National Council for Behavioral Health

Shelley Starkey

From funding for Certified Community Behavioral Health Clinics to state Medicaid waivers, 2020 is sure to be a whirlwind for behavioral health and for the health care system at large. While Congress remains split down party lines with Democratic control of the House and Republican control of the Senate, time will tell if any large changes will happen during this election year. Here is a preview of what is likely ahead in health policy in the first year of the new decade.

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Michael Petruzzelli

, National Council for Behavioral Health

Last week, the Tennessee legislature passed a bill that would make it the first state in the nation to transform its Medicaid program into a single lump sum block grant. The legislation was passed after continued promises from the Trump Administration to provide states greater flexibility in running their state Medicaid programs. The bill now heads to Governor Bill Lee’s desks for his review and approval.

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Stephanie Pellitt

, National Council for Behavioral Health

On Wednesday, a district court judge issued a pair of decisions blocking Medicaid work requirements in Kentucky and Arkansas. Consistent with an earlier ruling, the court found that the federal government had failed to justify how adding employment requirements advanced Medicaid’s central statutory objective to provide medical assistance to the state’s citizens. The impact of the ruling is likely to extend beyond these two states and complicate Trump Administration plans to expand Medicaid work requirements more broadly.

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Shelley Starkey

The Trump Administration this week continued encouraging states to weave work requirements into their Medicaid programs by releasing guidance on implementing, monitoring, and evaluating such changes. The new tools from the Centers for Medicare and Medicaid Services (CMS) are meant to provide guidance on creating effective demonstrations under Medicaid waiver authorities, particularly for waivers permitting states to implement work requirements and other experimental eligibility and coverage policies. As the Administration moves toward approving such waivers in more states, the National Council remains vehemently opposed to these harmful policies as they restrict access to needed mental health and addiction services.

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Katiri Zuluaga

Manager, State Initiatives

The Centers for Medicare and Medicaid Services (CMS) has approved Ohio’s Medicaid waiver to enact work requirements, even with legal challenges still pending in Kentucky and Arkansas for similar programs. Starting in 2021, Medicaid beneficiaries in Ohio not meeting certain exemptions will need to report 80 hours of “community engagement” per month to maintain coverage. Estimates indicate that approximately 18,000 people, about half of all eligible Medicaid beneficiaries, could lose coverage due to these new work requirements. The National Council for Behavioral Health remains strongly opposed to work requirements and other barriers that restrict access to needed behavioral health services.

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Shelley Starkey

A new informational bulletin from the Centers for Medicare and Medicaid Services (CMS) suggests a range of strategies for states to promote non-opioid chronic pain management options within their Medicaid programs by leveraging waivers, bundled payments, and other mechanisms. The bulletin builds upon previous CMS guidance to highlight successful programs already in place in some states and to describe Medicaid authorities at states’ disposal.

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Stephanie Pellitt

, National Council for Behavioral Health

The 116th Congress began on Thursday amid a government funding lapse that has shut down roughly 25 percent of the federal government. Democrats are set to lead the House chamber for the first time since 2010, while Republicans remain in control in the Senate. While legislation may be move less quickly in the new divided Congress, lawmakers will still face a number of “must-pass” bills that include health care priorities. Additionally, the Trump Administration will continue to shape the health care landscape with Medicaid waivers and potential payment reforms. Here is a preview of what’s ahead in health policy in 2019.

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Shelley Starkey

The Centers for Medicare and Medicaid Services (CMS) approved waivers from Michigan and Maine last month that would allow the states to implement requirements for Medicaid enrollees to report work or “community engagement” activities each month or risk losing health coverage. Michigan and Maine join five other states that have had Medicaid work requirement waivers approved, while more than ten others are in the process of requesting similar changes to their Medicaid programs. The National Council stands strongly opposed to any provisions that create barriers to health coverage for individuals with mental health or substance use disorders, including Medicaid work requirements.

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Stephanie Pellitt

, National Council for Behavioral Health

Late last week, the Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma announced four new Section 1332 state innovation waiver concepts for states to make changes to their individual insurance markets (fact sheet). The new waiver concepts build on the recently issued CMS guidance on Section 1332 waivers, under which CMS aims to strengthen states’ authority to shape their health insurance markets. The Administrator stated in her keynote address at the States and Nation Policy Summit of the American Legislative Exchange Council (ALEC) that it was a mistake to federalize so much of health care policy under the Affordable Care Act (ACA), and that the new concepts are “designed to illustrate how states can waive certain ACA provisions under section 1332 of the law and develop alternatives to the ACA’s otherwise one-size-fits-all approach.”

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Shelley Starkey

The Centers for Medicare and Medicaid Services (CMS) re-approved Kentucky’s request to add work requirements to the state’s Medicaid program last week, following a federal judge’s ruling earlier this year that overturned the first iteration of these requirements. These changes would require the population covered by Kentucky’s Medicaid expansion to report 80 hours of work or “work-related activities” each month, or face losing their coverage for a six-month lockout period. The approved 1115 waiver, which takes effect April 1, 2019, is almost identical to the state’s previously overturned application, and has been projected to result in at least 95,000 Kentuckians losing Medicaid coverage over the next five years.

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Stephanie Pellitt

, National Council for Behavioral Health

On Wednesday, the Centers for Medicare and Medicaid Services (CMS) approved Wisconsin’s request to enact a series of restrictions that would limit Medicaid eligibility and restrict enrollees’ use of Medicaid benefits. The newly-approved Section 1115 waiver will require certain adult beneficiaries to work 80 hours per month to maintain health coverage, institute premiums and subject applicants to drug use screening questions. This decision is the latest in a series of work requirement approvals, however, Wisconsin is the first non-Medicaid expansion state to receive permission from CMS to impose work requirements.

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Stephanie Pellitt

, National Council for Behavioral Health

The Trump Administration has issued new guidance to states that would relax requirements around 1332 waivers, the Affordable Care Act’s (ACA) vehicle for states to make changes to their individual insurance markets. The guidance tracks closely with the Administration’s stated goal of providing flexibility for states to offer cheaper insurance options outside of the ACA marketplaces. In short, the new guidance encourages states to utilize association health plans (AHPs) and short-term health plans as alternatives to current ACA marketplace plans.

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Shelley Starkey

New guidance from the Centers for Medicare and Medicaid Services (CMS) reports updated policies and procedures around state plan amendments (SPAs), 1115 waivers and 1915 waivers in states’ Medicaid programs. Two informational bulletins released within the past week outline the agency’s efforts to streamline approval processes and provide clarity around these options that are meant to give states flexibility in how they administer their Medicaid programs. These updates are part of CMS’s ongoing efforts to address concerns from states and federal policymakers around long administrative approval times and lack of transparency and oversight.

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Stephanie Pellitt

, National Council for Behavioral Health

On June 29th, a district court judge blocked Kentucky’s waiver request to require Medicaid enrollees to work or participate in a job-related activity for at least 80 hours per month or lose their health coverage. The court ruled that the Centers for Medicare and Medicaid Services (CMS) had not properly considered whether the initiative would violate Medicaid’s central objective of providing medical assistance to the state’s citizens. The decision could have broad implications for other states hoping to limit Medicaid enrollment through work requirements.

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Katiri Zuluaga

Manager, State Initiatives

Indiana is now the second state to receive approval from the Centers for Medicare and Medicaid Services (CMS) for a waiver request that imposes work requirements on Medicaid beneficiaries to maintain coverage. Indiana’s Section 1115 waiver also enacts a Substance Use Disorder (SUD) Program which will include coverage for residential treatment in Institutions for Mental Disease (IMD) and will increase premiums for beneficiaries who use tobacco and are not engaged in tobacco cessation activities. The National Council for Behavioral Health strongly opposes work requirements and any attempts to restrict access to needed behavioral health services.

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Katiri Zuluaga

Manager, State Initiatives

In a historic first, the Centers for Medicare and Medicaid Services (CMS) approved Kentucky’s Section 1115 waiver request that imposes work requirements on Medicaid beneficiaries to maintain coverage. The National Council for Behavioral Health strongly opposes work requirements and believes that work requirements not only prevent individuals with mental health or substance use disorders from receiving the treatment they need, but are in opposition to the core mission of Medicaid. Nine other states have pending work requirement waivers; however, any approvals will likely be challenged in court delaying their implementation.

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Stephanie Pellitt

Policy and Advocacy Associate

On Thursday, the Trump Administration released guidelines for states to create the first-ever work requirements for Medicaid recipients. The guidance targets “able-bodied adults” with some exemptions. While details are still emerging, the National Council has grave concerns that the policy’s exemptions will not be broad enough to protect all individuals with mental health and substance use disorders. Ten states have asked the federal government for approval to institute Medicaid work requirements. With this new guidance, the Administration is expected to begin approving these requests.

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Katiri Zuluaga

Manager, State Initiatives

Arizona has submitted a Section 1115 Medicaid waiver request that would institute a lifetime cap on Medicaid coverage and impose work requirements on enrollees. If approved by the Centers for Medicare and Medicaid Services (CMS), Arizona’s Medicaid program will have the ability to deny or disenroll eligible individuals who fail to meet criteria to work or take educational courses and limit Medicaid coverage to five years for “able-bodied adults.” Each of these measures could significantly harm individuals with mental health and/or addiction disorders who receive care for these conditions through Medicaid.

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Katiri Zuluaga

Manager, State Initiatives

Last week, the Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma gave a speech that further elaborated on new guidelines and priorities for Medicaid waivers. The Administrator’s comments to State Medicaid Directors included encouraging states to submit Section 1115 waivers that include work requirements, using the term “community engagements” to describe work requirements for able-bodied adults.

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Stephanie Pellitt

Policy and Advocacy Associate

Earlier this week, the Centers for Medicare & Medicaid Services (CMS) released guidance to streamline approvals of Medicaid waivers and state plan amendments. These tools are used by states to alter Medicaid benefits, eligible populations, and service delivery. While the Administration’s stated goal is to ensure Medicaid’s long-term fiscal sustainability and promote beneficiary independence, advocates should be aware of state proposals that could limit beneficiaries’ participation in the Medicaid program.

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