often have co-morbid conditions.
  • Utilization of mental health services. Most nonelderly adults with mental illness have either Medicaid or private insurance. Those with Medicaid are more likely to receive treatment than those with private insurance or without insurance. In addition, the receipt of psychiatric medication is more common among those individuals covered by Medicaid.

The role of Medicaid expansion

The Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148) and the Health Care and Education Reconciliation Act of 2010 (HCERA) (P.L. 111-152), (together referred to as the Affordable Care Act (ACA)) expanded Medicaid coverage to millions of low-income Americans. Sections 2001 and 2002 of the PPACA as amended by 1004 and 1201 of HCERA enabled many low-income individuals with mental health conditions to obtain coverage and access treatment through state Medicaid programs that choose to expand.

KFF pointed out that the American Health Care Act of 2017 (AHCA) (H.R. 1628), introduced by Republicans and passed by the House of Representatives on May 4, 2017 would limit enhanced federal support for the expansion population. The Congressional Budget Office projected that the reduction in federal funds would result in a cut of $834 billion over 10 years. “A reduction in federal funds of this magnitude would likely cause states to decrease Medicaid payment rates, covered services, and/or eligibility, limiting states’ ability to reach people with mental health conditions,” KFF said.

How the AHCA directly impacts significant parts of the ACA

Six weeks after pulling the American Health Care Act (AHCA) (H.R. 1628) from consideration, the House of Representatives passed an amended version of the bill on May 4, 2017, by a vote of 217 to 213. The legislation makes significant changes to some parts of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), in particular repealing the employer and individual mandates; scaling back Medicaid expansion; and repealing many of the taxes included in the ACA. The House also passed H.R. 2192, which would eliminate provisions that exempt members of Congress and congressional staff from state waiver provisions, in response to criticisms that the AHCA would affect all Americans except those voting on the bill (see The AHCA strikes back, Health Law Daily, May 4, 2017).

The Senate is now considering the legislation, and is likely to make substantial changes to the AHCA, or even start from scratch on new legislation. Moderate Republican senators in particular are concerned about the changes to Medicaid coverage that roll back the ACA’s expansion of the program.

This White Paper will compare provisions of the AHCA with the ACA. One thing to note at the outset is that the ACA as enacted in March 2010 included 10 titles, while the AHCA makes significant changes to only three of the titles. Much of the ACA, especially related to the Medicare program and the training of various types of medical practitioners, therefore, would remain intact if the AHCA passes in its current form.

In addition, the Trump Administration has stated more than once that it sees the rollback of the ACA as occurring in three stages—(1) legislation to repeal or change ACA provisions that would allow the Senate to pass a bill with a bare majority under the budget reconciliation process; (2) administrative actions to provide patients with additional insurance options and give states more flexibility in Medicaid spending, and (3) legislation on Trump’s other priorities including sale of health insurance across state lines and medical tort reform (see Is the American Health Care Act a ‘critical first step’ or unsupportable?, Health Law Daily, March 8, 2017).

Read further, “How the AHCA directly impacts significant parts of the ACA.”

For more information, visit http://health.wolterskluwerlb.com or call 800-449-6435.

HHS to receive $73.5B under House funding bill, ACA left out

The 2017 Omnibus Appropriations bill allocates a total of $73.5 billion to HHS for the 2017 Fiscal year, ending September 30, 2017. The House Appropriations Committee released the fiscal year 2017 Omnibus Appropriations bill on May 1, 2017. The bill provides discretionary funding for the federal government and prioritizes health while cutting funding for “ineffective or wasteful programs.”

HHS

The HHS funding represents an increase of $2.8 billion above the 2016 enacted funding level and $3.8 billion above the Obama Administration’s budget request. The budget is split among various agencies within HHS to fund what the bill calls “effective, proven programs.”

Funding

The bill allocates $34 billion to the National Institutes of Health (NIH) for research related to Alzheimer’s, antibiotic resistance, and precision medicine. The legislation includes funding for critical disease prevention and biodefense activities by allocating $7.3 billion for the Centers for Disease Control and Prevention (CDC). The bill provides the Substance Abuse and Mental Health Administration (SAMHSA) with $3.6 billion for 2017, with a focus on prevention and treatment of opioid and heroin use. The legislation provides $6.4 billion for HRSA Health Resources and Services Administration (HRSA), in part to fund Community Health Centers.

CMS and the ACA

The bill allocates $3 billion for CMS program management and operations and, notably, does not provide funding to implement Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) programs. The bill continues prohibitions and restrictions on use of federal funds related to the ACA.

Idea of proactive compliance plagues 60-day report and refund rule

The final rule implementing the 60-day report and refund statute was a “mixed bag” for providers because it provided guidance to mitigate risk but perpetuated uncertainty by relying on vague terms, said Robert L. Roth, managing partner at Hooper Lundy & Bookman, PC, and James S. Hinkle, vice-president and chief compliance officer at Ardent Health Services, at the American Health Lawyers Association’s Institute on Medicare and Medicaid Payment Issues. Roth and Hinkle emphasized that the buck stops with providers, even if they did not cause the overpayment.

Overpayments

Section 6402(a) of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) added Soc. Sec. Act Sec. 1128J(d) to provide that a person that receives an overpayment must report and return the overpayment within 60 days of when the overpayment was identified or when the corresponding cost report was due. CMS issued a final rule (81 FR 7564) February 12, 2016, effective March 4, 2016, implementing section 6402(a). Examples of overpayments include: (1) Medicare payments for noncovered services; (2) Medicare payments in excess of the allowable amount for an identified covered service; (3) errors and nonreimbursable expenditures in cost reports; (4) duplicate payments; (5) lack of medical necessity; and (6) insufficient documentation.

Proactive compliance

The final rule provides that an overpayment is “identified” if the person fails to act with reasonable diligence and the person in fact received an overpayment. CMS stated that “reasonable diligence” includes both proactive and reactive compliance. Roth and Hinkle concluded that the proactive compliance standard “raises the stakes”–the preamble does not explain the legal basis for proactive compliance, and the standard is “unreasonably vague” in light of possible civil money penalties, exclusion, and False Claims Act liability. They asked if a provider did not but arguably could have identified an overpayment by being proactive, has the provider identified an overpayment and, if so, when does the 60-day deadline start?

Quantification

An overpayment has not been “identified” until it is quantified or should have been quantified with reasonable diligence. However, CMS declined to adopt a minimum materiality threshold.