What the Heck is a Medicaid SUD 1115 Waiver?

Funny wonky name, huh? Here's the answer:  The West Virginia Medicaid Substance Use Disorder (SUD) 1115 Waiver gives our state a set of new tools to fight the opioid addiction crisis confronting our rural communities. The federal Secretary of Health and Human Services can let states deviate from certain Medicaid rules when necessary to implement demonstration projects (also called section 1115 waivers) that further Medicaid’s core objectives, including improving coverage or beneficiaries’ health outcomes.  Following guidelines developed by the Obama Administration, West Virginia was the first state to submit and be approved for a SUD 1115 waiver. The waiver allows West Virginia to cover critical SUD treatments and services with federal Medicaid matching dollar by: 

The West Virginia Medicaid Substance Use Disorder (SUD) 1115 Waiver allows West Virginia to cover critical SUD treatments and services with federal Medicaid matching dollar by:

  • Broadening the scope of SUD services that the state’s Medicaid program pays for, so the state can provide a full continuum of care. The waiver lets Medicaid pay for short-term residential treatment, which can be critical for people beginning recovery or rebounding from relapses — a common occurrence among people with SUD. It also expands beneficiaries’ options for evidence-based medication-assisted treatment (which combines medication with therapy) and adds coverage for peer recovery supports. Together, these reforms will help provide the community-based services and long-term recovery supports necessary to help people in all stages of SUD treatment and recovery.
  • Improving the quality of care. Along with increasing the scope of SUD services that Medicaid covers, the waiver aims to improve the quality of services. The continuum of care that West Virginia will provide is consistent with the American Society of Addiction Medicine Criteria — the nationally accepted treatment criteria for SUD. West Virginia will also work with CMS to create a system for monitoring quality and health outcomes.

The SUD Waiver is being implemented in two phrases. Beginning January 1,2018, coverage for methadone treatment services, the Naloxone Initiative and the introduction of the Screening, Brief Intervention and Referral to Treatment (SBIRT) method began.

As of July 1, 2018, short-term residential treatment services, peer recovery support services and withdrawal management services will be covered by Medicaid.

Other features of the SUD Waiver include the following:  

  • Strategies focusing on SUD prevention and treatment among adolescents.
  • Building on existing efforts to raise awareness and address the prevalence of babies born with exposure to substance use.
  • Expanding coverage of withdrawal management in regionally identified settings.
  • Enhancing access to outpatient SUD treatment as appropriate when residential treatment is not required.
  • Covering a set of clinical and peer recovery support services and recovery housing supports designed to promote and sustain long-term recovery.

All of these services will be available to the following:

  • All West Virginia Medicaid members as well as those served through managed care and fee-for-service (FFS) delivery systems.
  • At-risk families will be eligible for services to allow for community-based treatment and supports to prevent children from being placed out of the home.
  • Foster care youth will be able to receive SUD treatment services through the Early and Periodic Screening, Diagnosis and Treatment (ESPDT) benefit.

A copy of the waiver is available at http://dhhr.wv.gov/bms/CMS/Pages/Waiver-Approvals.aspx

West Virginians Together for Medicaid