As of 2019, over 800,000 Medicaid enrollees between the ages of 12 to 64 had a diagnosed stimulant use disorder that was recorded in Medicaid claims data (though this is likely an undercount). Stimulant use disorder—which can involve dependence on cocaine, methamphetamine, or other psychostimulants, like prescription stimulants—can lead to severe physical and psychological complications. Unlike opioid and alcohol use disorders, there are no FDA-approved medications for treatment, limiting treatment options for those affected. A November 2023 report from the Assistant Secretary for Planning and Evaluation (ASPE) included recommendations to expand “contingency management.”
Contingency management is an evidence-based psychosocial intervention that uses motivational incentives, such as vouchers or gift cards, to encourage recovery behaviors like stimulant abstinence and treatment session (e.g., cognitive behavioral therapy, group therapy) attendance. According to the American Society of Addiction Medicine, contingency management is the current evidence-based standard of care for treatment of stimulant use disorder. However, access through most payers, including Medicaid, remains limited. CMS policy only allows states to add contingency management coverage through Medicaid 1115 demonstration waiver authority.
The Biden administration has approved four state contingency management waivers (California, Delaware, Montana, and Washington); three additional state contingency management requests are currently pending federal review. These waivers are primarily for the treatment of stimulant use disorder. It is uncertain if these waivers will be a priority under the next Trump administration. This waiver watch briefly explains what contingency management is and summarizes contingency management 1115 waiver approvals to-date.
What is contingency management?
Contingency management is a treatment for stimulant use disorder that uses incentives (e.g., gift cards or vouchers) to reward patients for meeting treatment goals, such as stimulant abstinence. For instance, a contingency management treatment plan may involve weekly urine drug tests, with immediate rewards for negative results. Contingency management can also be combined with other therapies, such as cognitive behavioral therapy, with incentives tied to participation in treatments like group therapy or counseling sessions. The American Society of Addiction Medicine recognizes contingency management as the current standard of care for stimulant use disorder due its strong evidence base. Currently, there are no medication treatment options available for stimulant use disorder. Contingency management can also be used as a treatment or support for other types of substance use disorders, such as improving adherence to medication for opioid or alcohol use disorders. Although the Department of Veterans Affairs began implementing contingency management over a decade ago, access through most payers, including Medicaid, remains limited.
How are states using Section 1115 waivers to provide contingency management?
In December of 2021, CMS approved the first contingency management waiver in California and has since approved contingency management waivers in three additional states (Delaware, Montana, and Washington). Three states currently have pending contingency management requests (Hawaii, Michigan, and Rhode Island). In waiver approvals, CMS clarifies that for the purposes of these demonstrations, motivational incentives do not violate federal rules that prohibit or limit providers from offering incentives to patients, and contingency management is considered a Medicaid-covered item or service based on the available scientific evidence for treating a substance use disorder. Some states, such as Montana and Washington, are using waivers to build upon successful state contingency management pilots that are grant or state funded, or funded using opioid settlement funds. Key waiver approval details include (Table 1):
- Eligibility. All states with current approvals cover contingency management treatment services for people with stimulant use disorder. In some states, contingency management will also be used for people with other types of substance use disorders alongside FDA approved medication-assisted treatment for opioid or alcohol use disorders. CMS notes medication-assisted treatment should be prioritized for opioid and alcohol use disorders.
- Program length. State approvals range from 12-week programs to 64-week programs (based on target population).
- Incentive amounts. Gift cards (e.g., to Walmart or other retailers) begin at $10-$12 and increase with each week the participating beneficiary demonstrates non-use of stimulants but are “reset” back to the base amount if a participant submits a positive sample or has an unexcused absence. (Motivational incentives earned through these programs do not count towards gross countable income for determining Medicaid eligibility).
All waiver approvals include protections such as staff training requirements, incentive restrictions, and protections against fraud and abuse. Waiver special terms and conditions detail the following requirements for all states:
- Providers. Contingency management benefits are to be delivered through behavioral health providers approved by the state. States must conduct provider readiness reviews to ensure that providers are able to offer contingency management benefit in accordance with state standards. Staff providing or overseeing contingency management benefits must participate in contingency management-specific training.
- Incentive restrictions. Restrictions must be placed on incentives so they cannot be used to purchase cannabis, tobacco, alcohol, or lottery tickets.
- Provider fraud and abuse protections. To protect against fraud and abuse, states must set standard incentive amounts (i.e., providers will not have discretion to set these amounts). States also must use secure incentive management tools with safeguards against fraud and abuse that automatically calculate incentive amounts and generate incentives for patients based on drug test results inputted by the coordinator.
Of the 800,000 Medicaid enrollees aged 12 to 64 with a diagnosed stimulant use disorder recorded in Medicaid claims data in 2019, about 20% were residing in states that now have approved 1115 waivers for contingency management services (California, Delaware, Montana, Washington). If the currently pending waivers (Hawaii, Michigan, and Rhode Island) are also approved, this coverage could extend to 26% of enrollees with a diagnosed stimulant use disorder. However, these numbers likely underestimate the total number of Medicaid enrollees with a stimulant use disorder, as not all individuals are screened, and diagnoses are not always recorded. Not all individuals with stimulant use disorder in these states will be eligible for or receive contingency management services. In California, 3,255 people received contingency management services from the launch of the program in April 2023 to June 2024.
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