OCR Clarifies When SUD Records Can be Used to Verify Medicaid Community Engagement Exclusions
The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) has issued guidance for state Medicaid Agencies clarifying when the Part 2 regulations permit Medicaid applicants’ or beneficiaries’ SUD records to be used to verify an exclusion from the community engagement requirement for Medicaid eligibility.
The Confidentiality of Substance Use Disorder (SUD) Patient Records regulation, 42 CFR part 2 (Part 2), generally applies to federally assisted programs that provide SUD diagnosis, treatment, or referral for treatment, as well as organizations that receive Part 2-covered records such as health plans that pay for SUD treatment and government benefit programs such as Medicaid.
Under the Medicaid program, adult beneficiaries (aged 19-64) are generally required to engage in work, community service, or other activities for 80 hours per month, or be in at least half-time in education, as a condition of eligibility. There are certain exceptions to these requirements, such as individuals with special medical needs, which may include certain individuals with SUD or those participating in SUD treatment programs.
Under federal law, state Medicaid agencies are required to use reliable and available information to verify an applicant’s or beneficiary’s compliance or exclusion, where possible, without requiring the individual to submit additional information. The Centers for Medicaid and Medicare Services (CMS) has been working with OCR, which is responsible for administering and enforcing the Part 2 regulations, to produce technical assistance for state Medicaid agencies on the use of Part 2 records for verification of exclusion from the community engagement requirement.
“This OCR guidance will help state Medicaid agencies use information they already have to identify individuals who are excluded from the community engagement requirement, while continuing to protect the confidentiality of SUD patient records as required by Part 2,” said OCR Director Paula M. Stannard. “This new guidance helps ensure that state Medicaid agencies comply with Part 2 while also meeting their obligations to verify Medicaid eligibility — and without imposing unnecessary documentation burdens on eligible applicants and beneficiaries.”
