Just last week the Centers for Medicaid and Medicare Services (CMS) released proposed rules for Medicaid managed care programs for the first time since 2003. While there are many proposed rules, the one with significant implications for behavioral health is the prospect of a partial lift of the institution for mental disease (IMD) exclusion rule (see CMS Overhauls Medicaid Managed Care Regulations; Proposes End To IMD Exclusion For 15-Day Stays).
In short, the proposed rule allows federal financial participation if individuals between the ages of 21-64 are treated in an IMD for 15 days or less. By definition, an IMD provides inpatient psychiatric, substance use disorder (SUD) inpatient care, or SUD crisis residential services for at least 50% of their beds/capacity. In the history of the program, Medicaid has never allowed for reimbursement of IMD services for individuals between the ages of 21-64. (For more on the current IMD rules, see CMS State Medicaid Manual: Chapter 4, Requirements And Limits Applicable To Specific Services, Chapter, 4270 to 4390 and Getting A Bead On The IMD Issue.)
The ruling comes as a slight surprise as CMS is in the midst of the pilot program, Medicaid Emergency Psychiatric Demonstration (MEPD), which is testing the use of IMDs for individuals between the ages of 21-64 in eleven states and the District of Columbia. The pilot program ends in December 2015 and the findings aren’t due until September 2016. An interim report from CMS released in July 2014 had inconclusive findings and did nothing to indicate a change in ruling. (For OPEN MINDS coverage of this interim report, see What Is Up With The Medicaid Emergency Psychiatric Demonstration Project? and One-Third Of Admissions In Medicaid Emergency Psychiatric Demonstration Are For Schizophrenia Or Psychosis.)
In the proposed rule, CMS states the main reasons for partially lifting the ban is due to a decline in the number of inpatient psychiatric care facilities, concerns about access issues, and psychiatric boarding in emergency rooms (see Proposed Rule For Medicaid Managed Care, CHIP Delivered in Managed Care, Medicaid and CHIP Comprehensive Quality Strategies, and Revisions related to Third Party Liability). The new rule would provide more options for emergency psychiatric admissions (see Private Psychiatric Facilities Reported 5.4% Increase In Psychiatric Inpatient Days & 6.6% Increase In Outpatient Services In 2012). But, the limited length of stay precludes the use of IMDs for long-term care indicating that Medicaid is trying to balance the need for inpatient psychiatric beds with limiting institutionalization.
What are the implications for the delivery system? For consumers, this provides more options if hospital-based care is needed. For provider organizations, the opportunity for acute care programs with 16+ beds to participate in the Medicaid program – and to offer more robust crisis response programs and alternatives to hospitalization.
Even though the proposed rule limits the amount of time an individual can spend in an IMD, it does add to the recent debate about the use of institutions in psychiatric care. For more resources on this subject from the OPEN MINDS Industry Library, check out:
- Washington Ban On Psychiatric ER Boarding May Have Longer Legs
- Another Perspective On Psychiatric Boarding
- The Asylum Issue
- Should The U.S. Bring Back Psychiatric Asylums?
- Psych Bed Shortage – Mismatch Or Coverage Problem?
- Do Community Hospitals Have To Accept Involuntary Psychiatric Admissions?
Comments on the proposed rule are due on July 27, after which CMS will evaluate the comments and release the final rule. As this new set of rules progresses, we’ll keep you posted.