5.1 Private-Sector Healthcare Reform

(5.1.1) NAMI supports health care for all persons with brain disorders that is affordable, nondiscriminatory, and includes coverage for effective and appropriate treatment.

(5.1.2) NAMI supports the establishment of provisions to ensure the financing of basic health care for every American at costs affordable to individual citizens and families. It is critical that coverage of brain disorders be equal in scope and duration to coverage of other illnesses without lifetime maximum-benefit caps and without other limits more restrictive than limits for other diseases.

(5.1.3) NAMI urges passage of legislation to mandate nondiscriminatory coverage of brain disorders with other physical diseases.

(5.1.4) Private-sector health plans must cover all proven-effective modes of treatment: inpatient, outpatient, medications, case management, education, psychosocial rehabilitation, and others appropriate to the needs of individuals with brain disorders.

(5.1.5) NAMI supports federally mandated, minimum standards for health insurance coverage; however, federal standards should not pre-empt state laws that provide higher standards.

(5.1.6) NAMI believes that the Employee Retirement Income Security Act (ERISA) of 1974 represents a significant obstacle to state-government efforts to broaden access to services for those who have brain disorders. NAMI supports efforts of states to gain waivers of ERISA. These waivers would prohibit self-insured employers from avoiding compliance with state-mandated minimum-benefit laws.

(5.1.7) NAMI opposes the concept of healthcare rationing.

5.2 The Role of the Public Sector

(5.2.1) NAMI affirms that a just and humane society cares for its most vulnerable members with brain disorders when they are unable to care for themselves using the instrument of government for policy direction and public resources. The essential needs of these individuals and the obligations of society must be addressed irrespective of decisions which are made concerning what level of government should have control over such functions, what proportions of the financing each level should take, and how much should be privatized.

(5.2.2) Persons of all ages who suffer from brain disorders are frequently unable to provide for themselves because of acute or chronic symptoms that result from these disorders.

(5.2.3) The most basic needs of such persons when they are at their most vulnerable are for shelter, food, clothing, medical and social supports, and assistance toward self-sufficiency. Government in the United States has met such needs principally through programs for income maintenance, medical treatment, medical insurance, other health and social services, shelter and housing, education, transportation assistance, legal assistance, advocacy, training, and employment.

5.3 Medicaid, Medicare, and Veterans Benefits

Public sector benefits-including Medicare, Medicaid, Veteran’s benefits, and other Government-funded programs-upon which persons with brain disorders frequently depend due to discrimination in private health care programs, disability, military service, and/or poverty must not diminish and must be at least as comprehensive under managed care as the benefits presently available.

(5.3.1) Medicare

(5.3.1.1) Medication prescibed for the treatment of serious mental illnesses shall be covered benefit. (Revised February, 1999)

(5.3.1.2) The existing 50 percent copayment imposed on outpatient mental health services shall be equalized with all other Medicare copayments (20%).(Revised February, 1999)

(5.3.1.3) The existing 190-day lifetime limit on inpatient psychiatric hospitals shall be eliminated. (Revised February, 1999)

(5.3.1.4) The existing partial hospitalization benefit should be re-examined and revised to include a continuum including intensive case management, psychiatric rehabilitation, and assertive community treatment. All outpatient mental health services should meet the following criteria: (Revised February, 1999)

(5.3.1.4.1) All persons served should have a documented diagnosis of illness. (Revised February, 1999)

(5.3.1.4.2) All persons served should have an individualized treatment plan with stated clinical goals and progress notes. (Revised February, 1999)

(5.3.1.4.3) Providers should be licensed, certified, or recognized by the state and meet national standards for clinical care. (Revised February, 1999)

(5.3.1.5) Providers are obligated to clinically document medical necessity and accurately bill for services rendered. All records must document the medical necessity of the services rendered. (Revised February, 1999)

(5.3.1.6) Persons receiving Social Security Disability Insurance (SSDI) who seek work should be allowed to continue their Medicare insurance coverage for an indefinite period. Should persons go off Medicare because they have obtained employment and should they have a clinical relapse, they should be automatically re-enrolled in Medicare. (Revised February, 1999)

(5.3.1.7) Comprehensive patient protections should be consistently applied to all health benefit payers, including Medicare. [Refer to other sections of this Platform for specific protections] (Revised February, 1999)

(5.3.1.8) Any risk adjustment payment mechanism adopted by Medicare must adequately include both severity and chronicity of mental illness. (Revised February, 1999)

5.4 Public Financing

(5.4.1) NAMI recognizes that the cost of not treating brain disorders greatly exceeds the cost of treating them.

(5.4.2) Public funding for services to persons with brain disorders who are unable to care for themselves is the responsibility of society. Local, state and federal governments have the responsibility to develop an integrated system of care and to fund this system adequately. Accountability for expenditure of these funds for the priority population must be ensured. Where there is co-mingling of public and private funding streams, accountability measures must be stringent.

(5.4.3) NAMI urges adequate funding to avoid waiting lists and the "dumping" of persons with brain disorders from publicly funded systems for any reason. On the other hand, the systems of care should not be a repository for the "dumping" from private or public facilities of indigent, elderly, or other persons with disabilities who do not have brain disorders.

(5.4.4) NAMI advocates for maximum funding for both biomedical and services research for brain disorders and for federally-funded treatment and services for individuals with brain disorders. NAMI insists that biomedical research dollars for these brain disorders should be allocated to those grants most likely to help persons who have the most severe disabilities. Federal oversight of these grants through national institutes responsible for brain services and treatment research must continue.

(5.4.5) NAMI supports consumer and family education services to enable consumers and families to better communicate with service providers, better understand brain disorders and develop coping skills. NAMI believes that community service providers should fund and provide free consumer and family education programs.

(5.4.6) NAMI supports funding for respite care for caregivers.

(5.4.7) Federal Mental Health Services Funding

NAMI must monitor the expenditure of federal mental health service funds in each state. Advocacy efforts must continue to assure that there are regulations at the federal level which require that these funds are spent on services for the priority population. NAMI must monitor at the federal and state levels the activities and processes that assure these regulations are implemented. Failure by states to adhere to regulations should result in financial and public penalties.

(5.4.8) Institutions for Mental Diseases (IMDs)

(5.4.8.1) The federal government currently denies Medicaid reimbursement for persons otherwise Medicaid eligible who are over 21 and under 65 years of age if such persons reside in facilities designated as "Institutions for Mental Diseases" (IMDs). State hospitals, nursing homes, and residential facilities of 16 or more beds may be classified as IMDs if they provide specialized "mental illness" services, have over 50 percent of their patients diagnosed as "mentally ill," or meet certain other criteria.

(5.4.8.2) NAMI believes that the application of the IMD rule most dramatically affects persons suffering from schizophrenia and other brain disorders because these individuals tend to fall within the impacted age group and thereby are denied Federal Financial Participation (FFP) in their treatment solely on the basis of where they happen to reside, assuming they would meet all other Medicaid eligibility requirements.

(5.4.8.3) The IMD rule is thus discriminatory and works against the provision of necessary health care for young and middle-aged adults with brain disorders.

(5.4.8.4) NAMI calls upon the United States Congress to repeal the IMD rule and to adopt uniform standards of Medicaid eligibility based upon individual resources and the need for services, rather than upon the location in which services are provided or the residence of the recipient.

(5.4.9) Community Reinvestment

(5.4.9.1) If and when public hospitals are no longer needed for the treatment of persons with brain disorders, and such properties are sold or leased, the proceeds should be dedicated to community services for persons with brain disorders.

(5.4.9.2) The only priority for the use of public hospitals should be housing and/or service sites for persons with brain disorders.

(5.4.9.3) Public resources and all monies saved by reduced utilization of state hospitals as well as through other system efficiencies should be reallocated to expand community-based services and supports for persons with brain disorders.

(5.4.10) Dual-Diagnosis Funding

NAMI supports blending mental health, alcohol, and substance abuse funds at the state level for the treatment of persons with dual diagnoses of a brain disorder and co-occuring substance abuse.

(5.4.11) Developmental Disabilities (DD)

(5.4.11.1) Entitlements and programs for persons with brain disorders must compare equitably with those for other physical illnesses and disabilities.

(5.4.11.2) NAMI calls for changes in federal, state, and local laws so that those applicable services provided by state and local governments to persons with developmental disabilities must also apply to persons with brain disorders.

(5.4.11.3) NAMI encourages monitoring and supporting the activities and procedures of the State Planning Council on developmental disabilities and knowledge of the criteria used by the Administration on Developmental Disabilities when reviewing state plans and awarding and implementing grants.

(5.4.11.4) NAMI supports linkages between the Center for Mental Health Services and the Administration on Developmental Disabilities and between State Mental Health Planning Councils and State Planning Councils on Developmental Disabilities.

(5.4.12) Medicaid Choice of Health Plans

Choice of health plans should be the primary principle. However, local situations involving histories of poor quality, inadequate numbers of enrollees, possibility of adverse selection, and well-functioning, single carve-out, specialty health plans should allow for waivers to the choice principle. (Revised February, 1999)

5.5 Managed Care

(5.5.1) The public sector must continue to be accountable for the delivery of treatment and services for persons with brain disorders even when contracting out the services to private sector managed care organizations.

(5.5.2) NAMI advocates for research and services in response to these major brain disorders in persons of all ages: schizophrenia, bipolar disorder, major depression, obsessive-compulsive disorder, and panic disorder.

(5.5.3) There must be continued eligibility within the public system for persons with brain disorders who are employed but cannot obtain health coverage through their employers.

(5.5.4) State government must develop and maintain a comprehensive community-support system of treatment and services for the priority populations. Services must, at a minimum, be those required in a state mental health plan by PL 99-660. States must continue to maintain short- and long-range plans for those with brain disorders.

(5.5.5) There must be meaningful participation of consumers and families at every stage of the redesign, implementation, evaluation, and monitoring of the managed care system.

(5.5.6) All planning and delivery of services must be culturally sensitive to ethnically diverse populations and the communities in which they are located.

(5.5.7) Public sector entities that contract with managed care organizations (MCOs) or other entities for the management and/or delivery solely of Medicaid-funded services for persons with brain disorders must exercise great caution lest they inadvertently divide the mental health system and cause dumping of persons with severely disabling brain disorders who are heavy users of costly services back onto a public system that is generally considered to be underfunded.

(5.5.8) Public resources saved by managed care systems should be reallocated to expand services to the priority population.

(5.5.9) Provider personnel, both administrators and treatment staff, must have an understanding of brain disorders. They must have training to work with the priority population--including training in the consumer and family perspective--and must accept accountability for the quality of services they provide.

(5.5.10) All provider staff must be rigorously and appropriately credentialed by appropriate state agencies. (Revised February, 1999)

(5.5.11) A comprehensive array of community-support services must be available for individuals who meet the priority-population definition and either have a Global Assessment Functioning (GAF) scale score of 50 or below or who are at risk of declining to this level. These services must include new-generation medications, inpatient treatment, residential support services, intensive case management, psychosocial rehabilitation, consumer-run services, an around-the-clock crisis services seven days a week. Outpatient services must be mobile.

(5.5.12) MCOs must be held accountable by the public purchasers for linkages to housing with supportive services and employment services.

(5.5.13) There must be consumer and family involvement in individual treatment planning including choice of provider, treatment delivery, and appropriate access to peer-support groups.

(5.5.14) Appeal and grievance procedures must be in place that are user-friendly and time-sensitive to the life-threatening nature of psychotic episodes.

(5.5.15) The public sector purchasers must report quarterly to the public the number of recipients who 1) fail to present for services; 2) are in jail or prison; 3) have been placed in a state hospital; and/or 4) have died.

(5.5.16) Outcome measurement for people with brain disorders must be included in the contracts with managed care organizations and be required by the public sector purchaser on a regular basis. Outcomes should include relevant and scientifically sound measures of clinical status, general health status, functioning, quality of life (such as housing status, employment status, treatment compliance, substance abuse, involvement with the criminal justice system, and involvement with meaningful activities), and subjective measures, from patients and family members, of satisfaction with care.

Updated November 17, 1996