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The Legal Department articles are not intended to serve as legal advice and are offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and it is not intended to address every situation that could potentially arise. Please be aware that laws, regulations and technical standards change over time. As a result, it is important to verify and update any reference or information that is provided in the article.
The implementation of the Patient Protection and Affordable Care Act (ACA) and the resulting recent changes to California’s Medicaid system (Medi-Cal) have prompted many calls and questions from members about what healthcare reform will mean for the profession of Marriage and Family Therapy. This article is part of CAMFT’s ongoing efforts to keep members informed about how to thrive as a professional in a system that is undergoing major transformation.
Sara Jasper, JD Staff Attorney The Therapist November/December 2014
The implementation of the Patient Protection and Affordable Care Act (ACA) and the resulting recent changes to California’s Medicaid system (Medi-Cal) have prompted many calls and questions from members about what healthcare reform will mean for the profession of marriage and family therapy. This article is part of CAMFT’s ongoing efforts to keep members informed about how to thrive as a professional in a system that is undergoing major transformation.
Healthcare reform is drastically altering the system marriage and family therapists work within. While the system itself may be in flux, statistics indicate that LMFTs will continue to play an important role in the transforming healthcare system. Statistics also show that, during the next decade, the profession will grow at a much faster rate than other professions in the United States. According to the U.S. Bureau of Labor and Statistics, 37,800 LMFTs were employed in the U.S. in 2012. The latest statistics from the Board of Behavioral Sciences show there are 36,600 LMFTs in the State of California. The Bureau also anticipates the number of jobs for LMFTs will increase by 31 percent by 2022. Bureau of Labor estimates indicate by the year 2020, 11,600 additional jobs will have been created for LMFTs. The factors influencing this rate of growth are reduced stigmatization of those who seek mental health services, and the categorization of mental health counseling services as an essential health benefit, meaning that health insurance providers must cover mental health counseling services.
In order to have an accurate sense of what lies ahead for LMFTs, it is important to understand the objectives and forces driving healthcare reform. The country’s healthcare system is moving in an entirely new direction due to a universal desire to cut costs and improve care.
For better or worse, the ACA is, and will continue to be, a major influence on the restructuring of the healthcare delivery system. The ACA has prompted states, such as California, to expand Medicaid programs, and promotes the integration of primary and behavioral health care.
Expansion of the Medi-Cal System In January of this year, the Department of Health Care Services began implementing significant changes to the Medi-Cal system and the delivery of behavioral health services. The Medi-Cal system now has multiple pathways to services for eligible individuals who have behavioral health needs. The County Mental Health Plans (“MHPs”) are responsible for providing services to Medi-Cal enrollees with severe behavioral health needs. Medi-Cal Managed Care Plans (“MCPs”) are responsible for providing services to those with mild to moderate behavioral health issues.
LMFTs and Registered Interns were added to the list of Medi-Cal providers as the result of a State Plan Amendment, (SPA) 14-012, that was approved by the Center for Medicare and Medicaid Services on May 2nd. CAMFT worked closely with the DHCS to ensure the terms of the SPA would enable LMFTs and MFT Registered Interns to serve as Fee-For-Service providers for the State’s Medi-Cal system. LMFTs who are interested in becoming Medi-Cal providers can find out how to enroll by visiting www.medi-cal. ca.gov and clicking on the link to the Provider Enrollment page. Information about how to become a Medi-Cal provider is also available on www.camft.org. For more information on how to apply and how to handle reimbursement of intern services, read Sara Kashing’s article “How to Become A Fee-For- Service Medi-Cal Provider” on page 58.
In September, the Department of Health Care Services announced a plan to submit a State Plan Amendment (“SPA”) to the Center for Medicare and Medicaid Services (“CMS”) to add Behavioral Health Treatment (BHT) Services as a covered Medi-Cal benefit. The service will be available to individuals who are under 21 years of age, have been diagnosed with autism spectrum disorder, and have a medical need for the services. Before the state submits the SPA, it is required to request input from stakeholders. CAMFT attended the first of several stakeholder meetings in September and confirmed that LMFTs will be included in the SPA as qualified autism service providers given that they are listed in the Health and Safety Code that defines “qualified service provider.” During the meeting, the head of the DHCS’s Benefits Division, Laurie Weaver, also indicated the DHCS is considering including MFT Registered Interns in the list of providers for this benefit given that Interns were recently added to the list of Medi-Cal providers for behavioral health benefits. If they are included, Interns would be required to be supervised by a qualified autism service provider. CAMFT will continue to attend the DHCS’s stakeholder meetings and will keep the membership apprised of all developments related to SPA 14-026.
Integration of Primary and Behavioral Health Care Research has shown that mental health, substance use disorders, and physical health are interrelated. A main objective of healthcare reform is to create a seamless system of care designed to help children, adults, and older adults achieve their maximum potential in all spheres of life and at all points in their development. Of course, this vision will require a new structure for care and new procedures for delivery of that care.
Future systems of care are going to be comprehensive, coordinated, multi-disciplinary, and co-located. Comprehensive services will address medical, behavioral (mental health and substance use disorder), pharmacy and lab needs. Coordinated services will mean sharing records and treatment plans and providers will have constant contact with one another. Co-located services are services that are provided at one location. When services are co-located, charts are shared but treatment plans remain independent and providers will have occasional contact with each other. Multi-disciplinary services will be all encompassing: there will be one treatment plan, charts will be shared, and contact between providers will be frequent.
The Cal MediConnect Dual Eligibles Coordinated Care Demonstration that began in California in April is a prime example of what integrated care might look like. California’s Medicaid program partnered with the federal Medicare program to implement this three-year pilot project that will allow for the coordinated care of seniors and people with disabilities who are eligible for services under both the Medi-Cal and Medicare programs. The goal is to improve the care of these “dual eligibles” (people who are eligible for services under both programs) while shifting services from institutional settings to home and community-based care.
Eight counties including Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara are participating in the pilot project. As many as 456,000 of California’s 1.1 million dual eligibles are being served by the project. The Memorandum of Understanding entered into by the state and CMS enables LMFTs to take part in the project.
The creation of health or medical homes will serve as another opportunity for integration. Health or medical homes are designed to facilitate access to, and coordination of, the full array of primary, acute physical, behavioral health and long-term, community-based services and supports. In these settings, all of an individual’s caregivers communicate with one another so all of a patient’s needs are addressed in a comprehensive manner. This is done through a care manager, where all health records are shared, and services are provided through a community of providers, plans, and community-based organizations.
Accountable Care Organizations (“ACOs”) are comprised of many health/medical homes (many primary care providers and/or practices that work together), and are considered a “medical neighborhood.” Insurance companies contract with large medical systems to form ACOs that will provide healthcare services (medical, mental health, pharmacy, and lab services) for all of a plan’s members in certain geographic areas.
ACOs offer providers financial incentives for positive patient outcomes and they will probably embrace the model of a patientcentered medical home in which care is funneled through a primary care physician. Therapists will be working within ACOs to provide mental health triage and treatment in these collaborative settings. Due to the nature of these settings, therapists may have far less autonomy than they do in the current private practice model. Clinicians working in these more collaborative and medical settings will need a different kind of training to enable them to see more patients in shorter sessions and adapt to increased interaction with physicians and other health care providers. With more centralized and coordinated oversight of treatment decisions, the emphasis on providers using evidence based treatment approaches will likely continue to accelerate.
Preparing for the Future As the healthcare system evolves, the following concepts will be important for LMFTs:
Serious Mental Illness MFT educators and therapists can prepare for the future of healthcare reform by doing the following:
Conclusion Healthcare reform is impacting and shaping the future of the LMFT profession. CAMFT staff is working to stay on top of the changes to keep the membership informed as to what the healthcare system will look like in the future.
For a list of resources which provide information on healthcare reform and the future of the behavioral health care profession, visit camft.org/ACA.
Sara Jasper, JD, is a staff attorney for CAMFT. Sara is available to answer member calls regarding legal, ethical, and licensure issues.
Endnotes 1 The DHCS is co-sponsoring a number of free SBIRT trainings between now and March of 2015. For more information about the dates and locations of these SBIRT trainings, visit camft.org/ACA. 2 For more information about incident-to services, read the CAMFT article titled, What Therapists Should Know About Incident-to and Second Party Payer Medicare Reimbursements.