Form CMS-10398 #45 CMS-10398 #45 Application and Guidance to Participate in the Section 2

[Medicaid] Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

2024 CCBHC Demonstration Application- Fillable

[Medicaid] GenIC #45 (Revised): Certified Community Behavioral Health Clinic (CCBHC) 2024 State Proposal Demonstration Application

OMB: 0938-1148

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Guidance to Planning Grant States to Apply to Participate
in the Section 223 CCBHC Demonstration Program
Introduction
Section 223 of the Protecting Access to Medicare Act (PAMA) of 2014 (P.L. 113-93) 1
authorized the Certified Community Behavioral Health Clinic (CCBHC) demonstration to allow
states to test a new strategy for delivering and reimbursing a comprehensive array of services
provided in community behavioral health clinics. The demonstration aims to improve the
availability, quality, and outcomes of outpatient services provided in these clinics. It also
requires states to reimburse CCBHC providers using a Medicaid prospective payment system
(PPS) methodology intended to cover the full cost of providing CCBHC services to Medicaid
beneficiaries. In 2016, the U.S. Department of Health and Human Services (HHS) selected eight
states to participate in the demonstration (Minnesota, Missouri, Nevada, New Jersey, New York,
Oklahoma, Oregon, and Pennsylvania) and expanded the demonstration to two new states
(Kentucky and Michigan) through the Coronavirus Aid, Relief, and Economic Security Act (P.L.
116-136) in August 2020. Though there have been several extensions to what was an originally a
two-year demonstration program, the most recent expansion under the Bipartisan Safer
Communities Act of 2022 (P.L. 117-259) authorized an additional one-year planning grant phase
and the addition of up to 10 additional states to participate in the CCBHC Demonstration
beginning as early as July 1, 2024, and every two years thereafter.
The CCBHC Planning Grants awarded by SAMHSA in March 2023 2 are designed to support
states through the 1-year statutory planning phase of the CCBHC Demonstration and prepare
them and their clinics to participate in Demonstration program. As a planning grant recipient,
CCBHC planning grant states are expected to submit an application to formally apply to
participate in the four‐year Demonstration. Up to ten states will be selected to participate in the
Demonstration based on the quality of the applications and geographic distribution, per the
statute. All states that received a CCBHC Planning Grant, either in 2016 or 2023, are eligible to
apply to participate in the four-year Demonstration.
Applications will be reviewed by a panel of federal subject matter experts. Based on that review,
recommendations for selection will be made to federal officials of the Assistant Secretary for
Planning and Evaluation (ASPE), the Centers for Medicare & Medicaid Services (CMS), and the
Substance Abuse and Mental Health Services Administration (SAMHSA) for final selection no
later than June 17, 2024. This document outlines the key application materials that must be
H.R. 4302, 113th Congress. Protecting Access to Medicare Act of 2014. PL No 113-92; April 2, 2014.
https://www.congress.gov/bill/113th-congress/house-bill/4302
2
On March 16, 2023, the U.S. Department of Health and Human Services (HHS), through the Substance Abuse and
Mental Health Services Administration (SAMHSA), awarded 15 states each with $1 million, one-year CCBHC
planning grants. The 15 states selected were Alabama, Delaware, Georgia, Iowa, Kansas, Maine, Mississippi,
Montana, North Carolina, New Hampshire, New Mexico, Ohio, Rhode Island, Vermont, and West Virginia.
1

submitted and clarifies the evaluation criteria that will be used to select states to participate in the
demonstration.
PAMA (P.L. 113-93, 42 U.S.C. 1396a, note), at subsection 223 (d)(4)(A) under which the
program is authorized, is explicit that preference must be given to selecting demonstration
programs where participating CCBHCs will achieve at least one of the following:
•
•

•
•

Provide the most complete scope of services as described in the Criteria to individuals
eligible for medical assistance under the state Medicaid program; OR
Improve availability of, access to, and participation in, services described in subsection
Criteria to individuals eligible for medical assistance under the state Medicaid program;
OR
Improve availability of, access to, and participation in assisted outpatient mental health
treatment in the state; OR
Demonstrate the potential to expand available mental health services in a demonstration
area and increase the quality of such services without increasing net federal spending.

This guidance is provided to clarify the criteria that federal subject matter experts will use to
assess which states are most likely to achieve at least one of the above goal(s) during the
demonstration program. Other criteria will be considered such as each state’s readiness to
participate in the program in terms of meeting the expectations of the planning grant, the state’s
compliance with the updated CCBHC Criteria 3 and conformance of the state’s PPS to the
updated PPS Guidance 4.
Planning Grant States must submit applications to participate in the demonstration no later than
March 20, 2024, 11:59PM EST. Applications must be submitted by email to
[email protected]. States selected to participate in the demonstration program will be
announced in June 2024.

The updated criteria, released in March 2023, are available at https://www.samhsa.gov/sites/default/files/ccbhccriteria-2023.pdf.
4
The updated PPS guidance, anticipated to be released by December 31, 2023, will be available at
https://www.medicaid.gov/medicaid/financial-management/section-223-demonstration-program-improvecommunity-mental-health-services/index.html
3

Components of the Application to Participate in the Section 223
Demonstration Program
Applications to participate in the demonstration program will be assessed on the completeness of
the application and the score applied by an objective review of applications. There are three
parts to this application: Required Attachments, Program Narrative, and Prospective Payment
System Methodology Description. The components are described in greater detail below along
with the points assigned for each section in parentheses. The total possible score is 100 for the
complete application.

Part 1: Required Attachments
You must include all of the following attachments. Attachment 1 will be scored as described
under Part 2, item B.
Attachment 1.

Complete the Certified Community Behavioral Health Clinic (CCBHC)
Criteria Compliance Checklist 2023 according to the guidance included in
this application guidance. This single checklist will identify the readiness
of the proposed CCBHCs in your state to be compliant with the updated
CCBHC Certification Criteria by the proposed start date of your
demonstration program. Include the completed checklist as Attachment 1.

Attachment 2

Include a signed statement that verifies that all CCBHCs proposed to be a
part of the state’s demonstration program will be compliant with the
CCBHC Certification Criteria by the proposed start date of the state
demonstration program and that, as a part of this, all participating
CCBHCs will participate in SAMHSA’s treatment locator. The applicant
must document that they have provisionally certified at least two CCBHCs
in diverse geographic areas including rural and underserved areas. These
provisionally certified CCBHCs must substantially meet the criteria and
be ready to fully meet the certification criteria by the proposed date of
state entry into the demonstration.

Attachment 3.

Include a statement that describes the target Medicaid population(s) to be
served under the demonstration program.

Attachment 4.

Include a list of proposed certified community behavioral health clinics
including any designated collaborating organizations (DCOs) proposed to
work with each CCBHC and what portions of the nine required services
they would be providing.

Attachment 5.

Include a signed statement that verifies that the state has agreed to pay for
CCBHC services at a rate established under the prospective payment
system.
3

Attachment 6.

Include a description of the scope of services required by the state in
compliance with CCBHC Criteria, Scope of Services, provided by/through
CCHBCs in your state, available under the state Medicaid program, and
that will be paid for under one of the selected PPS methodologies tested in
the demonstration program. This is meant to be a verification of the scope
of services that the state has required in order to comply with the CCBHC
Criteria, including any additional services required through state discretion
and evidence-based practices.

Attachment 7.

Include the SAMHSA Budget Justification form from your state’s original
application for a Planning Grant for CCBHCs and modify it to project the
amount of unexpended funds, if any, and how they will be used after
March 30, 2024.

Part 2: Program Narrative
In the Program Narrative, you will describe your state’s readiness to participate in the
demonstration program and project the impact of participation. The Program Narrative will be
scored up to a total of 80 points and may not exceed 30 pages. Each of the sections will be
scored as listed below. More detailed guidance is provided in the next section.
A.
B.
C.
D.
E.

Solicitation of input by stakeholders in developing CCBHCs (10 points)
State Capacity to Support CCBHC and Certification of clinics as CCBHC (30 points)
Development of enhanced data collection and reporting capacity (10 points)
Participation in the national evaluation (15 points)
Projection of the impact of the state’s participation in the Demonstration program (15
points)

Part 3: Prospective Payment System Methodology Description
Please complete Part 3 Prospective Payment System Methodology Description, the form that is
attached later in this guidance. Part 3 will be scored up to a total of 20 points. Using this form,
you will describe the following:
1.
2.
3.
4.
5.
6.

CCBHC PPS Rate-Setting Methodology Options
Payment to CCBHCs that are FQHCs, Clinics, or Tribal Facilities
Cost Reporting and Documentation Requirements
Managed Care Considerations
CCBHC Claims and Service Level Encounter Detail
Funding Questions

Part 2: Program Narrative
In the Program Narrative, you will describe your state’s readiness to participate in the
demonstration program and project the impact of participation. This part will be scored up to a
total of 80 points and may not exceed 30 pages.
A. (10 points – approximately 3 pages) Solicitation of input by stakeholders with respect to
the development of such a demonstration program from consumers, family members,
providers, tribes, and other key stakeholders. Please provide the following:
•

•

A description of the steering committee or use of an existing committee, council,
or process composed of relevant state agencies, providers, service recipients, and
other key stakeholders to guide and provide input throughout the grant period.
A description of the outreach, recruitment, and engagement of the population of
focus including adults with serious mental illness and children with serious
emotional disturbances and their families, and those with long term serious
substance use disorders, as well as others with mental illness and substance use
disorders in the solicitation of input.
A description of the coordination with other local, state, and federal agencies and
tribes to ensure that services are accessible and available.

B. (30 points – approximately 11 pages) State capacity to support CCBHCs and certification
of CCBHCs for purposes of participating in a demonstration program, using the updated
CCBHC criteria. Reviewers will examine the state’s submission of the CCBHC Criteria
Compliance Checklist 2023 attachment
(https://www.samhsa.gov/sites/default/files/ccbhc-compliance-checklist.pdf). This
compliance checklist includes the updated criteria required for the CCBHCs and their
Designated Collaborating Organizations (DCOs) which together form the CCBHC. For
each of the criteria on the checklist, please indicate the number of clinics in your state
that fall within each of the following categories:
1. Ready to implement
•

The CCHBC fully satisfies all elements under this Program Requirement
Criteria.

2. Mostly ready to implement
•

The CCBHC satisfies almost all elements under this Program Requirement
Criteria although some minor adjustments are currently in process to fully
satisfy. The CCBHC has a plan to come into compliance within the
required timeframe.

3. Ready to implement with remediation
•

The CCBHC satisfies some elements but must make significant
improvements in other elements to fully satisfy this Program Requirement
Criteria. The CCBHC is responsive to implementing the needed changes
and has begun to do so. The CCBHC has a plan to come into compliance
within the required timeframe.

4. Unready to implement
•

The CCBHC has not demonstrated capacity to meet the elements under
this Program Requirement Criteria and will be unable to come into
compliance within the required timeframe.

In addition, please provide the following:
•

•

A description of the state’s current readiness and history implementing the
CCBHC program, including any current CCHBC Expansion grants in the state as
well as the efforts to support the CCBHC Demonstration program; CCBHC
initiatives under Medicaid state plan or waiver; any support of CCBHCs through
other funding sources managed by the State; and the State’s capacity and
infrastructure established to support the CCHBC Demonstration program in areas
such as certification, technical assistance, data systems, and payment.
A description of the selection processes and review procedures that you used to
select and certify clinics as CCBHCs that demonstrates attention to quality of
care, access and availability of services.
A description of the diversity of CCBHCs including geographic area, population
density, underserved areas or other data. Cite documentation, including medically
underserved area (MUA) designations, that at least one CCBHC is located in a
rural and/or underserved area. Include a description of how the state and
CCBHCs will address disparities, including systematic processes that have been
established to ensure under-served/historically marginalized populations,
including Black, Latino, Hispanic, and Indigenous and Native American persons,
Asian Americans and Pacific Islanders, and other persons of color; members of
religious minorities; lesbian, gay, bisexual, transgender, queer, and intersex
(LGBTQI+) persons; persons with disabilities; persons who live in rural areas;
and persons otherwise adversity affected by persistent poverty or inequity, have
access to high-quality healthcare.
A description of how the state has worked with selected CCBHCs to improve the
delivery of high-quality behavioral healthcare, such as support for evidence-based
practices, workforce development, development of interdepartmental
partnerships, recovery-oriented and trauma-informed models of care, and other
related areas as well as a description of plans to continue support CCBHCs in
these areas as a part of the demonstration program.
6

•

•
•

•

A description of how CCBHCs will be working with other community
organizations, including the 988 Suicide & Crisis Lifeline, and state mental health
and substance use crisis response systems.
A description of how the CCBHC needs assessments have been used to identify
behavioral health needs and resources in the service areas of included CCBHCs
across the lifespan, to include the impact the CCBHC needs assessment will have
on staffing, language and culture, services, locations, service hours, and evidencebased practices, while identifying and addressing barriers and increasing access to
healthcare.
A description and justification of the evidence-based practices 5 that the state has
required
For each proposed CCBHC, provide the definition of the CCBHC service area
using recognized geographic boundaries, such as municipal or county borders, zip
codes, or census tracts.
A description of the guidance to CCBHCs regarding the CCBHCs organization
governance that ensures meaningful input by consumers, persons in recovery, and
family members.
A description of any other areas that the state is exercising their discretion to
place additional requirements that go beyond the minimum expectations set in the
CCBHC criteria, using the State Discretion Guidance.
A description of the planned process for bringing additional CCBHCs into the
State CCBHC Demonstration program over time, if the state is planning to add
additional CCBHCs over the course of the 4-year demonstration program (note:
states may describe a process without identifying specific CCBHCs).

C. (10 points – approximately 4 pages) Development of enhanced data collection and
reporting capacity. Please provide the following:
•

•

A description of the ways in which the state and CCBHCs have developed or
enhanced data collection and reporting capacity in support of meeting PPS
requirements, quality reporting requirements, and demonstration evaluation
reporting requirements listed under Criteria Program Requirement 5: Quality and
Other Reporting in the Criteria.
A description of the designed or modified and implemented data collection and
reporting systems-including but not limited to registries or electronic health
record functionality that report on access, quality, scope of services, and costs and
reimbursement for behavioral health services. A description of how the state
assisted CCBHCs with preparing to use data to inform and support continuous
quality improvement processes within CCBHCs, including fidelity to evidencebased practices, and person-centered, and recovery-oriented care during

For more information about evidence-based practices for mental and substance use conditions, please visit the
SAMHSA Evidence-Based Practices Resource Center: https://www.samhsa.gov/resource-search/ebp
5

•

demonstration. A description of how the state plans or has developed processes by
which it can provide timely input to CCBHCs on interim results of statedcollected quality measures.
A description of how the state will work with CCBHCs to ensure that the
CCBHCs are billing for CCBHC services correctly using the federal CCBHC, or
state developed demonstration billing codes, in a way that results in proper
payment of the PPS and captures service level detail of CCBHC services
delivered under the claim.
A description of the format of all data described in this section and when and how
evaluators will be able to access this data.

D. (15 points – approximately 6 pages) Participation in the national evaluation of the
Demonstration Program. Please provide the following:
•

•

A description of the capacity and willingness to assist HHS to access data related
to the cost, quality, and scope of services provided by CCBHCs and the impact of
the demonstration programs on the federal and state costs for a full range of
mental health and substance abuse services (including inpatient, emergency, and
ambulatory services paid for through sources other than the demonstration
program funding).
A summary of discussions with the federal evaluation planning team regarding
the selection of an appropriate comparison group for an assessment of access,
quality, and scope of services available to Medicaid enrollees served by CCBHCs.
The status of requests or planned requests for an Institutional Review Board’s
approval to collect and report on process and outcome data (as applicable and
necessary).

E. (15 points – approximately 6 pages) Project the impact of the state’s participation in the
Demonstration program. Please project the impact of CCBHCs in your state to achieve at
least one of the goals listed below during the four-year demonstration program. Use the
following guidance to develop your narrative.
•

•

Select one or more goals from the four listed below to project the impact of
CCBHCs in your state. Explain the process by which you selected the goal(s) and
why it is important to your state and CCBHC communities. Include a description
of the impact from established State CCBHC efforts, if applicable.
List specific measures, selected from CCBHC Criteria: Appendix B, that will
show the impact on the population served by CCBHCs over the four-year
demonstration program period. 6 Explain how these measures are related to the
goal(s) selected.
Provide baseline data on selected measures from the planning grant period.

CCBHC Criteria - Appendix B: https://www.samhsa.gov/sites/default/files/ccbhc-criteria-2023.pdf

•
•

Describe your plan for data collection, documentation, tracking of outcomes, and
analysis to measure progress in achieving the outcome.
Using the selected measures, project the impact on the target population from
baseline to the completion of the demonstration program and justify your
projections. Include any data that was collected based on State CCBHC efforts
already implemented on the target population, if applicable.
Goal 1. Provide the most complete scope of services required in the CCBHC
Criteria to individuals who are eligible for medical assistance under the state
Medicaid program.
Goal 2. Improve availability of, access to, and participation in, services described
in subsection (a)(2)(D) to individuals eligible for medical assistance under the
State Medicaid program.
Goal 3. Improve availability of, access to, and participation in assisted outpatient
mental health treatment in the state.
Goal 4. Demonstrate the potential to expand available mental health services in a
demonstration area and increase quality of such services without increasing net
federal spending.

Part 3: Prospective Payment System Methodology Description
Using the following format, describe the state’s prospective payment system (PPS) methodology.
This part of the Guidance will be scored up to a total of 20 points and your response may not
exceed 30 pages. Each section of this part of the application corresponds to the same section of
the CCBHC PPS Guidance. Sections 1-5 of this form pertain to fee for service prospective
payment; managed care payment is addressed in section 6.

Section 1: Introduction
Section 223 of the PAMA, requires payment using a PPS for CCBHC services provided by
qualifying clinics and related satellite sites established prior to April 1, 2014. The Centers for
Medicare & Medicaid Services (CMS) offers a state the option of using one of four (4) PPS
payment methodologies. States may select from among the daily Certified Clinic PPS rate (CC
PPS-1), the monthly Certified Clinic PPS rate (CC PPS-2), the daily Certified Clinic PPS rate
that includes special crisis services (CC PPS-3), and the monthly Certified Clinic PPS rate that
includes special crisis services (CC PPS-4). The rate selected by the state must be used
demonstration-wide for payments that are either fee for service (FFS) or made through managed
care payment systems. CMS updated the PPS Technical Guidance in 2023 which outlines details
specific to the available PPS options currently available under the CCBHC demonstration.

Section 2: CCHBC PPS Rate-Setting Methodology Options
CMS offers a state the option of the CC PPS-1, CC PPS-2, CC PPS-3, or CC PPS-4
methodology for use demonstration-wide. The state chooses the following methodology (select
one):
Certified Clinic PPS-1 Methodology (CC PPS-1) (Continue to Section 2.1)
Certified Clinic PPS-2 Methodology (CC PPS-2) (Continue to Section 2.2)
Certified Clinic PPS-3 Methodology (CC PPS-3) (Continue to Section 2.3)
Certified Clinic PPS-4 Methodology (CC PPS-4) (Continue to Section 2.4)
Section 2.1: Certified Clinic PPS-1 Methodology (CC PPS-1)
The CC PPS-1 methodology is implemented as a fixed daily rate that reflects the expected cost
of all CCBHC services provided on any given day to a Medicaid beneficiary. This is a cost
based, per clinic rate that applies uniformly to all services rendered by a CCBHC and qualified
satellite facilities established prior to April 1, 2014. The state has the option of offering Quality
Bonus Payments (QBPs) that are to be paid in addition to the PPS rate to any certified clinic that
achieves on state established thresholds for payment in accordance with Section 3: Quality
Bonus Payments (QBPs) of the updated PPS Guidance.

Section 2.1.a Components of the CC PPS 1 Rate Methodology
Demonstration Year One (DYl) Rate Data
In the box below explain the source(s) of cost and visit data used to determine the DYl rate.
Detail any estimates that the state used to determine allowable cost and the appropriate number
of daily visits to include in the rate calculation. If more space is needed, please attach and
identify the page that pertains to this section.

Annual PPS-1 Rate Updates
The CC PPS-1 rates will be updated between DYs with mandatory rebasing by using
(select one):
The Medicare Economic Index (MEI)
Rebasing CC PPS-1 rate
Interim Payment Methodology for Rebasing
When rebasing PPS rates for an upcoming DY, the PPS rate for the upcoming DY is calculated
by rebasing the prior DY’s PPS rate so the rate calculated for the upcoming DY reflects the prior
DY’s cost experience. As the cost and visit data for the prior DY data will not be available to the
state in time to analyze and rebase the rate prior to the start of the upcoming DY, the state will
need to pay an interim PPS rate until the PPS rate(s) are finalized for that DY. In the box below,
please provide an explanation of the interim payment methodology 7 that your state will use
specifying what interim rate the state will pay providers, when the final PPS rate would be
calculated for that DY, and how the state intends to reconcile claims for that DY to ensure that
all CCBHC service encounters provided in that DY are paid that DY’s rebased PPS rate. If the
state intends to have a different interim payment methodology for the optional annual and
mandatory rebasing timeframes (DY3 and every three years thereafter), please include a
description of both methodologies below. If more space is needed, please attach and identify the
page that pertains to this section.

An interim rate is requested as it is likely that the current DY data will not be available to the state in time to
analyze and rebase the rate for the upcoming DY.

If Section 2.1 is completed, skip Sections 2.2, 2.3, and 2.4 and continue to Section 3.1.
Section 2.2: Certified Clinic PPS-2 Methodology (CC PPS-2)
The CC PPS-2 methodology is implemented as a fixed monthly rate that reflects the expected
cost of all CCBHC visits provided within any given month to a Medicaid beneficiary. This is a
cost-based, per clinic rate that applies uniformly regardless of the number of services rendered
within the month by a CCBHC and qualified satellite facilities established prior to April 1, 2014.
Under this methodology, separate rates are developed for both the base population and if elected
to implement by the state, clinic users with certain conditions, or special populations (SP). In
addition, the CC PPS-2 methodology includes outlier payments that are required to be paid for
costs exceeding state- defined thresholds and the implementation of QBPs in accordance with
Section 3: Quality Bonus Payments of the PPS guidance.

Section 2.2a Components of the CC PPS 2 Rate Methodology
DYl Rate Data
In the box below explain the source(s) of cost and visit data used to determine the DYl rate.
Detail any estimates that the state used to determine allowable cost and the appropriate number
of monthly visits to include in the rate calculation. If more space is needed, please attach and
identify the page that pertains to this section.

Annual PPS-2 Rate Updates
The DYl CC PPS-2 rate(s) will be updated between DYs with mandatory rebasing by using
(select one):
The Medicare Economic Index (MEI)
Rebasing CC PPS-2 rate
Interim Payment Methodology for Rebasing
When rebasing PPS rates for an upcoming DY, the PPS rate for the upcoming DY is calculated
by rebasing the prior DY’s monthly PPS rate so the rate calculated for the upcoming DY reflects
the prior DY’s cost experience. As the cost and visit data for the prior DY data will not be
available to the state in time to analyze and rebase the rate prior to the start of the upcoming DY,
the state will need to pay an interim PPS rate until the PPS rate(s) are finalized for that DY. In
the box below, please provide an explanation of the interim payment methodology 8 that your
state will use specifying what interim rate the state will pay providers, when the final PPS rate
would be calculated for that DY, and how the state intends to reconcile claims for that DY to
ensure that all CCBHC service encounters provided in that DY are paid that DY’s rebased PPS
rate. If the state intends to have a different methodology interim payment methodology for the
optional annual and mandatory rebasing timeframes (DY3 and every three years thereafter),
please include a description of both methodologies below. If more space is needed, please attach
and identify the page that pertains to this section.

PPS-2 Identification of Populations with Certain Conditions, or Special Populations (SP)
Under the PPS-2 Methodology states have the option to develop a monthly PPS rate for
populations with certain conditions, or Special Populations (SP). The state chooses to (select
one):
Implement SPs and develop monthly SP PPS Rate(s) as part of the PPS-2 Methodology
Not implement SPs, therefore no monthly SP PPS Rate(s) will be developed as part of the
PPS-2 Methodology (Continue to Section 2.2a, PPS-2 Outlier Payments)
An interim rate is requested as it is likely that current DY data will not be available to the state in time to analyze
and rebase the rate for the upcoming DY payment.
8

In the box below, identify populations with certain conditions for which separate PPS rates will
be determined by the state and explain the criteria used to identify them. If more space is needed,
please attach and identify the page that pertains to this section. Note: the populations listed below
should match those shown on the sample cost report submitted by the state.

PPS-2 Outlier Payments
Outlier payments are reimbursements to clinics in addition to PPS rates for participant costs that
exceed a state-defined threshold to ensure that clinics are able to meet the costs of serving their
users.
In the box below provide a description of the outlier payment methodology including an
explanation of the threshold for making payment and how much of total allowable cost is set
aside for outlier payment; how often outlier payment is calculated; and, how often certified
clinics receive outlier payment. If more space is needed, please attach and identify the page that
pertains to this section.

If Section 2.2 is completed, skip Sections 2.1, 2.3, and 2.4 and continue to Section 3.2.

Section 2.3: Certified Clinic PPS-3 (CC PPS-3)
The CC PPS-3 methodology is implemented as a fixed daily rate that reflects the expected cost
of all CCBHC services provided on any given day to a Medicaid beneficiary. This is a cost
based, per clinic rate that applies uniformly to all services rendered by a CCBHC and qualified
satellite facilities established prior to April 1, 2014. Under this methodology, separate rates are
developed for both the base population and for at least one of the categories of special crisis
services (SCS). In addition, under this methodology the state has the option of offering Quality
Bonus Payments (QBPs) that are to be paid in addition to the PPS rate to any certified clinic that
achieves on state established thresholds for payment in accordance with Section 3: Quality
Bonus Payments (QBPs) of the updated PPS Guidance.

Section 2.3.a Components of the CC PPS-3 Rate Methodology
Demonstration Year One (DYl) Rate Data
In the box below explain the source(s) of cost and visit data used to determine the DYl rate.
Detail any estimates that the state used to determine allowable cost and the appropriate number
of daily visits to include in the rate calculation. If more space is needed, please attach and
identify the page that pertains to this section.

Annual PPS-3 Rate Updates
The DYl CC PPS-3 rates will be updated between DYs with mandatory rebasing by using
(select one):
The Medicare Economic Index (MEI)
Rebasing CC PPS-3 rates

Interim Payment Methodology for Rebasing
When rebasing PPS-3 rates for an upcoming DY, the PPS rate for the upcoming DY is calculated
by rebasing the prior DY’s PPS rate so the rate calculated for the upcoming DY reflects the prior
DY’s cost experience. As the cost and visit data for the prior DY data will not be available to the
state in time to analyze and rebase the rate prior to the start of the upcoming DY, the state will
need to pay an interim PPS rate until the PPS rate(s) are finalized for that DY. In the box below,
please provide an explanation of the interim payment methodology9 that your state will use
specifying what interim rate the state will pay providers, when the final PPS rate would be
calculated for that DY, and how the state intends to reconcile claims for that DY to ensure that
all CCBHC service encounters provided in that DY are paid that DY’s rebased PPS rate. If the
state intends to have a different methodology interim payment methodology for the optional
annual and mandatory rebasing timeframes (DY3 and every three years thereafter), please
include a description of both methodologies below. If more space is needed, please attach and
identify the page that pertains to this section.

PPS-3 Special Crisis Services (SCS) Rates
Under the PPS-3 Methodology states are required to develop a daily PPS rate for at least one of
the three categories of Special Crisis Services (SCS). The state chooses to implement the
following SCS categories (select at least one):
9813 CCBHC mobile crisis services
Other CCBHC Mobile Crisis services (non- 9813 Mobile Crisis Services)
Crisis stabilization services occurring at the CCBHC

An interim rate is requested as it is likely that the current DY data will not be available to the state in time to
analyze and rebase the rate for the upcoming DY payment.

In the box below, please describe what demonstration services the CCBHC will provide under
each category of SCS service the state intends to implement. If more space is needed, please
attach and identify the page that pertains to this section. Note: the categories listed below should
match those shown on the sample cost report submitted by the state.

If Section 2.3 is completed, skip Sections 2.1, 2.2, and 2.4 and continue to Section 3.1.
Section 2.4: Certified Clinic PPS Alternative (CC PPS-4)
The CC PPS-4 methodology is implemented as a fixed monthly rate that reflects the expected
cost of all CCBHC visits provided within any given month to a Medicaid beneficiary. This is a
cost-based, per clinic rate that applies uniformly regardless of the number of services rendered
within the month by a CCBHC and qualified satellite facilities established prior to April 1, 2014.
Under this methodology, separate rates must be developed for both the base population and at
least one of the categories of special crisis services (SCS). Additionally, states have the option to
elect separate rates developed for clinic users with certain conditions, or special populations
(SP). In addition, the CC PPS-4 methodology requires outlier payments that are paid for costs
exceeding state- defined thresholds and the implementation of QBPs in accordance with Section
3: Quality Bonus Payments of the PPS guidance.

Section 2.4.a Components of the CC PPS-4 Rate Methodology
DYl Rate Data
In the box below explain the source(s) of cost and visit data used to determine the DYl rate.
Detail any estimates that the state used to determine allowable cost and the appropriate number
of monthly visits to include in the rate calculation. If more space is needed, please attach and
identify the page that pertains to this section.

Annual PPS-4 Rate Updates
The DYl CC PPS-4 rates will be updated between DYs with mandatory rebasing by using (select
one):
The Medicare Economic Index (MEI)
Rebasing CC PPS-4 rates
Interim Payment Methodology for Rebasing
When rebasing PPS-4 rates for an upcoming DY, the PPS rate for the upcoming DY is calculated
by rebasing the prior DY’s PPS rate so the rate calculated for the upcoming DY reflects the prior
DY’s cost experience. As the cost and visit data for the prior DY data will not be available to the
state in time to analyze and rebase the rate prior to the start of the upcoming DY, the state will
need to pay an interim PPS rate until the PPS rate(s) are finalized for that DY. In the box below,
please provide an explanation of the interim payment methodology 10 that your state will use
specifying what interim rate the state will pay providers, when the final PPS rate would be
calculated for that DY, and how the state intends to reconcile claims for that DY to ensure that
all CCBHC service encounters provided in that DY are paid that DY’s rebased PPS rate. If the
state intends to have a different methodology interim payment methodology for the optional
annual and mandatory rebasing timeframes (DY3 and every three years thereafter), please
include a description of both methodologies below. If more space is needed, please attach and
identify the page that pertains to this section.

PPS-4 Identification of Populations with Certain Conditions, or Special Populations (SP)
Under the PPS-4 Methodology states have the option to develop a monthly PPS rate for
populations with certain conditions, or Special Populations (SP). The state chooses to (select
one):
Implement SPs and develop monthly SP PPS Rate(s) as part of the PPS-4 Methodology
Not implement SPs, therefore no monthly SP PPS Rate(s) will be developed as part of the
PPS-4 Methodology (Continue to Section 2.4a, PPS-4 Special Crisis Services)
An interim rate is requested as it is likely that current DY data will not be available to the state in time to analyze
and rebase the rate for the upcoming DY payment.
10

PPS-4 Special Crisis Services (SCS) Rates
Under the PPS-4 Methodology states are required to develop a monthly PPS rate for at least one
of the three categories of Special Crisis Services (SCS). The state chooses to implement PPS
rates for the following SCS categories (select at least one):
9813 CCBHC mobile crisis services
Other CCBHC Mobile Crisis services (non- 9813 Mobile Crisis Services)
Crisis stabilization services occurring at the CCBHC
In the box below, please describe what services the CCBHC will provide under each category of
SCS service the state intends to implement. If more space is needed, please attach and identify
the page that pertains to this section. Note: the categories listed below should match those shown
on the sample cost report submitted by the state.

PPS-4 Outlier Payments
Outlier payments are reimbursements to clinics in addition to PPS rates for participant costs that
exceed a state-defined threshold to ensure that clinics are able to meet the costs of serving their
users.

In the box below provide a description of the outlier payment methodology including an
explanation of the threshold for making payment and how much of total allowable cost is set
aside for outlier payment; how often outlier payment is calculated; and, how often certified
clinics receive outlier payment. If more space is needed, please attach and identify the page that
pertains to this section.

If Section 2.3 is completed, skip Sections 2.1, 2.2, and 2.3 and continue to Section 3.2.

Section 3: Quality Bonus Payments (QBPs)
Section 3.1: Optional QBPs (CC PPS-1 and CC PPS-3)
When using the CC PPS-1 or CC PPS-3 methodology, a state may elect to offer a QBP to any
CCBHC that has achieved on the state-defined threshold for a measure in accordance with
Section 3: Quality Bonus Payments, of the PPS guidance. No incentive payment shall be made
solely on the basis of reporting on measures and shall only be paid for CCBHC performance
improvement at or above the measure threshold. The state can make a QBP for optional QBP
quality measures provided in the PPS Guidance and may propose its own additional QBP quality
measures. Any additional state-proposed measure must be approved by CMS.
The state chooses to (select one):
Not offer QBP(s) (Continue to Section 4)
Offer OBP(s)
In the box below provide a list of the quality measures that will be used in addition to the
required QBP measures listed in Section 3 of the PPS guidance. Please note any measure that is
state-defined and provide a full description of the measure. If additional space is needed, please
attach and identify the page that pertains to this section.

In the box below describe the QBP methodology, specifying (1) the state-developed thresholds
that trigger payment, (2) the methodology for calculating the payment, (3) the amount that will
be paid for each measure, and (4) how often the payment is made to CCBHCs. Also provide an
annual estimate of the amount of QBP payment by demonstration year (DY) for all clinics
expected to be certified, including an estimate of the percentage of QBP payment to be made
through the PPS rate. If additional space is needed, please attach and identify the page that
pertains to this section.

In the box below, please specify how the state-developed thresholds were developed in such a
way where QBPs made to providers are reflective of performance improvement, the provision of
a higher quality of care, improvement of beneficiary health, or a reduction in health disparities.
Please also explain how state needs assessments, priorities, and goals were used to determine the
thresholds for the QBP quality measures. If additional space is needed, please attach and identify
the page that pertains to this section.

Section 3.2: Required QBPs (CC PPS-2 and CC PPS-4)
Under the CC PPS 2 and CC PPS-4 methodologies, a state must offer a QBP to any CCBHC that
has achieved the state-defined threshold for a measure in accordance with Section 3: Quality
Bonus Payments, of the PPS Guidance. No incentive payment shall be made solely on the basis
of reporting on measures and shall only be paid for CCBHC performance at or above the
measure threshold. The state can make a QBP for optional QBP quality measures provided in the
PPS guidance and may propose its own additional QBP quality measures. Any additional stateproposed measures must be approved by CMS.
In the box below provide a list of the quality measures that will be used in addition to the
required QBP measures listed in Section 3 of the PPS guidance. Please note any measure that is
state-defined and provide a full description of the measure. If additional space is needed, please
attach and identify the page that pertains to this section.

Section 4: Payment to CCBHCs that are FQHCs, Clinics, or Tribal Facilities
In some instances, a CCBHC may already participate in the Medicaid program as a Federally
Qualified Health Center (FQHC), clinic services provider or Indian Health Service (IHS) facility
that receives payment authorized through the Medicaid state plan. In these instances, the state
should refer to the PPS guidance for how these Medicaid providers would be paid when a clinic
user receives a service authorized under both the state plan and this demonstration.
The state will require each certified clinic on its CCBHC cost report to report whether it is
dually certified as a FQHC, clinic services provider or IHS facility.

Section 5: Cost Reporting and Documentation Requirements
In order to determine CCBHC PPS rates, states must identify allowable costs necessary to
support the provision of services.
Section 5.1: Treatment of Select Costs
CMS provides additional guidance for the state regarding how to treat select costs, including
uncompensated care, telehealth, and interpretation or translation service costs.
The state excludes the cost of uncompensated care from its calculation of the CCBHC PPS
rate(s).

Section 5.2: Cost Report Elements and Data Essentials

Cost Reporting
The state will use the CMS CCBHC cost report and has attached a sample completed
CCBHC Cost Report form plus an explanatory narrative that demonstrates the rate for DY1.
The state will use its own cost report and has attached a sample completed CCBHC Cost
Report form plus an explanatory narrative that demonstrates the rate for DY1 and the cost
report instructions.
The attached state-developed cost report template includes following key elements as specified
in section 4.2 of the PPS guidance:
Provider Information
Direct and Indirect Cost-Identification
Direct and Overhead Cost-Allocations
Number of Visits
Rate Calculations

Section 6: Managed Care Considerations
The statute requires payment of PPS and allows payment to be made through FFS and/or through
managed care delivery systems for demonstration services. If the state chooses to include
CCBHC service coverage in their managed care contracts, CCBHCs must still receive the full
PPS payment.
Section 6.1: Managed Care Capitation CCBHC PPS Rate Methodology
Please check the box if at least some, if not all of the CCBHC services under the
demonstration will be delivered through managed care.
Please check the box to confirm that the PPS methodology selected in Section 2 will apply
to CCBHC demonstration services delivered in both managed care and FFS.
Please check the box if none of the CCBHC services under the demonstration will be
delivered through managed care. (Continue to Section 7)

Section 6.2: Building CCBHC PPS Rates into Managed Care Capitation
CMS offers states the option of using either of the following methodologies for incorporating the
CCBHC rate into the managed care payment methodology (select one):
Fully incorporate the PPS payment into the managed care capitation rate and require the
managed care plans to pay the full PPS.
Explain how the state will provide adequate oversight to ensure CCBHCs receive the actual
PPS rates, including provisions for special populations and outlier payments, as applicable
(PPS-2 and PPS-4). If additional space is needed, please attach and identify the page that
pertains to this section.

OR
Require the managed care plans to pay a rate to the CCBHCs that other providers would
receive for similar services, then use a state supplemental payment (wraparound) to ensure
payment to CCBHCs is equal to the PPS.
Explain how the state will provide adequate oversight related to reconciling managed care
payments with full PPS rates, including provisions for special populations and outlier payments.
If additional space is needed, please attach and identify the page that pertains to this section.

Explain the frequency and timing of the wraparound payment used by the state:

Section 6.3: Managed Care Delivery System Operational Considerations
Strategies for avoiding duplication of payments: There is significant variation of how services
are delivered through Medicaid managed care. Several states contract with PIHPs and PAHPs
that specialize in behavioral health services. Medicaid enrollees may be members of a PIHP or
PAHP and MCO at the same time. As such, a CCBHC may not be aware which managed care
plan is responsible for payment of behavioral health services. Please indicate the contractual
arrangement(s) that will be delivering services under the demonstration:
CCBHC demonstration services will be delivered by multiple managed care plans (MCOs,
PIHPs, PAHPs).
OR:
The state will require all CCBHC services to be delivered under the contract for one
managed care plan.
Describe which managed care plans will be responsible for providing CCBHC services and what
services provided in other managed care plans may duplicate the CCBHC services.

Explain the methodology for removing services that duplicate CCBHC demonstration services
from the managed care plans not responsible for the CCBHC services, how managed care
capitation rates will be changed, the timing/process for determining that the new managed care
rates will be actuarially sound, and how the state will ensure no duplication of expenses. If
additional space is needed, please attach and identify the page that pertains to this section.

If a state chooses not to include all demonstration services under one contractor, define the
delineation of services between contractors. If this delineation will require a change to managed
care capitation rates, explain how rates will be affected, the timing and process for determining
that the new managed care rates will be actuarially sound, and how the state will ensure nonduplication of payments. If additional space is needed, please attach and identify the page that
pertains to this section.

Section 6.4: Data Reporting and Managed Care Contract Requirements
Describe the data reporting polices and processes, including specific data deliverables to be reported
by each entity, collection of data, timing of reporting, and contract language for data reporting. If
additional space is needed, please attach and identify the page that pertains to this section.

Explain how the state will ensure access to CCBHC services from Managed Care Organizations
(MCO), Prepaid Inpatient Health Plans (PIHP), or Prepaid Ambulatory Health Plans (PAHP),
particularly how it will address out-of-network access to CCBHCs. Please also indicate if the
state plans to develop quantitative networks adequacy standards specific to CCBHCs (note: this
is recommended but not required). If additional space is needed, please attach and identify the
page that pertains to this section.

Section 6.5: Identification of Expenditures Eligible for Enhanced Federal Matching
Percentage (FMAP)
Describe the process whereby the state will ensure proper claiming of enhanced FMAP for
CCBHC services by identifying the portion of the capitation payment(s) applicable to the
services/populations that are eligible for the enhanced match. States should reference the SMD-230005 guidance CMS issued in August 2023 on Medicaid managed care claiming methodologies. If
additional space is needed, please attach and identify the page that pertains to this section.

Section 7: Identifying CCBHC Claims and Service Level Encounter Detail
States participating in the CCBHC demonstration must have a mechanism for identifying claims
attributable to the CCBHC demonstration as well as service level detail of the CCBHC services
provided during the encounter. The CMS Alpha Numeric Healthcare Common Procedure Coding
System (HCPCS) File & Code Sets contain dedicated 223 demonstration encounter “T” billing
codes that are for CCBHCs to bill solely for demonstration encounters and a Q2 billing code
modifier that can be used for billing service-level data associated with each demonstration
encounter.
The State will use one of the following mechanisms to identify claims attributable to the CCBHC
demonstration (select one):
T1040 Medicaid certified community behavioral health clinic services, per diem
demonstration billing code
T1041 Medicaid certified community behavioral health clinic services, per month
demonstration billing code
Another state-developed mechanism for identifying CCBHC claims, as described below.

The State will use one of the following mechanisms to identify the service level detail associated
with each demonstration encounter (select one):
Q2 Demonstration procedure/service modifier
Another state-developed mechanism for identifying service level detail associated with each
demonstration encounter, as described in detail below.

Section 8: Funding Questions: Section 223 Behavioral Health Demonstration
The questions below should be answered relative to all payments made to CCBHCs reimbursed
pursuant to Section 223 of P.L. 113-93 Protecting Access to Medicare Act of 20143 and the
methodology described in the state’s application to participate in the demonstration program.
CMS requests the following information about the source(s) of the non-federal share of payment
made for demonstration services.
1. Section 1902(a)(2) stipulates that the lack of adequate funds from local sources will not result
in lowering the amount, duration, scope, or quality of care and services available under the
plan.
a. Describe how the non-federal share of each type of Medicaid payment (e.g., basic PPS
rate, outlier payment and quality bonus payments) is funded.

b. Describe whether the state share is from appropriations from the legislature to the
Medicaid agency, through intergovernmental transfer agreements (IGTs), provider
taxes, or any other mechanism used by the state to provide state share. Note that, if the
appropriation is not to the Medicaid agency, the source of the state share would
necessarily be derived through an IGT. In this case, please also identify the agency to
which the funds are appropriated.

c. If any of the non-federal share of payment is being provided using IGTs, fully describe
the matching arrangement including when the state agency receives the transferred
amounts from the local governmental entity transferring the funds.

d. For any payment funded by IGTs, please provide the following information:
i.
ii.
iii.
iv.
v.

A complete list of the names of entities transferring funds;
The operational nature of the entity (state, county, city, other);
The total amounts transferred o by each entity;
Clarify whether the transferring entity has general taxing authority: and,
Whether the transferring entity received appropriations (identify level of appropriations)

2. Do CCBHC providers receive and retain the total Medicaid expenditures claimed by the state
for demonstration services (includes PPS and quality bonus payments) or is any portion of
the payments returned to the state, local governmental entity, or any other intermediary
organization?
If providers are required to return any portion of payments, provide a full description of the
repayment process. Include in your response a full description of the methodology for the
return of any of the payments, a complete listing of providers that return a portion of their
payments, who they return the funds to (state, local governmental entity, or any other
intermediary organization), the amount or percentage of payments that are returned, and the
disposition and use of the funds once they are returned (e.g., general fund, medical services
account, etc.).

File Type	application/pdf
File Title	Guidance to Planning Grant States to Apply to Participate in the Section 223 CCBHC Demonstration Program
Subject	Fillable Form
File Modified	2024-01-31
File Created	2023-12-11