An Illinois Medicaid expansion enabled by the nation’s health-care overhaul might not cover some mental health services designed to keep people from landing in psychiatric hospitals, nursing homes and jails, WBEZ has learned.
“We don’t have a final answer,” confirmed Mike Claffey, a spokesman for the Illinois Department of Healthcare and Family Services, which manages Medicaid in the state. “It’s not a simple question.”
The services include “assertive community treatment” and the less intensive “community support treatment,” both designed for outpatients (often homeless) who have a hard time reaching mental-health clinics and keeping appointments due to severe depression, bipolar disorder, schizophrenia and other conditions.
ACT and CST feature specialist teams with low caseloads and around-the-clock availability. Every team member works with each of the team’s “participants,” as the persons with the illnesses are known. The teams meet the participants wherever necessary to help with all aspects of recovery, from medication and counseling to nutrition, hygiene and money management.
Team members range from social workers to substance-abuse experts, from occupational therapists to peer counselors. ACT teams, as defined by the Illinois Department of Human Services, also include a psychiatrist and registered nurse.
An Illinois failure to cover ACT and CST in the Medicaid expansion “will cost the state in the short and the long run,” according to a letter that Gov. Pat Quinn’s administration received from leaders of Thresholds, a Chicago-based nonprofit agency that set up some of the nation’s first ACT teams more than three decades ago. “Many individuals with a serious mental illness will be unable to get the services they need to stabilize their lives, costing the state millions of dollars in preventable hospitalizations and nursing-home stays.”
Most ACT and CST teams in Illinois are run by nonprofits such as Thresholds, Trilogy Inc. and Community Counseling Centers of Chicago Inc., better known as C4.
For decades, the funding for ACT and other community mental-health services consisted largely of state grants. In recent years, Illinois has switched to financing the care through Medicaid, a fee-for-service insurance partially bankrolled by the federal government. An Illinois budget crisis, meanwhile, has led to deep cuts in the state grants since 2009, making it difficult for the nonprofit providers to continue serving people who lack Medicaid and can’t afford any other insurance.
“These overwhelmingly are the folks that end up in one of the state’s seven psychiatric hospitals,” said Mark Heyrman, a University of Chicago clinical professor of law who defends the rights of people with mental disabilities.
Many of these uninsured people also seem to have cycled through the emergency departments of hospitals across the state. Those departments treated almost 220,000 people with a primary diagnosis of mental illness or substance-abuse disorder in 2012, according to unpublished figures from the Illinois Hospital Association. That was 19.1 percent more than the 2009 total. By comparison, according to the association, emergency-department visits during the period overall increased by 6.4 percent.
As part of the federal Affordable Care Act, Illinois is among 24 states that have chosen to expand their Medicaid programs to more of the uninsured low-income population. The plan, signed into law by Quinn in July and set to take effect in January, will be available to people with income up to 138 percent of the federal poverty level — $15,415 for an individual this year.
The state expects 342,000 Illinois residents to sign up for the Medicaid expansion by 2017. The federal government is planning to finance 100 percent of the coverage through 2016 and no less than 90 percent in later years.
“This can be the biggest improvement in mental-health services that the state has seen in decades,” Heyrman said, “but only if all of the services that are needed by this very sick population are afforded to them.”
The Quinn administration, questioned by WBEZ, said it had yet to determine whether the state’s Medicaid expansion would cover the community-based teams.
“State agencies have been working with federal authorities to explore all the options for mental-health coverage, including ACT and CST,” Claffey, the spokesman, said in a statement. “We are still finalizing the policy and do not know at this time what, if any, rulemaking will be required. As always, in accordance with federal rules, we will formally post the service plan for public comment prior to implementation. We hope to have a better idea of when that will take place in the coming weeks.”
The uncertainty puzzles Jennifer Mathis, deputy legal director of the Washington-based Judge David L. Bazelon Center for Mental Health Law. “States are always cautious about adding services to their Medicaid plans,” she said. “But many of these people with serious mental illnesses are already in their systems. The states are already paying for them as they cycle in and out of hospitals, jails and nursing homes.”
If Illinois chooses not to include ACT and CST in the Medicaid expansion benefits, mental-health advocates say their Plan B is a federal rule about state-level expansions that allows the “medically frail,” a group defined as including people with a serious mental illness, to receive all the services of the state’s traditional Medicaid.
“So anyone enrolled in the Illinois Medicaid expansion who has a serious mental illness — which would include anyone eligible for ACT and many people eligible for CST — must be given the option of receiving the full scope of benefits covered under the state’s regular Medicaid plan,” Mathis said.
But winning the right to a service isn’t the same as receiving it. In Cook County, where a Medicaid expansion began a year early under a federal waiver, some providers say they have had a hard time getting ACT payments from Evanston-based PsycHealth Ltd., which has a county contract to manage the expansion’s mental-health care.
“Some of the larger nonprofits are turning away clients because they know they won’t be reimbursed,” said Heyrman, the law professor. “The county is not providing services that the state was providing for many years.”
Cook County Health and Hospitals System officials insist that their Medicaid expansion program, dubbed CountyCare, covers ACT and CST. Officials of both the health system and PsycHealth say they have received no formal complaints from providers alleging inappropriate denial of reimbursement for the services.
“The community-based facilities are used to getting whatever they want from the state,” said Cathryn Shemroske, the PsycHealth official who manages CountyCare’s mental-health provider network. “The state is bankrupt for a reason. This is definitely something contributing to that.”
Shemroske also voiced a perspective on ACT effectiveness that conflicts with at least some academic research on the topic. “Often I’m hearing that the model doesn’t necessarily keep members well,” she said. “The treatment outside the hospital isn’t always what gets people healthy.”
PsycHealth’s lack of enthusiasm for ACT owes partly to its lack of accountability for “all of the things that can go badly if they don’t provide enough services,” Heyrman said. “The costs will not be borne by PsycHealth if, for example, [patients] commit a low-level crime and end up in a jail or a state psychiatric hospital.”