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Health Law and Policy Update

Headlines of the week

Colorado high-risk pool open for applications
Colorado Gov. Bill Ritter this week announced the Colorado high-risk pool, required to be established under the Affordable Care Act, is now taking applications for health insurance coverage. The new program, Getting Us Covered, is run as a partnership between CoverColorado, Rocky Mountain Health Plans, the State of Colorado and the U.S. Department of Health and Human Services. Getting Us Covered will operate until 2014, when high risk pools will no longer be necessary because insurance companies will be required to accept applicants with pre-existing conditions.

Colorado will receive $90 million from the federal government to cover an anticipated 4,000 people. The program is not free; there will be monthly premiums, a $2,500 medical deductible and a $500 prescription drug deductible. Co-pays are $30 for an office visit and $45 to see a specialist. The total out-of-pocket cost for an individual is $5,950 (that's in addition to premium charges). More information and an application are available from the governor's health refrom website.

Consumer advocates press for more disclosure about rate hikes
The National Association of Insurance Commissioners (NAIC) is developing recommendations for the U. S. Department of Health and Human Services (HHS) regarding the type of information insurers must provide to justify premium increases.

The new health reform law requires insurers seeking "unreasonable" premium increases to publicly provide justification for the rate increase to consumers, state regulators and HHS.

Consumer advocates, including the Colorado Center on Law and Policy, are pushing to require enough detail about prices charged by doctors, hospitals and drug companies, CEO salaries, broker commissions and other administrative expenses to determine if premium increases are justified.

Consumer groups outlined the additional information needed in comments to an NAIC task force. The American Medical Association also agreed more information is needed. Insurers said in their comments that the draft premium increase form asked for too much information.

HHS does not have the power to reject premium increases. Some states, including Colorado, have that ability.

Consumer groups agreed the information on the draft form provided enough information for a casual consumer, but it lacked enough detail to allow more sophisticated analysis. Most states, including Colorado, do not make full rate filing information available to the public. This year Oregon started to post filings on a public website.

Question of the week

What are the implications for mental health coverage under health reform?
There are a number of benefits in the federal health reform package for people with mental health needs, ranging from provisions that by 2014 eliminate pre-existing condition exclusions and annual and lifetime caps to provisions specifically targeted at making improvements in mental health services and supports. Following is a list of many, but not all of the provisions of the act that affect people with mental illness.

Generally:

  •  Pre-existing condition exclusions are eliminated for children on Sept. 23, 2010, and for adults by 2014.
  • By 2014, Medicaid coverage will be expanded to include single adults and parents up to 133 percent of the federal poverty level. Many people with serious mental health conditions who are homeless or have very low incomes will for the first time be eligible for Medicaid. The issue in Colorado will be whether childless adults receive the full Medicaid benefit or a "benchmark" plan with more limited benefits. While mental health parity is required, the ability to limit benefits overall in a benchmark plan may affect access to mental health services. Ultimately, benefit design for this population will have to meet certain minimum standards but beyond that, benefits levels in Colorado will depend on the state and HHS approval.
  • States have the option in 2014 to extend Medicaid coverage up to age 26 to children aging out of foster care. Currently, these children/young adults are only eligible to age 21.
  • The health reform law permits states to improve care coordination for people in Medicaid with chronic conditions, including mental illness. States that choose this option may allow someone to choose a mental health provider as their health care home and community mental health centers may be designated as health homes. A health care home can mean collaboration and/or co-location of care providers or care management and coordination. States that choose this option get enhanced federal funding for two years. According to the Bazelon Center for Mental Health Law, "collaborative care models that entrust one entity with the comprehensive management and coordination of an individual's care have been found very effective in treating mental illness."
  • Some drugs that have been excluded from Medicaid coverage will be covered beginning in 2014, including barbiturates and benzodiazepines as well as smoking-cessation medication. Closing the Medicare "donut hole", (the gap in coverage for prescription drugs in the Medicare program) will also help people who rely on prescription drugs to treat mental illness.
  • Simplifying enrollment procedures for Medicaid will reduce barriers that present particular problems to people with mental illnesses.
  • The health reform law includes improved funding for maternal and child health, including required community needs assessments and grant funding for early intervention through the nurse home visitor program, which has been demonstrated to improve the social and emotional development of infants and toddlers.
  • The law eliminates lifetime caps in 2010 and annual caps by 2014, with restrictions on the use of annual caps beginning in 2010. This is important for anyone with a chronic condition or high medical needs.
  • The law establishes high-risk pools in each state. To be eligible, a person must have been uninsured for at least six months and have been denied coverage due to a pre-existing condition or have one of a group of listed health conditions. Colorado's high-risk pool is called Getting Us Covered (see more above).

Specific mental health provisions:

  • State-based exchanges must offer at least a minimum or "essential" benefit package through a "qualified health plan." That package is required to include, among other services, emergency services, prescription drugs, and mental health and substance abuse treatment.
  • State-based exchanges are required to offer mental health parity (parity means that mental health conditions are treated equally with physical health, for example a plan couldn't have a higher co pay structure for mental health than physical health).
  • No co-payments for primary care services recommended by the U.S. Preventative Services Task Force. Screenings for depression and alcohol misuse are currently on that list.
  • The bill encourages co-location of primary care in community mental health settings (Section 5604) through demonstration grants.
  • The bill establishes the Centers of Excellence for Depression for the treatment of depression and bipolar disorder to be administered by the Substance Abuse and Mental Health Services Administration. The legislation includes grants for up to 20 centers across the country the first year and up to 30 within the first 5 years. Hosted by eminent research facilities, each center of excellence will engage in research on the causes and evidence-based treatments of depressive disorders and will host clinical programs that bring this knowledge to patients.
  • The law grants new authority for the secretary of the Department of Health and Human Services to establish federal standards for Community Mental Health Centers.
  • Grants are provided for mental and behavioral health education and training programs.
  • Establishes a quality measure reporting program for psychiatric hospitals beginning in 2014.
  • The Melanie Blocker Stokes Post-Partum Depression Act (Section 2952) offers money to states to serve women experiencing postpartum depression and psychosis including education for mothers and their families. There is also funding for research into the causes, diagnoses, and treatments for postpartum depression.
  • The law establishes a Medicaid emergency psychiatric demonstration project. Currently, non-governmental free-standing inpatient psychiatric facilities are not eligible to receive payments under Medicaid. This project offers up to $75 million to as many as eight states over three years to participate in a demonstration project to determine the efficacy of providing care in such settings.

Colorado health leaders should consider the benefits and limits of new programs so the state can build and maintain an integrated system of care that provides adequate, high-quality support for people with mental health needs. One major issue advocates should consider is the coordination of mental health services provided through insurance offered inside the exchange with community-based mental health services. Another issue is that if the Medicaid benefit for single adults is not comprehensive, people with serious mental illness might still need to depend at least in part on a community-based mental health safety net.

Thanks to the comprehensive work of the Bazelon Center for Mental Health Law for much of the information in this summary. The center's full analysis is available on its website.

What's new

Colorado terminating Old Age Pension benefits for lawfully present immigrants
Elderly legal immigrants who have had their green card status for fewer than five years received notice recently that their Old Age Pension (OAP) benefits will be terminated as of Aug. 1. OAP provides up to $699 per month and medical coverage for people who are not eligible for Medicaid. The program either supplements existing income or is the sole source of income for participants. Until this year, help had been provided to legal immigrants regardless of how long they had been permanent resident aliens. But this year the Colorado Legislature changed the program in a budget-cutting move estimated to save $13 million to $14 million.

The recent notices leave very little time for these recipients to get their affairs in order, to make alternative arrangements or apply for the available hardship exceptions. An OAP recipient may apply for one of two types of hardship exception - indigence or abuse/neglect - by contacting the local county department of human services. The criteria for the indigence exception are:

  • The immigrant's sponsor has income less than 125 percent of the federal poverty level for the household size, including the qualified alien; and,
  • The qualified alien is not living with the sponsor, and not receiving free room and board from another source.

Also, if a recipient has been the victim of abuse or neglect, he or she can qualify for a hardship exception.

CCLP is hearing from very distraught sponsors and concerned case workers about people who are losing their income and their access to medical care. Even in situations where an immigrant's sponsor is able to provide food and shelter, providing health insurance coverage is all but impossible given the age, medical frailty and poverty of many of these families. The loss of access to doctors and prescription drugs will be devastating. Because of their short time in the United States and their limited or complete lack of work history, OAP recipients age 65 and older do not qualify for Medicare. Former OAP recipients can qualify for the Colorado Indigent Care Program (CICP), which reimburses certain hospitals and clinics for providing discounted services to low-income Coloradans. OAP recipients who have received terminations notices were provided the phone number for CICP information: 303-866-3513 in the Denver metro area or toll-free 1-800-221-3943.

CCLP has historically been in the forefront of protecting access to medical care for lawfully present immigrants, who are often the first to bear the brunt of state budget cuts. Many of the people losing services are going to have to manage with no income and no medical care outside of an emergency room. CCLP opposed House Bill 10-1384, the legislation making the changes to legal immigrant eligibility for OAP, and along with other advocates successfully sought the inclusion of hardship exemptions. However, CCLP is concerned those exemptions will not be enough. CCLP continues to be deeply troubled by the fact that the state is cutting services to these vulnerable people because of their status as legal immigrants.

What you can do

Speak up for sensible solutions to the budget crisis
Contact the governor's office, the Department of Human Services and your state legislators, and let them know the change to OAP eligibility rules was the wrong solution to the state's budget crisis. Don't know who your representatives are? Check Project Vote Smart.

Schedule a presentation on health reform
Health reform can be confusing. The health staff at the Colorado Center on Law and Policy is ready to help community groups, medical professionals, lawmakers and others understand the complexities of health reform and how it will roll out during the next few years. Please contact us to schedule a presentation.

Health Law and Policy Update is issued weekly by the health staff of the Colorado Center on Law and Policy. Subscribe by e-mail or read previous editions.

Health Care Director
Elisabeth Arenales   

Health Care Attorney
Adela Flores-Brennan   

Special Counsel
Ed Kahn   

Communications Director
Perry Swanson

Released July 9, 2010