WASHINGTON, D.C. – The Association for Behavioral Health and Wellness (ABHW) submitted comments to the U.S. Centers for Medicare and Medicaid Services (CMS) regarding the Interim Final Rule on Medicaid Community Engagement requirements (“the Rule”). As the rule currently stands, ABHW fears that access to comprehensive, evidence-based mental health and substance use disorder coverage may be constrained. Chief among these concerns is that eligible beneficiaries may not be properly identified due to technology limitations and interoperability failures.
“The reality of the behavioral health system is that providers have historically been excluded from meaningful federal health IT investment,” says Debbie Witchey, President and CEO of ABHW. “This has had the unfortunate result of lower interoperable EHR adoption and less complete clinical claims data.” As a result, states may have difficulty identifying beneficiaries with mental health or substance use conditions who qualify for exclusions or exceptions when relying on automated processes.
A second, no less significant, concern is that the medical frailty requirement in the Rule does not align with statute. As written, the Rule includes a requirement that individuals demonstrate a functional limitation that impairs their ability to meet the 80-hour monthly community engagement requirement, in addition to having a qualifying medical condition.
“This requirement is not stipulated in statute and complicates implementation unnecessarily,” says Witchey. “A diagnosis of medical frailty should be sufficient to establish eligibility” for the exemption.
In addition, ABHW urges CMS to:
- Provide clear guidance on 42 CFR Part 2. ABHW encourages CMS and OCR to provide clear implementation guidance before January 1, 2027, addressing how SUD information may be used to verify eligibility while complying with Part 2.
- Eliminate the arbitrary five-year recovery limit. Individuals in recovery from substance use disorders should not lose the medical frailty exemption based solely on the length of their recovery.
- Clarify the role of Managed Care Organizations: ABHW encourages CMS to issue practical implementation guidance, develop model managed care contract language, provide examples of permissible plan activities, and establish ongoing opportunities for dialogue among CMS, states, and MCOs to promote consistent implementation nationwide.
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ABOUT 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 who care for approximately 200 million people. Together, we work to reduce stigma and advance federal policy on mental health and substance use disorder care. ABHW member companies include Aetna Behavioral Health, Elevance Health, Centene Corporation, Evernorth, a Cigna company, 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
