Key Themes in Medicaid Section 1115 Behavioral Health Waivers

Issue Brief
  1. Kaiser Family Foundation, CMS’s Final Rule on Medicaid Managed Care:  A Summary of Major Provisions (June, 2016), https://www.kff.org/medicaid/issue-brief/cmss-final-rule-on-medicaid-managed-care-a-summary-of-major-provisions/.

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  2. States can effectively receive federal matching funds for capitation payments made for enrollees with IMD stays up to 30 days if the stay does not exceed 15 days in a single month.  Id.  Prior to the revised managed care rule, some states were using “in lieu of” authority to cover IMD services without day limits.

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  3. California allows a one-time 30-day extension if medically necessary, and peri-natal patients may stay for the duration of pregnancy and 60 days post-partum.

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  4. Without waiver authority, federal law allows states to use a portion of their Medicaid disproportionate share hospital funds to offset IMDs’ uncompensated care costs.  See, e.g., GAO, States Fund Services for Adults in Institutions for Mental Disease Using a Variety of Strategies, GAO-17-652,  at 34 (Aug. 2017), http://www.gao.gov/assets/690/687212.pdf.

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  5. CMS, SMD #15-003, New Service Delivery Opportunities for Individuals with a Substance Use Disorder (July 27, 2015), https://www.medicaid.gov/federal-policy-guidance/downloads/SMD15003.pdf.

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  6. CMS, SMD #17-003, Strategies to Address the Opioid Epidemic (Nov. 1, 2017), https://www.medicaid.gov/federal-policy-guidance/downloads/smd17003.pdf.

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  7. Medicaid community-based behavioral health services can be covered under state plan or waiver authority.

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  8. CMS, SMD #15-003, New Service Delivery Opportunities for Individuals with a Substance Use Disorder (July 27, 2015), https://www.medicaid.gov/federal-policy-guidance/downloads/SMD15003.pdf.

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  9. Id. 

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  10. CMS, SMD #17-003, Strategies to Address the Opioid Epidemic (Nov. 1, 2017), https://www.medicaid.gov/federal-policy-guidance/downloads/smd17003.pdf.

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  11. For example, states must include an “independent process for reviewing placement in residential treatment settings.”  Id.

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  12. Another state (Maryland) indicated that CMS denied its request for IMD mental health payment waiver authority, while approving its request for IMD substance use payment authority.  GAO, States Fund Services for Adults in Institutions for Mental Disease Using a Variety of Strategies, GAO-17-652,  at 30 (Aug. 2017), http://www.gao.gov/assets/690/687212.pdf.

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  13. In Olmstead, the Supreme Court found that the unjustified institutionalization of people with disabilities violates the Americans with Disabilities Act. Kaiser Family Foundation, Olmstead’s Role in Community Integration for People with Disabilities Under Medicaid:  15 Years After the Supreme Court’s Olmstead Decision (June, 2014), https://www.kff.org/medicaid/issue-brief/olmsteads-role-in-community-integration-for-people-with-disabilities-under-medicaid-15-years-after-the-supreme-courts-olmstead-decision/.  Although the ADA’s anti-discrimination provisions do not apply to individuals who are currently using illegal drugs, the ADA does protect people who previously used illegal drugs and people with mental health disabilities.  ADA Title II Technical Assistance Manual, § II-2.3000, https://www.ada.gov/taman2.html.

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  14. While federal Medicaid funds cannot be used to pay for rent, states can use Medicaid to cover housing transition and tenancy-sustaining services.  CMS Informational Bulletin, Coverage of Housing-Related Activities and Services for Individuals with Disabilities (June, 2015), https://www.medicaid.gov/federal-policy-guidance/downloads/CIB-06-26-2015.pdf.

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  15. Kaiser Family Foundation, Medicaid Home and Community-Based Services Programs:  2013 Data Update (Oct., 2016), https://www.kff.org/medicaid/report/medicaid-home-and-community-based-services-programs-2013-data-update/.

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  16. Kaiser Family Foundation, Money Follows the Person:  A 2015 State Survey of Transitions, Services, and Costs (Oct. 2015), https://www.kff.org/medicaid/report/money-follows-the-person-a-2015-state-survey-of-transitions-services-and-costs/; Kaiser Family Foundation, Medicaid Balancing Incentive Program:  A Survey of Participating States (June, 2015), https://www.kff.org/medicaid/report/medicaid-balancing-incentive-program-a-survey-of-participating-states/.

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  17. Kaiser Family Foundation, Medicaid Financial Eligibility for Seniors and People with Disabilities in 2015 (March, 2016), https://www.kff.org/medicaid/report/medicaid-financial-eligibility-for-seniors-and-people-with-disabilities-in-2015/.

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  18. Id. 

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  19. Enrollees receive state plan physical and behavioral health benefits and home and community-based services.

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  20. Enrollees must qualify for state-funded limited mental health benefit program.

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  21. Enrollees receive state plan services.

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  22. Enrollees receive all state plan services and targeted home and community-based services.

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  23. Enrollees receive state plan behavioral health services and targeted home and community-based services only.

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  24. Enrollees receive state plan and home and community-based services.

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  25. Enrollees receive service coordination, community supports, flexible supports including day recovery and psychoeducation (including support for families and significant others), skilled therapy, residential treatment (excluding IMD services), housing and home supports, crisis support, environmental safety devices, counseling, respite, and supported employment.

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  26. New York’s pending waiver amendment also would move its existing financial eligibility expansion for children with behavioral health and HCBS needs who currently meet an institutional level of care from Section 1915 (c) to Section 1115 authority.

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  27. Virginia’s Governor’s Access Plan for the Seriously Mentally Ill Evaluation Report, Year 1 at 2, 21 (June 27, 2016),

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  28. Id. at 12.

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  29. Id. at 10, 11.

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  30. Id. at 14, 23.

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  31. Id. at 22, 23.

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  32. This summary is based on the state’s June, 2016 waiver application that is pending with CMS and does not reflect any changes in the August, 2017 proposed managed care program design that has not yet been submitted to CMS.  North Carolina’s Proposed Medicaid Managed Care Program Design (August, 2017), https://files.nc.gov/ncdhhs/documents/files/MedicaidManagedCare_ProposedProgramDesign_REVFINAL_20170808.pdf.

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