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Radar On Market Access: New Opioid Law Has Implications for MA, Medicaid Plans

Posted by Lauren Flynn Kelly on Nov 8, 2018


One year after the Trump administration declared the opioid crisis a public health emergency, the president signed The SUPPORT for Patients and Communities Act (H.R. 6), a bipartisan legislative package containing myriad provisions aimed at addressing the opioid epidemic. One of the main objectives of the law is to expand access to substance use disorder (SUD) treatment in Medicaid, AIS Health reported.

The new law contains certain flexibilities related to the IMD exclusion, which refers to a longstanding exception that prevented state Medicaid programs from using federal funds to cover care for patients in mental health and SUD residential treatment facilities with more than 16 beds. The primary change is that Section 5052 amends federal Medicaid law by giving state programs the option to cover care in certain IMDs, which may be otherwise not reimbursable for federal funds, for Medicaid beneficiaries aged 21 to 64 with an SUD for fiscal years 2019 to 2023. Through a state plan amendment, states may receive federal reimbursement for up to 30 total days of care in an IMD during a 12-month period for eligible individuals.

As a condition of receiving federal payments, states will be subject to a "maintenance of effort" provision that essentially says they have to maintain the same levels of funding for "what they've been doing in other areas of care, so having IMDs doesn't mean you can cut back on some of the home and community-based services that were going on for opioid treatment," remarks Stephanie Kennan at McGuireWoods Consulting. "It'll be expensive for the states, but it's important for the continuum of care. The trade-off is that you'll have patients hopefully who are getting the kind of care they need faster and won't need other things on the other end."

As states add IMDs to their programs, plans will have to figure out who will be eligible and how to manage the care, "because not everyone is going to need inpatient treatment and it is only for 30 days," adds Kennan. "And I think in general whether it's Medicare or Medicaid, the plans are going to have to do some identifying and managing of patients, but in a little more detail than they had to do it before." 

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Topics: Industry Trends, Provider, Payer