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Rebecca Farley

Director, Policy & Advocacy, National Council for Behavioral Health

Clarifying the Medicare Conditions of Participation for CMHCs

December 12, 2013 | Medicare | Comments
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A recently published federal rule from the Centers for Medicare and Medicaid Services established, for the first time, conditions of participation (CoP) for community mental health centers in Medicare. In the weeks since the CoPs were issued, the National Council has received many questions from our members asking whether and to what extent these guidelines apply to them. Keep reading for answers.

What organizations count as CMHCs for the purpose of the new guidelines?

“Community mental health center” is a widely-used term with no standard definition in federal law. Medicare defines CMHCs as outpatient organizations that provide partial hospitalization services to Medicare beneficiaries. The Centers for Medicare and Medicaid Services (CMS) estimates there are about 100 CMHCs that provide partial hospitalization services through Medicare and that will be affected by this rule.

It is important to note that states may use differing definitions of “CMHC.”

The term is also used colloquially as shorthand for community-based providers of outpatient mental health services. Remember that the CoPs apply only to those organizations that meet the official Medicare definition of CMHC and that are Medicare-certified as a CMHC.

How do I know if my organization is considered a CMHC by Medicare?

Your organization is considered a CMHC if you are Medicare-certified and bill Medicare using the place of service code 53. Place of service codes are two-digit codes used to indicate the setting in which a service was provided. There are a number of other codes that may be used by mental health organizations participating in Medicare – most commonly, code 11. Check with your billing office to find out the place of service code under which you are registered with Medicare.

My organization is registered with Medicare as a CMHC (using the place of service code 53), but we no longer provide partial hospitalization services. Do the CoPs apply?

Yes. The CoPs apply to any organization registered under the code 53, even if they are not actively providing partial hospitalization services. CMS considers any organization that is registered under 53 to be capable of providing partial hospitalization services and therefore subject to the CoPs.

My organization is designated as a CMHC under Medicaid in our state. Do the CoPs apply?

Some states define, regulate and license community mental health centers. These practices vary by state. States are not compelled to abide by the Medicare CoPs in setting policies for provider participation in Medicaid. However, they are free to do so if they choose – and some states will choose to adopt these guidelines. Check with your state Medicaid office if you have questions about whether the guidelines will be applied in your state.

If the CoPs apply to my organization, do we have to comply with them for all patients, or only Medicare beneficiaries?

The CoPs apply to the care provided to all patients by your organization.

More questions?

Contact Chuck Ingoglia or Rebecca Farley at the National Council – or leave a comment below.