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Public Policy: Medicaid, Insurance, and Medication

Access to health insurance does not always guarantee that people with mental illness get access to care.  Often, our members don’t get medically-necessary treatments and services and report adverse outcomes because of this. Texas should strengthen requirements for robust, comprehensive, and affordable mental health coverage in both the public and private insurance sectors. Additionally, Texas should pursue policy options that would reduce the uninsured rate.

NAMI Texas Medicaid, Insurance, and Medication Policy Priorities

Medicaid and CHIP

Medicaid – the single most important funding source for mental health services – should be appropriately financed to offer the full range of mental health services and supports. If Medicaid is appropriately financed and managed, it can provide incredible value to the state and improve the lives of Texans with mental illness. When caseload growth outpaces funding, overly restrictive cost containment or provider rate cuts are implemented, and those served by Medicaid are adversely affected. In recent times, serious issues around Medicaid have come to light, indicating the need for improvements. Texas should focus on ensuring strong provider networks, increasing utilization of care coordination, boosting reimbursement rates, improving complaint and resolution processes, and holding managed care organizations and providers accountable for providing high-quality care.

The coverage gap

The federal government offers states Medicaid expansion funding to create an insurance option for low-wage adults, but so far, Texas has rejected these funds. The consequences of that decision have been devastating for Texans with mental illness: Over 400,000 Texans with mental illness or substance use disorder could enroll in health insurance if state leaders accepted Medicaid expansion funding. Texans with health insurance are nearly 50 percent more likely to receive treatment for mental illness or a substance use disorder compared to Texans who lack insurance. Texas should accept federal funding to open up Medicaid eligibility to low-wage adults.

Mental health insurance coverage

While Texas passed a robust mental health parity law in 2017, that law only has an impact if health plans actually offer coverage for mental health care. Texas does not require plans in the individual or small group health insurance market to include mental health coverage.

  • Texas should implement stronger insurance protections for mental health:
    • required robust coverage for mental health care
    • prohibition of coverage denial due to a mental health diagnosis
    • short-term, limited-duration health plans should be addressed
Protections against people losing access to medications

Far too often, insurance companies drop or deny medications, without having any medical rationale for doing so.  This practice of non-medical switching can have a devastating impact on outcomes for those whose health outcomes and stability depend upon ongoing access to the most effective medication, which may have taken them a long time to find. Because medication is often a critical component of recovery, continuity of care must be provided for Texans with mental illness. Texas should strengthen protections to ensure that people with mental illness have medication continuity of care in their insurance plans.

Safe and effective medications for Medicaid enrollees

Not getting the best, first-choice medication can put a person at increased risk of expensive emergency room visits, hospitalization, and other poor outcomes. All too often, prior authorization policies in Medicaid have caused delayed or unavailable access to the right medications for people with mental illness. Texas should provide stronger oversight of the Medicaid mental health medication pharmacy benefit.

86th Legislative Session Key Bills on Medicaid, Health Insurance, and Medication

Senate Bill 107 (Menendez) – Relating to coverage for serious mental illness under certain group health benefit plans.

Info pending

Senate Bill 145 (Rodriguez) – Relating to health benefit plan coverage in this state.
Info pending
Senate Bills 147 (Rodriguez) and 308 (Watson)/House Bills 241 (Farrar), 411 (Thierry), 610 (Walle), and 744 (Rose) – Relating to the Medicaid eligibility of certain women after a pregnancy.

Senate Bills 147/308 and House Bills 241/411/610/744 would extend Medicaid eligibility for low-income women from two months of coverage to one year postpartum coverage.

Senate Bill 189 (Miles)/House Bill 606 (Thierry) – Relating to the automatic enrollment of certain women in the Healthy Texas Women program.

Senate Bill 189/House Bill 606 would automatically enroll young women who were on Medicaid into the Healthy Texas Women program after their Medicaid eligibility expires.

Senate Bill 307 (Watson) – Relating to the Medicaid eligibility of certain women for behavioral health services after a pregnancy.
Senate Bill 344 (Watson) – Relating to the participation of campus-based mental health professionals in certain health benefit plans.

Senate Bill 344 would require HMOs and provider preferred health plans to not rule out the initial application for a campus-based mental health provider to contract as a preferred provider based on if they otherwise have a sufficient mental health provider network, and expedites application process for campus-based mental health providers.

Senate Bill 580 (Campbell) – Relating to modification of certain prescription drug benefits and coverage offered by certain health benefit plans.
House Bill 342 (Cortez)/829 (Rose) and Senate Bill 637 (Zaffirini) – Relating to the period of continuous eligibility for the medical assistance program.

House Bills 342/829 and Senate Bill 637 would extend Medicaid eligibility review for children from six months to one year.

House Bill 394 (Minjarez) – Relating to the duties of a hearing officer following a Health and Human Services Commission fair hearing regarding the denial of certain services.

House Bill 394 would require hearing office in an HHSC fair hearing on denial of medical services to review case with medical director prior to decision on case.

House Bill 501 (S. Thompson) – Relating to the requirement and study of insurance coverage for serious emotional disturbance of a child.

House Bill 501 would require group health plans to cover treatment for serious emotional disturbance in children in line with parity, and requires study of how many claims made and impact on coverage cost.

House Bill 565 (Coleman) – Relating to healthcare coverage in this state.

House Bill 565 would expands Medicaid and codify protections of Affordable Care Act into law.


Testimony on Medicaid, Insurance, and Medication

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