CMS Issues 1115 Waiver Mentioning ASAM's Criteria

Medicaid is playing an increasingly important role as a payer for services provided to individuals with addiction in the United States. There have been some exciting developments regarding The ASAM Criteria in Medicaid's expanding role......"exciting" for me anyway, because I have been on a mission for 25 years to have The ASAM Criteria accepted as the model for addiction treatment's continuum of care.

Last month, the Center for Medicare and Medicaid Services (CMS) announced new opportunities for states to design service delivery systems for Medicaid beneficiaries with a substance use disorder (SUD). Numerous federal authorities are offering states the flexibility to implement system reforms to improve care, enhance treatment and offer recovery supports for SUD. ASAM's criteria is mentioned in several places as integral to that service delivery design.

Here are excerpts from that announcement. If you want to read more, here's the link: http://medicaid.gov/federal-policy-guidance/downloads/smd15003.pdf

• "An estimated 12% of adult Medicaid beneficiaries ages 18-64 have an SUD. 
• An estimated 15% of uninsured individuals who could be newly eligible for Medicaid coverage in the New Adult Group have an SUD.
• CMS is committed to helping states effectively serve these individuals and introduce benefit, practice and payment reforms through the technical assistance and coverage initiatives described below."

"States have compelling reasons to provide Medicaid coverage for the identification and treatment of SUD, many of which are given urgency by the national opioid epidemic. Untreated substance use disorders are associated with increased risks for a variety of mental and physical conditions that are costly."

• "In 2009, health insurance payers spent $24 billion to treat SUD. Of those expenditures, Medicaid accounted for 21%.
• Two of the top ten reasons for Medicaid 30-day hospital readmissions are SUD-related.
• Individuals with SUD and co-morbid medical conditions account for high Medicaid costs, such that $3.3 billion was expended in one year on behalf of 575,000 beneficiaries with SUD as a secondary diagnosis.
• Beyond health care risk, the economic costs associated with SUD are significant. States and the federal government spend billions every year on the collateral impact associated with SUD, including criminal justice, public assistance and lost productivity costs.
• Alarmingly, the rate of fatal drug overdose in the U.S. has quadrupled between 1999 and 2010.
• Drug overdose has become the leading cause of injury death, causing more deaths than traffic crashes.
• Other problems also relate to opioid prescribing including opioid exposed pregnancies, drugged driving, and increases in Hepatitis C and in some circumstances HIV from prescription opioid injection."

"As states expand Medicaid coverage to millions of new beneficiaries that may have been previously uninsured, states are also expanding access to behavioral health services including covering these services in Alternative Benefit Plans as required by the Affordable Care Act. CMS has received a number of requests from states and stakeholders interested in enhancing care for individuals with SUD." 

The CMS announcement mentioned examples of practice changes including "Enhancing provider competencies to deliver SUD services with fidelity to industry standard models, such as the American Society for Addiction Medicine (ASAM) Criteria."

Here are more excerpts from the CMS announcement that align with what ASAM's criteria has been advocating since the first edition in 1991:

"Strong Network Development Plan"
"States will be asked to develop a network development and resource plan to ensure there is a sufficient network of knowledgeable providers in each of the levels of care recognized by ASAM and recovery support services. In addition, the state should have the resources to ensure that providers have the ability to deliver services consistent with the ASAM Criteria and provide evidence-based SUD practices. The network should be sufficiently robust so that access can be assured in the event that some providers stop participating in Medicaid, are suspended or terminated."

"Care Coordination Design"
"Coordination of care design is integral to SUD delivery reform. This entails developing processes to ensure seamless transitions and information sharing between levels and settings of care (withdrawal management, short-term inpatient, short-term residential, partial hospitalization, outpatient, post-discharge, recovery services and supports), as well as a collaboration between types of health care (primary, mental health, pharmacological, and long-term supports and services). CMS encourages states to test how to best achieve care transitions across the care continuum, including aftercare and recovery support services."

"Short-term acute SUD treatment may occur in inpatient settings and/or residential settings. ...Inpatient services are described by the ASAM Criteria as occurring in Level 4.0 settings, which are medically managed services. Inpatient services are provided, monitored and observed by licensed physician and nursing staff when the acute biomedical, emotional, behavioral and cognitive problems are so severe that they require inpatient treatment or primary medical and nursing care. "

"Residential services are provided in in ASAM Level 3.1, 3.3, 3.5 and 3.7 settings, which are clinically managed and medically monitored services typically provided in freestanding, appropriately licensed facilities or residential treatment facilities without acute medical care capacity. "

California was one of the first states to seize new opportunities from CMS for demonstration projects. These projects are approved under section 1115 of the Social Security Act (Act) to ensure that a continuum of care is available to individuals with SUD. Section 1115 demonstration projects allow states to test innovative policy and delivery approaches that promote the objectives of the Medicaid program.

If your state is considering enhancing care for individuals with SUD, take a look at what California is just now embarking on in their system of care redesign. Here is the introduction to California's system re-design states:

"The Drug Medi-Cal Organized Delivery System (DMC-ODS) provides a continuum of care modeled after the American Society of Addiction Medicine Criteria for substance use disorder treatment services, enables more local control and accountability, provides greater administrative oversight, creates utilization controls to improve care and efficient use of resources, implements evidenced based practices in substance abuse treatment, and coordinates with other systems of care."

"This approach provides the beneficiary with access to the care and system interaction needed in order to achieve sustainable recovery. The DMC-ODS will demonstrate how organized substance use disorder care increases the success of DMC beneficiaries while decreasing other system health care costs."

The State Implementation Plan and Standard Terms and Conditions for the DMC-ODS are located at http://www.dhcs.ca.gov/provgovpart/Pages/Drug-Medi-Cal-Organized-Delivery-System.aspx