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H.R. 5797, Individuals in Medicaid Deserve Care that is Appropriate and Responsible in its Execution, or the IMD CARE Act

Floor Situation

On Wednesday, June 20, 2018, the House will consider H.R.5797, the IMD CARE Act, under a structured rule. This bill was introduced on May 15, 2018 by Rep. Mimi Walters (R-CA) and was referred to the House Committee on Energy and Commerce, which ordered the bill reported, as amended, by voice vote on May 17, 2018.


Summary

H.R. 5797 allows state Medicaid programs to remove the Institutions for Mental Diseases (IMD) exclusion for Medicaid beneficiaries aged 21 to 64 with an opioid use disorder for fiscal years 2019 to 2023. By removing the exclusion, Medicaid would pay for up to 30 total days of care in an IMD during a 12-month period for eligible individuals. Opioid use disorder as defined in H.R. 5797 includes, but is not limited to: heroin, fentanyl, oxycodone, tramadol and oxycodone. In addition, the legislation requires states to include in their State plan amendment information on 1) How the State will improve access to outpatient care during the State plan amendment period. 2) The process for transitioning individuals to appropriate outpatient care. 3) A description of how individuals will receive appropriate screening and assessment.


Background

According to the Centers for Disease Control and Prevention (CDC), on average, 1,000 people are treated for opioid misuse in emergency departments per day, an average of 115 Americans die per day.

Under the Medicaid statute, Federal funding cannot be used to finance care for Medicaid beneficiaries aged 21 to 64 receiving mental or substance use disorder care in a residential facility that has more than 16 beds. When a Medicaid-eligible individual is a patient in an IMD, he or she cannot receive Medicaid coverage for services provided inside or outside the IMD. The Medicaid IMD exclusion is one of the few instances in the Medicaid program where federal financial participation cannot be used for medically necessary and otherwise covered services for a specific Medicaid enrollee population receiving treatment in a specific setting. According to the Medicaid and CHIP Payment and Access Commission (MACPAC), “The Medicaid IMD exclusion acts a barrier for individuals with an opioid use disorder to receive residential treatment, which, depending on an individual’s treatment plan, may be the most appropriate setting for care.”[1]

The Centers for Medicare and Medicaid Services’ (CMS) has allowed for some administrative flexibility to this prohibition, issuing regulatory guidance in 2016 that would allow for IMD payment for up to fifteen days in any given month. Additionally, in 2015 CMS authorized a new Section 1115 Demonstration Project pathway for substance use disorder, allowing states to receive federal financial participation for IMD stays so long as certain other criteria are met and as part of a full continuum of care. However, these 1115 waivers take significant time to approve as well as state resources.


Amendments

A List of amendments may be found here.


Cost

The Congressional Budget Office (CBO) estimates that enactment of the bill would cost $991 million over the 2019-2028 period (page 7).


Staff Contact

For questions or further information please contact Jake Vreeburg with the House Republican Policy Committee by email or at 2-1374.


115th Congress