Certified Community Behavioral Health Clinics:  What’s in it for states?

When it comes to behavioral health systems, many states struggle with the lack of “system.” Services provided are often a compilation of available Medicaid state plan options, with little in the way of unifying structures to ensure coordination of care or linkages to other systems. The Substance Abuse and Mental Health Services Administration (SAMHSA) recently announced Certified Community Behavioral Health Clinic (CCBHC) program seeks to address these challenges through the development of community behavioral health organizations that offer a comprehensive array of services, with standards designed to foster continuity and coordination.

On May 20, SAMHSA released the Request for Applications (RFA) for its CCBHC program. The two-phase program includes a RFA for one-year planning grants (of up to two million dollars) to support states in developing CCBHCs.  States will use the planning grants to certify community behavioral health clinics based on SAMHSA criteria, develop a prospective payment system for reimbursement of CCBHCs, and prepare an application for the demonstration phase of the program. Phase two, slated to begin in 2017, will engage eight states in a two-year demonstration to implement CCBHCs and evaluate the impact of these new providers on access, cost, and quality of community behavioral health care. States that participate in the two-year demonstration will receive matching federal funding at their state’s Children’s Health Insurance Program (CHIP) Federal Medicaid Assistance Percentage (FMAP) for services delivered by the CCBHCs during the two-year demonstration. Note, this CHIP FMAP rate for CCBHC services does not include the 23-percentage point bump that applies to CHIP between October 1, 2015 and September 30, 2019. Higher FMAP rates do apply to CCBHC services provided to CHIP expansion enrollees and certain newly eligible Medicaid enrollees, however.

Advocates welcomed the announcement of the CCBHC program as one of the most significant investments in behavioral health system transformation in decades, citing the opportunity to create a more standardized and high-performing community mental health system nationwide.

Does the CCBHC program provide solutions to critical state mental health systems issues, and if so, at what cost? The answer for each state may depend on both the existing community mental health infrastructure and the state’s broader healthcare context:

Is your state’s community behavioral health system able to deliver?  

State community behavioral health systems are increasingly viewed as a key piece of the health reform puzzle. Whether we are talking about integrating with physical health care, addressing the needs of Medicaid’s most expensive and complex populations, or being the go-to system for high-visibility public health issues (suicide prevention, opioid addition) more is expected of community behavioral health systems than ever before. However, these systems often lag behind in critical areas such as workforce, HIT, common quality measurement tools, and other infrastructure.  The CCBHC program, with its focus on establishing standards, beefing up services and systems, and the potential for enhanced Medicaid funding during the demonstration phase, could provide a very timely vehicle for states to do some comprehensive system planning and reform.

Are CCBHCs a good fit with your state’s regulatory framework?

CCBHCs are required to provide – either directly or through formal arrangements with other providers – a comprehensive set of behavioral health services, including crisis services (unless the state has an existing system), screening, assessment, and diagnosis, treatment planning, outpatient mental health and substance use services, targeted case management, psychiatric rehabilitation services, peer and family supports, and community-based mental health care for members of the armed forces and veterans.   Although states are ultimately responsible for certifying CCBHCs based on state criteria, SAMHSA has also laid out some fairly detailed baseline requirements, covering topics such as staffing, cultural competence, access and care coordination.  All of this creates a fairly robust regulatory structure, which may or may not align with a state’s existing behavioral health services and systems. States will want to think about how this overlay could help them leverage and strengthen what is already on the ground.

Who (and what) is currently covered?

States that are selected for the CCBHC demonstration must ensure that their CCBHCs are ready to provide a mandated minimum set of services to all in need, regardless of ability to pay or residency requirements. The CCBHC prospective payment, however, may only include costs related to serving eligible Medicaid recipients. States, especially those that have not expanded Medicaid coverage, will need to understand how CCBHCs will support delivery of services to this uninsured/self-pay population. Similarly, states whose benefit package does not currently include all mandated CCBHC services will want to think about how this set of services can be sustained post-demonstration. 

Does the CCBHC framework align with other reform efforts and initiatives?

States are engaged in a multitude of delivery system and payment reform initiatives, from improving care coordination to the development of system-wide, value-based purchasing strategies.  Behavioral health, while often included in these efforts, can sometimes feel like a sideshow to the main event: carved out, lacking data, and limited by state plan option restrictions.  States that have struggled with how to bring behavioral health into the big tent of payment reform may find an opportunity in the CCBHC program. The Centers for Medicaid and Medicare Services lays out two different prospective payment strategies for the CCBHCs, both of which permit states to use quality bonus payments to incentivize good care.  States may certify as few as two CCBHC sites as a way to explore these changes while minimizing disruption or conflict with existing reform efforts.  CCBHCs may also provide health home services, so these initiatives need not be mutually exclusive.

High-performing behavioral health systems are critical to broader state health reform efforts, and opportunities for major investment in these systems have been few and far between.  The CCBHC program may be an important tool for state policymakers to consider as they think about improving these important systems of care; states will want to review this opportunity to see if it’s a good fit.

Applications from states for CCBHC planning grants are due to SAMHSA on August 5th, 2015. For more information on the program, visit the SAMHSA CCBHC webpage.