21st Century Cures Act Section 12002 IMD Study Survey

SECTION 12002 IMD STUDY: OMB PACKAGE ATTACHMENT B MATHEMATICA POLICY RESEARCH

Attachment B1

Note: the information contained in this summary will be available as a reference for survey respondents via the web-based survey platform.

Summary of Relevant Regulations and Legislation

Medicaid Managed Care Final Rule

Section 438.6(e) of the final rule states that:

The State may make a monthly capitation payment to an MCO or PIHP for an enrollee aged 21–64 receiving inpatient treatment in an Institution for Mental Diseases, as defined in
§ 435.1010 of this chapter, so long as the facility is a hospital providing psychiatric or substance use disorder inpatient care or a sub-acute facility providing psychiatric or substance use disorder crisis residential services, and length of stay in the IMD is for a short term stay of no more than 15 days during the period of the monthly capitation payment. The provision of inpatient psychiatric or substance use disorder treatment in an IMD must meet the requirements for in lieu of services at §438.3(e)(2)(i) through (iii). For purposes of rate setting, the state may use the utilization of services provided to an enrollee under this section when developing the inpatient psychiatric or substance use disorder component of the capitation rate, but must price utilization at the cost of the same services through providers included under the State plan.

Medicaid and CHIP Managed Care Final Rule Frequently Asked Questions (FAQs) – Section 438.6(e)

FAQs published in August 2017 state:

A state can make a pro-rated capitation payment to cover the days when the enrollee is not a patient in an IMD, but FFP is not available for payments related to days when the enrollee is in an IMD when the requirements of §438.6(e) are not met….[W]e understand that there may be circumstances in which the enrollee will be a patient in an IMD for more than 15 days within a month, but for less than 30 days. In some of these circumstances, such enrollees will remain in states’ managed care programs, and the MCO or PIHP will assume some level of risk for Medicaid-covered services once the enrollee is back in the community and not a patient in an IMD. In such cases, states are permitted to make a pro-rated capitation payment to the MCO or PIHP to cover only the days within the month when the enrollee is not a patient in the IMD. FFP is not available for payments related to days when the enrollee is in an IMD when the requirements of §438.6(e) are not met.

21st Century Cures Act Mandate

Section 12002 of the 21st Century Cures Act, entitled Study and Report Related to Medicaid Managed Care Regulations, requires HHS to conduct a study on coverage under the Medicaid program of services provided through a Medicaid managed care organization (MCO) or prepaid inpatient health plan (PIHP) with respect to individuals over the age of 21 and under the age of 65 for the treatment of a mental health disorder in institutions for mental diseases.

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