Serious Mental Illness and Serious Emotional Disturbance Waiver
Seeking to improve mental health care
Federal law limits the ability of state Medicaid programs to pay for services provided to members in an institution for mental disease (IMD) who are being treated for serious mental illness or serious emotional disturbance. Today, Wisconsin is only allowed to cover these services for members under age 21 and adults 65 and older.
Our approved 2018 waiver added coverage for residential substance use disorder treatment for members aged 21-64.
Now, we are asking the Centers for Medicare & Medicaid Services (CMS) for a new waiver to let us add mental health coverage for members aged 21-64.
| Services in an IMD for treatment of: | Members covered today: | If waiver is approved: |
|---|---|---|
| Serious mental illness | Under 21, 65 and older | All ages |
| Serious emotional disturbance | Under 21, 65 and older | All ages |
| Residential substance use disorder | All ages | All ages |
Documents and timeline
- September 4, 2024 | Medicaid Advisory Committee
- September 11, 2024 | Tribal Nation Consultation
- September 30, 2024 | Public notice published
- October 1 – October 31, 2024 | Public Comment Period
- October 9, 2024 | Public Hearing webinar
- Watch a recording of the hearing
- Download the presentation: English (PDF) | Hmong (PDF) | Spanish (PDF)
- December 16, 2024 | Final waiver application (PDF) submitted to CMS
- To be determined | CMS approval
- As soon as possible after CMS approval | Implementation
Frequently asked questions
An IMD is “a hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services” (SSA §1905(i)).
IMDs include:
- A facility licensed or accredited as a psychiatric facility.
- A facility in which mental disease is the current reason for institutionalization of more than 50% of the patients.
Yes. Wisconsin provides coverage for medically necessary services provided in an IMD for members younger than 21 and older than 64. And in 2018, Wisconsin received authority from CMS to reimburse IMDs for treating people aged 21 to 64 with substance use disorders. However, we can't reimburse IMDs for treating individuals ages 21 to 64 with serious mental illness or serious emotional disturbance. This waiver amendment would close that gap.
If approved by CMS, this waiver would provide coverage for short-term stays in an IMD primarily to treat serious mental illness and serious emotional disturbance. To be eligible for this benefit, a member must be between the ages of 21 and 64, meet medical necessity criteria, and be enrolled in a full-benefit Medicaid program:
- BadgerCare Plus
- Medicaid for the Elderly, Blind, or Disabled (full-benefit plans only)
- Foster Care Medicaid (includes subsidized guardianship and adoption assistance)
- Wisconsin Well Woman Medicaid
These groups provide limited Medicaid benefits only. As a result, they will not be eligible for services under the waiver:
- BadgerCare Plus Prenatal Program
- Emergency Services for non-qualifying aliens
- Family Planning Only Services (FPOS)
- Qualified Disabled and Working Individual (QDWI) Program
- Qualified Medicare Beneficiary (QMB) Program
- Qualifying Individual (QI) Program
- SeniorCare
- Specified Low-Income Medicare Beneficiary (SLMB) Program
- Temporary enrollment for pregnant members
- Tuberculosis-Related Medicaid