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For decades, if someone on Medicaid wanted treatment for drug or alcohol addiction, they almost always had to rely on money from state and local sources. Now a big change - the federal government is considering chipping in. In one state though, this isn't welcome news. Ben Allen of member station WITF explains.
BEN ALLEN, BYLINE: It always sounds bureaucratic to hear Medicaid rule change, but this could start to transform drug and alcohol addiction treatment. The federal agency that oversees Medicaid known as CMS is proposing to cover 15 days a month of inpatient treatment for anyone in a Medicaid managed care plan. That's a version of Medicaid managed by insurance companies.
CINDY MANN: This was a big step forward for CMS to get to the 15 days.
ALLEN: Cindy Mann is a former top administrator at CMS who now works for Manatt Health Solutions, a law and consulting firm. Insurance companies and states are all over the map for how many days they'll pay for, but federal law restricted Medicaid funding for any length of stay. So, Mann says...
MANN: Maybe it's half a loaf for somebody who needs 30 days but it's half a loaf of of new federal dollars coming in that could be available.
ALLEN: Most states will gladly take what they can. But this story gets more complicated in one state. For years, Pennsylvania has been using an obscure provision to get federal reimbursement for rehab stays much longer than 15 days. Take Chris Benedetto. He's 30 years old and started shooting heroin at age 13.
CHRIS BENEDETTO: I was really young, so I actually was arrested in school. I was doing outpatient, and then I went directly to inpatient because I had no way of stopping.
ALLEN: Growing up in Scranton, he bounced from school to probation to jail to rehabs. He knew how to play the treatment game.
BENEDETTO: I'm good at, like, putting on that mask. I'm good at, like, everybody around me - you know, my sibling, my dad - everybody was like man, he's doing good every time.
ALLEN: But then in 2009, he got into an inpatient facility and didn't have to leave before he was ready because of Pennsylvania's Medicaid maneuver, which state officials fear will no longer be an option if the proposed rules go through. Turns out he needed more than five months in rehab.
BENEDETTO: For that amount of time and in that type of environment, you know, I will show up.
ALLEN: Now he's been clean for more than five years and works as an assistant to an addiction counselor. Mike Harle is the head of treatment nonprofit Gaudenzia, which serves about 20,000 patients a year in Pennsylvania, Maryland and Delaware. He's thinking about Chris Benedetto and others when he says this...
MIKE HARLE: Where they came up with the 15 days, I don't - but it's not based on research. Fourteen days has no outcome. You know how expensive that would be with no outcome? We wouldn't want to do it. We would not want to do it.
ALLEN: Cindy Mann says the feds are trying to push the limit by allowing 15 days, and experts haven't found that magic number for treatment. Dr. Jeffrey Samet, a professor at Boston University's Clinical Addiction research unit, says no one really wants to fund studies looking at the best length for stays. Still, he likes the fed's idea. Samet just wants to make sure less-expensive outpatient treatment gets considered, too.
JEFFREY SAMET: It's the challenge of public policy. So I think this is why the feds go into this type of work because a lot of good can be done. But it can be edgy, and the risk of it being taken advantage of is real.
ALLEN: Cindy Mann says states can continue to pay for as much treatment as they think a patient needs just as they have been doing.
MANN: The state and the locals are completely free to continue to finance that stay if they think that it's the right place for somebody to be.
ALLEN: And if they're still not happy, states can put together innovative treatment programs to apply for more federal money. For NPR News, I'm Ben Allen in Harrisburg.