When Cans States File for the Limited Imd Waiver
Introduction
As the nation experiences unprecedented levels of behavioral health needs—even further exacerbated by the COVID-xix pandemic—state Medicaid programs accept increasingly looked for flexibility to craft services and payment models that back up improved admission and outcomes. Equally the single largest payer for behavioral health services nationwide, Medicaid is in a unique position to impact millions of Americans' admission to quality behavioral wellness care. To engender this effort, the Centers for Medicare & Medicaid Services (CMS) has waived historical restrictions on inpatient substance use and mental wellness services and permitted states to leverage Section 1115 demonstrations to support wide-based reform.
Background on Substance Employ Disorder and Serious Mental Disease/Serious Emotional Disturbances Waivers
Institutions for Mental Affliction Waivers for Substance Use Disorders
Over the last v years, 32 states (see Figure ane) have obtained federal waivers of the institutions for mental disease (IMD) exclusion—the historical prohibition on using federal Medicaid funds to pay for treatment delivered to individuals ages 21 to 64 residing in institutions with more than than 16 beds—for individuals receiving substance employ disorder (SUD) services. In November 2017, CMS released a state Medicaid director (SMD) letter—replacing July 2015 guidance—notifying states of the opportunity to design Section 1115 demonstrations focused on SUDs. In the SMD letter, CMS brash states that they could apply to waive the IMD exclusion if they met key weather condition, including providing access to SUD handling across disquisitional levels of care, increasing use of evidence-based SUD treatment and placement criteria to ensure individuals are placed at the appropriate level of care, introducing SUD provider quality standards, and strengthening care coordination for individuals with SUDs. These demonstrations have solidified Medicaid's office as the largest source of coverage and funding for substance apply prevention and handling in the land, covering nearly xl percentage of adults with an opioid employ disorder (OUD) and 17 percent of adults experiencing whatsoever type of habit. Since the first state waivers were approved in late 2015 and 2022, expanding access to bear witness-based SUD treatment beyond all levels of care remains a disquisitional need due to continued ascension in drug utilise and overdose deaths.
IMD Waivers for Serious Mental Illness & Serious Emotional Disturbance
In contempo years, CMS and states take taken an integrated approach to treating mental illness and SUD to effectively address ascent behavioral health (BH)—mental health (MH) and SUD—needs. Nearly one-half of the 19.iii one thousand thousand adults with SUD have a co-occurring mental illness, and 18 percent of adults with mental illness have a co-occurring SUD. In November 2018, CMS released some other SMD letter notifying states of the opportunity to design Section 1115 demonstrations focused on adults with a serious mental affliction (SMI) and children with a serious emotional disturbance (SED). In the SMD letter, CMS advised states that they could similarly apply to waive the IMD exclusion for individuals obtaining care for serious MH weather if they ensure the quality of inpatient and residential care; ameliorate care coordination and care transitions; improve access to a continuum of treat MH handling; and promote earlier identification of and engagement in MH care. To forbid over-institutionalization of individuals with SMI/SED, states must meet additional requirements, including maintaining their current funding for outpatient community-based MH services and adhering to a thirty-day average length of stay in IMDs.i A growing number of states—seven with approved waivers and three with pending waivers equally of May 2021—are pursuing waivers of the IMD exclusion for SMI/SED.
Figure 1. States With Approved or Pending Waivers of the IMD Exclusion
Fundamental Features of SUD and SMI/SED Section 1115 Demonstrations
In addition to waiving the IMD exclusion for SUD and MH treatment, states are using Section 1115 demonstrations to implement a range of strategies to better intendance for Medicaid enrollees with BH needs.
Additional Handling and Recovery Services
A number of states are using waiver dominance to cover or pilot a range of BH treatment and recovery services, many of which tin can be covered via Medicaid State Plan dominance, and link these services to waivers of the IMD exclusion. States usually use Section 1115 IMD-focused waivers to encompass SUD and MH treatment and detoxification services, particularly residential levels of care that are often provided in IMDs. Other states like Illinois and Washington, D.C., are using their Section 1115 demonstrations to comprehend or airplane pilot crisis intervention and mobile crunch response services—a move that may become increasingly more common amid states one time the American Rescue Plan (ARP) Act community mobile crisis intervention services option—which allows states to cover qualifying services using Medicaid Land Plan or Section 1115, 1915(b) or 1915(c) authorities—becomes effective in April 2022.ii
A significant number of states with Section 1115 BH-focused demonstrations are using their waivers to comprehend peer back up services, which use the lived experience of individuals recovering from SUD to back up others in treatment and recovery, for individuals with SUD and/or SMI. Of the 37 states roofing peer supports for individuals with SUD, most are covering this service using Medicaid State Program authorisation. Peer support services can be provided in a range of clinical and non-clinical settings, and as a complement to or replacement for clinical treatment, including for crisis response services.
Additionally, states employ their Section 1115 BH demonstrations to provide enhanced home and community-based services (HCBS) to individuals with SMI, SED and/or SUD. In recognition that individuals with BH needs account for approximately one-third of all homeless individuals, states like Washington, Illinois, Florida and Hawaii are providing supportive housing benefits to adults with SUD and/or SMI who are or at risk of condign homeless. In addition to Department 1115 waiver authority, states can cover supportive housing services through Section 1915(c) or 1915(i) authority. These supportive housing and tenancy support services assist beneficiaries with a range of services including securing appropriate housing, edifice relationships with landlords and neighbors and obtaining the skills necessary to manage a household.
Targeted Delivery System Reform With Behavioral Health Components
Several states also use waiver authority to obtain Medicaid funding to pursue delivery organisation and payment reforms targeted to specific populations, including those with BH needs. A shrinking number of states operate Delivery System Reform Incentive Payment (DSRIP) programs with BH components, which provide states with meaning funding to help providers, especially hospitals, invest in delivery system reform.3 For example, Washington'due south DSRIP program, authorized through a Department 1115 demonstration in 2017, includes waivers of the IMD exclusion for SUD and SMI/SED, likewise as projects targeted toward the integration of physical and behavioral wellness services and strategies to accost SUD and projects focusing on SUD and projects focusing on physical health and BH integration. It will be critical to watch whether the Biden Administration reverses the grade set out by the Trump Assistants, which was gradually phasing downwards DSRIP programs in an attempt to shift Medicaid programs toward more than sustainable value-based purchasing integrated into Medicaid delivery systems. Nether the Trump Administration, states were still able to leverage Medicaid funding for and pursue BH-focused delivery system and payment reforms using 1115 waivers other than DSRIP waivers. For case, Hawaii, Massachusetts and Due north Carolina obtained Medicaid funding through broader Section 1115 demonstrations for health-related initiatives addressing social determinants of heath for specific populations, including those with BH needs.
Coverage Expansion for Individuals With Behavioral Health Needs
Select states also utilize Section 1115 authority to extend either limited or full Medicaid coverage to adults and children with SED, SMI or SUD who are otherwise ineligible for Medicaid. For example, Rhode Island uses its 1115 demonstration to expand Medicaid eligibility to children with SED who crave handling in a psychiatric residential treatment facility and do non meet income requirements for Social Security Income. The state as well provides a express do good packet to uninsured adults with incomes from 133–200 pct of the federal poverty level who have a mental disease or SUD.
Looking Ahead
As the first land-focused IMD demonstrations come upwards for renewal and more than 60 percent of states gain experience operating these demonstrations, federal and state governments accept an opportunity to take stock of these demonstrations. Key questions to scout in the months ahead include:
- How constructive take SUD demonstrations been at increasing SUD treatment and leading to reductions in overdose deaths?
- Will CMS accelerate approval of SMI waivers?
- What pressures may emerge for additional protections confronting over-institutionalized care as more than states brainstorm to seek such waivers?
- What efforts volition be fabricated to integrate MH and SUD handling via Section 1115 demonstrations?
- Will states integrate kid-focused BH reforms into these waivers that have long focused on adults with BH needs?
- How will CMS bring its strong focus on equity into these waivers going frontwards?
As BH intendance needs among Americans alter, it is essential that CMS and state Medicaid agencies remain nimble and innovative.
1 States may non claim Medicaid matching funds for any part of an IMD stay for mental health that exceeds 60 days.
ii The ARP Deed enacted on March 11, 2021, establishes a country selection to provide community mobile crisis intervention services for a five-year menses beginning in April 2022. As an incentive to state adoption, the law provides for an 85 percent enhanced federal matching rate for qualifying services for the first iii years of state coverage.
3 Thirteen states originally had DSRIP waivers with 12 approved by the Obama Administration and one—Washington—approved past the Trump Administration in 2017.
Source: https://www.jdsupra.com/legalnews/states-are-leveraging-medicaid-waivers-5534902/
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