Repeal of Medicaid’s IMD Exclusion

TO THE EDITOR: The National Association of State Mental Health Program Directors (NASMHPD) represents the state executives responsible for the public mental health service delivery systems in the states and territories. We read with interest the recent debate in Psychiatric Services on whether the Medicaid’s institutions for mental diseases (IMD) exclusion should be repealed. Both sides in the debate made important points in their well-written position statements (1, 2).

We found it interesting that both debaters cited the same August 2016 Mathematica Medicaid Emergency Psychiatric Services Demonstration evaluation (3) to support opposing positions. That this citation was used by both parties is indicative of the scarcity of data available regarding the potential impact of the IMD exclusion and its repeal. The Centers for Medicare and Medicaid Services (CMS) recently proposed revising the Medicaid managed care rule. CMS leadership expressed reluctance to increase the limit on IMD services beyond 15 days per month under those rules because it had “conducted a literature and data review since publication of the [original] rule, but could not identify any new data sources other than those [it] relied upon in the 2016 final rule that supported 15 days” (4). CMS invited public comment on any data sources it may have missed supporting longer stays.

One week after CMS published the proposed Medicaid managed care rules revision, it issued State Medicaid Director Letter 18–011 authorizing state §1115(a) Medicaid waivers that would allow individuals with serious mental illness or serious emotional disturbance to be covered under Medicaid for IMD services for average stays of no more than 30 days. Those waivers will be conditioned on each participating state’s maintaining its efforts in providing community-based services, especially crisis stabilization services, and reporting the full array of services offered by the state—a condition designed to ensure a comprehensive continuum of care. The waivers would require the reporting of data and measures to help ensure that future evaluations of the IMD exclusion would be evidence based.

NASMHPD strongly supports the need for a comprehensive continuum of care for individuals with serious mental illness, as illustrated by its Beyond Beds series of white papers (https://www.nasmhpd.org/content/tac-assessment-papers). One of the papers, written by the NASMHPD Research Institute, reviews the number of inpatient and community residential beds, including crisis beds (5).

The final decision on an IMD exclusion repeal must be evidence based. NASMHPD welcomes the waivers proposed by CMS as a way of quantifying the need for inpatient services and the effectiveness of providing those services as part of a continuum of care.