infants’ withdrawal more difficult. See Mark L. Hudak and Rosemarie C. Tan, American Academy of Pediatrics. “Neonatal Drug Withdrawal,” Pediatrics, vol. 129, no.2 (2012). Page 21 GAO-18-32 Newborn Health Medicaid pays for NAS treatment services provided in the non-hospital settings we identified in certain states, according to CMS officials and other stakeholders we spoke with, but generally pays for these services separately, in contrast with the single bundled payment paid to hospitals.36 State officials and health care providers in the non-hospital settings we examined described various ways in which Medicaid covered services they provided to treat infants with NAS. For example: • Outpatient follow-up clinic in Vermont. State officials and staff at this facility told us that the Vermont Medicaid program pays for an infant’s outpatient physician visits using a fee-for-service payment schedule. They added that the Vermont Medicaid program also pays for the infant’s medication used in pharmacologic treatment and explained that the pharmacy that dispenses the medication bills Medicaid for these services. • Neonatal withdrawal center in Washington. Health care providers at this facility told us that the Washington Medicaid program or their contracted managed care plans pay for physician visits using a feefor-service payment schedule, noting that the facility decided to stop billing Medicaid for medical supplies because of the low reimbursement.37 Additionally, these providers suggested that because the facility does not meet the Medicaid standards required for receiving payment for hospital inpatient, nursing, or other covered facility services, the facility is ineligible to receive Medicaid payment for the costs of room and board. These providers said that they receive funding for the cost of these services through state 36In addition, Medicaid only pays for the cost of room and board in certain types of facilities, including hospitals, nursing facilities, and psychiatric residential treatment facilities that meet Medicaid standards for such payment. See, e.g., 42 C.F.R. §§ 440.10, 440.150, 440.155. 37According to a state agency report, the facility previously received Medicaid payment in 2012 for NAS-related services including physician visits, medication, gloves, and syringes. See Children’s Administration, Division of Program and Practice Improvement, Washington State Department of Social & Health Services, Report to the Legislature: Pediatric Interim Care Center Performance-Based Contracts (Olympia, WA: December 1, 2012), accessed September 25, 2017, https://app.leg.wa.gov/ReportsToTheLegislature/Home/GetPDF?fileName=Pediatric%20In terim%20Care%2012-1-12_0e865170-67d7-4235-8992-68729e324c93.pdf. However, health care providers told us that Medicaid reduced its payment for these medical supplies and as a result, these providers did not bill Medicaid for these supplies in 2016. We did not interview Washington state officials about this facility. Medicaid Payments for NAS Treatment Services Provided in Non-Hospital Settings Page 22 GAO-18-32 Newborn Health appropriations, foster care payments, city contracts, grants, and private donations.38 • Neonatal withdrawal center in West Virginia. State officials and health care providers at this facility told us that West Virginia pays for NAS services through two mechanisms, depending on whether the infant is in foster care.39 Specifically, if the infant is in foster care, the facility receives a bundled payment from the state Medicaid program and the Bureau of Children and Families.40 However, if the infant is not in foster care, the state Medicaid program pays for physician visits using a fee-for-service schedule. Additionally, the facility can receive payment under a per diem rate that is negotiated with state Medicaid managed care plans.41 The health care providers said that they also receive funding through grants and private donations to help cover the costs of NAS services. Stakeholders we interviewed and literature we reviewed suggest that the costs of treating infants with NAS in non-hospital settings were lower than treating them in hospital settings. However, supporting data and research of the costs in different settings are anecdotal or otherwise limited. For example: • Health care providers from the neonatal withdrawal center in Washington told us that their facility could treat infants at a lower average cost per day than could hospitals—at about $700 per infant per day compared to an average cost of about $1,500-2,500 per infant per day in a hospital. These providers said that this cost savings is in part due to their limited staffing of nurses and their ability to leverage 38According to health care providers, this facility is licensed by the state as a group care facility and received $668,000 in the state appropriations for fiscal year 2016. These providers told us that they received a foster care payment of about $18 per day for each infant in state custody in 2016. 39The West Virginia Department of Health and Human Resources administers a foster care program, in which it can accept custody of dependent children. Parents may also voluntarily request placement of their child into foster care on a short-term basis. 40The facility is eligible to receive this type of bundled payment because it is licensed by the state as a residential child care facility. Facility staff