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Issue Brief Examines Medicaid Coverage for Medically Frail Individuals

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Rebecca Farley

Director, Policy & Advocacy, National Council for Behavioral Health

Issue Brief Examines Medicaid Coverage for Medically Frail Individuals

July 30, 2015 | Medicaid | Comments
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An obscure clause in the Affordable Care Act’s Medicaid expansion allows individuals with serious mental health or substance use needs to access the traditional state Medicaid plan benefit package, which often covers more services. A new issue brief from the National Council for Behavioral Health and Community Catalyst provides information and resources to help states identify and reach out to this population, ensuring they enroll in the plan that is most appropriate to meet their needs.

The Affordable Care Act permits states to offer Medicaid expansion plans (known as Alternative Benefit Plans) that differ from, and in some cases cover fewer services than, traditional Medicaid. However, individuals identified as “medically frail” – including those with serious mental illness or substance use disorders – are exempt from mandatory enrollment in Medicaid Alternative Benefit Plans.

The issue brief, Promoting Effective Identification of “Medically Frail” Individuals Under Medicaid Expansion, is designed to help state policymakers to develop an effective strategy for ensuring medically frail individuals get appropriate services. Some consumers are designated as medically frail because of their complex health conditions, and have needs that may not be met in Medicaid expansion plans that offer less coverage than traditional Medicaid.

This poses a challenge to states that pursue the Alternative Benefit Plan: how can they effectively identify and link individuals who are medically frail to the Medicaid option that best fits their needs?

Promoting Effective Identification of “Medically Frail” Individuals Under Medicaid Expansion draws lessons from early-adopter states such as Arkansas and Iowa and offers guidance to state policymakers to define the medically frail population and develop policies and procedures that facilitate smooth access to services that are necessary to meet their health needs.

The National Council and Community Catalyst are committed to ensuring all consumers have adequate access to mental health and substance use disorder treatments. This can improve care and yield cost savings for the state’s Medicaid program, while helping Medicaid beneficiaries lead healthy and productive lives.

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