AMBHA Introduction


Directory of AMBHA Public Policy Statements (as of April 2000):
	AMBHA ASAM Joint Statement on Practice Guidelines Any Willing Provider Bill of Rights for Consumers Accessing Behavioral Health Services Clinically Appropriate Access to Medical Records Medicaid's IMD Prohibition Parity in Benefit Coverage: A Joint AMBHA-ASAM Statement Parity in Benefit Design Provider Sponsored Organizations (PSOs) Statement of Confidentality Statement on Co-occuring Disorders AMBHA ASAM Joint Statement Guideline for Credentialing and Privileging

Medicaid's IMD Prohibition

Statement
In a managed care structure, arbitrary health plan benefit limitations, such as the Medicaid IMD prohibition, are anachronistic. In capitated payment systems which emphasize performance based contracting, positive clinical outcomes, consumer satisfaction, and organized and integrated networks of services which coordinate treatment specialties, there is no need for arbitrary treatment site prohibitions.

Background and Explanation
Since the beginning of the Medicaid program in 1965, Medicaid payment has been denied to residents of institutions for mental diseases (IMDs). Not only are the treatment facilities denied Medicaid reimbursement, but payment cannot be made for any Medicaid service, including physical illness and dental treatment.

IMDs are inpatient facilities whose overall character and purpose is the specialization of psychiatric care. The most typical IMDs are state inpatient psychiatric hospitals, private psychiatric hospitals, and residential substance abuse facilities. Psychiatric and substance abuse units of general hospitals are not classified as IMDs.

Since 1965 those persons age 65 and over have not been subject to the IMD exclusion. In 1972, persons age 21 and under could receive the inpatient psychiatric services benefit. In 1988, facilities with 16 or fewer beds were exempted from the IMD prohibition. And beginning in the late 1980s, roughly 30 states avoided the IMD prohibition by declaring psychiatric hospitals with significant indigent populations eligible for disproportionate share hospital (DSH) payments.

Several states have been granted Health Care Financing Administration (HCFA) limited "waivers" of the IMD exclusion as part of HCFA approved managed care demonstrations.

Recommendation
In the context of a managed care program, arbitrary benefit limits and prohibitions, such as the Medicaid IMD prohibition, make no clinical or programmatic sense.