House Medicaid Budget
The House budget proposes a waiver be submitted to the Centers for Medicare and Medicaid (CMS) to modify who is eligible for Medicaid under the expansion. In order to qualify under the waiver, an individual would have to meet income eligibility and one of the following:
- be at least 55 years of age;
- be employed;
- be enrolled in school or an occupational training program;
- be participating in an alcohol and drug addiction treatment program; or
- have intensive health care needs.
While Medicaid expansion is continued, these new requirements for the Group VIII population will remove critical coverage from many Ohioans. Continuing coverage for those enrolled in a drug or alcohol addiction program is positive, but the language as drafted would eliminate coverage for those waiting for a spot in treatment to open. Other requirements like Intensive health care needs is unclear at this point as to if it will include people with serious mental illness. Finally, work requirements also leave out those actively searching for employment and will lead many people to drop off Medicaid expansion rolls.
Controlling Board Approval:
Medicaid is now required to seek Controlling Board approval for all Medicaid expenditures every six months. This is an unworkable funding system for the Medicaid program to operate given the multitude of programs contained in Medicaid. With this language, nursing homes, addiction programs, developmental disability programs and mental health services are in jeopardy of losing funding twice a year.
As the behavioral health system is carved-in to Medicaid managed care, this approval requirement will make it challenging for the Department of Medicaid to enter into long term contracts, likely driving the pricing of services higher than they would be without the need for Controlling Board approval. Providers and others will not be able to forecast and budget to determine workforce and other needs. Should funding not be approved by the Controlling Board, providers will not be able to provide services to clients.
Although not included in budget language, the Medicaid Executive Budget realized savings from a proposal to require premiums for the expansion population. The MHAC will continue to advocate against additional barriers such as premiums.
Monthly premiums for childless, non-pregnant adults who have income between 100% and 138% of the modified adjusted gross income (MAGI). The amount is expected to be $20 per month or not more than 2% of household income. According to the 2017 Federal Poverty Guidelines, a single person with an annual income of $12,060 would be expected to pay the proposed premium. This requires the state to apply for a waiver under Section 1115 of the Social Security Act. This provision would take effect January 1, 2018.
Table 1: Predicted Annual Savings Generated by Proposed Premiums for the Medicaid Expansion Population, in millions of dollars.
The Ohio Medicaid program was expanded in 2014 to provide benefits to low-income adults. As the Federal Government is in the process of repealing the Affordable Care Act (ACA), it is uncertain what the State's plan is for the Medicaid program and the expansion population. We feel strongly that continuing coverage for those affected by mental illness and substance use disorders must be a priority.
Ohio's population is around 11.5 million, with approximately 3 million covered by Medicaid. Of those covered by Medicaid, nearly 726,000 are part of the Group VIII or expansion population. After Medicaid was expanded, the uninsured rate for non-senior low income adults declined to 14.1%, the lowest ever recorded. Of those who gained coverage through the provisions in the ACA that allowed Ohio to expand Medicaid, 500,000 Ohioans received care for mental health needs.
Heroin, Opioids, Prevention, Education, Safety (HOPES) Agenda
The Heroin, Opioids, Prevention, Education, Safety (HOPES) Agenda infuses $170.6 million in funding for workforce, mental health, prevention, and treatment initiatives.
- $30 Million for acute substance use disorder stabilization centers and mental health crisis centers - The House budget proposal appropriates $9 million per fiscal year to finance six collaborative 16-bed acute substance use disorder stabilization centers and $6 million per fiscal year for six mental health crisis centers in the state psychiatric hospital regions. The facilities will assist first responders in having a medical response to families with addiction and mental health crises and to reduce the use of jails for this purpose. This will be accessible both pre and post emergency room hospitalization and pre and post jail. The facilities are to be an existing structure with no new construction and cannot be an existing jail.
- $24 Million for Alcohol Drug Addiction and Mental Health Boards - Earmarks $12 million each fiscal year to the Continuum of Care line item and specifies that $75,000 be allocated to each board and the remainder based on a formula taking into account the population and number of opioid deaths.
- Provides $20 million to expand treatment facilities through a capital appropriation for recovery housing.
- $12 Million for transitional housing - Allows up to $6 million per fiscal year to go to a fund under OhioMHAS from the Housing Trust Fund for housing opportunities for individuals exiting residential opiate addiction treatment. Ask legislators to consider expanding this to other substance use disorders and for those in other treatment programs who need safe, sober living arrangements.
- $10 Million for prevention - Appropriates $5 million per fiscal year to create an opioid addiction website, public service announcements, a 24-hour hotline, as well as fund the Start Talking Initiative.
- $2.2 Million county hub programs to combat opioid addiction -Appropriates $2.2 million, which includes $25,000 to each county, to address the opiate crisis. It requires County Commissioners to designate a hub coordinating agency to be responsible for local efforts such as an opiate task force.
- $2 Million for Residential State Supplement Program (RSS) for housing - The House appropriates $1 million per state fiscal year to expand the RSS program. The Department of Mental Health & Addiction Services provides financial help to adults with a serious mental illness that need housing through the RSS program. RSS pays for a portion of the monthly rent expenses for housing accommodations, which often include supervision and personal care services for residents at certain RSS eligible community living arrangements. Ohio is running out of RSS funding and is in the process of creating a waiting list, which will lead to increased emergency department visits, homelessness, incarceration, or worse for many individuals with serious mental illness.
- $30 Million for child protective services and $20 Million for kinship caregivers. Caseloads for child protective services are increasing beyond what caseworkers can handle as the opiate crisis compounds child neglect. This funding will help with both child protective agencies across the state and kinship caregivers who take responsibility for these children impacted by opiates.
- $7.4 Million to expand Medication Assisted Treatment (MAT) drug courts and mental health court supports - The House allocates $6 million to expand drug courts to the following MHAC Hub Counties: Butler; Clermont; Lake; Lorain, and Medina. The House appropriated $1.4 million for a pilot program to provide mental health services and recovery supports to offenders in the criminal justice system who are participating in a certified mental health court program in the following counties: Cuyahoga, Franklin, and Warren.
- $4 Million for processing drug lab reports- The House allocates $2 million for the Bureau of Criminal Investigation, within the Attorney General's office, and $500,000 for the Department of Public Safety in fiscal year 2018 for funding criminal laboratory case work primarily related to opioid or other criminal cases submitted. The Attorney General fund earmarks $1,500,000 in funding for each public forensic laboratory in Ohio to perform chemistry laboratory work.
- $9 Million to support workforce training programs - Provides $4 million as a state match for the Supplemental Nutrition Assistance Program Employment and Training Program. It requires funding to be used for programs that provide non-degree credit short-term certificates. The House appropriated $5 million for short-term certificates for workforce development.
Behavioral Health Redesign
The House delayed the Behavioral Health Redesign coding and rate changes and the carve-in of managed care until January 1, 2018 and July 1, 2018, respectively. The Senate is considering this language carefully. The Administration has testified before the Senate that July 1 must be the start date for the Redesign as planned.
On May 10, a behavioral health panel testified which included: Director Plouck, OhioMHAS; Emily Higgins, Molina Healthcare; Terry Russell, NAMI Ohio; Dave Turner, The Counseling Source Inc.; King Stumpp; Netcare Access; and Sue Fralick, Mental Health Services for Clark and Madison Co. Director Plouck firmly believes that the implementation of the Redesign should take place on July 1. Emily Higgins testified that managed care will do everything they can to ensure claims are paid internally. Terry Russell explained that families and people with mental illness should not have to wait longer for the new benefits such as Assertive Community Treatment or Intensive Home Based Treatment services. The providers each discussed concerns they have with the Redesign and the implementation process. Each have issues with their IT vendors meeting the July 1 start date and are concerned about timely payments.
Director Plouck was asked if she is willing to risk the successful implementation on the IT software issues. She said she can meet with the vendors and ask about readiness.
Since the panel discussion, MHAC members have testified on concerns about the Redesign implementation date and have met with Senators during MHAC Day at the Statehouse on May 17. Through these testimonies and meetings, MHAC members were able to share the work they have done to prepare for the Redesign, the benefits of the Redesign, and outstanding progress with implementing the system changes, as well as concerns about billing claims being paid and some agencies lack of cash reserves to cover any issues that arise during the transition.
Other Executive Budget Items
The Department of Rehabilitation and Corrections proposed a new policy to keep more individuals from entering the prison system. Beginning July 1, 2018, people who are sentenced to prison for less than a year for a felony 5 shall serve the term in jail or in a community-based correctional facility. However, this only applies to non-violent offenses and must not be an offense of sexual assault or carry a mandatory prison term.
The Department of Education requires instruction in opioid and other substance abuse prevention be included in teacher preparation programs for educators and other school personnel for all content areas and grade levels. Educators and school personnel will be instructed on the magnitude of opioid and substance use, the role teachers can play about adverse effects of substance use, the resources available to teach students about the consequences of substance use and resources to help fight and treat opioid abuse.