-
Minnesota Substance Use Disorder (SUD) System Reform 1115 Demonstration Temporary Extension
- The Department of Human Services (DHS) submitted an extension request to CMS on Dec. 21, 2023, to continue the SUD System Reform waiver for a five-year period beginning July 1, 2024.
- On May 30, 2024, CMS provided an initial temporary extension that continued the operational terms of the waiver through June 30, 2025. On June 18, 2025, CMS provided a second temporary extension that continues the operational terms of the waiver through September 30, 2025.
- The temporary extension of the waiver does not impact providers or people receiving services. DHS anticipates that CMS will complete its review of the waiver extension request during the second temporary extension period.
- This demonstration project is an important component of the state’s larger reform effort to address the opioid crisis as well as transform the health care delivery system for Medicaid members who need substance use disorder treatment.
- The waiver authorizes federal Medicaid matching funds for residential programs that have been determined as Institutions for Mental Diseases. The demonstration waiver tests the impact of evidence-based provider referral arrangements and practices on improving health outcomes for Medicaid members with substance use conditions
Substance Use Disorder (SUD) facilities required to certify an ASAM level of care
Please visit the ASAM resources for Minnesota SUD treatment providers webpage for more information.
Substance use disorder providers invited to attend ASAM trainings
The Department of Human Services invites Minnesota substance use disorder treatment providers to participate in ongoing trainings offered by Acentra Health. The trainings will help improve clinical documentation, explain the utilization management ANG (Atrezzo) Provider Portal and increase ASAM knowledge and effective implementation. Follow links below for upcoming trainings.
Contact
Send your questions about the 1115 Substance Use Disorder System Reform Demonstration to 1115demonstration.dhs@state.mn.us.
-
1115 Substance Use Disorder (SUD) System Reform federal demonstration project
Minnesota is piloting a new approach to strengthen the state’s behavioral health care system by improving access to substance use disorder treatment across the state for Medicaid recipients. The state is doing this under the 1115 Substance Use Disorder (SUD) System Reform Demonstration. The Centers for Medicare and Medicaid Services (CMS) uses 1115 SUD Demonstrations to expand access to high quality, clinically appropriate SUD treatment using American Society for Addiction Medicine (ASAM) levels of care. Providers enrolled in the Demonstration comply with the ASAM Criteria and are eligible for funding incentives.
Minnesota’s 1115 Demonstration (“the Demonstration”) breaks down into two main areas:
- Increase the use of the American Society of Addiction Medicine’s (ASAM) Criteria in SUD treatment and placement.
- Expand state Medical Assistance (MA) coverage to Institutions for Mental Disease (IMDs), residential facilities with more than 16 beds.
SUD providers licensed under Minnesota Statute 245G or 245F and enrolled in MHCP are eligible to enroll in the Demonstration. Out-of-state providers who are enrolled in MHCP are also able to enroll in the 1115 Demonstration.
By expanding the use of the ASAM Criteria and expanding MA coverage to IMDs, Minnesota’s goal is to address the six federal goals and objectives:
- Increased rates of identification, initiation and engagement in treatment for Opioid Use Disorders (OUD) and other SUDs
- Increased adherence to, and retention in, treatment for OUD and other SUDs
- Reductions in overdose deaths, particularly those due to opioids
- Reduced utilization of emergency departments and inpatient hospital settings for OUD and other SUD treatment when the utilization is preventable or medically inappropriate, through improved access to more appropriate services available through the continuum of care
- Fewer readmissions to the same or higher level of care for readmissions that are preventable or medically inappropriate
- Improved access to care for physical health conditions among beneficiaries with SUDs
Components of the 1115 Demonstration
ASAM Criteria/Level of Care Requirements
The ASAM Criteria is the nation’s most widely used set of guidelines for people with SUD and co-occurring disorders. The Demonstration is implementing the ASAM Criteria to create a long-term chronic disease model that uses the evidence-based treatment methods. The Demonstration’s Level of Care Requirements incorporate ASAM Criteria.
SUD providers must implement the Level of Care Requirements into their policies and procedures in order to participate in the 1115 Demonstration. The Level of Care Requirements include patient referral arrangement agreements (PRAAs) for ASAM Levels of Care that providers don’t offer, medications for opioid use disorder (MOUD) access for residential providers, as well as medical, psychiatric, psychological and toxicology consultation and referrals. Overall, the goal is for people receive the right level of care at the right time.
Medications for Opioid Use Disorder
MOUD is an important component of person-centered and evidence-based treatment and in meeting the six CMS goals and objectives of the Demonstration. Minnesota DHS supports and encourages the use of all FDA-approved MOUD as part of an evidence-based, person-centered approach to treating OUD. DHS is dedicated to providing high-quality, effective individualized care to all Minnesotans seeking treatment.
Access to all forms of MOUD is an essential component for equitable access and success of treatment. In order to increase access to evidence-based treatment and promote equitable treatment, DHS encourages providers to accept clients receiving any FDA-approved MOUD.
Rate Enhancements
Residential and outpatient providers who enroll in the Demonstration are eligible for rate enhancements for services delivered to Medical Assistance (MA) fee-for-service (FFS) and Managed Care Organizations (MCOs) recipients. CMS approved rate enhancements from the 2021 1st Special Session as follows:
- 20% rate enhancement over the base rate for outpatient SUD providers
- 25% rate enhancement over the base rate for residential SUD providers
These rate enhancements are effective for dates of service on or after Jan. 1, 2022. There are no rate enhancements for withdrawal management providers or hospitals. The MHCP SUD Provider Manual contains more information on rates and billing.
Utilization Management
CMS requires Minnesota to implement utilization management processes to assure beneficiaries receive SUD treatment at the appropriate level of care, interventions are appropriate for the diagnosis and include an independent process for reviewing residential treatment placements, in particular, the types of services, hours of clinical care and credentials of staff.
SUD providers enrolled in the Demonstration are required to follow the utilization management process. DHS has collaborated with Kepro for the FFS utilization management process. MCOs are required to align with the FFS UM process and ASAM Criteria.
-
Federal Background
What are 1115 Demonstrations/Waivers?
Section 1115 of the Social Security Act allows the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) to approve demonstration projects that are likely to improve state Medicaid programs (“Medical Assistance” in Minnesota). CMS waives certain federal requirements in 1115 Demonstrations in order to test new or existing ways to deliver and pay for health care services. States must apply to CMS to implement 1115 Demonstrations. After approval, CMS monitors the implementation progress and impacts on clients, providers, health plans and state agencies.
1115 SUD Demonstrations
In 2015, CMS announced an opportunity for state Medicaid agencies to apply for 1115 Demonstrations to address the opioid crisis. In 2017, they announced a revision that streamlined the process for states to implement a SUD-focused 1115 Demonstration.
States were instructed to improve access to high quality, clinically appropriate treatment for SUD. Specifically, improvements were to be made through the implementation of evidence-based treatment guidelines, such as the American Society of Addiction Medicine (ASAM) Criteria and by covering critical levels of care, Medication for Opioid Use Disorder (MOUD) and withdrawal management. States are able to receive federal financial participation (FFP) for services provided in Institutions for Mental Diseases (IMDs), defined as residential facilities with more than 16 beds. Federal laws typically exclude IMDs from Medicaid reimbursement.
CMS Goals and Objectives
CMS established six goals and objectives for all 1115 SUD Demonstrations:
- Increased rates of identification, initiation and engagement in treatment for Opioid Use Disorders (OUD) and other SUDs
- Increased adherence to, and retention in, treatment for OUD and other SUDs
- Reductions in overdose deaths, particularly those due to opioids
- Reduced utilization of emergency departments and inpatient hospital settings for OUD and other SUD treatment when the utilization is preventable or medically inappropriate, through improved access to more appropriate services available through the continuum of care
- Fewer readmissions to the same or higher level of care for readmissions that are preventable or medically inappropriate
- Improved access to care for physical health conditions among beneficiaries with SUDs
State Implementation
Minnesota has been moving towards an SUD treatment system aligned with a chronic disease model for SUD for 20 years. DHS’ 1993-99 The challenges and benefits of chemical dependency treatment study’s key recommendation was to create an SUD continuum of care consistent with chronic disease management. In 2013 Minnesota’s Model of Care for SUD Legislative Report (DHS-6708) recommended updating Minnesota’s treatment system from an acute episodic model, to a chronic, longitudinal model of health care.
In 2016, the Minnesota Legislature directed the Department of Human Services (DHS) to design an SUD system with a full continuum of services available to all Minnesotans (MN Section 254B.15). The streamlined 1115 SUD Demonstrations gave Minnesota the opportunity to implement the recommended changes. In March 2018, DHS submitted an SUD demonstration request to CMS.
Legislation enacted in 2019 provided DHS the resources to implement the demonstration (MN Section 256B.0759). Minnesota’s Demonstration application was approved by CMS in June 2019. Minnesota couldn’t receive FFP or begin implementation until CMS approved the Implementation Plan. On July 22, 2020, CMS approved the state’s original Implementation Plan and Special Terms & Conditions (STCs) , marking the official start of Minnesota’s 1115 Demonstration (“the Demonstration”). The STCs are the state’s contract with CMS during the Demonstration.
Updates to the Implementation Plan as a result of the 2021 legislation, as well as the state’s evaluation design plan completed by DHS’ independent evaluator, NORC at the University of Chicago, were approved by CMS on July 28, 2021.
The Implementation Plan provides the details necessary to operationalize the Demonstration’s in six federal-required milestones:
- Access to critical levels of care for SUDs
- Widespread use of evidence-based, SUD-specific patient placement criteria
- Use of nationally recognized, evidence-based SUD program standards to set residential treatment provider qualifications
- Sufficient provider capacity at each level of care, including medication assisted treatment (MAT)
- Implementation of comprehensive treatment and prevention strategies to address opioid abuse and OUD
- Improved care coordination and transitions between levels of care
The Demonstration is scheduled to run until June 30, 2024; however, Minnesota state statute requires DHS to apply for an extension. The extension request is due to be submitted to CMS by June 30, 2023.
-
Locations approved to enroll in the 1115 Demonstration
The substance use disorder (SUD) treatment locations that have certified their ASAM level of care can be found using the MHCP Provider Search tool. You can use the contact information to make Patient Referral Arrangement Agreements as needed.
-
Trainings
Policy and operations experts will offer support to demonstration providers through the use of presentations and special training events that are specific to the 1115 SUD System Reform Demonstration.
Questions sent to 1115demonstration.dhs@state.mn.us will be reviewed and presentations will be designed around themes whenever provider feedback supports a training session.
Questions? Contact 1115demonstration.dhs@state.mn.us.
American Society of Addiction Medicine (ASAM) training
The Behavioral Health Administration is collaborating with Great Lakes Addiction Technology Transfer Center Network (ATTC), the University of Nevada, Reno Center for the Application of Substance Abuse Technologies (UNR-CASAT) and the National Frontier and Rural Telehealth Education Center (NFARtec) to offer ASAM training:
- American Society of Addiction Medicine: Navigating Levels of Care
SUD providers interested or planning to enroll in the 1115 SUD System Reform Demonstration are encouraged to participate in ASAM trainings.
Additional ASAM resources
On-the-Spot: ASAM Integration and Application – Am I doing this right? | Addiction Technology Transfer Center (ATTC) Network (attcnetwork.org)
ASAM - American Society of Addiction Medicine
Utilization Management training
The Behavioral Health Administration is partnering with Kepro to implement the federally required utilization management and review process for participating 1115 Demonstration providers. This is a required component for participation and a part of the approved Implementation Plan.
For more information, visit Kepro’s Minnesota Health Care Programs website.
-
Reports
Reporting is an important component of the Demonstration. Federal authority gives Minnesota additional flexibility to design and improve their SUD Medicaid program. Due to the added flexibility, the Centers for Medicare and Medicaid Services (CMS) has specific reporting and evaluation requirements. In addition to federal requirements, DHS is conducting ongoing stakeholder engagement.
Federal Deliverables
Federally required reports are published on DHS’ Federal health care waivers webpage within 30 days of CMS approval.
Quarterly Annual Monitoring Reports
DHS submits three quarterly reports and one annual report to CMS each year of the Demonstration. These reports include operational updates, performance metrics, financial reporting, evaluation activities and interim findings and SUD Health IT updates. Performance Metrics incorporate 35 claims-based measures to track trends related to the six goals and objectives of the Demonstration.
Independent Evaluation
As part of the Special Terms and Conditions to CMS, DHS is required to work with an independent evaluator to evaluate the Demonstration’s implementation and impact on the six goals and objectives. DHS has partnered with the National Opinion Research Center (NORC) to conduct the independent evaluation. The evaluation process includes the following:
Annual Public Comment Forum
DHS is required to host annual public comment forums throughout the Demonstration. Public comment forums offer the public an opportunity to give feedback on the progress of the Demonstration.
Provider Capacity Assessment (PCA)
In this report NORC assess the baseline provider capacity and availability of provider organizations for SUD treatment for Medical Assistance enrollees. This study used information from Jul. 1, 2018 to Jun. 30, 2019.
Provider Capacity Assessment: Baseline Assessment (DHS-8278)
Medication-assisted treatment (MAT) Access Report
Access to MAT, now referred to as Medication for Opioid Use Disorder (MOUD), is an important component of the ASAM Criteria. Although not federally required, NORC conducted an analysis of MOUD access across Minnesota to assess for potential disparities among different communities.
Examining Potential Disparities in Medication-Assisted Treatment (DHS-8267)
Early Adopters Report
DHS worked with eight different SUD providers to gather feedback on the Demonstration implementation. Topics of discussion include strengths, barriers, areas for improvement, as well as recommendations for SUD system alignments.
1115 Substance Use Disorder System Reform Demonstration Early Adopters Report (DHS-8234-ENG)
Evaluation Design Plan
A condition of participation in 1115 SUD demonstrations is that DHS arrange with an independent party to conduct an evaluation of the demonstration to ensure that the necessary data is collected at the level of detail needed to research the intended outcomes of the demonstration. The state must require the independent party to sign an agreement that the independent party will conduct the evaluation in an independent manner and according to CMS’ Special Terms and Conditions and Evaluation Design Plan Template. DHS contracted with NORC at the University of Chicago (NORC) to serve as the independent evaluator for the demonstration. CMS approved NORC’s Evaluation Design Plan on Jul. 28, 2021.
-
Resources
State Legislation Statute
-
Extension Request
The current 1115 SUD Demonstration continues through Jun. 30, 2024. DHS is required by law to request an extension from CMS of the 1115 Demonstration (Minnesota Statutes, Chapter 256B.0759 Subd. 8). That extension request will be submitted to CMS by Jun. 30, 2023 and, if approved, will move the Demonstration end date out five years.
DHS is dedicated to transparency and will share the extension request with its partners and the public. There will be two public hearings with an opportunity for providers and the public to provide feedback. Feedback from these hearings will be incorporated into the extension request before final submission.
The details of these two hearings will be announced on this page in the near future.
