Washington, D.C. – The Association for Behavioral Health and Wellness (ABHW) today recognizes the Centers for Medicare & Medicaid Services (CMS) for adopting key recommendations from ABHW and its member health plans as the agency implements the community engagement requirement provision of the One Big Beautiful Bill Act of 2025 (OBBBA). CMS’s decision reflects broad stakeholder input and advances approaches that better protect individuals with mental health and substance use conditions from losing coverage.
Under OBBBA, certain groups are exempt from the new Medicaid community engagement requirements, including individuals who are considered “medically frail” and those with a “Substance Use Disorder (SUD)” or a “Disabling Mental Disorder.”
“We are encouraged that CMS listened to the behavioral health community and adopted some of our recommendations to safeguard people with serious mental illness and substance use disorders,” said ABHW President and CEO Debbie Witchey. “Congress created these exemptions because many individuals simply cannot meet community engagement requirements, and CMS’s actions will help ensure they are accurately identified and do not lose vital Medicaid coverage.”
ABHW had recommended that CMS:
- Adopt the Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) definition of Serious Mental Illness (SMI) as the standard for determining whether an individual qualifies for the “Disabling Mental Disorder” exception. Although CMS declined to codify a specific definition, it directs states to use established clinical standards, including ISMICC, DSM-5, and ICD-10, when making eligibility determinations. This represents meaningful progress toward a clinically grounded approach, though variation in state implementation remains a concern.
- Define “Substance Use Disorder” using the latest edition of the Diagnostic and Statistical Manual (DSM) and International Classification of Diseases (ICD) diagnostic criteria. While CMS did not adopt a formal regulatory definition, it recognized DSM-5 and ICD-10 as appropriate clinical frameworks and clarified that the exemption applies to individuals in treatment, early recovery, and excluding individuals who are in stable recovery (which means, in recovery for 5 or more years). This represents an important recognition of the recovery continuum, although states retain flexibility in how they implement and apply the exemption. CMS also adopted ABHW’s recommendations for implementation regulations that support states and beneficiaries. These include giving states the option to allow individuals to use screening tools to help determine whether they meet the “medically frail” behavioral health definitions and to self-attest when documentation is not reasonably available.
In addition, CMS has clarified that sharing SUD patient data to verify exemption status must remain compliant with 42 CFR Part 2 (Part 2), in line with ABHW’s recommendations. This clarification is intended to support appropriate data use while maintaining strong privacy protections for individuals receiving SUD treatment. CMS is committed to working with the Office for Civil Rights (OCR) to provide states with technical assistance.
“By adopting these recommendations, CMS is helping states administer OBBBA in a way that is both clear and workable, without creating unnecessary burdens or barriers for those seeking exemptions,” Witchey added. “We are encouraged to see that the Interim Final Rule released yesterday includes an opportunity for public comment. We are hopeful that CMS will incorporate recommendations from commenters committed to preserving continuity of care and ensuring that individuals Congress intended to protect through these important exceptions can continue to access needed services without disruption.”
ABOUT THE ASSOCIATION FOR BEHAVIORAL HEALTH AND WELLNESS
The Association for Behavioral Health and Wellness (ABHW) is the leading health plan association working to improve access and quality of care for mental health and substance use disorders. ABHW’s members include national and regional health plans that care for approximately 200 million people, working together to reduce stigma and advance federal policy on mental health and substance use disorder care. ABHW member companies – Aetna, a CVS Health Company; CareFirst BlueCross BlueShield; Carelon Behavioral Health, an Elevance Health Company; Centene Corporation; Evernorth; Health Care Service Corporation; Kaiser Permanente; Lucet; Magellan Health; Molina Healthcare; Optum; and PerformCare, a subsidiary of AmeriHealth Caritas. To learn more, visit www.abhw.org and follow us on BlueSky and LinkedIn.
MEDIA CONTACT
Jennifer Salopek
salopek@abhw.org
703-909-9059
