On November 9, the Centers for Medicare & Medicaid Services (CMS) approved the District of Columbia’s 1115 waiver, Behavioral Health Transformation. The approval is noteworthy because it is the first to receive approval to provide psychiatric and addiction treatment covered by Medicaid in an institution for mental disease (IMD) under the guidance released by CMS in November 2018 (see CMS Approves D.C. Medicaid Payment For IMD Services).
As a reminder, IMD is a Medicaid-specific term that refers to residential or inpatient facilities with more than 16 beds in which individuals are primarily receiving care for a “mental disease” (for states, parsing this definition and determining those facilities that count as IMDs can be difficult, see Code of Federal Regulations). Traditionally, services in these facilities has been excluded from Medicaid coverage for individuals between the ages of 21 to 64. The rationale has been attributed to the desire of the federal government to prevent states from leveraging federal funding for state psychiatric hospitals.
For executives of specialty provider organizations, understanding state-specific IMD exclusion waivers is important to building a strategy for how to provide care. In states with waivers for IMDs, provider organizations have an opportunity to receive Medicaid funding for these services. For organizations providing outpatient or community-based services there is an increased opportunity to be a referral source for step-down services.
Our team reviewed states with IMD exclusion waivers in The 2019 Update On States With IMD Waivers report and found that there are 27 states that have waivers to provide addiction treatment in IMDs. This is an increase from just 10 states with waivers to provide addiction treatment in IMDs in February 2018. Additionally, D.C. has the ability to provide psychiatric care in an IMD and at least one state, Oregon can receive payment for services provided outside an IMD for pregnant/postpartum women who are residing in an IMD. This report does not analyze states that allow Medicaid health plans to provide services in an IMD as an “in lieu of service.”
The specifics of IMD exclusion waivers in each state varies. Most states must hit an average statewide length of stay and are limited in the number of days a single person can reside in an IMD. Additionally, states must agree to implement specific initiatives in order to receive federal funding. For example, states must use the American Society of Addiction Medicine criteria or a similar evidence-based tool in consumer placement and certification of residential addiction treatment provider organizations. States must show that residential treatment facilities are either providing medication assisted treatment (MAT) or are connected to organizations that provide MAT. States with IMD waivers for mental health treatment must ensure maintenance of effort in funding community-based mental health services.
In the future, additional options for providing care in IMDs will be available to states. On November 6, CMS released additional guidance that states may cover addiction treatment services in IMDs for individuals between the ages of 21 to 64 in an IMD for up to 30 days during a 12-month period under a state plan amendment. Funding is available on a time-limited basis from October 2019 to September 30, 2023. Importantly, eligible IMDs must offer at least two types of MAT medications on-site (see Implementation of Section 5052 of the SUPPORT for Patients and Communities Act – State Plan Option under Section 1915(l) of the Social Security Act).
For more on the topic of IMD waivers check out The 2019 Update On States With IMD Waivers report, which provides a list of states with waivers to provide care in IMDs. It details what services may be provided in IMDs for addiction treatment and provides a deep dive into each state’s addiction treatment waiver. The report also explains the different state options for providing care in an IMD.
For even more, join us at The 2020 OPEN MINDS Performance Management Institute in Clearwater, Florida on February 14 for the session, The Future Of Residential Treatment: How Technology & Innovative Program Models Are Redefining Service Delivery Models featuring Dyann Roth, president and chief executive officer, Inglis.