DEPARTMENT OF HEALTH  & HUMAN SERVICES  
Centers for Medicare & Medicaid Services  
7500 Security Boulevard,  Mail  Stop S2-26-12  
Baltimore, Maryland    21244-1850  
 
Center for Medicaid  and  CHIP Services  
 
 
CMCS Informational Bulletin  
 
 
DATE:    July 26, 2019   
 
FROM:   Calder Lynch, Acting  Deputy Administrator and Director  
Center for Medicaid and  CHIP Services   
 
SUBJECT:   State Guidance for the New Limited Exception to  the IMD Exclusion  for Certain  
Pregnant and Postpartum Women included in Section 1012 of the  Substance  
Use-Disorder Prevention that Promotes Opioid Recovery and Treatment  
(SUPPORT)  for  Patients and Communities Act  (Pub.  L. 115-271), entitled  
Help for Moms and Babies   
 
The Center for Medicaid and CHIP Services (CMCS) is issuing this  Informational Bulletin  
(Bulletin) to  provide  guidance to states on section 1012 of  the Substance Use-Disorder 
Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, 
(SUPPORT for Patients and Communities Act), entitled  Help  for Moms and Babies.  Section 
1012 creates a new  limited  exception to the institution for mental diseases  (IMD) exclusion  for 
certain pregnant and postpartum women as discussed below.  
  
Background  
 
Institution for Mental  Diseases  (IMD) Exclusion  
 
Section 1905(i) of the  Social  Security  Act (Act)  defines  an  IMD  as 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.  
  
Under  section 1905(a)  of the  Act1, there  is a  general prohibition on Medicaid payment  for  any  
services provided to  an individual  who  has not  yet  attained 65 years  of  age  who  is residing  in  an  
IMD.  This  is commonly  known as the  IMD  exclusion, and  it applie s t o an y care o r service s 
provided to  patients  residing  in  an  IMD inside  or outside of the  IMD.  There  are  two  exceptions  
to the  IMD  exclusion under  section 1905(a).  First, inpatient hospital  services, nursing  facility  
services,  and  intermediate  care  facility  services  for individuals  age 65 and  older  in  IMDs  can  be  
reimbursed (42  C.F.R. 440.140).  Second, inpatient  psychiatric hospital  services  for individuals  
under  age 21 furnished by  a  psychiatric hospital, a  general hospital  with a  psychiatric program  
that  meets the  applicable  conditions of  participation, or  an  accredited  psychiatric  facility,  
                                                 
1  Clause (B) following section  1905(a) of the Act.   Page 2  CMCS  Informational Bulletin  
 
commonly  referred  to  as  a  Psychiatric  Residential  Treatment  Facility  (PRTF),  that  meet  certain  
requirements,  can  also be  reimbursed  (42  C.F.R. 440.160).2   This is commonly  referred  to  as the  
psych under 21  benefit.   
 
Medicaid Coverage for Pregnant and Postpartum  Women  
 
Eligibility and coverage  of the category of low-income pregnant women is subject to income  
limits and is mandatory in Medicaid.   Pregnant womn, as defined in 42 C.F.R. 435.4, 
includes the postpartum period, which extends until the last day of the mon th in which a 60-day  
period has elapsed after the end of  the pregnancy.  
  
Federal law  requires states to extend Medicaid eligibility and  coverage to categorically needy  and 
medically needy pregnant women who are eligible for Medicaid on the basis of being pregnant.  
At a minimum, qualified pregnant women are entitled to coverage of pregn ancy and pregnancy-
related services  and services for the treatment of  conditions that may  complicate pregnancy, 
when available under the state plan (42 C.F.R. 435.116(d); 435.301(b)(1)(i)).  These services  
are defined by the  state and  are not necessarily  specifically identified or defined in the state plan,  
but they  generally include prenatal care, delivery, postpartum care, family  planning services and 
can also include diagnosis or treatment of illnesses or medical conditions that might threaten the  
health or well-being of the mother or fetus.  Under 42 C.F.R. 440.250(p), states may  also  
provide extended services  to pregnant women that are not available to non-pregnant individuals, 
and may provide these services in  greater amount, duration or scope than is  provided under the  
state plan to other individuals eligible for  Medicaid, providing the services  are 1905(a) coverable  
services, are related to the pregnancy or  are  related to any other condition that may  complicate  
pregnancy.3 
  
New  Limited  Exception to the IMD Exclusion for Certain  Pregnant and Postpartum  
Women  
 
Section 1012 of the SUPPORT for Patients and Communities Act  creates  a new  limited  
exception to the IMD exclusion.  Specifically,  section 1012(a) states that  for a woman who is  
eligible on the basis of being pregnant (and up to 60-days postpartum), who is a patient in an 
IMD  for purposes of receiving treatment  for a substance use disorder (SUD), who is  either  
enrolled under the state plan immediately before becoming  a patient in the  IMD, or who becomes  
eligible to enroll while  a  patient in an IMD, the  IMD exclusion shall not be construed to prohibit  
federal financial participation for medical  assistance for items and services  provided outside of  
the  IMD to such women.  
 
   
                                                 
2  Section  12005 of the 21st  Century  Cures  Act requires Medicaid reimbursement for Early and Periodic Screening,  
Diagnostic and Treatment (EPSDT) services for children  under age 21 who are receiving inpatient psychiatric 
hospital services.   More information  is available at  https://www.medicaid.gov/federal-policy-
guidance/downloads/cib062018.pdf  
 
3  440.210(a)(2), 440.210(a)(3)   Page 3  CMCS  Informational Bulletin  
 
Implementation  
 
Section 1012(b) specifies that the effective date of  section 1012  was  the date of enactment  of the 
SUPPORT  for Patients and Communities  Act, which was October 24, 2018.  CMS encourages  
all states to implement this provision as quickly as possible to ensure that pregnant women, 
including women in the postpartum period, receive these important services.  Women eligible for  
this limited exception to the  IMD exclusion must  either be enrolled  as a pregnant woman  (or in  
the 60 day postpartum period)  in Medicaid immediately prior to becoming  a patient in the  IMD  
or become  eligible to enroll in Medicaid as a pregnant woman (or in the 60 day postpartum  
period)  while a patient in  an IMD.   
 
Per section 1012(b), some Medicaid state plans may  require state legislation in order for the  state 
plan to be amended to add the additional coverage requirements, and CMS  shall not consider  
such state plans  as failing to comply with  section 1012 of the SUPPORT for Patients and 
Communities  Act before  the first day of the first calendar quarter beginning after the  close of the  
first regular session of the states legislature that begins after  October 24, 2018.   In the case of a 
state that has a two-year legislative session, each  year of such session shall  be deemed to be a 
separate regular session  of the state legislature.  States will be expected to  be in compliance by  
October 1, 2020, relative to  certain  state legislative timeframes.  
 
Conclusion  
 
Women diagnosed with a SUD, who a re pregnant or i n the 60 day postpartum period, require   
access not only  to  effective  SUD treatment but  also  to the  full  array  of  mandatory  and optional  
pregnancy  and pregnancy-related  services  available through Medicaid, including  treatment of  
conditions  that  may  complicate pregnancy.  Section 1012 of the  SUPPORT  for  Patients  and  
Communities  Act provides support  for those pregnant  and postpartum  women  facing and/or  
recovering  from substance use disorder, including  opioid use disorder, and  aids  them  in  their  
recovery.    For  additional  information about  this  Bulletin, or  for  states  requesting  technical  
assistance, please  contact  Kirsten  Jensen,  Director  of  Division of  Benefits and Coverage,  at  
Kirsten.Jensen@cms.hhs.gov.