Medicaid beneficiaries with chronic psychiatric disorders may lose their
access to rehabilitative services under a proposed rule from the Centers for
Medicare and Medicaid Services (CMS).
The proposed rule is part of revisions to regulations governing Medicaid
rehabilitative services, proposed in August, that CMS says will strengthen
beneficiary protections through "person-centered" written
rehabilitation plans and maintenance of case records. The changes also are
expected to have considerable cost savings for Medicaid, estimated by CMS
officials to be about $180 million in the first year and $2.2 billion over the
next four years.
The tightening of rehabilitative language was meant to keep non-Medicaid
programs, such as local jails, from using Medicaid funds to provide benefits
to people in programs "with a focus other than that of Medicaid,"
according to CMS.
"These facilities are under the domain of the juvenile justice or
youth systems in the state, rather than Medicaid, and there is no assurance
that the claimed services reflect an independent evaluation of individual
rehabilitative needs," according to a CMS statement on the need for the
rules changes. "This proposed [rule] is designed to clarify the broad
general language of the current regulation to ensure that rehabilitative
services are provided in a coordinated manner that is in the best interest of
the individuals, are limited to rehabilitative purposes, and are furnished by
The proposed changes also would limit Medicaid reimbursement to those whose
rehabilitation care is designed to return them to a higher level of
functioning, as opposed to trying to improve the functioning of those who have
always been impaired.
APA and other advocates maintain, however, that those changes would cut off
some beneficiaries with chronic psychiatric disorders from receiving
rehabilitative services through Medicaid.
In comments submitted to the agency in response to the proposal, APA urged
CMS to broaden rehabilitative services language to include rehabilitative
services for beneficiaries who do not have a previous higher level of function
and for those who need the services just to maintain their current level of
"This concept is essential to a broad spectrum of beneficiaries who
should receive Medicaid rehabilitative services, especially those with chronic
psychiatric disorders," said APA Medical Director James H. Scully Jr.,
M.D., in an October 12 letter to CMS. "It is not always clear in advance
who may experience functional improvement through access to these
"Those with chronic, serious psychiatric disorders may experience
benefits from rehabilitative treatments that are improvements other than
restoration of pre-existing functional levels," Scully stated.
APA and other mental health groups, including the U.S. Psychiatric
Rehabilitation Association (USPRA), did commend CMS for some of the proposed
changes such as the requirement that those who provide rehabilitation services
develop rehabilitation plans and "recovery-oriented goals" for
"The creation of a rehabilitation plan is good practice and is
necessary for shared decision making and accountability," said Marcie
Granahan, CEO of USPRA, in a letter to CMS.
The most effective approach for beneficiaries with serious, chronic
psychiatric disorders is acute treatment along with ongoing rehabilitative
services, Scully noted.
Another change sought by APA is clarification of language in the proposed
rules that critics interpret as a categorical exclusion of Medicaid payment
for "personal care services, transportation, [and] vocational and
prevocational services." Scully suggested that such an interpretation
should not be accepted by CMS, since it would be inconsistent with CMS's
stated intent to allow Medicaid coverage for at least some such services
related to rehabilitation.
The CMS rules also need language to require that physicians perform the
mandatory "comprehensive assessment" of beneficiaries proposed by
the rules, said Scully, with psychiatrists performing the psychiatric
assessments, "especially where physical comorbidities are at
"The better the assessment, the more well targeted the rehabilitation
plan can be for maximum outcomes," Scully wrote.
The proposed rule was open to public comments until mid-October. There is
no timetable for CMS to issue final regulations.
The proposed changes can be accessed at<www.gpoaccess.gov/fr/index.html>
by selecting volume 72, pages 45201-45213. ▪