Toolkits Guide State Advocacy for Medicaid MH Services

The Affordable Care Act (ACA) includes provisions that may make it possible for state Medicaid managed care plans to dramatically improve services for people with mental illness by providing a range of home- and community-based services not typically available. These provisions may be implemented even in states that do not opt to expand Medicaid eligibility under the ACA.

Advocating for those changes at the state level, however, requires teamwork and coalition building, as well as a level of technical expertise that many psychiatrists may lack.

Now, APA is providing members two online toolkits around state-based advocacy for these services. They were developed by a special action-oriented work group on health care reform appointed by former APA President Jeffrey Lieberman, M.D., and chaired by Howard Goldman, M.D., Ph.D., editor of Psychiatric Services. They provide a practical strategy for taking advantage of opportunities—some of which made possible by the ACA—to improve Medicaid services for people with mental illness.

(A new work group to continue this work has been appointed by APA President Paul Summergrad, M.D., and is chaired by APA Trustee-at-Large Anita Everett, M.D.)

One of the toolkits, “Managing Managed Care: A Toolkit for Advocates,” outlines the historical role Medicaid has played in behavioral health care and how its role as the core financing mechanism for individuals, particularly those with serious mental illness, has been enhanced and enlarged by the ACA—most significantly because in those states accepting the ACA’s incentives to expand Medicaid eligibility, many previously ineligible lower-income children and adults will now have access to Medicaid coverage.

The second toolkit, “An Advocacy Toolkit—Improving Care for People With Serious Mental Illness: Medicaid’s 1915(i) Option,” focuses on a little-known provision in the ACA that allows states to provide a host of ancillary services—such as Assertive Community Treatment and supported employment—under their Medicaid programs.

Both toolkits were developed with the consultation of Michael Hogan, Ph.D., a former state mental health commissioner who also chaired the President’s New Freedom Commission on Mental Health.

In an interview with Psychiatric News, Goldman said the approach of both toolkits is to provide an “advocate’s guide” specifically focused on opportunities and risks under Medicaid, including various managed care approaches, with suggestions on how to address these challenges via collaborative, issue-focused advocacy. The toolkits address issues that are relevant even in states that do not expand their Medicaid programs under the ACA.

The Medicaid managed care toolkit outlines several “best practices” for care of people with serious mental illness that can be achieved under Medicaid managed care (as well as some of the barriers and obstacles, well known to psychiatrists working in public settings, to achieving best practices). Among them:

“Best practices in managed care would include covering all these services, while employing clinically sensitive care management tools to ensure that consumers get care appropriate to their needs and preferences,” according to the toolkit. “Additionally, Medicaid should cover Assertive Community Treatment for adults, wraparound services for youth, and peer specialists; have close coordination assured for housing and employment services; and have a periodic process of modestly adjusting or improving benefits with new investments or savings.”

The second toolkit focuses on a provision in the ACA known as 1915(i). “The 1915(i) option allows—but does not require—states to create home- and community-based services by amending their Medicaid state plans,” the toolkit states.

“The state’s 1915(i) plan may target particular populations (individuals with SMI are specifically mentioned as a possible eligible group), and different programs may be developed for different populations. The 1915(i) option does not require cost neutrality. … The ‘package of services’ allowable under the option is quite flexible. It may include traditional services (clinic, medication, and inpatient services) … but states may also propose and include [with CMS approval] some services not traditionally covered under Medicaid …if they are essential to the individual’s treatment/rehabilitation. Importantly, 1915(i) services are individualized and provided to persons who meet clinical eligibility criteria based on an individual plan that is based on an assessment of needs. …”

“With many pressures on state Medicaid programs, advocacy and support may be needed to encourage them to take this step. This is an opportunity for psychiatric leadership—preferably in conjunction with natural allies such as the National Alliance on Mental Illness (NAMI), Mental Health America (MHA), and community mental health centers—to improve care.”

Goldman explained that for decades the Medicaid program has offered states the opportunity to obtain “waivers” to include these services—but with the caveat that they had to be shown to be budget neutral. But because Medicaid has never paid for inpatient care in freestanding psychiatric hospitals for beneficiaries between ages 22 and 64—costs for which would likely be reduced by better provision of home- and community-based care—the mental health community has found it difficult to prove cost neutrality.

The ACA 1915(i) provision removes that requirement, Goldman said, and it opens the door for states to be more creative in how they align services for people with mental illness.

Both toolkits emphasize that capitalizing on these opportunities will require a coordinated approach by clinicians, advocates, patient-rights groups, policymakers, and others. Among the toolkit’s practical list of recommendations for how to get started are the following:

“This is an opportunity for psychiatrists and other advocates to really dramatically expand services for people with mental illness,” Goldman said. “But for this to happen, they will have to form partnerships with each other and with other state-based advocates such as NAMI and MHA. Psychiatrists should be an informed part of these coalitions and can take a lead in this state-based advocacy.” ■

The toolkits are posted on APA’s website and can be accessed here.