Montana is pursuing federal waivers to expand inpatient mental health and addiction treatment, part of Governor Greg Gianforte’s HEART Initiative aimed at improving behavioral health services. However, progress has been complicated by the loss of accreditation at Montana State Hospital, the state’s flagship psychiatric facility.
Rimrock Foundation in Billings provides a clear example of the federal barriers facing treatment expansion. Despite operating a 40-bed addiction treatment facility, about half the beds sit empty because the facility cannot accept Medicaid patients—a restriction stemming from the 1965 Institutions of Mental Disease (IMD) rule. This decades-old federal regulation, designed to prevent warehouse-like institutions, restricts Medicaid coverage to facilities with fewer than 16 beds. Rimrock CEO Lenette Kosovich calls this a “parity issue,” as the restriction prevents access to publicly insured patients while allowing those with private insurance. With roughly 90,000 Montanans estimated to have substance use disorders and only about 10% seeking treatment, demand far exceeds available capacity.
In July, the Centers for Medicaid and Medicare Services (CMS) approved part of Montana’s waiver request, allowing Medicaid to cover addiction treatment at large inpatient facilities like Rimrock—projected to serve an estimated 350 additional Medicaid patients annually. However, CMS denied the state’s request for coverage of serious mental illness treatment at large facilities, specifically citing Montana State Hospital’s loss of federal accreditation in April following investigations into patient injuries, deaths, and severe staffing shortages. That denial carries significant financial implications: Medicaid could have reimbursed the state hospital between $13 and $15 million annually for short-term patients aged 21 to 65, totaling over $70 million over five years—costs now borne entirely by state taxpayers.
State officials have not committed to pursuing accreditation for Montana State Hospital, saying the facility’s future remains under review by a consulting firm. That decision has raised concerns among some observers about potential downsizing or privatization. Mental health advocates remain divided on strategy: some support expanding inpatient beds while others argue Montana should prioritize community-based preventative services and case management to prevent crises before they require hospitalization. State health officials contend that both approaches are necessary for a complete behavioral health system.
This article is an AI-assisted summary. All facts and figures are drawn from the original report: https://montanafreepress.org/2022/07/25/montanas-push-for-inpatient-mental-health-and-addiction-treatment/