How do States Deliver, Administer, and Integrate Behavioral Health Care? Findings from a Survey of State Medicaid Programs
Issue Brief
The three states are KY, MA, and MI:
KY reported that both the State Medicaid Services (Department for Medicaid Services, DMS) and Behavioral Health (Department for Behavioral Health, Developmental and Intellectual Disabilities, DBHDID) are under the Kentucky Cabinet for Health and Family Services.
MA reported that Medicaid and behavioral health were within the same executive office, under different agencies/programs.
MI reported that adult behavioral health and Medicaid are in the same administration (the Behavioral and Physical Health and Aging Services Administration) within the Michigan Department of Health and Human Services (MDHHS), while children's behavioral health policy is administered by a separate area of MDHHS.
Qualified residential treatment programs (QRTPs) are child care institutions that provide trauma-informed therapeutic programming designed to address the needs, including clinical needs, of children with serious emotional or behavioral disorders or disturbances. QRTPs may receive federal foster care maintenance payments, but may be subject to the IMD exclusion for federal Medicaid payment.
On KFF’s Behavioral Health survey, of 43 states responding, 16 states reported reimbursing for QRTPs in FY 2022 and an additional 5 states planned to add reimbursement in FY 2023.
Two states reported a Section 1115 waiver in place to allow coverage of services provided to enrollees in QRTPs that meet IMD criteria, while 5 states planned to seek such a waiver. Of these 5 states, all planned to seek Section 1115 authority to exempt the limitations on lengths of stays under the waiver for foster care children residing in QRTPs.
The Protecting Access to Medicare Act of 2014 established a demonstration program to improve community mental health services by funding planning grants for states to implement Certified Community Behavioral Health Clinics (CCBHCs), and the 2022 Safer Communities Act expanded this program.
In addition to setting requirements for CCBHCs, the 2014 Act directed CMS to issue guidance on a prospective payment system for mental health services furnished by CCBHCs to account for the total cost of comprehensive services they provide. The CCBHC demonstration aims to improve the availability and quality of ambulatory behavioral health services and to provide coordinated care across behavioral and physical health. CCBHCs provide nine types of services: crisis mental health services; screening, assessment, and diagnosis; patient-centered treatment planning; outpatient mental health and substance use services; outpatient clinic primary care screening and monitoring; targeted case management; psychiatric rehabilitation; peer support and counselor services and family supports; and intensive, community-based mental health care for members of the armed forces and veterans. CCBHCs may partner with designated collaborating organizations to provide some of these services.
Including CT (which reported it is analyzing the CCBHC model and may implement a modified version in the future), ME (which reported that its goal is to cover CCBHCs by July 1, 2024), and WA (which reported it is currently conducting a research study for the adoption of CCBHCs with a target of FY 2024).
Of the 15 states that reported recognizing CCBHCs in FY 2022 or 2023, 12 provided information on their current CCBHC reimbursement structure(s). Some of these states reported the use of multiple reimbursement strategies.
PPS methodologies: On May 20, 2015, the Centers for Medicare and Medicaid Services (CMS) issued guidance to states specific to the development of a PPS to be tested under the Section 223 Demonstration Program for CCBHCs, and required in Section 223 of the Protecting Access to Medicare Act of 2014. CMS released proposed updates to that CCBHC PPS Guidance in May 2023 to coincide with an additional round of state CCBHC grantees.
CMS developed two PPS methodologies for reimbursing CCBHCs: one that pays a fixed daily rate for all service rendered to a Medicaid enrollee (similar to the methodology used by Federally Qualified Health Centers) and one that pays a fixed monthly rate. 8 states reported using the daily PPS model (ID, KS, KY, MI, MO, NV, NY, and OR) and 2 states reported a monthly PPS model (NJ and OK).
Other methodologies: 3 states reported using FFS (NJ, NM, and NV), 3 states reported using outlier or bonus payments (MI, NJ, and NV), and 2 states reported using another methodology (AK reported that CCBHs are grant-funded; NY reported using a PPS methodology but carved out of managed care and paid using a CCBHC-specific code with a provider-specific rate based on each agency's total cost of operations divided by total visits).
Including SC, which reported that it intended to cover these codes and hoped to do so in FY 2023, but a firm date had not been established.