MACPAC to Examine Effect of IMD Exclusion on Foster Children’s Access to Care

The Medicaid and CHIP Payment and Access Commission (MACPAC) met on April 8 and 9 to, among other things, finalize a chapter for its June Report to Congress on access to children’s behavioral health services in Medicaid and CHIP. As anticipated based on discussions during the March 4 MACPAC meeting, the chapter doesn’t appear to directly address the Medicaid Institutions for Mental Diseases (IMD) exclusion. It’s hard to be sure because the public sees only a presentation about the chapter, not the language itself, until finalized. However, NACBH’s public comments at last month’s meeting seem to have finally persuaded the Commission to take up the issue in depth in a future report. Although the Next Steps identified in last week’s draft chapter review are not explicit, the reference to access for children in foster care is the relevant commitment.

As part of the chapter review, the Commissioners approved two recommendations for Congress – and, again, until we see the final language as submitted to Congress in June, we can’t be sure of whether they begin to address NACBH’s concerns. The first would require HHS to direct CMS, SAMHSA, and ACF to issue joint guidance on the design and implementation of benefits for children and adolescents with significant mental health conditions. The second would require similar joint guidance related to home and community-based services.

NACBH Public Policy Director Pat Johnston has communicated regularly with MACPAC policy analysts and Commissioners over the past two years, in response to public requests for information and direct invitations for more in-depth conversation, as well as during public meetings, to provide information about how the IMD exclusion restricts children's access to necessary health care services. Our most recent letter highlighted the urgency of resolving the IV-E/IMD conflict before the October 1, 2021 deadline to implement the Family First Prevention Services Act, and we are preparing another set of comments now in anticipation of the “next steps” announced last week. In part, those comments will stress that it is not only behavioral health services that are not covered for children residing in excluded IMDs, it is all otherwise covered Medicaid health services until the child is unconditionally discharged.  We will prepare separate comments on current Medicaid requirements for home and community-based services, not all of which are age- or developmentally-appropriate for children. Please email Pat Johnston with questions, concerns, and suggestions about all of the above.