The Association for Community Affiliated Plans (ACAP) thanks you for the opportunity to comment on H.R. 2646, the Helping Families in Mental Health Crisis Act of 2015, and other behavioral health legislation in the 114th Congress.
ACAP is an association of 60 nonprofit and community-based Safety Net Health Plans (SNHPs) located in 24 states. Our member plans provide coverage to approximately 15 million individuals enrolled in Medicaid, the Children’s Health Insurance Program (CHIP), Medicare Special Needs Plans for dually-eligible individuals, and Qualified Health Plans through the Marketplaces. Nationally, ACAP plans serve roughly one-third of all Medicaid managed care enrollees, including around one-third of all enrollees in the Medicaid-Medicare demonstrations. ACAP plans are members of their communities, partnering with states to improve the health and well-being of their members who rely upon the Medicaid and CHIP programs.
SNHPs are deeply supportive of efforts to improve mental health services to Americans and we consider the integration of mental, medical, and prescription medications to be essential elements in any such efforts. Your efforts in this area are timely, thoughtful, and much-needed, and as such, we thank you for leadership on mental health issues.
ACAP respectfully submits comments on four issues related to H.R.2646:
1. Privacy Exemptions. At section 403, the bill addresses an existing issue with 42 CFR Part 2 privacy regulations, which impose standards that are significantly more stringent than the protections now afforded by HIPAA. ACAP in general strongly supports privacy protections. However, 42 CFR in its current form stifles efforts to share information in order to better integrate physical and behavioral health care. The exemptions in the bill at section 403 are highly likely to aid efforts to better integrate physical and behavioral health care because they will allow caregivers and certain types of organizations to start sharing information.
Unfortunately, while section 403 explicitly exempts accountable care organizations, health information exchanges, and health homes, it fails to include health plans explicitly in the list of exempted entities. As health plans provide key coordination and benefit services millions of Americans, we believe it is important that health plans be included under this umbrella.
Recommendation: ACAP strongly supports explicit inclusion of health plans in the list of exempted entities, including health plans serving Medicaid, Medicare, and the Exchanges, by amending section 403(3) of the bill to include “health plans as defined in Sections 1851 and 1903(m) of the Social Security Act, and Section 1301 of the Public Health Service Act, as well as health plans operating under Title XXI of the Social Security Act.”
2. Study on Dual-Eligible Beneficiaries. ACAP is interested in seeing inclusion in the bill of a new GAO study on unmet need and underreporting of behavioral health conditions among dual-eligible beneficiaries. Dual-eligible beneficiaries with primary or comorbid behavioral health conditions have complex service and care management needs. However, anecdotal evidence suggests that these individuals experience high amounts of unmet need in Medicare fee-for-service (FFS) and their behavioral health conditions often go undiagnosed.
Medicare-Medicaid Plans (MMPs) and Dual-Eligible Special Needs Plans (D-SNPs) comprehensively assess these individuals and provide them with the services and care management they are unable to receive through FFS. However, since Medicare payments to MMPs and D-SNPs are based on FFS spending, the payments are often lower than these individuals’ true cost of care, which threatens the ability of these beneficiaries to continue accessing needed services.
Recommendation: ACAP recommends that the GAO issue a report on the prevalence of unmet need for dual-eligible beneficiaries with primary and comorbid behavioral health conditions, and underreporting of behavioral health conditions in Medicare FFS. Such a report would contribute greatly to the understanding of these individuals’ experiences in Medicare FFS and their true cost of care. The study would also shed light on policy solutions to ensure that health plans are able to provide these beneficiaries with all of the services and care coordination they require.
3. Prescription Drug Formulary and Utilization Management. ACAP also is concerned about section 502 around prescription drug formularies, which prohibits Medicare and Medicaid (and managed care entities with a contract with those programs) – from managing covered outpatient drugs used to treat a mental health disorder.
As you know, formularies are a tool plans use to target care and effectively control costs. Furthermore, many plans employ effective utilization strategies to prevent and control prescription drug abuse and shopping behaviors. It is important to strike the right balance between access to pharmacy and the importance of integrating pharmacy into broader care and utilization management strategies for this population. Our reading of the legislation suggests that plans’ ability to use effective utilization management techniques may be curtailed. As such, we strongly oppose language in this section that would limit health plans ability to integrate and manage prescription drug services and support clear language clarifying that nothing in the bill changes the way that health plans currently integrate and manage prescription drug benefits for their enrollees.
Recommendation: Strike Section 502(b)(2) from the legislation.
4. No Single Medicaid Prescription Drug Formulary. Although the legislation doesn’t focus on this specific issue, we are concerned about a growing trend related to Medicaid drug policy. Some states have opted to implement a single state formulary in Medicaid, requiring Medicaid health plans serving the program to use the state’s fee-for-service formulary. As described above, Medicaid health plans employ drug formularies as part of a broader strategy to manage enrollee care. Single state formularies prevent Medicaid health plans from developing their own drug formularies, and thereby prevent them from managing the mix of drugs to maximize clinical and cost effectiveness and avoid the use of high-cost products that have limited additional clinical value. We think that requiring plans to use a statewide formulary is counter to the reasoning behind Medicaid managed care in general, and also believe it to be more costly. As such, we oppose any efforts to move Medicaid health plans to a single formulary as the legislation is being considered in the Committee.