Week 6: Mental Health Coverage and Long-Term Care

Question 1

What are the mental health issues that are most common at an early vs. late age?

Answer 1

○ Children
■ Mood disorders: Depression, oppositional defiant/conduct disorder, eating disorder,
ADHD, and substance abuse

○ Adults
■ Anxiety disorders: phobias, panic disorder, generalized anxiety disorder, PTSD

Question 2

Where are mental health services primarily provided? Outpatient vs. inpatient vs.
community-based? Home health?**

Answer 2

People with serious mental illness also require non-medical services (income support, vocational
training, housing assistance)

Question 3

What is the Mental Health Parity Act of 1996?

Answer 3

○ Originally was enacted to apply to group health plans (typically purchased by employers) that
offer both behavioral health services and medical/surgical services
○ Cannot impose annual or lifetime dollar limits on mental health benefits as compared to
medical/surgical benefits

Question 4

What is Medicaid Section 1115 Behavioral Health Waivers?

Answer 4

Under the waivers, states have considerable flexibility to:
○ Expand eligibility to individuals who are not otherwise Medicaid or CHIP eligible.
○ Provide services not typically covered by Medicaid.
○ Use innovative service delivery systems that improve care, increase efficiency and
reduce costs.
Authorizing federal Medicaid payment for mental health services provided to people in IMDs.
These include services for adults with a serious mental illness (SMI) or for children with a
serious emotional disturbance (SED).

Question 5

What is the most common service(s) provided to individuals on an outpatient
basis with mental health?

Answer 5

Psychotherapy/ talk therapy/ Counseling

Question 6

What is the biggest payer for mental health care services in the US healthcare
system?

Answer 6

○ Medicaid is the largest sources of financing for MH & substance use disorders
■ 28% total expenditure
■ Many w/ serious mental illness qualify for Medicaid b/c they get
Supplemental Security Insurance SSI (5% of total pop)
● Since 1972, states are required to provide Medicaid coverage to SSI
recipients
● By 2009, 41% of SSI recipients under 65yrs qualified for SSI on the
basis of mental illness

○ With implementation of ACA, expanded to more individuals who have mental illness

Question 7

What is the Mental Health Parity Addiction Equity Act (MHPAEA)?

Answer 7

○ Adds substance use disorder services to the 1996 medical health parity act

Question 8

What did ACA add to the Mental Health Parity Addiction Equity Act
(MHPAEA)?

Answer 8

○ Amended by the Patient Protection and Affordable Care Act (Health Care and Education
Reconciliation Act of 2010) to apply to individual health insurance coverage
○ Requires group health plans and insurers that offer mental health and substance use
disorder benefits to provide coverage that is comparable to coverage
○ ACA added: Apply to individual health insurance coverage (not just employer based)

Question 9

What is the alternative benefit plan (ABP)?

Answer 9

○ Adults newly eligible for Medicaid under the Medicaid expansion must receive an alternative
benefit plan (ABP)
○ at state option, may or may not include all services covered by the traditional Medicaid
state plan
■ ABPs must cover all ACA’s essential benefits
■ Comply with mental health and substance abuse parity
■ However, states have flexibility in designing APB
● Match ABP to traditional state plan
● Base ABP on market based coverage

Question 10

What is long-term care? Name some of the populations who may need long-term
care services.

Answer 10

○ Incudes health, social, housing, transportation, and other supportive services needed by
persons with physical, cognitive, and /or mental limitations that impede a person’s ability to
be (I) in ADL
○ The need is usually evaluated by the person’s difficulty with ADL and IADL
○ 13 million people in US require assistance with one or more ADLs or IADLs, thus are
considered in need of LTSS
○ Age 65+ may need long-term care services. Followed by 65-74, 75-84, 85+
■ With the Aging of America, the demand for LTSS is expected to
increase in the coming decades
● “Baby Boomers aging”
● Medical advances and technology find more ways to maintain life
Increased Life expectancy

Question 11

What are the eligibility criteria for Medicaid coverage for long term care services
and support?

Answer 11

○ To qualify for Medicaid and LTSS (Low incomes, Limited assets, Based on functional needs
(1 or more self care or household activities), Have Supplemental Security Income (SSI))
○ Coverage of home and community-based services (HCBS) can be provided at the state
discretion
■ Traditionally, had to meet institutional level of care to qualify for Medicaid HCBS
■ The Deficit Reduction Act of 2005: Gives states option to provide HCBS with
functional limitations that do not rise to institutional level of care (Kaiser fact sheet
2016)
■ Home and community-based waiver programs are special programs that are run by
states to provide services to those who live in the community but are at risk of
needing institutional care. States have also used waiver programs to assist specific
populations such as people with developmental disabilities, the elderly, or people
with HIV/AIDS.

Question 12

What is the difference between Medicaid and Medicare coverage for LTC?

Answer 12

Question 13

What is the most common reason for nursing home placement?

Answer 13

Absence of home caregiver

Question 14

What is the states’ obligation under the U.S. Supreme Court Olmstead decision?

Answer 14

Home and community-based setting
○ State’s Obligation under the U.S. Supreme Court Olmstead decision to provide services to
persons with disabilities in community settings versus institutions

Question 15

Which ACA long-term care program provides additional federal payment for beneficiaries transitioning from institutional care to the community?

Answer 15

Balancing Incentive Program
■ Financial assistance to states to increase access to non-institutional LTSS (October
1st, 2011 – September 20th, 2015)
■ 21 states approved and 13 continue past Sept. 2015 deadline
○ Money Follows the Person Demonstration
■ A program provides the states with additional federal payment for beneficiaries
transitioning from institutional care to less restrictive community settings
■ Eliminates barriers in state law (i.e., State Medicaid plans that restrict the use of
Medicaid funds) to let people get long term care in the setting of their choice
■ Quality assurance and improvements of HCBS
■ Expanded to more states and an additional 2.25 billion through 2016

Question 16

Who provides the most informal care in the home?

Answer 16

○ “Sandwich Generation”
○ Over 5 million people serve as caregivers
○ Can provide 10-40 hours/week of informal assistance
○ 85% receive care from their family and friends
○ 58% are female spouses & adult female children
○ Absence of informal caregiver - nursing home placement
○ Economic value of informal care - $196 billion annually
○ Lost productivity due to care giving - $11.4 billion

Question 17

What are the types of long-term care services that are paid for/not paid for by
Medicare?

Answer 17

○ Covers home health services for the homebound (skilled care)
○ Covers nursing home stay, BUT only for 100 days after hospital discharge
○ Does NOT cover personal/custodial care services

Question 18

Is the demand for long-term care expected to increase or decrease? And why?

Answer 18

○ With the aging of America, the demand for LTSS is expected to increase
■ “Baby Boomers aging”
■ Medical advances and technology finds more ways to maintain life
■ Increased life expectancy

Question 19

Describe the services provided in each of the following LTC settings and identify the main differences between services provided: Respite care, Assisted living, Hospice, Adult day services Respite Care Facilities, and nursing homes?

Answer 19

○ Respite care (formal care)
■ Temporary surrogate care given to a patient when that patient’s primary caregiver
must be absent.
■ Criterion: individual requires supervised medical treatment and nursing care that is
provided by family or friends as principal caregivers.

○ Assisted living (formal care)
■ Special combination of housing, personalized supportive services and health care
designed to meet the needs of those who need help with ADLs
■ This is best for individuals that require assistance with custodial care and supportive
services
■ 28,000 assisted living facilities housing over 1 million people. Expected to grow to
over 2 million individuals by 2025
■ Similar to residential care facilities, but usually larger and have private apartments
○ Hospice (formal care)
■ Provides care for individuals with terminal illness and their support systems during
and after the dying process
■ Median length of stay in hospice is 23 days—to qualify for hospice benefits, patients
with terminal illness are usually expected to die within six months
○ Adult care services
■ Non-residential facility that supports the health, nutritional, social support & daily
living needs of adults in professionally staffed, group settings.
■ Day-Programs
○ Respite care facilities
■ Respite could take the form of enlisting friends and family to watch your loved one
so you can take a break to visit others, go to the gym, or handle chores, for example.
Or respite care can mean finding volunteers or paid carers to provide in-home
services for your loved one, either occasionally or on a regular basis.

○ Nursing homes
■ Nursing homes provide skilled care to disabled and vulnerable populations. Nursing
homes provide room and board, on-site nursing care, supervision, and personal
assistance to people who are unable to care for themselves
■ Skilled Nursing Facilities
● 24 hour acute care services
● Private vs Public rum

Question 20

What is the largest payer for LTC services?

Answer 20

Medicaid- 48.11%

Question 21

Which LTC is most costly for the healthcare system? And why?

Answer 21