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Nina Marshall

, National Council for Behavioral Health

Bundled Payments, Quality Bonuses: Payment for CCBHCs

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One of the persistent questions of the past nine months, as we at the National Council have reviewed iterations of the certification criteria for Certified Community Behavioral Health Clinics (CCBHCs), has been “but how will the payment work?” The statute that created the demonstration program requires a Prospective Payment System (PPS), but what that has historically meant has varied from state to state and provider type to provider type. How would quality measures be built in? And what if the CCBHC services weren’t already part of that particular state’s Medicaid program?

Three answers:

  1. Bundled payments – daily or monthly, stratified for severity
  2. Quality Bonus Payments – for CCBHCs that hit certain benchmarks
  3. States get federal Medicaid match for all CCBHC services – regardless of what’s in the State Plan.

Let’s unpack those a bit.

Bundled Payments. States will choose between two PPS options: either (1) an FQHC-like daily encounter rate or a (2) monthly rate. Both are triggered by actual encounters with clients – so they are distinct from a capitated or case rate – but will incorporate costs incurred by non-encounter activities (such as care management work). They will also require sophistication on the part of the provider with respect to forecasting the volume and type of services to be delivered for specific populations. Why for specific populations? Because for the monthly PPS option, the rates can be layered for more complex cases – a base rate that applies regardless of the Medicaid beneficiary seen, and a second payment for people with different clinical profiles, such as Serious Mental Illness or a Substance Use Disorder.

Quality Bonus Payments. The CCBHC payment guidance developed by CMS is in line with the agency’s overall goal of moving the system more towards Value-Based Payments. The Quality Bonus Payments are required for states that opt for the monthly PPS rate, and optional for the daily PPS rate. There are a core set of quality measures that CCBHCs must hit before they are eligible for the bonus payment; states are allowed to negotiate with SAMHSA and CMS to include additional measures. The full list of required measures are included in the guidance (Appendix 3, pg. 9),but are a combination of process and outcome measures, such as follow up after hospitalization, medication adherence for people with schizophrenia, and depression remission.

Enhanced Medicaid Match, Regardless of State Plan. CMS made very clear that states get to draw down their federal Medicaid match for CCBHC services (aka FMAP), regardless of what is in the Medicaid State Plan; the authority vested via the demonstration is sufficient. States can also claim an administrative match for efforts by the state to administer the program.

Want to learn more about the Excellence Act? The National Council is proud to offer you the following: an MTM Services CCBHC Readiness Assessment Tool, information on upcoming webinars, an updated National Council Excellence Act fact sheet and much more. Join us. Learn more. Get on the value-based payment bandwagon.