NABH Issue Brief

The Centers for Medicare & Medicaid Services (CMS) on Wednesday released guidance to state Medicaid directors that clarifies how section 5052 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patient and Communities (SUPPORT) Act permits institutions for mental diseases (IMDs) to provide treatment to Medicaid beneficiaries with at least one substance use disorder (SUD).

NABH was a driving force behind section 5052 becoming law and the NABH team has talked with CMS staff about the law’s implementation.

The guidance from CMS covers five key areas: requirements for beneficiaries, requirements for IMDs, requirements for states, maintenance of effort, and interaction with existing IMD policies. This NABH Issue Brief provides a summary of each of those areas.

Requirements for Beneficiaries

An eligible individual for section 5052 (the new IMD authority) is a person who is:

• a Medicaid enrollee,
• between the ages of 21 and 64,
• residing in an IMD primarily to receive withdrawal management or SUD treatment services,
• diagnosed with at least one SUD, and
• in an IMD primarily to receive treatment for a SUD (SUD must be the primary diagnosis).

Requirements for IMDs

Eligible IMDs must follow reliable, evidence-based practices and make available at least two forms of medication as part of medication-assisted treatment (MAT). The two drugs may be offered on site upon request or furnished off site by a qualified provider in the community that has an arrangement with the IMD. IMDs “should also offer behavioral health services alongside MAT,” CMS noted.

Requirements for States

States are required to:

• ensure placement in an IMD will allow the beneficiary to successful transition to the community;
• ensure that eligible IMDs provide services at lower levels of clinical intensity or establish relationships with providers offering those services;
• notify CMS how it will ensure eligible individuals receive appropriate evidence-based clinical screening and periodic reassessments to determine the appropriate level of care;
• cover outpatient SUD treatment services, including early intervention, outpatient services, intensive outpatient services, partial hospitalization, and at least two of the following residential and inpatient levels of care:
  • low-intensity residential services,
  • population specific, high-intensity residential services for adults,
  • medium-intensity residential services for adolescents,
  • high-intensity residential services for adults,
  • high-intensity inpatient services for adolescents,
  • intensive inpatient services withdrawal management for adults, and
  • intensive inpatient services.

Maintenance of Effort

On an annual basis states must:

• maintain or exceed the level of state and local funding for patients in eligible IMDs as well as services furnished to eligible individuals in outpatient, community-based settings;
• report the total state and local expenditures, excluding the state share of Medicaid expenditures, for:
  • items and services provided while a patient in an eligible IMD,
  • outpatient and community-based SUD treatment,
  • evidence-based recovery and support services,
  • clinically-directed therapeutic treatment to facilitate recovery skills, relapse prevention and emotional coping strategies,
  • outpatient MAT, related therapies, and pharmacology,
  • counseling and clinical monitoring,
  • outpatient withdrawal management and related treatment, and
  • routine monitoring of medication adherence.

Interaction with Existing IMD Policies
 
States that add the new IMD authority (Section 5052) may also receive monthly capitation payments paid to managed care plans for beneficiaries age 21 through 64 who receive inpatient treatment in an IMD.

Section 5052 does not prevent states from pursuing or conducting a section 1115 demonstration to improve access to, and the quality of, SUD treatment for eligible populations.

Additional Information

CMS is developing a state plan amendment and maintenance of effort reporting templates to assist states. Click here for specific guidance related to state plan amendment submission procedures, including guidance on developing comprehensive methodologies and bundled rates.

If you have questions, please contact Scott Dziengelski, NABH’s director of policy and regulatory affairs.