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CMS to Help Medicaid Reimburse for Maternal Opioid Misuse Care

The new Maternal Opioid Misuse (MOM) model will give 12 states funding to create care and payment strategies for treating opioid misuse among pregnant and postpartum women.

Medicaid reimbursement and maternal opioid misuse

Source: Xtelligent Healthcare Media

By Jacqueline LaPointe

- CMS recently announced that it will be awarding up to $64.6 million to 12 state Medicaid agencies to help develop Medicaid reimbursement and care delivery strategies for maternal opioid misuse treatment.

The awards are part of the new five-year Maternal Opioid Misuse (MOM) model. Driven by state transformations, the model aims to reduce the healthcare costs and improve outcomes of pregnant and postpartum Medicaid beneficiaries with opioid use disorder.

“Too many barriers impede the delivery of well-coordinated, high-quality care to pregnant and postpartum women struggling with opioid misuse, including lack of access to treatment and a shortage of providers in rural areas, where the opioid crisis is especially destructive,” HHS Secretary Alex Azar stated in the announcement. “The MOM model will support state Medicaid agencies, front-line providers, and healthcare systems to help ensure that mothers and infants afflicted by the opioid epidemic get the care they need.”

Substance abuse is now the leading cause of maternal death, CMS reported. And pregnant and postpartum women with substance abuse disorders are also at greater risk for poor maternal outcomes, such as preterm labor and delivery complications.

Their babies also experience poor health outcomes. Infants born to mothers with substance abuse disorders are at higher risk for preterm birth, low birth weight, and neonatal abstinence syndrome (NAS).

Poor maternal and infant outcomes are also typically exacerbated by social determinants of health, including food insecurity and domestic safety.

Medicaid pays the largest portion of the hospital charges related to maternal substance abuse treatment, CMS added. The federal healthcare program also shoulders the majority of the $1.5 billion spent annually on NAS.

In light of poor outcomes and high Medicaid spending, CMS developed the MOM model to improve care quality and reduce the costs of pregnant and postpartum women suffering from an opioid use disorder.

The new model also aims to increase access to treatment, service-delivery capacity, and infrastructure, as well as develop sustainable coverage and payment strategies to support ongoing coordinated and integrated treatment of opioid use disorder.

CMS will enter 12 cooperative agreements with states to execute the MOM model. Medicaid agencies in the selected states will work with health systems and payers in their communities to remove the barriers of high-value maternal opioid misuse treatment.

The agencies and “care-delivery partners” will create a single delivery model that provides coordinated and integrated behavioral and physical care through a multi-disciplinary team of healthcare professionals.

Under the agreement, state Medicaid agencies must ensure care coordination, beneficiary engagement, and prompt referrals, CMS added. To achieve the goals, the federal agency will give states the flexibility to define a specific set of services that that incorporate the following:

  • Comprehensive care management
  • Care coordination
  • Health promotion
  • Individual and family support
  • Community and social services referrals

Awardees will develop and pay for the coordinated and integrated care delivery model through three funding stages.

First, CMS will provide implementation funding to the 12 awardees. The implementation funding will cover building and increasing capacity and infrastructure. State Medicaid agencies will have the authority to determine the appropriate use of the implementation funding based on their health system and payer partners.

The selected Medicaid agencies will then receive transition funding. The awards will support the reimbursement of wrap-around coordination, engagement, and referral activities taking place in Year 2 of the MOM model. The transition funding will ensure wrap-around services are covered when the activities are not yet or adequately covered by the state’s health plans.

CMS expects Medicaid programs in the awardee states to adequately reimburse for activities in the care delivery model by Year 3 of the model.

Finally, CMS will ensure the sustainability of the MOM model through milestone funding in the last three years of the program. State Medicaid agencies in the model will be able to gain access to the milestone funding based on quality performance.

The MOM model will launch in the fall of 2019, according to the CMS announcement. CMS anticipates release a Notice of Funding Opportunity in early 2019.


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