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  Implementation  of  the  Treatment  for  Infants  with 
Neonatal Abstinence Syndrome in Residential Pediatric Recovery Centers 
provisions of Section 1007 of Pub. L. 115-271, the Substance Use-Disorder 
Prevention  that  Promotes  Opioid  Recovery  and  Treatment  (SUPPORT)  for 
Patients and Communities Act. 
This Informational Bulletin (Bulletin) provides clarification to states about section 1007 of the 
Substance Use-Disorder Prevention that Promoted Opioid Recovery and Treatment (SUPPORT) 
for Patients and Communities Act, entitled Caring Recovery for Infants and Babies, which 
added a new section 1902(a)(86) to the Social Security Act (Act) to add an optional provider 
type of residential pediatric recovery center (RPRC) for treatment of infants with Neonatal 
Abstinence Syndrome (NAS) without any other significant medical risk factors. 
Background 
Prior to the passage of the SUPPORT for Patients and Communities Act, CMS issued a prior 
Bulletin addressing Neonatal Abstinence Syndrome: A Critical Role for Medicaid in the Care of 
Infants.1  In this prior Bulletin, CMS discussed the complex condition of NAS, NAS Diagnosis 
and Treatment, Medicaid Coverage for NAS Treatment for Infants as well as their Mothers, and 
Potential Payment Options for these Services. 
NAS is a constellation of symptoms in newborn infants exposed to any of a variety of substances 
in utero, including opioids.  Clinically significant neo-natal withdrawal most commonly results 
from exposure to opioids, but symptoms of neonatal withdrawal have also been noted in infants 
exposed to antidepressants, anxiolytics, and other non-opioids.  NAS is not characterized as an 
addiction or substance use disorder; rather, it is a medical condition resulting in a physiologic 
response to the infants exposure to cessation of the opioid or other substance the mother was 
using.2  
Section 1007 of the SUPPORT for Patients and Communities Act, entitled Caring Recovery for 
Infants and Babies, added a new section 1902(a)(86) to the Social Security Act (Act) to add an 
optional provider type, residential pediatric recovery center," defined as a center or facility that 
1 https://www.medicaid.gov/federal-policy-guidance/downloads/cib060818.pdf 
2 https://www.medicaid.gov/federal-policy-guidance/downloads/cib060818.pdf  Page 2  CMCS Informational Bulletin 
furnishes items and services for which medical assistance is available under the state plan to 
infants with the diagnosis of neonatal abstinence syndrome without any other significant medical 
risk factors.3 
In addition, a RPRC may offer counseling and other services to mothers (and other appropriate 
family members and caretakers) of infants receiving treatment at such centers if such services are 
otherwise covered under the State plan under this title or under a waiver of such plan.  Such 
other services may include (A) Counseling or referrals for services, (B) Activities to encourage 
caregiver-infant bonding, and (C) Training on caring for such infants.4 
Impact of the Newly Defined Residential Pediatric Recovery Center 
Infants with NAS have traditionally been treated in hospital inpatient settings, often with lengthy 
stays.  As the number of infants born with NAS continues to rise,5 states are increasingly 
utilizing NAS treatment settings outside of inpatient hospital settings to provide treatment to 
these infants and their appropriate caretakers.  Included in these treatment settings are RPRCs, as 
newly defined by section 1007 of the SUPPORT for Patients and Communities Act. 
RPRCs may treat infants with less severe NAS or care for infants with NAS who are not 
medically stable and ready to go home, but who are stable enough to transfer to a lower level of 
care and can be safely discharged from the hospital.  Section 1007 of the SUPPORT for Patients 
and Communities Act defines a RPRC is a center or facility that furnishes items and services for 
which medical assistance is available under the State plan to infants with the diagnosis of 
neonatal abstinence syndrome without any other significant medical risk factors.6 
Under current Medicaid law, medical assistance payment for room and board is only available 
with respect to the facilities that provide Medicaid-covered, institutionally-based, benefits: 
nursing facilities, inpatient hospitals, psychiatric hospitals for individuals under age 21, 
institutions for mental diseases for individuals age 65 or older that otherwise would qualify as an 
inpatient setting, and intermediate care facilities for individuals with intellectual disabilities that 
also meet certain federal standards and conditions of participation requirements prescribed by the 
Secretary.  Thus, a RPRC would only be able to receive a Medicaid payment for room and board 
if the RPRC furnishes services under one of these benefits and meets the applicable 
requirements. 
However, the Medicaid covered services delivered by providers furnishing items and services in 
a RPRC that is not one of these facilities may be appropriately covered and paid under a variety 
of Medicaid state plan benefits.  Determination and enforcement of any licensing or certification 
standards for RPRCs will lie within the states sole purview. 
3 Section 1902(pp)(1) of the Act. 
4 Section 1902(pp)(2) of the Act. 
5 Dramatic Increase in Maternal Opioid Use Disorder and Neonatal Abstinence Syndrome, National Institute on 
Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services 2019 
https://www.drugabuse.gov/related-topics/trends-statistics/infographics/dramatic-increases-in-maternal-opioid-
use-neonatal-abstinence-syndrome 
6 Section 1902(pp)(1) of the Act.  Page 3  CMCS Informational Bulletin 
 
For infants with NAS, specific services may include, but are not limited to, assessments, 
development of care plans, swaddling, feeding, and specialized care of the infants.  These 
services may be covered under a variety of Medicaid state plan benefits provided they meet the 
requirements for the benefit under which the services are provided.  Potential benefit categories 
include, but are not necessarily limited to, physicians services; services provided by other 
licensed practitioners; physical and occupational therapies; speech, hearing and language 
disorder services; respiratory care services; diagnostic and rehabilitative services; prescription 
drugs; non-emergency transportation to medical care; and case management.  
 
States have significant flexibility in how they may pay for services for treating infants with NAS.   
A state may pay providers for medically necessary Medicaid state plan services provided to 
infants with NAS who are receiving services in the hospital or other facility setting, in a RPRC, 
or at home and recognize the varied costs of providing care based on the service location or the 
severity of need.  States may also pay for individually covered services or, if determined as a 
more efficient payment method, may develop bundled rates for services provided to infants by 
providers like RPRCs.  In addition, states may develop methodologies that offer incentives for 
improved outcomes and quality care. 
 
Inclusion of Mothers, Appropriate Family Members, and Caretakers 
 
Section 1007 of the SUPPORT for Patients and Communities Act permits RPRCs to offer certain 
services to mothers and other appropriate family members and caretakers that are for the benefit 
of infants receiving treatment at RPRCs if the services are otherwise covered under the state plan 
(or a waiver of the state plan).  These services may include counseling or referrals for services, 
activities to encourage caregiver-infant bonding, and training on caring for infants with NAS.7   
Medicaid-covered services are only available to Medicaid-eligible individuals.  CMS has 
previously stated in a Bulletin, however, that whether or not a mother is Medicaid eligible, she 
may receive some benefit from certain services that are for the direct benefit of the child and 
directed at treating and promoting the health of the child to reduce or treat the effects of the 
mothers condition on the child.8 
 
The medical literature supports the importance of the involvement of mothers and their physical 
interaction with the newborns during treatment for NAS.9  Supporting the mother and other 
appropriate family members and caretakers alongside the infants provides a direct benefit to the 
infant, by encouraging the future caretakers to learn and practice specialized strategies to comfort 
and assist an infant with NAS, which would benefit the infant throughout all phases of 
treatment.10 
 
For these services to a mother, family member, or caretaker who is not Medicaid eligible to be 
covered, the therapeutic interventions must be for the direct benefit of the infant, meaning the 
services must actively involve the infant, be directly related to the individualized needs of the 
                                                 
7 Section 1902(pp)(2) of the Act 
8 Maternal Depression Screening and Treatment:  A Critical Role for Medicaid in the Care of Mothers and Children  
https://www.medicaid.gov/federal-policy-guidance/downloads/cib051116.pdf 
9 https://www.medicaid.gov/federal-policy-guidance/downloads/cib060818.pdf 
10 https://www.medicaid.gov/federal-policy-guidance/downloads/cib060818.pdf  Page 4  CMCS Informational Bulletin 
infant and be delivered to the infant and mother together.  Finally, the services must be covered 
under a benefit in section 1905(a) of the Act (e.g. medical or remedial services provided by a 
physician or other licensed practitioner) or pursuant to a waiver of such plan.  In such cases, 
services that involve a non-Medicaid eligible mother or appropriate family member and caretaker 
may be billed by the RPRCs for the infant, and claimed by the state as a direct service to the 
infant. 
State Process for SPA Submission 
States may need to make changes to their Medicaid state plans through a SPA submission in 
order to recognize RPRCs as a provider type and, as necessary, update their payment
methodologies to describe differences in payments to the RPRCs.  To the extent a state chooses
to pay for covered services provided within RPRCs differently from other provider types, the 
state will need to issue a public notice and amend the state plan to comprehensively describe the 
payment methodology.  As with any SPA submission, CMS will request information on the 
source of non-federal share of the service payments and information on the rate setting 
methodology.  Specific guidance related to SPA submission procedures, including guidance on 
developing comprehensive methodologies and bundled rates, may be found on Medicaid.gov:
https://www.medicaid.gov/state-resource-center/spa-and-1915-waiver-processing/medicaid-spa-
toolkit/index.html. 
Conclusion 
Infants experiencing symptoms of NAS are particularly vulnerable medically, as they are 
experiencing withdrawal from powerful opioids.  They require access to treatment that 
incorporates the best evidence-based practices, and involves their mothers and families to the 
greatest extent possible, to help them withdraw from exposure to opioids in utero and to lead 
healthier lives.  Section 1007 of the SUPPORT for Patients and Communities Act provides a new 
optional provider type, RPRCs, for delivery of this critical treatment to infants with NAS.  CMS
is available to work with states as needed in order to reach these goals.  For additional
information about this Informational Bulletin, or for states requesting technical assistance, please 
contact Kirsten Jensen, Director, Division of Benefits and Coverage at
Kirsten.Jensen@cms.hhs.gov.