As of March 2021, 340 Certified Community Behavioral Health Clinics (CCBHCs) were in operation across 40 U.S. States, Guam, and the District of Columbia. About 93% of CCBHCs provide services outside of the physical clinic space.

The CCBHC demonstration program was a provision of the federal, bipartisan Protecting Access to Medicare Act (PAMA) of 2014. The CCBHC model launched in 2017 with 66 clinics across eight demonstration states. Two more states joined the CCBHC demonstration in March 2020. Another 32 states have clinics that were awarded CCBHC expansion grants from the federal Substance Abuse and Mental Health Services Administration (SAMHSA).

In the 10 demonstration states, the state Medicaid program pays the CCBHCs a clinic-specific daily or monthly prospective payment to reimburse for the expected cost of the demonstration services. Since 2018, Congress has appropriated parallel grant funding that SAMHSA awards directly to local provider organizations to become CCBHC grantees, many of which are county-based mental health and addiction treatment provider organizations. In the expansion states, the grantees receive traditional Medicaid fee-for-service payments for state plan services, and the grant funding covers additional costs.

All CCBHCs, demonstration or grantees, provide a comprehensive range of evidence-based behavioral health services directly or through referral to designated collaborating organizations (DCOs). All CCBHC clinics must provide access to person- and family-centered services for individuals with serious mental illness or addiction, including opioid disorders; children and adolescents with serious emotional disturbance; and individuals with co-occurring disorders. CCBHCs provide the following nine core services:

1. Crisis services
2. Screening, assessment, and diagnosis; includes risk assessment
3. Person-centered treatment planning
4. Outpatient mental health and addiction treatment services
5. Primary care screening and monitoring of key indicators/health risk
6. Targeted case management
7. Psychiatric rehabilitation services
8. Peer support and family supports
9. Community-based mental health care for active-duty military members and veterans

About 93% of CCBHCs provide services outside of physical clinic space through formalized partnerships with non-health entities within a county or region. In the past 12 months, CCBHCs offered services in the following “other” locations:

• 78% provide services in consumer homes.
• 47% provide school-based services.
• 33% provide services in courts, police offices, and other justice-related facilities.
• 20% provide services on-site at community service organizations and other non-profit organization locations.
• 11% provide services in homeless shelters.

These findings were reported in “Certified Community Behavioral Health Clinics And County Governments, March 2021: A National Model Tailored For Local Mental Health And Substance Use Care” by the National Council for Behavioral Health and the National Association of Counties. The report outlines the tenets of the CCBHC model, which aligns federal funding with a care model founded on person-centered treatment, care coordination and integration, evidence-based practice, timely access to services (including 24/7 crisis response) and the flexibility to deliver support outside the four walls of the clinic. The authors discussed how counties can leverage the CCBHC model to address key policy priorities around mental health including: expanding access to addiction treatment and strengthening the local response to the opioid crisis, serving more people, and reducing wait times for treatment.

The full text of “Certified Community Behavioral Health Clinics And County Governments, March 2021: A National Model Tailored For Local Mental Health And Substance Use Care” was published April 6, 2021, by the National Council for Behavioral Health and the National Association of Counties. A free copy is available online at https://www.naco.org/sites/default/files/documents/032421_CCBHCs_CountyGovernments_v2.pdf (accessed April 16, 2021).

OPEN MINDS last reported on this topic in “SAMHSA Accepting Applications For CCBHC Expansion Grants,” which published on March 5, 2020. The article is available at https://openminds.com/market-intelligence/news/samhsa-accepting-applications-for-ccbhc-expansion-grants/.

For more information, contact: Rebecca Farley David, Senior Advisor, Public Policy & Special Initiatives, The National Council for Behavioral Health, 1400 K Street Northwest, #400, Washington, District of Columbia 20005; 202-684-3735; Email: rebeccad@thenationalcouncil.org; Website: https://www.thenationalcouncil.org/

Of the eight states participating in a time-limited demonstration to establish certified community behavioral health clinics (CCBHC), the evaluation data is mixed. The eight states participating in the CCBHC demonstration that started in mid-2017 were Minnesota, Missouri, Nevada, New Jersey, New York, Oklahoma, Oregon, and Pennsylvania. During fiscal years 2017 through 2019, the eight states reported about $1.2 billion in Medicaid CCBHC expenditures, with federal expenditures of about $900 million, and state expenditures of about $300 million.

Officials in five of the eight demonstration states—Minnesota, Missouri, New Jersey, New York, and Oregon—reported generally increased state spending on CCBHCs, which officials from these states attributed to an increased number of individuals receiving treatment, an increased array of services provided, or both. In contrast, officials from Nevada, Oklahoma, and Pennsylvania did not report that the demonstration resulted in greater state spending.

In addition, four of the eight states —Missouri, New York, Oklahoma, and Oregon—assessed potential cost savings from the demonstration resulting from reductions in the use of more expensive care, such as emergency department visits. Officials from Missouri, New York, and Oklahoma viewed the results of their assessments as suggestive of potential cost savings, while officials from Oregon did not.

1. Minnesota’s demonstration started July 1, 2017. Six CCBHCs participated.
2. Missouri’s demonstration started July 1, 2017. Fifteen CCBHCs participated.
3. Nevada’s demonstration started July 1, 2017. Three CCBHCs participated.
4. New Jersey’s demonstration started July 1, 2017. Seven CCBHCs participated.
5. New York’s demonstration started July 1, 2017. Thirteen CCBHCs participated.
6. Oklahoma’s demonstration started April 1, 2017. Three CCBHCs participated.
7. Oregon’s demonstration started April 1, 2017. Twelve CCBHCs participated.
8. Pennsylvania demonstration started July 1, 2017. Seven CCBHCs participated.

The CCBHC demonstration was a provision (Section 223) of the Protecting Access to Medicare Act, which was signed into law on April 1, 2014. The eight states participating in the CCBHC demonstration were among 24 that were awarded a one-year planning grant in October 2015 by the federal Substance Abuse and Mental Health Services Administration (SAMHSA). In the eight states, 66 provider organizations became CCBHCs, a new Medicaid provider organization type that was eligible to receive a daily or monthly fixed rate prospective payment in exchange for providing nine core outpatient, community-based behavioral health services for adults, children, and families. The core services could be delivered by the CCBHC entity directly or through formal partnerships with other provider organizations. The nine core CCBHC services are as follows:

1. Crisis mental health services, including 24-hour mobile crisis teams, emergency crisis intervention services, and crisis stabilization
2. Screening, assessment, and diagnosis, including risk assessment
3. Patient-centered treatment planning or similar processes, including risk assessment and crisis planning
4. Outpatient mental health and substance use services
5. Outpatient clinic primary care screening and monitoring of key health indicators and health risk
6. Targeted case management
7. Psychiatric rehabilitation services
8. Peer support and counselor services and family supports
9. Intensive, community-based mental health care for members of the armed forces and veterans, particularly those members and veterans located in rural areas, provided the care is consistent with minimum clinical mental health guidelines promulgated by the Veterans Health Administration, including clinical guidelines contained in the Uniform Mental Health Services Handbook of such Administration

These findings were reported in “Medicaid Behavioral Health: CMS Guidance Needed To Better Align Demonstration Payment Rates With Costs & Prevent Duplication” by the Government Accountability Office (GAO). The GAO described what states did to measure the effects of the CCBHC demonstration on quality of care, consumer health outcomes, and state spending on behavioral health services. The GAO also examined federal guidance on Medicaid CCBHC payments.

The GAO reviewed summary information and results from state assessments that states voluntarily undertook to examine the demonstration’s effects on state spending on behavioral health services. GAO also reviewed other relevant documentation describing state-related demonstration costs, spending, and planning, including information available on state and federal websites, such as budget documentation and state plan amendments. Between November 2020 and April 2021, GAO also interviewed officials from state Medicaid agencies, behavioral health agencies, or both from the eight demonstration states, as well as officials from three selected CCBHCs.

A link to the full text of “Medicaid Behavioral Health: CMS Guidance Needed To Better Align Demonstration Payment Rates With Costs & Prevent Duplication” may be found in the OPEN MINDS Circle Library at https://openminds.com/market-intelligence/resources/092321cmsmedicaidbhrates/.

OPEN MINDS last reported on this topic in “75 Behavioral Health Provider Organizations In 8 States Prepare For CCBHC Demonstrations,” which published on February 12, 2017. The article is available at https://openminds.com/market-intelligence/news/77-behavioral-health-provider-organizations-eight-states-participating-ccbhc-demonstration/.

For more information, contact: Carolyn L. Yocom, Director, U.S. Government Accountability Office, 441 G Street, Northwest, Room 7149, Washington, District of Columbia 20548; 202-512-7114; Email: yocomc@gao.gov; Website: http://www.gao.gov/

On October 1, 2021, the Michigan Department of Health and Human Services (MDHHS) program launched a two-year Certified Community Behavioral Health Clinics (CCBHC) Demonstration Program. MDHHS selected 13 provider organizations to become CCBHCs from the 14 named in its 2016 application, which included 11 Community Mental Health Services Programs (CMHSPs) and three non-profit behavioral health entities, together serving 18 Michigan counties. The 13 selected sites are eligible for full Medicaid reimbursement and a daily payment through the Medicaid prospective payment system (PPS), similar to that paid to federally qualified health centers.

Since 2018, 34 Michigan behavioral health provider entities have directly received $135 million in two-year CCBHC Expansion Grant awards from the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). The direct-to-grantee awards are intended to help immediately provide CCBHC services while preparing an entity for the state-based CCBHC program. Of the 34 sites funded by the SAMHSA grants, 10 sites are participating in the state’s CMS CCBHC demonstration. Until the CCBHC demonstration program started, the sites received Medicaid reimbursement for covered services and used federal grant or other funding to pay for non-Medicaid services.

The 13 organizations participating in the CCBHC demonstration receive a daily per-beneficiary/recipient, clinic-specific PPS rate based on the average expected daily cost to deliver core CCBHC services. The non-demonstration sites will continue with their previous reimbursement method. MDHHS anticipates roughly 100,000 Michigan residents will be served by the 13 sites (over 80% of which are estimated to be Medicaid beneficiaries). The 13 sites, and their PPS rates for the first demonstration year, are as follows:

1. Community Mental Health and Substance Abuse Services of St. Joseph County: $292.62
2. Community Mental Health Authority of Clinton, Eaton, and Ingham Counties: $373.07
3. Community Network Services (Oakland County): $342.23
4. Easter Seals (Oakland County): $327.63
5. HealthWest (Muskegon County): $383.02
6. Integrated Services of Kalamazoo (Kalamazoo County): $445.73
7. Macomb County Community Mental Health: $338.01
8. Saginaw County Community Mental Health Authority: $432.16
9. Clair County Community Mental Health Authority: $332.37
10. The Guidance Center (Wayne County): $478.53
11. The Right Door (Ionia County): $384.14
12. Washtenaw County Community Mental Health: $281.33
13. West Michigan Community Mental Health (Lake, Mason, and Oceana Counties): $357.85

The 13 CCBHCs serve Medicaid beneficiaries and consumers with other types of health insurance. The state’s Medicaid managed care plans for physical health are not required to contract with the CCBHCs. The state’s 10 regional prepaid inpatient health plans (PIHPs) that manage the public behavioral health system for Medicaid and publicly funded behavioral health specialty services and supports are required to contract with the CCBHCs. The PIHPs administer supports and services for persons with serious mental illness, serious emotional disturbance, intellectual/developmental disabilities, and drug addiction. The PIHPs also directly manage SAMHSA Substance Abuse Block Grant funding and local substance addiction. For the CCBHC demonstration, MDHHS provides a capitated payment to the applicable PIHPs for CCBHC services and the PIHPs pay the PPS to the CCBHC demonstration sites for qualifying services.

The pilot project was authorized by the U.S. Centers for Medicare & Medicaid Services (CMS) under Section 223 of the Protecting Access to Medicare Act of 2014. MDHHS originally applied to CMS in 2016 to become a CCBHC Demonstration state. That request was approved on August 5, 2020 by virtue of the Federal Coronavirus Aid, Relief, and Economic Security Act (CARES Act) of 2020, adding Michigan and Kentucky to the CMS demonstration.

To see the latest on Michigan’s CCBHC demonstration, including information for both those servied, and for provider organizations, go to http://www.michigan.gov/CCBHC

A link to the full text of “MI CCBHC Demonstration — Final DY1 PPS-1 Rates by CCBHC Site” may be found in the OPEN MINDS Circle Library at https://openminds.com/market-intelligence/resources/100121miccbhcdemoppsrates/.

OPEN MINDS last reported on this topic in “Michigan & Kentucky Now Participating In CCBHC Demonstration,” which published on September 16, 2020. The article is available at https://openminds.com/market-intelligence/bulletins/michigan-kentucky-now-participating-in-ccbhc-demonstration/.

For more information, contact: Jon G. Villasurda Jr., MPH, State Assistant Administrator, Behavioral Health and Developmental Disabilities Administration, Michigan Department of Health and Human Services, 320 South Walnut Street, Elliot-Larsen Building, 5th Floor, Lansing, Michigan 48933; 517-230-9707; Email: villasurdaj@michigan.gov;  Website: http://www.michigan.gov/CCBHC

Editor’s note: the informational link for CCBHC updates was added on 11/15 per Mr. Villasurda.

The eight states participating in the Certified Community Behavioral Health Clinics (CCBHC) demonstration (Minnesota, Missouri, Nevada, New Jersey, New York, Oklahoma, Oregon, and Pennsylvania) reported that the number of consumers served by the organizations licensed as CCBHCs increased by about 11% between the first and second demonstration years. In the first demonstration year, the 66 community mental health provider organizations licensed as CCBHCs, and operating 377 service sites, served 301,285 people covered by Medicare, Medicaid, commercial insurance plans, and the uninsured. In the second demonstration year they served 335,325 people – an increase of 11%.

The states attributed the increase in utilization to greater availability of same-day appointments, expanded hours of operation facilitated by increased hiring and efforts to conduct outreach to underserved groups. The demonstration also enabled the CCBHCs to hire staff and reduce turnover rates, which gave the CCBHCs capacity to provide more treatment and support services. Although the states measured outcomes differently, in general, they reported an increase in CCBHC utilization, reductions in emergency department and hospital visits among CCBHC consumers, which led to cost offsets. The CCBHCs had higher performance than non-CCBHCs in terms of treatment initiation, engagement, and follow-up for both mental health and addiction services.

Four of the CCBHC demonstration states reported serving more consumers, as follows:

• Missouri reported serving 27% more people from baseline to the fourth year of the program, from 119,022 in 2017 to 150,578 people in 2021.
• Nevada reported serving 250% more people from baseline through the third year of the program, from 908 to 2,270 people.
• New York reported serving 21% more Medicaid beneficiaries in the first demonstration year. Of this new group, about a quarter had not received a behavioral health service in the prior three years.
• Oregon reported that CCBHCs served 17% more people diagnosed with serious and persistent mental illness (SPMI) between 2016 and 2018. This increase in number of people with SPMI served was three times greater than what the state’s non-CCBHCs reported.

In four of the CCBHC demonstration states, CCBHCs reported reductions in emergency department and hospital visits among CCBHC consumers, leading to cost offsets. Their outcomes are as follows:

• Oklahoma reported that the share of consumers served by its three CCBHCs that made an emergency department dropped over the first four years of the program compared to baseline; for one CCBHC the rate dropped by 18% and by 47% for another CCBHC. Outcomes for the third CCBHC were not reported. The share of CCBHC consumers who were admitted to inpatient care dropped by 20% to 69%.
• New York reported that in its first year, the number of CCBHC consumers using behavioral health inpatient services dropped by 54%. The drop translated to a 27% decrease in associated monthly costs. The state also reported a 46% drop in the number of CCBHC consumers who made emergency department visits, which led to a 26% decrease in associated monthly costs. The number of CCBHC consumers using general hospital inpatient services dropped by 61%, and all-cause readmissions dropped by 54%.
• New Jersey reported a decline in all-cause readmission rates from the first to second demonstration year, but did not report the statistics.
• Missouri reported that among CCBHC consumers with a prior emergency department visit engaged in outpatient care at a CCBHC, 76% experienced reduced emergency department visits and hospitalizations. Of those engaged in care who had some type of prior law enforcement involvement, nearly 70% had no further law enforcement involvement at six months.

In three CCBHC demonstration states, the CCHBCs reported higher performance than non-CCBHCs on key metrics for treatment initiation, engagement and follow-up care:

• New Jersey reported the rate of follow-up after hospitalization for mental illness nearly doubled in the second year of the demonstration. New Jersey also reported that treatment initiation and engagement rates for alcohol and other drug use in adults increased from the first to the second demonstration year. CCBHCs far outperformed statewide averages on these measures.
• New York reported that CCBHCs outperformed other provider organization types on initiation and engagement of alcohol and other drug treatment and seven-day follow-up after hospitalization.
• In Missouri, by the third demonstration year, CCBHCs had a 75% rate of 30-day post-hospitalization follow-up for adults hospitalized with mental illness, compared to a statewide average of just 33% for Medicaid provider organizations.

Three states reported that CCBHC demonstration increased access to a comprehensive, evidence-based addiction treatment services to curb the opioid crisis, including medication assisted treatment (MAT), as follows:

• New Jersey’s CCBHCs nearly doubled the number of consumers receiving MAT from the first to the second demonstration year.
• Missouri reported a 122% increase in MAT from baseline to the third demonstration year, increasing the number individuals receiving MAT from 3,128 at baseline to 6,929 by the third demonstration year.
• Oklahoma reported a 700% increase in the number receiving MAT prior to the CCBHC demonstration to the fourth demonstration year.

The CCBHC demonstration resulted in improved integration of physical care with behavioral care for mental health disorders or addiction. The CCBHC sites in some states exceeded the federal requirements to offer onsite primary care services, as follows:

• Minnesota CCBHCs collected and monitored physical health information such as HbA1c, weight, cholesterol, tobacco use and metabolic syndrome screening, which can help identify, intervene, and treat chronic conditions including diabetes and hypertension.
• Nevada CCBHCs carved in primary care services, beyond the primary care screening and monitoring requirements in the program requirements. The Nevada CCBHCs took on this additional service due to a general lack of primary care in the communities served by CCBHCs.
• Oregon enhanced the federal CCBHC requirements to require 20 hours per week of onsite primary care services provided by medical personnel, such as primary care physicians or nurse practitioners. The CCBHCs also enhanced the availability of physical health screenings: all CCBHCs in Oregon are now regularly screening for tobacco use, body mass index (BMI) and blood pressure. Most CCBHCs regularly conduct lipid profiles and glucose screenings.

These findings were reported in “Transforming State Behavioral Health Systems: Findings From States On The Impact Of CCBHC Implementation” by National Council on Mental Wellbeing. The researchers conducted semi-structured interviews with state officials from the eight states participating in the CCBHC demonstration; and they reviewed reports, program data and other documents shared by state officials. They also reviewed other publicly available evaluation reports on the CCBHC program. The researchers sought to collect comprehensive data on service delivery, costs and outcomes for the entire duration of the CCBHC demonstration program. However, some of the states were unable to share more current CCBHC program data beyond the first year or two due to time and resource constraints. The researchers noted that in December 2021, the federal Department of Health and Human Services (HHS) is expected to submit a report to congress assessing the preliminary impact of the demonstration for the first two years on care utilization using Medicaid claims and encounter data.

The full text of “Transforming State Behavioral Health Systems: Findings From States On The Impact Of CCBHC Implementation” was published in October 2021 by the National Council on Mental Wellbeing. A free copy is available online at https://www.thenationalcouncil.org/wp-content/uploads/2021/10/21.10.04_CCBHC-State-Impact-Report.pdf?daf=375ateTbd56 (accessed October 28, 2021).

OPEN MINDS last reported on this topic in “Evaluation Of The Eight Original CCBHC Demonstration States Reveals Mixed Results,” which published on October 22, 2021. The article is available at https://openminds.com/market-intelligence/news/review-of-eight-initial-ccbhc-demonstration-states-found-three-that-reported-potential-savings/.

For more information, contact: National Council for Mental Wellbeing, 1400 K Street Northwest, Suite 400, Washington, District of Columbia 20005; 202-684-7457; Email: Communications@TheNationalCouncil.org; Website: https://www.thenationalcouncil.org/.