Mental Health Care Coverage in Minnesota – Supplementing Federal Healthcare Reform

In 2007, the governor of Minnesota proposed a mental health initiative and the legislature passed it. One of the more important components of the initiative was legislation amending Minnesota’s two programs for the uninsured – General Assistance Medical Care and Minnesota Care – to add to the comprehensive mental health and addictions benefit.

Who Is Covered?

General Assistance Medical Care covers those with income at or below 75% of the federal poverty level who meet one or more of additional criteria known as General Assistance Medical Care qualifiers. Qualifiers include waiting or appealing disability determination by Social Security Administration or state medical review team; or being in a homeless or live in shelter, hotel, or other place of public accommodation.

Minnesota Care covers children and pregnant women, parents, and caretakers up to 275% of the federal poverty level, except that parents and caretakers gross income cannot exceed $50,000. Single adults without children increased to 200% of federal poverty level by January 1, 2008 and will rise to 215% of federal poverty level by January 1, 2009.

What Services Are Covered?

For Minnesota Care, there are limits of $10,000 on inpatient care for any condition (physical, mental health, or addictions) for parents over 175% of federal poverty level and childless adults. For General Assistance Medical Care, inpatient benefits are fully covered. Both programs cover chemical dependency outpatient services. An intensive array of outpatient and residential mental health services are available.

What Is The Cost?

In Minnesota, the Medicaid Temporary Assistance for Needy Families population, General Assistance Medical Care and Minnesota Care are enrolled in comprehensive nonprofit health plans that are responsible to deliver and are at risk for the entire health benefit, including behavioral health. Adding mental health rehabilitative services (including adult rehabilitative mental health services individual and group rehabilitation services, assertive community treatment, intensive residential treatment and mobile and residential crisis services) to Minnesota Care was projected to cost $3.40 per person per month. For General Assistance Medical Care, which includes a homeless population, the cost was $7.01 per person per month. The additional targeted case management service was projected to cost $2.22 per person per month for Minnesota Care and $7.66 for General Assistance Medical Care.

The legislature appropriated a total of $1 million in additional state dollars in fiscal year 2008 and $ 3.5 million in fiscal year 2009 to add the adult rehabilitative services and case management in Minnesota Care. State funds previously targeted for case management were moved from the counties to the state in an amount of $4.4 million in fiscal year 2009.

What Led To Comprehensive Coverage?

The state collected data on the residents served by Minnesota Care, General Assistance Medical Care, and Medicaid managed care plans serving non-disabled populations, and discovered that an increasing number of individuals with serious mental illnesses were in these plans. Several insurance reforms – similar to those included in the national healthcare reform bill – modified the private market, including guaranteed issue in small and large group plans, broader rate bands, parity for mental health and chemical dependency services, medical loss ratios, high risk insurance pool, and others. A lawsuit by the attorney general called attention to health plan denials of payment for court-ordered treatment, for example for civil commitment or out of home placement for adolescents.

Health plans settled with an agreement that behavioral and mental health benefits would be covered by a health plan if the court based its decision on a diagnostic evaluation and plan of care developed by a qualified professional. In addition to the court-ordered services provision, the state contracts and capitation with prepaid health programs (Minnesota Care and General Assistance Medical Care) were amended to align risk and responsibility for services in institutions for mental illnesses, 180 days of nursing home or home health, and court-ordered treatment. There were also highly successful experiments reducing costs and improving outcomes for commercial and non-disabled Medicaid clients who were offered a more intensive community based mental health service that improved coordination with and linkages to behavioral healthcare, primary care, and other needed services.

These demonstrations produced a positive return on investment – $0.38/person/month – and gave the health plans tools to manage the increased risk that resulted from several insurance reforms, including parity, a statutory definition of medical necessity, and the court-ordered treatment provision.