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Building a Strong Substance Use Disorder (SUD) 1115 Waiver Demonstration

Is your state Medicaid agency considering a Centers for Medicare and Medicaid Services (CMS) Section 1115 Waiver to fight the opioid epidemic in your state? States want the waiver because it provides flexibility to test different approaches to finance and deliver Medicaid services. The skyrocketing prevalence of substance use disorders nationwide calls for such flexibility and innovation to expand existing services for treatment and recovery. Although applying for an 1115 waiver can be daunting, here are some guidelines to help you succeed with implementation.

Be Pragmatic

Be honest and pragmatic in planning discussions for the essential resources you need to have in place for a successful implementation. Ask yourselves who and how many people you need to involve to develop and execute each stage. Plan enough time to develop policies and agency protocols, make sure you have the right providers for your members, set provider rates, and then train the providers.

Ask Hard Questions

Once you identify key requirements to address first in your waiver, ask yourself what elements need to be in place to meet these requirements. Here are elements to consider and questions to answer:

Fee-for-service and managed care organization (MCO) rates — new services, such as adult residential treatment services aligned with care standards (e.g., American Society of Addiction Medicine (ASAM®) levels), may require changes to reimbursement rates. What needs to happen to develop new rates? What obstacles do you anticipate and how will you overcome them?
Care standards (e.g., ASAM® levels of care) and training your providers — consider what the levels mean given the range of providers in your state and the services your members receive. What is required to move to these standards? How you will work with providers to ensure adherence, including certification and training? What will this cost?
Policy changes — your state’s Medicaid agency will need to revamp and create policies to cover the service expansion and other changes. How will you complete all necessary policy and protocol changes early enough to inform MCO and provider actions?
MCO provider network adequacy — it’s worth investing the time in your application development to assess whether the MCOs serving Medicaid recipients in your state have the right mix of providers to ensure that you can fully implement the new service structure. How long should you give the MCOs for network expansion or recruitment?
MCO care coordination guidelines — each MCO will have its own approach. How are you going to ensure adherence to your waiver’s vision of care coordination?
Indicators — how will you evaluate the success of your program? How will you collect and analyze data? The earlier you determine how you will evaluate your program, the easier it will be to report on, and make improvements.

Get Started

Applying for and implementing an SUD 1115 waiver is a complex and time-consuming process — but by dedicating the time up front to address the many details of time and resources, you’ll find implementation to be far smoother, and effective treatment and recovery services provided sooner for those who need it most. Interested in learning more about Section 1115 waiver application and implementation strategies? Email me.

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