July 31, 2026
Dear Secretary Kennedy and Administrator Oz:
Thank you for the opportunity to submit comments on the Centers for Medicare & Medicaid Services’ (CMS) interim final rule with comment period (IFC) on the Medicaid community engagement requirements (CMS-2454-IFC).
On behalf of the Advocates for Opioid Addiction Treatment (AOAT), we appreciate the opportunity to comment on the Interim Final Rule regarding Medicaid Community Engagement Requirements. We are a national coalition of opioid treatment facilities committed to providing evidence-based care to our patients while protecting and expanding access to medication-assisted treatment (MAT) for all Americans. AOAT members represent more than 700 Opioid Treatment Program (OTP) facilities and Office-Based Opioid Treatment (OBOT) practices across 46 states.
AOAT supports policies that promote recovery, stability, employment, education, and engagement in the community. We also recognize the importance of implementing these requirements in a manner that protects access to lifesaving treatment and prevents unintended barriers to care for individuals with opioid use disorder (OUD) and other substance use disorders (SUD).
For individuals with substance use disorders, access to evidence-based treatment is often the foundation for successful community engagement, including employment. Medications for opioid and alcohol use disorders, behavioral therapies, peer recovery support services, and other recovery-oriented services help individuals stabilize their health, sustain recovery, and develop the capacity to work, pursue education, and contribute to their communities. Disrupting access to these essential services increases the likelihood of relapse, overdose, and other adverse health outcomes. Community engagement policies should therefore support continuous access to treatment and recovery services, recognizing that recovery often makes employment possible—not the other way around.
The recently published CMS Interim Final Rule implementing the Medicaid Community Engagement Requirement recognizes that individuals with substance use disorders may qualify for the “medically frail or otherwise has special medical needs” exclusion. As CMS and states begin implementing these requirements, we respectfully request consideration of the following changes to the Interim Final Rule to better ensure individuals with substance use disorder can access the exclusion as Congress intended
1. Require States to Ensure That Any Claims in the Past 12 months for Opioid Use Disorder Treatment Qualifies a Beneficiary for the Medically Frail Substance Use Disorder Exclusion from Community Engagement Requirements
P.L 119-21 included a list of populations (“specified excluded individuals”) who are explicitly exempt from the community engagement requirements; this list included individuals with a substance use disorder. Patients actively receiving services through licensed Opioid Treatment Programs (OTPs) are, by definition, diagnosed with an OUD. As such, it is critical that any enrollee participating in any OTP should be considered for eligibility for exclusion from community engagement requirements. OTP services are largely dictated by state and federal regulations. There are no substantive differences in the services received from OTPs based on the providers’ tax status. And patients don’t seek services based on provider tax status. Therefore, CMS should ensure states use the broadest possible flexibilities under the statute in assuring all enrollees receiving services at any OTP qualify for exclusions.
We request that CMS require states to accept as sufficient any claims data for opioid use disorder treatment and that such claims automatically qualify as deemed compliance throug exclusion during both initial and redetermination processes. We further request that CMS clarify that no additional documentation is required of beneficiaries to establish compliance via exclusion.
We further recommend that CMS specify that states shall include all applicable DSM-5 and ICD-11 diagnosis codes for determining opioid use disorder, including mild opioid use disorder. Individuals with mild opioid use disorder may require ongoing treatment through licensed OTPs and may experience functional impairments or clinical circumstances that qualify them for the substance use disorder exclusion. Limiting automated identification to moderate or severe diagnoses could result in eligible beneficiaries being overlooked.
2. Establish an Automatic Review Process for Active OTP Patients
Individuals receiving medication for opioid use disorder often experience significant functional impairments, relapse risk, co-occurring mental health conditions, housing instability, transportation barriers, and other challenges that may impact their ability to comply with community engagement requirements. Further, unlike most other treatment modalities, many patients are continuously enrolled in OTPs for years as they go through phases from induction through stabilization and work toward recovery.
As such, we request that CMS require states to review OTP enrollment data for any beneficiary with OTP claims in the prior 12 months prior to termination of benefits for any reason. Such review will help prevent lapses in coverage, and thus treatment access, that often result in relapse to drug use, increased criminal activity, overdose and death.
In addition, we request that CMS require states to ensure a meaningful grace period in which to cure any alleged lack of compliance before coverage termination and allow retroactive reinstatement following any procedural coverage loss. An automatic review process would help prevent inappropriate disenrollment and avoid interruptions in treatment.
3. Require States to Accept Provider Attestation as Sufficient Verification
We request that CMS require states to accept attestation from licensed clinicians working in an OTP, including physicians, nurse practitioners, physician assistants, counselors, and other qualified behavioral health professionals, when determining whether an individual qualifies for the SUD exclusion. The application of a severity component to these criteria necessitates the use of clinical assessments by trained clinicians to ensure a comprehensive view of beneficiary functioning. Such assessments should align with determinations of medical necessity.
Treating providers are often in the best position to assess:
- Severity of opioid use disorder
- Functional impairment
- Co-occurring mental health conditions
- Relapse risk
- Medical necessity of ongoing treatment
Provider attestation should be accepted whenever claims data are unavailable, incomplete, or insufficient to make a determination. We additionally encourage CMS to mandate a streamlined provider attestation process that utilizes concise, standardized forms, permits electronic submission, and avoids burdensome chart review requirements. Consistent with the chronic and often long-term nature of substance use disorders, we additionally recommend limiting re-verification requirements to no more than annually and avoid requiring additional documentation absent a material change in an individual’s clinical condition or treatment status.
Further, we request that CMS require states to accept patient self-attestation in 2027 when many states won’t have fully functioning systems to verify exclusion on an ex parte basis.
4. Ensure Immediate Access to Treatment for Individuals Seeking Care
We encourage CMS to require states to build reliable pathways that allow individuals with substance use disorders to access treatment immediately while eligibility, exemption, or medical frailty determinations are being completed. Many individuals first encounter the Medicaid system when they present for substance use disorder treatment, and delays in verification can create unnecessary barriers to care during a critical window of opportunity.
We recommend CMS requires states to allow qualified providers to initiate provisional exclusion determinations, support the use of self-attestation where permitted under federal requirements when data and documentation are not immediately available, and maintain temporary coverage while verification is completed.
In addition, we request CMS mandate retroactive eligibility, retroactive reinstatement, and payment for covered services furnished during verification periods so that providers can deliver timely, medically necessary care without assuming undue financial risk. These policies will help ensure that administrative processes do not delay access to critical, life-saving treatment.
5. Remove Five-Year Stability Limitation on Exclusions
Congress clearly intended to provide exclusions for people with substance use disorders. Imposing an arbitrary limit on people with SUD is inconsistent with the statute. Moreover, from a practical perspective, if enrollees are required to demonstrate compliance with community engagement requirements every six months, there should be no limit on how long an impaired enrollee may qualify for the exclusion. While most enrollees who participate in treatment will become employed and thus no longer require Medicaid, others will require continued coverage in order to improve functioning.
6. Require States to Make Coverage Retroactive to Treatment Enrollment Based on Diagnosis Exclusion and Prevent Disenrollment While Eligibility Reviews Are Pending
We recommend establishing safeguards that ensure provider services are covered from the start of treatment and prevent Medicaid disenrollment while medically frail determinations, provider attestations, appeals, or reconsideration requests are pending.
Much of the cost of treatment is front-loaded and even short interruptions in coverage can create barriers to medication access, counseling services, toxicology testing, and other essential treatment services. Maintaining continuity of care during review periods will support both patient safety and treatment retention.
Conclusion
Opioid Treatment Programs play a vital role in reducing overdose deaths, improving recovery outcomes, increasing workforce participation, and supporting long-term community stability. We share CMS’ commitment to ensuring that Medicaid beneficiaries receive the support necessary to achieve recovery and self-sufficiency while maintaining access to medically necessary treatment.
We welcome the opportunity to discuss these recommendations further and serve as a resource as implementation moves forward.
Thank you for your leadership and partnership.
Sincerely,
Advocates for Opioid Addiction Treatment (AOAT)
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