On Nov. 1, Milestone Foundation, a detoxification program for alcoholics and substance abusers in Portland, Maine, faced possible closure because of perceived non-compliance with the Center for Medicare and Medicaid Services (CMS) requirements. Mental health advocates appealed to the Department of Health and Human Services, as well as to Senators Olympia Snowe-R and Susan Collins-R, fearing that homeless individuals and those with alcohol and substance abuse problems would be left on the streets. In what appeared to be a last minute reprieve, the facility’s doors remained open.
Guy R. Cousins, LCSW, LADC, CCS, director of the Office of Substance Abuse and acting director of the Office of Adult Mental Health Services within the DHHS, explains that, although the story attracted significant local attention from media, consumers and mental health advocates, the root of the issue lies in a misunderstanding over language. Milestone appeared to fall outside the definition of an “institution for mental diseases (IMD)” as determined by CMS, which would impact its Medicaid funding. CMS defines an IMD as “a hospital, nursing facility or other institution with more than 16 beds primarily engaged in providing diagnosis, treatment or care of persons with mental diseases including medical attention, nursing care and related services.”
At the time of the controversy, the Milestone facility in Portland had 18 beds for its detoxification program, as well as a 41-bed emergency homeless shelter. The fact that these two services shared the same physical space and operated under the same financial structure raised concern with CMS, according to Cousins. “In our experience with CMS, if it looks like an IMD, it would be considered an IMD. If CMS determined it to be an IMD, Milestone couldn’t bill for non-hospital detox services,” he says. “But by operating this model, for every dollar we spend, we save seven dollars that would be spent for hospital-based detox.”
While Milestone’s detox program serves those who have a medical necessity, often from withdrawal, the emergency shelter operates under a different premise. “Milestone provides medical stabilization for people with addictions and then plugs them into community-based services,” Cousins says, adding that the average length of stay is three to five days. The 41-bed emergency shelter housed in the same building offers sleeping quarters for the homeless, but no medical care. “The two populations don’t intermix. The emergency shelter is open from 6 p.m. to 7 a.m. and then the facility clears out,” he says. “There are no diagnostic criteria. All you have to do is present as homeless.”
Richard McGreal, associate regional administrator for CMS, indicates that his agency will continue to work with the state to help clarify the situation. “We’ll help them better understand what we are looking for,” he says. “With 16 beds or less and a homeless shelter, on the surface Milestone appears not to be an IMD.”
Milestone continues to operate with 16 detox beds, two fewer than before, and 41 emergency shelter beds. “Co-location was the issue,” Cousins says. “We are trying to get a better and more full understanding of the definition as CMS lays it out.” CMS has given the state three to six months to redraft a letter that spells out the services and programs at Milestone.
By Phyllis Hanlon