CMS Issues Revised Guidance on Certified Community Behavioral Health Clinic (CCBHC) Prospective Payment Methods
June 20, 2023
On May 12, 2023, the Centers for Medicare and Medicaid Services (CMS) released proposed revisions to the Certified Community Behavioral Health Clinic (CCBHC) Prospective Payment System (PPS) Guidance governing CCBHC programs operating under Section 223 Demonstration authority.1 This brief highlights the key proposed reimbursement changes as CMS requested comments by June 2, 2023.
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Separate Cost-Based Rate for Special Crisis Services for CCBHC Demonstration Participants
In this guidance, CMS sets forth three approaches for CCBHC Demonstration states using the proposed PPS-3 (daily) or PPS-4 (monthly) rate methodologies to create a separate daily cost-based rate for mobile crisis and on-site crisis stabilization services and receive enhanced federal funding. CCBHC Demonstration states would need to select at least one of the options for daily special crisis service rates.2 Mobile crisis and crisis stabilization are some of the most expensive services to provide due to the cost of the multidisciplinary provider team, the immediate response requirement, and the supplies and medications necessary to maintain readiness. The proposed daily rates for special crisis services are intended to support expansion of these critical services.
Option 1: Mobile crisis services that meet CMS criteria for qualifying community-based crisis intervention services
This option allows for a separate reimbursement rate for qualifying mobile crisis services that would be matched at 85% federal matching rate (FMAP) for the first three years (i.e., twelve fiscal quarters) that mobile crisis services meet the requirements of Section 1947(d) of the Social Security Act.3 Qualifying mobile crisis services require patients to be treated in the community by a multidisciplinary team trained in trauma-informed care, de-escalation, and harm reduction strategies.4 Absent congressional action, the 85% FMAP is set to expire on March 31, 2027.5
Option 2: Mobile crisis services authorized under CCBHC programs that do not meet the CMS criteria for qualifying community-based intervention services
This option allows for a separate reimbursement rate for mobile crisis services that do not meet the statutory criteria that would be matched at the standard Children’s Health Insurance Program (CHIP) rate.6
Option 3: On-site crisis stabilization at the CCBHC
This option allows for a separate reimbursement rate for on-site crisis stabilization services that would be matched at the enhanced CHIP rate.7
Quality Bonus Payment Measure Set
While quality bonus payments remain optional for CCBHCs reimbursed via daily rates (PPS-1 and PPS-3), CMS proposes to modify the six core required quality measures for CCBHCs reimbursed via monthly PPS rates (PPS-2 and PPS-4) to receive a quality bonus payment (QBP).8 A summary of the proposed changes to the quality bonus measure set is as follows:9
- Addition of Comprehensive Diabetes Care: HbA1c (HBD-AD) (state collected) and Time to Services (I-SERV) (clinic collected) to the mandatory QBP measure set.
- The technical specifications for Depression Remission at Six Months (DEP-REM-6) (clinic collected) changed, and the measure would become mandatory.
- Both the adult and the child and adolescent measures for suicide risk assessment (clinic collected) would become optional.
- The QBP measure set would have an expanded list of optional measures.
CCBHCs will still need to achieve on all six required measures in order to receive a QBP and states will now have clarification on the use of tiered thresholds for payment.10 The guidance emphasizes that QBPs must be tied to quality and cannot be made for CCBHC reporting alone.11
Other key proposed changes:
- CMS created additional flexibility for monthly rates (PPS-2 and PPS-4) by making the special populations rate requirement optional.12
- To address rate discrepancies caused through anticipated costs and to maintain efficiency in rates, CCBHCs will be required to rebase rates in year two after projecting anticipated costs in their first cost report, and at least every three years thereafter.13
- In response to a few states that legislated costs for 988 hotlines into the PPS, CMS clarifies that states may claim FMAP for the 988 hotline only as an administrative expense and not through the PPS rate.14
States not participating in the CCBHC demonstration should consider updating their CCBHC state plan payment methodology in accordance with the new PPS methods, rebased rate schedule, and quality bonus changes, as applicable. For additional information or a free 30-minute technical assistance call, states and CCBHCs can contact us at email@example.com, firstname.lastname@example.org, or email@example.com.
1: “Certified Community Behavioral Health Clinic (CCBHC) Prospective Payment System (PPS) Guidance: Proposed Updates May 2023,” Centers for Medicare & Medicaid Services (May 12, 2023), https://www.medicaid.gov/medicaid/financial-management/downloads/ccbh-pps-prop-updates.pdf.
2: Ibid., p. 2. Note that all references to federal matching rates apply unless the service is provided to Medicaid eligibility groups subject to different federal matching rates, e.g., newly eligible adults.
4: Daniel Tsai, “SHO #21-008. RE: Medicaid Guidance on the Scope and Payments for Qualifying Community-Based Mobile Crisis Intervention Services,” Centers for Medicare & Medicaid Services, Center for Medicaid and CHIP Services (December 28, 2021): 7. https://www.medicaid.gov/federal-policy-guidance/downloads/sho21008.pdf.
5: Ibid., p. 9.
6: See footnote 1 at page 2 of “Certified Community Behavioral Health Clinic (CCBHC) Prospective Payment System (PPS Guidance), Proposed Updates May 2023,” Centers for Medicare & Medicaid Services (May 12, 2023) https://www.medicaid.gov/medicaid/financial-management/downloads/ccbh-pps-prop-updates.pdf.
8: Ibid., pp. 4, 6.
9: Ibid., p. 6.
12: Ibid., p. 2.
13: Ibid., p. 4.
14: Ibid., p. 9.