As of 2019, over 800,000 Medicaid enrollees between the ages of 12 to 64 had a recognized stimulant use dysfunction that was recorded in Medicaid claims knowledge (although that is seemingly an undercount). Stimulant use dysfunction—which may contain dependence on cocaine, methamphetamine, or different psychostimulants, like prescription stimulants—can result in extreme bodily and psychological problems. In contrast to opioid and alcohol use issues, there are not any FDA-approved medicines for remedy, limiting remedy choices for these affected. A November 2023 report from the Assistant Secretary for Planning and Analysis (ASPE) included suggestions to broaden “contingency administration.”
Contingency administration is an evidence-based psychosocial intervention that makes use of motivational incentives, equivalent to vouchers or present playing cards, to encourage restoration behaviors like stimulant abstinence and remedy session (e.g., cognitive behavioral remedy, group remedy) attendance. Based on the American Society of Habit Drugs, contingency administration is the present evidence-based commonplace of look after remedy of stimulant use dysfunction. Nevertheless, entry by means of most payers, together with Medicaid, stays restricted. CMS coverage solely permits states so as to add contingency administration protection by means of Medicaid 1115 demonstration waiver authority.
The Biden administration has accepted 4 state contingency administration waivers (California, Delaware, Montana, and Washington); three extra state contingency administration requests are at the moment pending federal overview. These waivers are primarily for the remedy of stimulant use dysfunction. It’s unsure if these waivers might be a precedence below the following Trump administration. This waiver watch briefly explains what contingency administration is and summarizes contingency administration 1115 waiver approvals to-date.
What’s contingency administration?
Contingency administration is a remedy for stimulant use dysfunction that makes use of incentives (e.g., present playing cards or vouchers) to reward sufferers for assembly remedy objectives, equivalent to stimulant abstinence. As an illustration, a contingency administration remedy plan might contain weekly urine drug assessments, with fast rewards for unfavorable outcomes. Contingency administration will also be mixed with different therapies, equivalent to cognitive behavioral remedy, with incentives tied to participation in remedies like group remedy or counseling classes. The American Society of Habit Drugs acknowledges contingency administration as the present commonplace of look after stimulant use dysfunction due its robust proof base. At present, there are not any remedy remedy choices accessible for stimulant use dysfunction. Contingency administration will also be used as a remedy or help for different varieties of substance use issues, equivalent to enhancing adherence to remedy for opioid or alcohol use issues. Though the Division of Veterans Affairs started implementing contingency administration over a decade in the past, entry by means of most payers, together with Medicaid, stays restricted.
How are states utilizing Part 1115 waivers to supply contingency administration?
In December of 2021, CMS accepted the primary contingency administration waiver in California and has since accepted contingency administration waivers in three extra states (Delaware, Montana, and Washington). Three states at the moment have pending contingency administration requests (Hawaii, Michigan, and Rhode Island). In waiver approvals, CMS clarifies that for the needs of those demonstrations, motivational incentives don’t violate federal guidelines that prohibit or restrict suppliers from providing incentives to sufferers, and contingency administration is taken into account a Medicaid-covered merchandise or service based mostly on the accessible scientific proof for treating a substance use dysfunction. Some states, equivalent to Montana and Washington, are utilizing waivers to construct upon profitable state contingency administration pilots which can be grant or state funded, or funded utilizing opioid settlement funds. Key waiver approval particulars embody (Desk 1):
Eligibility. All states with present approvals cowl contingency administration remedy providers for individuals with stimulant use dysfunction. In some states, contingency administration can even be used for individuals with different varieties of substance use issues alongside FDA accepted medication-assisted remedy for opioid or alcohol use issues. CMS notes medication-assisted remedy ought to be prioritized for opioid and alcohol use issues.
Program size. State approvals vary from 12-week packages to 64-week packages (based mostly on track inhabitants).
Incentive quantities. Present playing cards (e.g., to Walmart or different retailers) start at $10-$12 and enhance with every week the collaborating beneficiary demonstrates non-use of stimulants however are “reset” again to the bottom quantity if a participant submits a constructive pattern or has an unexcused absence. (Motivational incentives earned by means of these packages don’t rely in the direction of gross countable revenue for figuring out Medicaid eligibility).
All waiver approvals embody protections equivalent to employees coaching necessities, incentive restrictions, and protections towards fraud and abuse. Waiver particular phrases and circumstances element the next necessities for all states:
Suppliers. Contingency administration advantages are to be delivered by means of behavioral well being suppliers accepted by the state. States should conduct supplier readiness evaluations to make sure that suppliers are capable of provide contingency administration profit in accordance with state requirements. Employees offering or overseeing contingency administration advantages should take part in contingency management-specific coaching.
Incentive restrictions. Restrictions have to be positioned on incentives so that they can’t be used to buy hashish, tobacco, alcohol, or lottery tickets.
Supplier fraud and abuse protections. To guard towards fraud and abuse, states should set commonplace incentive quantities (i.e., suppliers won’t have discretion to set these quantities). States additionally should use safe incentive administration instruments with safeguards towards fraud and abuse that mechanically calculate incentive quantities and generate incentives for sufferers based mostly on drug take a look at outcomes inputted by the coordinator.
Of the 800,000 Medicaid enrollees aged 12 to 64 with a recognized stimulant use dysfunction recorded in Medicaid claims knowledge in 2019, about 20% had been residing in states that now have accepted 1115 waivers for contingency administration providers (California, Delaware, Montana, Washington). If the at the moment pending waivers (Hawaii, Michigan, and Rhode Island) are additionally accepted, this protection may lengthen to 26% of enrollees with a recognized stimulant use dysfunction. Nevertheless, these numbers seemingly underestimate the entire variety of Medicaid enrollees with a stimulant use dysfunction, as not all people are screened, and diagnoses aren’t at all times recorded. Not all people with stimulant use dysfunction in these states might be eligible for or obtain contingency administration providers. In California, 3,255 individuals acquired contingency administration providers from the launch of this system in April 2023 to June 2024.
