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Medicaid Reform

District of Columbia Section 1115 Medicaid Behavioral Health Transformation Demonstration

On November 6, 2019, the Centers for Medicare and Medicaid Services (CMS) approved the District’s Behavioral Health Transformation demonstration with an effective date of January 1, 2020. Most new services authorized under the waiver were phased in beginning on the effective date. The demonstration allows the District’s Medicaid program to pay for services provided to adults with serious mental illness (SMI)/serious emotional disturbance (SED) or substance use disorder (SUD) residing in an institution for mental disease (IMD). Additionally, the demonstration will add new community-based services designed to improve behavioral health treatment capacity and strengthen transitions from emergency, inpatient and residential treatment.

The demonstration furthers the District’s goals of 1) ensuring that Medicaid provides a broader continuum of behavioral health services and supports for individuals with SMI/SED, SUD, or other behavioral health needs; 2) advancing the District’s goals in the Opioid Strategic Plan, Live.Long.DC., to improve outcomes for individuals with opioid use disorder and other SUDs; and 3) supporting movement towards a more person-centered system of physical and behavioral health care for Medicaid beneficiaries that facilitates coordinated treatment.

Approved services include:

  • Services for individuals aged 21-64 with SMI or SUD in an IMD setting;
  • Comprehensive Psychiatric Emergency Program Services
  • Youth Mobile Crisis
  • Adult Mobile Crisis and Behavioral Health Outreach
  • Psychiatric Residential Crisis Stabilization Services
  • Transition Planning Services for individuals leaving a hospital, IMD or other facility
  • Recovery Support Services
  • Psychologist and Other Licensed Behavioral Health Provider Services
  • Psychosocial Rehabilitative Services (also known as “Clubhouse” services)
  • Trauma Targeted Behavioral Health Services
  • Supported Employment Services, and
  • Eliminating the $1 copayment for prescriptions for medication assisted treatment (MAT)

The demonstration tests whether the expenditure authority granted under this demonstration, in addition to other concurrent behavioral health delivery system enhancements and re-design efforts, results in increased access to health care services and improved health outcomes for individuals with SUD and SMI/SED. Some of these services have transitioned to being covered under the authority of the District’s State Plan, as covered below.

The proposed demonstration application was submitted on April 12, 2019, and the final draft demonstration application was submitted June 3, 2019. The District held a public comment period from April 12th through and May 13th and the demonstration was available for federal public comment from June 10th through July 11th, 2019. CMS approved the demonstration on November 6, 2019.

In order to provide the public the opportunity to provide meaningful comment on the Demonstration, the District has hosted Post Award Forums in an online setting on October 20, 2020, October 18, 2021, October 28, 2022, and October 27, 2023. Recordings of the previous events may be found at links below. The District will continue to host a Post Award Forum yearly going forward.

On April 26, 2022, CMS approved a State Plan Amendment (SPA) to allow the District to transition its Section 1115 Behavioral Health Transformation Demonstration Program services for Mental Health Rehabilitative Services (MHRS) and Adult Substance Use Rehabilitative Services (ASURS) to permanent State Plan authority. The approved SPA added new services to MHRS and ASURS: Clinical Care Coordination, Clubhouse, Recovery Support Services (RSS), and Trauma Recovery Empowerment Services. The SPA also made changes to qualified provider requirements, updated requirements to comply with the Mental Health Parity and Addiction Equity Act, and added new requirements for certain providers to enroll as Medicaid providers to receive Medicaid reimbursement. To address behavioral stabilization, the approved SPA also outlines the scope of services covered by Comprehensive Psychiatric Emergency Program (CPEP), Adult Mobile Crisis Intervention/Outreach, and Youth Mobile Crisis and Psychiatric Residential Crisis Stabilization, authorized providers, and rates for Medicaid reimbursement for behavioral health stabilization services that are available on an emergency basis to respond to an individual in crisis who needs assistance and/or treatment to manage their psychiatric or substance use related symptoms without de-escalation or other intervention. The approved SPA adds transition planning services previously covered under the 1115 Waiver to the State Plan. Transition planning services under the SPA provide treatment and support services for beneficiaries being released from certain institutional treatment settings to aid recovery and reduce the chances of avoidable hospital or residential treatment readmissions. Under the SPA, these services will be expanded for service delivery to 30 days before and 30 days after discharge, which is a change from the Waiver’s permitted services 30 days before discharge.

For further information, please contact DHCF at [email protected]

Waiver-Related Documents: 

Approval Materials
Original DHCF Demonstration Special Terms and Conditions 11.6.19 - (pdf)
Press Release Waiver Approval 11.6.19 -  (pdf)
DHCF Demonstration STCs with Evaluation Design and Monitoring Protocol 010621 - (pdf)

Application Materials
Summary of 1115 Waiver Demonstration Application 6-3-19 - (pdf)
District Letter from DM Turnage to Administrator Verma 6-3-19 -  (pdf)
1115 Draft Demonstration Waiver Application 4.12.19 -  (pdf)
Summary of Draft 1115 Waiver Demonstration Application - (pdf)
1115 Final Demonstration Application 6-3-19 -  (pdf)
Section 1115 Medicaid Waiver Demonstration Press Release 4.12.19 - (pdf)

Waiver-Related Transmittals

Transmittal #21-22 FFS Authorization Guidance for SUD Residential Treatment Services - (pdf)
Transmittal #21-23 Managed Care Program Authorization Guidance for SUD Residential Treatment Services - (pdf)
Behavioral Health Transformation Demonstration Rates for Transition Planning - (pdf)
Behavioral Health Transformation Demonstration Rates for Crisis Services - (pdf)
Compiled Behavioral Health Demonstration Rates 10.23.20 - (pdf)
Behavioral Health Transformation Demonstration Rates for TREM and TST- (pdf)
Transmittal 19-31- Services Provided in Institutions for Mental Disease for Medicaid Beneficiaries Aged 21-64 -  (pdf)
Transmittal 19-25 Enrollment of New Behavioral Health Provider Types -  (pdf)
Transmittal 19-26 Billing Guidance for Medicaid Section 1115 Behavioral Health Transformation Demonstration Service - (pdf)
Transmittal 19-27 Removal of MAT Co-Pay - (pdf)
Transmittal 19-28 Independent Practice for Psychologists and Other Licensed Behavioral Health Providers (pdf)
Behavioral Health Transformation Demonstration Program Rates 12-09-2019 - (pdf)
Behavioral Health Transformation Demonstration Rates for Supported Employment - (pdf)
Transmittal 20-12 – Behavioral Health Transformation Demonstration Program – HIE Participation Requirements for IMDs - (pdf)

Stakeholder and Meeting Materials

Medicaid Director Letter - MDL 23-03 - 1115 Waiver
October 2023 Post Award Forum Slides - (pdf)
Recording of October 27 2023 DHCF Post Award Forum
Slides Post Award Forum DHCF October 2022 102822 - (pdf)
Recording of October 28 2022 DHCF Post Award Forum
Medicaid Director Letter 21-06 – Behavioral Health Transformation: Updated Timeline - (pdf)
Recording of October 18 2021 DHCF Post Award Forum
October 2021 Post Award Forum Slides
Behavioral Health Integration Stakeholder Advisory Group
Behavioral Health Tranformation Demonstration Post-Award Stakeholder Forum - WebEx
Presentation for 10.20.20 Post Award Forum - (pdf)
Behavioral Health Transformation Demonstration Program Services Grid - (pdf)
District Medicaid Section 1115 Behavioral Health Transformation Waiver Frequently Asked Questions (FAQ) -  (pdf)
Public Hearing #2 Agenda -  (pdf)
Flyer Waiver Kickoff Meeting 11.21.19 -  (pdf)
Agenda for Waiver Kickoff Meeting - (pdf)
Waiver Kickoff Meeting Presentation 112119 - (pdf)


Rulemakings and Other Documents
Approved SPA for Demonstration Service Transition 042622 -(pdf)
DHCF Chapter 86 Third Rulemaking - (pdf)
Monitoring Protocol Materials
DC SUD and SMI Evaluation Design Approval Letter (Signed) - (pdf)
DHCF DC Behavioral Health Transformation Evaluation Design 010621 - (pdf)
DBH Chapter 65 Transition Planning Services - (pdf)
DBH Chapter 80 Crisis Services Second Rulemaking - (pdf)
DHCF 1115 Demonstration SUD Implementation Plan - (pdf)
DHCF 1115 Demonstration SMI/SED Implementation Plan  - (pdf)
CMS Approval Letter for DHCF Implementation Plan - (pdf)
DHCF Chapter 86 Demonstration Services Second Rulemaking - (pdf)
DHCF Chapter 86 Demonstration Services First Rulemaking - (pdf)
DBH Chapter 34 Mental Health Rehabilitation Services Provider Certification Standards Rulemaking - (pdf)
DBH Chapter 37 Supported Employment Services Rulemaking - (pdf)
DBH Chapter 63 Rule SUD Providers 070320 - (pdf)
DBH Chapter 80 Crisis Services First Rulemaking - (pdf)