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H.R. 5797 (115th): Individuals in Medicaid Deserve Care that is Appropriate and Responsible in its Execution Act

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.

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.”

Last updated Jun 20, 2018. Source: Republican Policy Committee

The summary below was written by the Congressional Research Service, which is a nonpartisan division of the Library of Congress, and was published on Jun 20, 2018.

Individuals in Medicaid Deserve Care that is Appropriate and Responsible in its Execution Act or the IMD CARE Act

(Sec. 2) This bill temporarily allows states to apply to receive federal Medicaid payment for services provided in institutions for mental diseases (IMDs) and for other medically necessary services for enrollees (aged 21 to 64) with opioid-use or cocaine-use disorders. Services may be covered for a total of up to 30 days in a 12-month period for an eligible enrollee. States must include specified information in their applications, including plans to improve access to outpatient care.

Current law generally prohibits federal payment under Medicaid for services provided in IMDs for individuals under the age of 65 (although states may receive payment through certain mechanisms, such as through a Medicaid demonstration waiver).

(Sec. 3) Additionally, the bill temporarily eliminates the enhanced federal matching rate for Medicaid expenditures regarding specified medical services provided by certain managed care organizations.