Providing More Access to Quality Mental Health Care / HealthChoice

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good evening everybody I'm Alan dotor line the president of the depression and bipolar support Alliance and it's wonderful to have you all with us tonight for health care reform providing more access to quality mental health care and this is a collaborative presentation by the depression and bipolar support alliance and janssen this promotional educational activity is not accredited and the program content is developed by Janssen pharmaceuticals

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incorporated speakers presents on behalf of the company and are required to present information in compliance with FDA requirements for communications about its medicines this document is presented for informational purposes only and is not intended to provide reimbursement or legal advice nor does it promise or guarantee coverage levels of reimbursement payments or charge it is not intended to increase or maximize reimbursement by any player laws

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regulations and policies concerning reimbursement are complex and are updated frequently while we have made an effort to be current as of the issue date of this document the information may not be as current or comprehensive when you view it we strongly recommend you consult the payer organization for its reimbursement policies and that's a little different beginning then we have for our webinars typically and it's a bit different in format we've delet

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developed this content in partnership with a long time supporter and partner of ours Janssen and like to tell you that about Janssen pharmaceuticals incorporated Janssen is a member of the Johnson & Johnson family of companies & Janssen's dedicated to addressing and solving some of the most important unmet medical needs of our time including mental health Jansen was named after dr. paul janssen a leading Belgian researcher and general practitioner who

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changed the treatment paradigm mental health patients and Jensen remains at the forefront of advancing central nervous system treatments and improving care for people with brain disorders and a bit about VBS a the depression and bipolar support Alliance was founded in 1985 and we r the leading national peer directed organization reaching millions of people through over three hundred chapters offering more than 700 support group meetings as well

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as through online education and support tools dbsa envisions wellness for people living with depression and bipolar disorder it is our mission to provide hope help support and education to improve the lives of people who have mood disorders we at DBS a recognized that there are many paths to wellness and promote numerous treatment components that are beneficial for individual achievement of self defines

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success we believe that a successful approach to mental health is balanced based on equal and trusting partnerships and starts best with a knowledgeable empowered individual so in terms of what we'll cover today much has happened in the last several years to change the landscape of how people living with bipolar disorder access quality mental health care this health care reform is

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the result of legislation on the national level that has an effect on delivery of health insurance plans from employer-sponsored plans to individual marketplace pan plans and state medicaid programs during the next 40 or so minutes you will learn how the Affordable Care Act which is often referred to as Obamacare and the mental health parity and addiction act of 2008 which is often referred to as parity can

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improve access to quality mental health care for people living with bipolar disorder now you may have heard all of these terms but may as a lot of us do main confused on just what they mean to you and how any of this affects your daily life so the goal of today's webinar is to bring some clarity around these topics and provide you with information that will enable you to take advantage of changes in health insurance plans and support you in maximizing access to quality mental health care but

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like any new program whether it is from the government or the private sector the devil is in the details we need to remain vigilant to ensure health insurance plans are implementing these reforms to the full extent of the law in the last section of the webinar I'll review several common scenarios that could present barriers to mental health care and provide you with the tools to help you redress any non-compliance you might encounter so how does one simple

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law accomplish this well for starters the Affordable Care Act mandates that health insurance policy adhere to previously legislated parity laws it provides assistance in paying health care premiums and it increases your options in acquiring health care coverage additionally one significant barrier to obtaining health insurance has been the practice that insurance plans could deny coverage to individuals because of a pre-existing condition in the past people living with bipolar

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disorder could be denied insurance coverage simply because they had sought services in the past for any mental health condition according to statements made by President Obama at the national conference on mental health in june 2013 in any given year one in five adults experience a mental illness 45 million Americans suffer from things like depression or anxiety schizophrenia or post-traumatic stress disorder but today less than forty percent of people with

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mental illness receive treatment but beginning this year the Affordable Care Act requires non-grandfathered health plans to cover essential health benefits among those ten essential health benefits are coverage for mental health and substance use disorder the Department of Health and Human Services has granted implementation of those benefits to the individual states the regulations require that states define essential health benefits or eh BS for policies

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issued in that particular state to meet this requirement each state selected an existing health plan that that was already around as a benchmark to establish services and items included in that state's essential health benefits package the Department of Health and Human Services also offered guidance to the states when choosing a benchmark plan they could select from the following when creating their benchmarks the largest plan based on enrollment in

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any one of the three largest small group products in the state the largest HMO plan offered in the state's commercial market any of the three largest state employee health plans or any one of the three largest federal employee health plan options now as you can quickly see the exact details of mental health coverage will vary slightly from state to state but the intent of this directive was to ensure that all the

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plans offered were consistent in their coverage and this will make it a lot easier for you when selecting a plan in other words the level of mental health coverage offered by one plan must be the same for all plans offered in your particular state generally speaking the Affordable Care Act requires that all Americans obtain health insurance the deadline for open enrollment was March 31st although many people began using

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these new plans at the first of the year therefore we're now able to see and get some idea about how these plans are going to work in supporting access to mental health care so first of all how do you obtain health insurance one way to obtain coverage is through your employer sometimes calls group health insurance plans and they refer to a number of individuals covered under a single health insurance contract it's usually a group of employees in this case

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companies provide a health benefit for employees of a business or members of an organization while no employer must offer coverage some larger businesses may have to make a payment in twenty fifteen or twenty sixteen if they choose not to offer group insurance to their employees employers with less than 50 full-time employees however are not subject to the employer shared responsibility payment parts of the law

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then there's individual and family health insurance and this is a type of health insurance purchased by an individual or family as the name suggests but independent of an employer group or organization individuals can purchase insurance for themselves and their families from the healthcare marketplace and we'll go into detail on who is eligible and how you can acquire healthcare insurance from the marketplace during this webinar including how to evaluate your annual out-of-pocket costs in other words the total amount of money you will need to

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spend on health care needs for you and/or your family in any given year another significant new way to access health insurance is through Medicaid expansion the federal federal government has provided incentives for states to expand their Medicaid programs some states are expanding and others haven't therefore your eligibility and coverage options depend on the state in which you live as well as your income and household size and other factors and

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we'll cover this in a little more detail in just a few minutes so the question am i eligible to purchase health insurance from the healthcare marketplace well generally speaking anyone who does not currently have health insurance is eligible to purchase a plan on the healthcare marketplace but there are always exceptions so for our conversation today we will focus on the general population and not

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the exceptions that do exist if you do not currently have insurance and are not eligible for Medicare you can purchase health insurance on the health care marketplace the open enrollment period clothes on March 31st but if you had insurance prior to March 31st and no longer have it due to a change in your personal circumstances like changing jobs or no longer being employed you may still be able to imply at to apply excuse me and the next open enrollment

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period is coming up on November 15th you may already be purchasing health insurance for yourself but regardless you can still purchase insurance from the marketplace and you may find by shopping and comparing that you find a more affordable plan tailored to fit your particular needs if you own a small business that employs 50 people or less you can purchase insurance from the marketplace a special word about employer-sponsored plans even if your

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employer offers insurance you can still purchase from the marketplace now why would you want to do that well perhaps your employer's plan does not meet the minimum standards for essential benefits for your state your employer is required to provide you with documentation outlining the plan and whether or not it does meet those minimum standards and if they've not provided that documentation you are entitled to ask for it now what if your employer offers a plan but it is

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extremely expensive the Affordable Care Act takes that into consideration as well if the employer sponsored plan for an individual plan costs more than nine point five percent of your income you can purchase insurance on the marketplace and receive subsidies regardless of whether or not you qualify for tax credits you can still purchase a plan on the marketplace you just won't receive the subsidies now this next slide shows a map of the

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country the dark gray represents the states that have adopted the Medicaid expansion program while the light gray represents those states that were not considering Medicaid expansion as of februari this continues to be a fluid situation as state legislators take up the issue in the General Assembly's you should contact your State Health and Human Services Agency to learn more about the options in your particular State one of the intents of the Affordable Care Act is not only to make

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in health insurance accessible for those who may have been excluded due to pre-existing conditions or reaching maximum coverage limits in their current policies but also to make it affordable healthcare gov provides this chart that demonstrates three different ways in which you may qualify for assistance in acquiring health insurance so if you go to the horizontal line across the top and select the number of members in your family then look at the boxes down the

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side of the chart and select your income the first row in this chart is applicable for middle-income people who are not eligible for coverage through their employer Medicaid or Medicare these individuals can apply for tax credit subsidies which are available through state-based exchanges and individual making between eleven thousand four hundred ninety dollars and forty-five thousand nine hundred and

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sixty dollars would be eligible for income tax credits to help cover the cost of the insurance premium for example an individual making between eleven thousand four hundred ninety dollars and twenty-eight thousand seven hundred and twenty-five dollars would not only be eligible for support in paying the premiums but could be eligible for lower out-of-pocket expenses so this could mean help in covering the costs of psychiatric visits or the cost of medications additionally

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states have the option to expand their Medicaid programs to cover all people may up to a hundred and thirty three percent of the federal poverty level which is about sixteen thousand dollars for one person this may be one of the most significant changes in increasing access to health care typically typically Medicaid provides coverage to people on disability mothers and children living

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at the poverty level defined by the number of people in their family but the medicaid expansion program raises threshold to 133 percent of the poverty level however the states had the option to opt out of Medicaid expansion and in those states that opted out of expanding Medicaid as shown in row for some people making below this amount will still be eligible for Medicaid some will be eligible for subsidized coverage through marketplaces and others will not be

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eligible for subsidies using a calculator at the kaiser foundation website you can enter different income levels ages and family sizes to get an estimate of your eligibility for subsidies and how much you might expect to pay for your health insurance based on your individual circumstances so in terms of what you can expect to pay insurance purchase on the marketplace has a cap for out-of-pocket expenses for

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individuals that cap is six thousand three hundred and fifty dollars and for families it's twelve thousand seven hundred and fifty dollars this raises to six thousand six hundred dollars for individuals and thirteen thousand two hundred dollars for families in 2015 what that means is if you are an individual you will not spend more than 6350 on total healthcare expenses and the total expenses you will incur for

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your entire family would not exceed 12 thousand seven hundred and fifty dollars as I noted this amount will go up slightly next year but once you reach those thresholds the plan picks up one hundred percent of any future health care costs some examples of out-of-pocket expenses include deductibles co-pays or coinsurance and prescription drug costs so what about premiums these are the monthly amounts you pay to the insurance carrier for

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your insurance plan and plans are categorized as bronze silver gold or platinum the deductible is the amount you must pay out of your own pocket before the health insurance plan kicks in so if you have for example a bronze plan be prepared to pay about five thousand and eighty dollars in a deductible compared with a much lower 1227 dollars for your gold plan so it's

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important to compare both the monthly premium and the deductible when you're comparing plans many services like doctor visits may be available without meeting the deductible limit first this is where co-pays or co-payments and coinsurance come into play a copay is a set amount you pay for a service for example you might pay twenty dollars or forty dollars for a visit to the doctor

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another way that expense can be calculated is as a percentage of the total cost of the visit that is what we mean when we talk about coinsurance so if your visit to a therapist for example is a hundred and twenty-five dollars with a copay plan you would pay us that amount and it's usually twenty dollars or forty dollars however if your plan uses the co-insurance formula it could be fifty dollars for example if the coinsurance amount was target targeted

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at forty percent of the total cost of the doctor's visit so the percentage of co-insurance varies by plan level the coinsurance amount for the bronze plan which has the lowest cost premiums is typically forty percent and then the higher your monthly premium costs the lower accordingly you can expect the coinsurance percentage to be now the other expense category people living with bipolar disorder will want to consider is the costs for prescription drugs which will vary from

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plan to plan and as you can see this can be confusing the ACA requires that all plans provide a summary of benefits for their plan the summaries of benefits look identical from plan to plan so that it's easier to compare and among the information that must be provided in the form is the cost of the monthly premium the cost of the annual deductible and the cost of any co-pays or coinsurance as well as the prescription drug

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coverage so in terms of choosing what plan is right for you the information about the level of coverage is particularly important for those of us living with bipolar disorder in addition to information on the cost of the monthly premium the annual deductible co-pays or coinsurance and prescription drug coverage it's important to view the list of in-network doctors and the cost for seeing an out-of-network doctor or

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getting services at an out-of-network hospital so while it's true that the maximum out-of-pocket expense remains the same six thousand three hundred and fifty dollars for individuals each plan has a different mix as to how that maximum is reached so understanding that mix becomes the real heart of how we compare plans so does the plan charge a copay or use a coinsurance formula is your doctor in network or out all of

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these factors will make a difference on how much you end up paying for mental health services is your psychiatrist in network the summary of benefits should clearly state what the costs are for using out-of-network services and we can't assume that these costs will apply to annual deductibles some do and some don't in other words you could be paying eight hundred dollars a year towards psychiatric services out of your pocket if your doctor we're out of

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network and you find that none of the out of network expense has been applied towards your annual deductible so it's incredibly important to read and understand the fine print prescription drugs are another area of cost confusion and again it's important to look at the difference between co-pays and coinsurance a copay of ten dollars drug that costs a hundred dollars is a lot less expensive than coinsurance of twenty percent which would cost twenty dollars for that same drug and some plans won't pick up prescription drugs

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until your deductible is met thus there's all the more reason to understand if these you pay out of your own pocket for out-of-network doctor's visits such as this psychiatrist visit will be applied towards your deductible and then another area of some confusion around drugs are the plans formulary the formulary is the list of available medications the particular plan may for example state that the cost to you for

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the generic drugs is zero dollars and for a Tier one drug is forty-two your two drug is 100 however the drug formularies are not part of the summary of benefits and it's extremely difficult to get access to an insurance plans drug formulary prior to enrolling unfortunately you may not know the true cost between one insurance companies prescription drug coverage and another's until you have enrolled in the plan now

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in terms of how mental health parity increases access people who are living with bipolar disorder have often found that their insurance coverage was inequitable when it was compared with other benefits offered in medical plans for quote unquote physical health conditions many plans enforce much higher financial obligations and set higher bars for defining when care was necessary than they did for these other medical conditions and this blatant

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discrimination experienced a severe blow with the passage of the 2008 mental health parity and addiction Equity Act while the law went into effect in 2009 many plans were exempt from implementing it or were not providing mental health coverage so there was not a question of it being on par with the other coverage much of this disparity has thankfully been resolved through the Affordable Care Act which requires that group

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insurance plans for employers with over 50 employees and the Federal Employees Health Benefits program State Children's Health Insurance program's some state and local government health plans and any plan purchased through the health insurance marketplaces adhere to provisions in that 2008 act and is dated before the ACA lists mental health as one of the essential benefits that all plans must offer so that means most

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mental health but most excuse me that means that most health plans are required to provide mental health benefits and they need to be equal to benefits for other medical conditions that are offered in the plan insurance carriers carriers must also provide consistency around decisions for determining what is quote medically necessary they must apply the same standards they use in determining limitations on other medical conditions again this does not mean that they must

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decide that all mental health treatment programs are medically necessary but they can't have a different set of standards for determining that threshold finally the criteria for deciding if the subscriber is eligible must be transparent that means the insurance carrier must make the information use to make whatever decision they ultimately make available to the subscriber so if a plan is required to follow parity rules you can expect equal coverage when it

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comes to treatment limits and payment amounts with respect to inpatient in-network and out-of-network outpatient in-network and out-of-network intensive outpatient services partial hospitalization residential treatments emergency care prescription drugs co-pays deductibles maximum out-of-pocket limits geographic locations facility type and provider

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reimbursement rates a key component of the Act is that health insurance plans must ensure that the financial requirements of the plan such as deductibles co-pays and coinsurance are no more restrictive than for other benefits offered in the plan so your plan can't charge a higher copay or higher coinsurance percentage to see and in network psychiatrist than it does to see any other in-network medical

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specialists of any other kind for example the plan also can't have two separate deductibles one for physical and the other for mental health conditions in other words if your deductible is a thousand dollars you reach that thousand dollar limit by adding up all of your plans to find out of pocket medical expenses if you had surgery for example and met the $1,000 deductible the plan can't tell you that you have to meet a new separate

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deductible for mental health care this also applies to the lifetime dollar amount limits if there are no lifetime limits for other medical conditions that can't be lifetime limits placed on mental health coverage the Act also addresses treatment limitations meaning limits on the frequency of treatment the number of visits days of coverage or duration of treatment if it doesn't have these same restrictions in place for other medical conditions now it's

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important we not confuse parity with meaning you can have unlimited treatment however what it does mean is that what is offered for mental health must be the same as what is offered for other medical conditions the plan also can't place Geographic restrictions on where you receive treatment if it doesn't have the same restrictions for other medical conditions and this can be particularly important for people who live in rural areas where there is less access to

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quality mental health care in particular if if the plan can't allow a subscriber to obtain mental health care at a large urban teaching hospital miles away from their home it can't restrict a person with bipolar disorder from seeing a psychiatrist at that same institution if those doctors are in network while the health care reform victories won in the recent years clearly provide increased access there unfortunately still barriers so for the remainder of the

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webinar will look at some common health care reform scenarios for people who live with bipolar disorder and explore how they might be looked at and handled so we'll look at some case studies so to speak and we'll start off with Joseph 35 years old has a diagnosis of bipolar disorder he has past experience working with a major corporation as a social media manager stable relationship with a psychiatrist been seeing for five years

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also sees a therapist twice a month takes five different medications to treat bipolar disorder and high blood pressure Joseph lost employer-sponsored group health insurance when he left his last full time job and the Cobra premiums are too expensive for him to afford those he hopes to work periodically as a consultant he's never considered whether or not he is eligible for Medicaid assuming it was only of

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available for mothers with children and because his annual income had been too high so here are the key issues to consider with Joseph and whether he's eligible for Medicaid if his state is participating in the Medicaid expansion he may be eligible if he anticipates that his annual income will now be less than fifteen thousand two hundred and eighty two dollars he could explore this option the recent

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health care reforms have also increased the definition of quote-unquote medically frail to include quote individuals with disabling mental disorders so this means that Joseph might have two options available for his coverage the standard Medicaid program or the alternative benefit package developed by his state typically the Medicaid programs offer more robust

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coverage than these alternative benefit packages so he will want to see first if he qualifies as medically frail because Joseph is able to obtain periodic freelance or consultant work he's unsure of what his income will be but at the moment he has some clients lined up that would push his income above the ceiling to consider for Medicaid coverage however he still projects that he'll make less than forty nine thousand nine hundred and sixty dollars in the coming

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year so he may qualify for subsidies from the federal government which would lower his premium payments and because he has had a qualifying life events he can apply for insurance even though the open enrollment period has closed when he goes to the marketplace exchange he will be required to estimate his annual income that means Joseph needs to do a very realistic and careful assessment because there are consequences to both

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under and over reporting annual income the federal government can adjust his premiums throughout the year based on his own self reporting of this estimate of annual income as it changes if his consultant business does not prosper or if he proves unable to work Joseph can apply for Medicaid if his income falls below the roughly fifteen thousand dollars as stated earlier joseph has stable relationships with his mental health providers he wants to keep them he has numerous out-of-pocket expenses paying for

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visits and medication so when comparing plans is essential that that Joseph review the in network doctors if his doctors are out of network he needs to know what the coverage is for those out of network clinicians he also needs to look at the plans prescription drug coverage Joseph takes generic drugs and he knows that many plans offer generic drugs for free but he can also see that some plans require that he meet the deductible before the plan picks up the

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cost of medication so Joseph needs to weigh the total out-of-pocket costs which include premiums before deciding what plan is right for him and we'll take another case study number two is Aaron Aaron is a student and attends College away from home Aaron also has bipolar disorder and his mother Ellen works for a small architectural firm has

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less than 30 employees every year the architectural firm brings in the owners good friends who is an insurance agent and offers the employees and opportunity to purchase health insurance for their families Aaron takes several generics and a one brand medication to treat bipolar disorder and also sees a psychiatrist when Aaron returned to college in September and picked up the refill for his prescription which used to cost thirty dollars now costs a

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hundred dollars so Ellen Erin's mother suggested Aaron try to find a local psychiatrist and see if there's an alternative Aaron had seen an in-network doctor while away at school for other ailments never had a problem locating a doctor however when he looks for an in-network psychiatrist none were listed in the plan ok in this situation the key issues to consider first of all Ellen his mother works for an employer with

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less than 50 employees so this this company is not required to offer insurance to the employees the insurance agent that offers the plan is now required to offer health insurance marketplace plans when presenting the plans to be employees so in terms of resolving the barriers to care since the insurance agent is offering plans that are not off the marketplace exchange the plans are not governed by ACA or by

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parity rules when Ellen inquired as to the price increase she was told that the insurance company had moved the brand medication to a more expensive tier insurance plans are allowed to change their formularies and determining the cost here for prescription drugs without notice at any time this is true for all plans whether or not they are governed by the Affordable Care Act with regards to locating an in-network psychiatrist Ellen and Erin still have no recourse because the plan is not governed by the

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Affordable Care Act or parity rules now while Ellen did not have recourse I hope that it's evident that there are many ways that we have increased access to mental health care because of these health care reforms and always an educated consumer is the most successful advocate the key is to be willing to work in concert with both your health care providers and the insurance

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carriers to obtain favorable results these case studies are only a very high level overview on the ways in which access to mental health care has improved as a result of health care reforms but I encourage you to learn as much as possible about the topic and then share your knowledge with others so that we all enjoy fair and equitable access to quality mental health care let's look at another scenario this is

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Susan 45 married to Bob Susan's covered under her husband's group employment excuse me group employer health insurance policy recently Bob's been concerned about Susan's erratic havior tried to talk to Susan but she insists that nothing is wrong tonight when he came home from work Susan was still in bed she said she couldn't see any reason to get up today tomorrow or the next she told Bob that she was going to swallow the bottle of pills by her

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bedside Bob immediately got Susan in the car and took her to the emergency room at their small rural Hospital the ER doc told Bob that Susan should be admitted to a hospital 60 miles away where they could actually provide mental health services and Susan agreed to go after five days in the hospital she was released and it was recommended that she began a partial hospitalization program the partial hospitalization program was

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meeting from nine to three Monday through Friday when Susan showed up for the program the next day she was told that her insurance would not cover the program because they said it was not medically necessary Bob also received an explanation of benefits in the mail from the insurance company denying the hospital stay because there was a hospital closer to home the community hospital where he had first taken Susan so as we look at this scenario the key

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issues are that the same criteria for defining medically necessary and for defining the geographic location of treatment must be applied to mental health in the same way as its applied for mental health conditions so Susan and Bob have the right to learn from their insurance carrier carrier what criteria are used to define medically necessary once they understand the criteria working together with healthcare providers and the insurance

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company they may be able to come to a better understanding and ultimately agreement as to why a particular intervention is medically necessary / the advice of the doctors in question the important thing to remember though is to ask and to be willing to work and collaborate with both your provider and the insurance carrier so you can collaborate to resolve issues I'm really grateful to all of you for listening to admittedly very complicated

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information the prospects as I hope you've seen through the presentation today are very good for those of us who are affected by mental health conditions and depression and bipolar disorder it is a time when there should unquestionably be broader and more complete access to quality mental health care still we need to make sure to educate ourselves about the various ways in which the Affordable Care Act and mental health parity will affect us

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individually and to be committed to sharing what we learn with others and working collaboratively with providers and insurance carriers so that we realize the wonderful benefits of these plans I'd like to thank all of you for participating today I'd like to thank our colleagues at janssen for making it possible for us to present this information and I hope you will continue to look at all of our educational resources about treatments about

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coverage advocacy and all of the issues affecting those of us who live with depression and bipolar disorder thanks so much for your time tonight and we look forward to welcoming you to other webinars in the future thank you you you you you you

Providing More Access to Quality Mental Health Care

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SENIOR PRESCRIPTION COVERAGE

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SENIOR VISION COVERAGE