SUD Waivers And Tackling The Opioid Crisis Go Hand In Hand


To allow greater flexibility and encourage greater innovation in tackling Substance Use Disorder (SUD) and Opioid Use Disorder (OUD), special waivers are available for each state to relax Medicaid requirements and implement uniquely crafted programs. CMS oversees the application of these waivers, and are the ultimate arbiters of their approval. A type of Section 1115 waiver, SUD and OUD waivers empower states to design demonstration projects that result in greater access to treatment for opioid use and other substance abuse disorders. In recent weeks, Utah and New Jersey had SUD waivers approved. 

A driving purpose of these waivers is to provide better treatment for Medicaid patients suffering from substance abuse disorder. West Virginia, which had the nation’s highest drug overdose death rate in 2015, has implemented a section 1115 waiver and their demonstration project, as approved by CMS, highlights many of the desired outcomes for other states seeking waivers. Building on the Medicaid expansion of 2014, their project seeks to further their efforts by: 

  • Broadening the scope of SUD services that the state’s Medicaid program pays for so the state can pay for multiple services that may be needed in order to deliver whole person care 
  • Improving the quality of care by aligning their continuum of care guidelines with those recommended by the American Society of Addiction Medicine Criteria 
  • Working with CMS to create a system for monitoring quality and health outcomes
  • Thoroughly evaluating their demonstration by having an independent third party evaluate how well it meets its objectives 
  • Sharing lessons learned with the national SUD community to help improve their system of care 

The efforts in West Virginia are a prime example of how to implement the general guidelines created by CMS that must be incorporated into any state’s demonstration project. Earlier this year, the CMS administration issued a letter to governors clarifying the programs primary objectives. Their approach has become more flexible and streamlined as part of their efforts, enabling states to respond to the growing opioid crisis with greater speed and efficiency.  

As the opioid and substance use problems have increased in occurrence, CMS has actively tried to improve access to OUD and other SUD treatment services for Medicaid beneficiaries. Medicaid beneficiaries have higher rates of Opioid Use Disorder (OUD) than the general population, accounting for 25% of adult cases in 2015. Sadly, only 32% of those beneficiaries received treatment. Adding to the difficulty or providing treatment to Medicaid beneficiaries is the fact that 40% of counties in the U.S. do not have an addiction treatment facility that provides outpatient care and accepts Medicaid. CMS has keenly followed the research growing the OUD and SUD epidemics, and are actively working to improve Medicaid beneficiaries’ access to high-quality, evidence-based treatment services for addiction to opioids or other substances. They are hoping states use these waivers to help accomplish these goals. 

Recognizing that states will bring a degree of creativity and unique ideas to their demonstration proposals, CMS has helped direct these efforts to provide the goals that any project must accomplish, and the milestones they will use in evaluating the success of the project. For their primary goals, CMS has determined all projects must accomplish:  

  • Increased rates of identification, initiation, and engagement in treatment 
  • Increased adherence to and retention in treatment 
  • Reductions in overdose deaths, particularly those due to opioids 
  • Reduced utilization of emergency departments and inpatient hospital settings for treatment where the utilization is preventable or medically inappropriate through improved access to other continuum of care services 
  • Fewer readmissions to the same or higher level of care where the readmission is preventable or medically inappropriate 
  • Improved access to care for physical health conditions among beneficiaries 

States wishing to participate in these efforts are encouraged to develop proposals incorporating these goals. Recognizing that the implementation of these demonstration projects may not always go according to plan, CMS is helping states by providing implementation and monitoring protocols designed to make useful data from other states efforts available for all to learn from, and allow states the ability to make project adjustments as needed. Milestones established by CMS that must be accomplished by SUD and OUD demonstration projects include: 

  • Access to critical levels of care for OUD and other SUDs 
  • Widespread use of evidence-based, SUD-specific patient placement criteria 
  • Use of nationally recognized, evidence-based SUD program standards to set residential treatment provider qualifications 
  • Sufficient provider capacity at each level of care 
  • Implementation of comprehensive treatment and prevention strategies to address opioid abuse and OUD 
  • Improved care coordination and transitions between levels of care 

As states such as West Virginia and Maryland have proceeded in their demonstration projects, they have provided valuable data that CMS has incorporated into their updated goals and milestones. Washington state has even seen significant reductions in medical costs among Medicaid beneficiaries who accessed addiction treatment compared to those who did not. CMS is hoping this success can lead the way for other states as we work together to address the growing SUD and OUD crisis. 

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