Collins Leads Bipartisan Senators, including King, in urging CMS to Expand Substance Abuse Treatment Coverage

Senators argue changes to outdated Medicaid rules necessary in response to worsening opioid addiction epidemic

WASHINGTON, D.C. – U.S. Senators Susan Collins and Dick Durbin (D-IL) today led a bipartisan group of 29 senators, including Senator Angus King, in urging the Centers for Medicare and Medicaid Services (CMS) to improve access to substance abuse treatment by modifying the Institutions for Mental Disease (IMD) Exclusion.  The IMD Exclusion currently limits options for individuals seeking substance abuse treatment by prohibiting federal reimbursement for services provided to Medicaid beneficiaries between ages 22 and 64 in certain settings, including residential mental health and substance use disorder treatment facilities with over 16 beds.   In a letter to CMS Acting Administrator Andy Slavitt, the senators asked the agency to use existing authorities to provide greater flexibility in order to ensure patient access to medically necessary substance abuse treatment.

      “Our nation’s opioid and heroin epidemic has devastated countless families and communities across the country.  Maine has been particularly hard hit by this unprecedented addiction crisis, with a record 272 overdose deaths in 2015, the vast majority of which were caused by heroin, fentanyl, or prescription opioids,” said Senator Collins.  “As we look for ways to stymie this burgeoning public health crisis, we must identify and correct outdated federal reimbursement policies that can exacerbate the problem of access to life-saving care.  I have long been concerned that the IMD exclusion limits timely access to needed mental health and substance abuse treatment.  To mitigate this problem and help increase access to evidence-based substance abuse treatment, I led my colleagues, including Senator King, in urging CMS to use existing authorities to expand treatment opportunities, including removing substance use disorder treatment and facilities from the IMD Exclusion.”

      “There are an estimated 25,000 to 30,000 people in Maine who want drug treatment but don’t have access to it. That’s a tragedy, especially when we know that, in some of those cases, the availability of treatment will mean the difference between life and death. By revising outdated federal rules, like the IMD Exclusion, to better address the challenges presented by today’s opioid and heroin crisis, we can expand treatment options and help people get the help they need,” said Senator King, who earlier this year introduced the Medicaid Care Act, which would modify the IMD Exclusion to allow more people to seek substance abuse treatment.

The letter was also signed by Senators Patty Murray (D-WA), Lisa Murkowski (R-AK), Barbara Mikulski (D-MD), Shelley Moore Capito (R-WV), Sherrod Brown (D-OH), Kelly Ayotte (R-NH), Rob Portman (R-OH), Chris Murphy (D-CT), Mark Kirk (R-IL), Maria Cantwell (D-WA), Barbara Boxer (D-CA), Ben Cardin (D-MD), Bob Casey (D-PA), Bob Menendez (D-NJ), Diane Feinstein (D-CA), Jeanne Shaheen (D-NH), Richard Blumenthal (D-CT), Ed Markey (D-MA), Jeff Merkley (D-OR), Elizabeth Warren (D-MA), Kirsten Gillibrand (D-NY), Heidi Heitkamp (D-ND), Amy Klobuchar (D-MN), Claire McCaskill (D-MO), Al Franken (D-MN), and Cory Booker (D-NJ).


Full text of the letter is below:


The Honorable Andy Slavitt

Acting Administrator

Centers for Medicare & Medicaid Services

7500 Security Boulevard

Baltimore, MD 21244


Dear Administrator Slavitt:

      In December 2014, 18 bipartisan Senators wrote to the Centers for Medicare and Medicaid Services (CMS) regarding the Institutions for Mental Disease (IMD) Exclusion, which prohibits federal financial participation (FFP) for services furnished in an IMD setting to adults age 22-64 years. This existing policy limits treatment for those who need it most, is clinically inappropriate for proper care, and is rooted in an outdated definition of mental health. In light of the ongoing heroin and prescription opioid epidemic that is impacting communities across the nation, we urge CMS to take additional steps, utilizing existing authorities, to provide greater flexibility in ensuring patient access to medically necessary evidence-based substance abuse treatment.

      Over the past two decades, CMS has taken important strides to expand eligibility, protect benefits, and improve provider capacity for the coverage of substance use disorder (SUD) services in Medicaid. The emergence of coordinated and integrated service delivery models that include behavioral health care services in Medicaid have improved outcomes and reduced costs. We also applaud CMS for its leadership in identifying innovative approaches to expand access to SUD treatment, through recent measures including the July 2015 1115 waiver guidance letter, the focus of the Innovation Accelerator Program on SUD treatment, the March 2016 mental health and SUD parity final rule, and the April 2016 Medicaid managed care final rule. Specifically, we commend CMS on the acknowledgement that the IMD Exclusion poses a barrier to beneficiary access to SUD treatment, and for incorporating new tools to mitigate the effect of this policy.

      However, we remain concerned that these measures may be insufficient to respond to the opioid epidemic and will not afford enough states the opportunity to enact meaningful changes for beneficiaries. For example, only one state has received approval from CMS for an 1115 waiver for SUD treatment overhauls, whereas many states have indicated an inability to marshal the resources to undertake such a broad, budget-neutral proposal.

      Furthermore, the recent managed care rule only allows for 15 days of care furnished in an IMD setting over a 30-day period to be eligible for FFP, and it is our understanding that only American Society of Addiction Medicine (ASAM) Level 4 facilities are eligible. We have serious concerns about limiting eligibility to medically managed intensive inpatient care settings, while precluding all types of Level 3 residential treatment facilities when such settings may be more clinically appropriate.  Further, we question whether a 15-day length of stay is evidence-based for SUD treatment, considering numerous studies suggesting the cost-savings, readmissions reductions, overdose preventions, and recovery efficacy from longer lengths of stay in residential settings as a patient progresses down the clinical continuum of care.

      CMS’ recent mental health and SUD parity final rule extends certain protections from the Wellstone-Domenici Mental Health Parity and Addiction Equity Act of 2008 to Medicaid managed care organizations. CMS noted in its fact sheet that this final rule “helps to prevent inequity between beneficiaries who have mental health or substance use disorder conditions in the commercial market and Medicaid.” We seek clarification from CMS on whether the IMD Exclusion can be justified given these parity laws and regulations, especially considering the fact that Medicaid beneficiaries are not covered for medically necessary treatment within settings that play an important role within the continuum of care. Such an exclusion appears to be discriminatory to the estimated 12 percent of adult Medicaid beneficiaries ages 18-64 who have SUDs.  

      Our nation is in the midst of a heroin and prescription opioid epidemic that has shined a spotlight on barriers to patient access to life-saving care.  Improved understanding of addiction pathologies has also informed novel therapies, and patients with SUDs can now manage addiction and reach recovery using medication-assisted treatments.  There are numerous Congressional efforts underway seeking to address this issue, but we strongly urge CMS to use existing authorities to broaden treatment opportunities, such as by removing SUD treatment and facilities from the IMD Exclusion.

           We look forward to your timely response.