Step-by-step resource supports accurate, efficient exemption determinations for enrollees with mental health and substance use conditions.
WASHINGTON, D.C. — Today, national mental health advocacy organizations, Inseparable and Mental Health America, released a guide for states to help them protect patients and preserve access to mental health and substance use care as they adapt to the significant changes to Medicaid that were made in H.R. 1.
H.R. 1 requires states to meet certain requirements, including verifying whether Medicaid enrollees meet community engagement requirements or qualify for an exemption. These determinations have significant implications for mental health care because Medicaid is the nation’s single largest payer for mental health and substance use treatment, covering nearly one-third of adults with mental health conditions and one-fifth of adults with substance use disorders.
Medicaid, Mental Health, and H.R. 1: A State Guide to Using Data for Community Engagement Determinations provides Medicaid directors, policy leads, and eligibility staff with a clear, step-by-step roadmap for using existing administrative data to identify individuals who qualify for an exemption.
Federal law requires states to use available data to identify and exempt eligible enrollees from community engagement requirements if they meet certain criteria. This behind-the-scenes check is called an “ex parte” determination. For individuals with mental health and substance use disorders, who are among those most likely to qualify for an exemption, the evidence to support an exemption is often already in state systems — Medicaid claims, prescription data, and disability determinations. The guide’s recommendations make clear how states can leverage this existing data to comply with H.R. 1’s requirements and help preserve enrollees’ access to necessary care.
“Medicaid is a cornerstone of our mental health system, supporting care for children, parents, veterans, seniors, and people with disabilities in every state. We are grateful to be able to provide this tool to help states adapt to the significant changes H.R. 1 is making to the system,” said Angela Kimball, Chief Advocacy Officer at Inseparable. “With these recommendations, states will be able to effectively and efficiently protect access for their enrollees who rely on Medicaid for mental health and substance use care every day.”
“Medicaid provides lifesaving care to millions of Americans with mental health and substance use conditions, and we must work together to protect access to this vital program in communities across the country,” said Tim Clement, Vice President of Federal Government Affairs at Mental Health America. “This playbook provides states with clear, actionable guidance for using existing data to keep as many people as possible covered on Medicaid, and supported on their path to health and recovery.”
Specifically, the guide helps states:
- Use existing data to make ex-parte determinations: Leverage Medicaid claims, prescription data, and administrative records to automatically identify exemptions—reducing paperwork and preventing avoidable coverage loss.
- Adopt a “multiple data source” approach: Review diagnosis codes, procedure codes, medications, and other data points together to create a more complete and accurate eligibility picture.
- Implement a tiered framework for mental health diagnoses: Distinguish between conditions that are presumptively disabling and those requiring additional evidence, ensuring consistent and clinically grounded decisions.
- Establish clear policies and workflows: Define data sources, thresholds, and audit processes—while coordinating with clinical experts and CMS—to ensure transparency and program integrity.
The guide, available at inseparable.us/medicaid, includes real-world examples illustrating how data sources work together, a state policy checklist for Medicaid directors, and fillable appendix templates.
This latest guide builds on Inseparable’s previous Medicaid reports, including Medicaid is Mental Health: State-by-State Impacts of Proposed Cuts, which detailed how proposed Medicaid cuts would affect access to mental health services nationwide, and Medicaid, Mental Health, and H.R. 1, which examined the practical challenges and opportunities that states face in sustaining access to care while maintaining fiscal balance and program integrity.
About Inseparable
Inseparable is a leading mental health advocacy organization founded on the belief that mental health is inseparable from physical health. Inseparable drives transformative change at the federal and state levels by engaging policymakers, mobilizing support and advancing mental health and substance use disorder policies that help people thrive. Inseparable works to expand coverage of care, promote youth mental health, improve crisis response and bolster the mental health workforce.