Criteria for the Demonstration Program to Improve 

Community Mental Health Centers and to Establish 

Certified Community Behavioral Health Clinics

Table of Contents 

Introduction.................................................................................................................... 1

Structure of the Criteria ........................................................................................... 3

Definitions....................... .................................................................................... 3

Program Requirement 1: STAFFING ................................................................................ 9

Program Requirement 2: AVAILABILITY AND ACCESSIBILITY OF SERVICES.........15

Program Requirement 3: CARE COORDINATION ......................................................... 22

Program Requirement 4: SCOPE OF SERVICES .......................................................... 33

Program Requirement 5: QUALITY AND OTHER REPORTING .................................... 53

Program Requirement 6: ORGANIZATIONAL AUTHORITY, GOVERANCE AND 

ACCREDITATION ................................................................................................. 57

References................................................................................................................... 61

UPDATED Appendix A: Quality Measures and Other Reporting Requirements ...... 63
1

Introduction

On April 1, 2014, the Protecting Access to Medicare Act of 2014 (hereinafter “PAMA” or 

“the statute”) was signed into law. Among other things, PAMA requires the 

establishment of demonstration programs to improve community behavioral health 

services, to be funded as part of Medicaid (PAMA, § 223). PAMA specifies criteria for 

certified community behavioral health clinics to participate in demonstration programs. 

These criteria fall into six areas: (1) staffing, (2) availability and accessibility of services, 

(3) care coordination, (4) scope of services, (5) quality and other reporting, and (6) 

organizational authority. The criteria within this document address each of the areas. 

The behavioral health clinics participating in this demonstration program and meeting 

criteria will be known as Certified Community Behavioral Health Clinics (CCBHCs). 

The CCBHCs represent an opportunity for states1 to improve the behavioral health of 

their citizens by: providing community-based mental and substance use disorder 

services; advancing integration of behavioral health with physical health care; 

assimilating and utilizing evidence-based practices on a more consistent basis; and 

promoting improved access to high quality care. Care coordination is the linchpin 

holding these aspects of CCBHC care together and ensuring CCBHC care is, indeed, 

an improvement over existing services. Enhanced federal matching funds made 

available through this demonstration for services delivered to Medicaid beneficiaries 

offer states the opportunity to expand access to care and improve the quality of 

behavioral health services. 

PAMA is clear that, regardless of condition, CCBHCs are to provide services to all who 

seek help, but it is anticipated the CCBHCs will prove particularly valuable for 

individuals with serious mental illness (SMI), those with severe substance use 

disorders, children and adolescents with serious emotional disturbance (SED), and 

those with co-occurring mental, substance use or physical health disorders. Those who 

are most in need of coordinated, integrated quality care will receive it from CCBHCs. 

The statute directs the care provided by CCBHCs be “patient-centered.” It is expected 

CCBHCs will offer care that is person-centered and family-centered in accordance with 

 

1

 The term “State” is defined in the statute (PAMA § 233(e)(4)) as having “the meaning given such term for purposes 

of title XIX of the Social Security Act (42 U.S.C. 1396 et seq.). 
2

the requirements of section 2402(a) of the Affordable Care Act (ACA), trauma-informed, 

and recovery-oriented, and that the integration of physical and behavioral health care 

will serve the “whole person” rather than simply one disconnected aspect of the 

individual. The criteria are infused with these expectations and states are encouraged 

to certify clinics providing care consistent with these principles.

Although the CCBHC demonstration program and Prospective Payment System (PPS) 

are designed to work within the scope of state Medicaid Plans and to apply specifically 

to individuals who are Medicaid enrollees, the statute also requires the CCBHCs not to 

refuse service to any individual on the basis of either ability to pay or place of residence. 

In addition to these requirements for inclusive service, CCBHCs will serve persons for 

whom services are court ordered.2 These conditions, together with the fact that 

improving access to and the quality of health care for the Medicaid population also may 

positively affect the health of others through changes in overall methods of care 

delivery, means the CCBHC demonstration program may have long lasting and 

beneficial effects beyond the realm of Medicaid enrollees. 

These criteria were developed based on a review of selected state Medicaid Plans, 

standards for Federally Qualified Health Centers and Medicaid Health Homes, and 

quality measures currently in use by states. The criteria were refined and finalized 

through a public participatory process that occurred between November 2014 and 

March 2015, and included a National Listening Session, consultation with tribal leaders, 

written public comments, and solicitation for public response on the Substance Abuse 

and Mental Health Services Administration (SAMHSA) website.3 

The criteria are intended to extend quality and to improve outcomes of the behavioral 

health care system within the authorities of state regulations, statutes and state 

Medicaid Plans. These criteria establish a basic level of services at which the CCBHCs 

should, at a minimum, operate. They allow the states flexibility in determining how to 

implement the criteria in a manner best addressing the needs of the population being 

served. The criteria are designed to encourage states and CCBHCs to further develop 

their abilities to offer behavioral health services that comport with current best practices. 

Thus, the criteria set high expectations which are likely to require changes and 

 

2 This program does not extend Medicaid coverage or payment to inmates of correctional institutions. 

3

 Also see guidance issued by CMS regarding the state PPS to be used as part of the demonstration program 

(PAMA, § 223(b)). 
3

adjustments to current service delivery systems. SAMHSA recognizes state behavioral 

health programs vary widely in structure, content, funding and organization, and state 

Medicaid programs also differ widely. Consequently, there will be differences in the 

ease with which states can meet the criteria specified for this program. Although 

SAMHSA, in collaboration with staff in the Centers for Medicare & Medicaid Services 

(CMS) and the Assistant Secretary for Planning and Evaluation (ASPE), plans to select 

states for the demonstration program that can best satisfy the goals of PAMA, it also 

intends to consider carefully the extent to which applicant states are positioned to make 

substantial strides in care, using the demonstration program to improve access and 

quality of care. 

Structure of the Criteria 

Each program requirement corresponds to a section of PAMA, with the statutory 

authority for each program requirement identified at the beginning of the pertinent 

section. Also within the criteria, are “Notes.” In some instances, Notes are 

clarifications of a criterion. In other instances, Notes provide states an opportunity to 

explain why a criterion may not be satisfied. 

Definitions 

Important terms used in these criteria are defined below. SAMHSA recognizes states 

may have existing definitions of the terms included here and these definitions are not 

intended to supplant state definitions to the extent a state definition is more specific or 

encompasses more than the definition used here. 

Agreement: As used in the context of care coordination, an agreement is an 

arrangement between the CCBHC and external entities with which care is 

coordinated. Such an agreement is evidenced by a contract, Memorandum of 

Agreement (MOA), or Memorandum of Understanding (MOU) with the other

entity, or by a letter of support, letter of agreement, or letter of commitment from 

the other entity. The agreement describes the parties’ mutual expectations and 

responsibilities related to care coordination.

Behavioral health: Behavioral health is a general term “used to refer to both mental 

health and substance use” (SAMHSA-HRSA [2015]). 

Care coordination: The Agency for Healthcare Research and Quality (2014) defines 

care coordination as “deliberately organizing consumer care activities and 

sharing information among all of the participants concerned with a consumer’s 

care to achieve safer and more effective care. This means the patient’s needs 

and preferences are known ahead of time and communicated at the right time to 

the right people, and that this information is used to provide safe, appropriate, 
4

and effective care to the patient.” As used here, the term applies to activities by 

CCBHCs that have the purpose of coordinating and managing the care and 

services furnished to each consumer as required by PAMA (including both 

behavioral and physical health care), regardless of whether the care and services 

are provided directly by the CCBHC or through referral or other affiliation with 

care providers and facilities outside the CCBHC. Care coordination is regarded 

as an activity rather than a service. 

Case management: Case management may be defined in many ways and can 

encompass services ranging from basic to intensive. The National Association of 

State Mental Health Program Directors (NASMHPD) defines case management 

as “a range of services provided to assist and support individuals in developing 

their skills to gain access to needed medical, behavioral health, housing, 

employment, social, educational and other services essential to meeting basic 

human services; linkages and training for patient served in the use of basic 

community resources; and monitoring of overall service delivery” (NASMHPD 

[2014]). See also the definition of “targeted case management.”

CCBHC or Clinic: CCBHC and Clinic are used interchangeably to refer to Certified 

Community Behavioral Health Clinics as certified by states in accordance with 

these criteria and with the requirements of PAMA. A CCBHC may offer services 

in different locations. For multi-site organizations, however, only clinics eligible 

pursuant to these criteria and PAMA may be certified as CCBHCs. 

CCBHC directly provides: When the term, “CCBHC directly provides” is used within 

these criteria it means employees or contract employees within the management 

structure and under the direct supervision of the CCBHC deliver the service. 

Consumer: Within this document, the term “consumer” refers to clients, persons 

being treated for or in recovery from mental and/or substance use disorders, 

persons with lived experience, service recipients and patients, all used 

interchangeably to refer to persons of all ages (i.e., children, adolescents, 

transition aged youth, adults, and geriatric populations) for whom health care 

services, including behavioral health services, are provided by CCBHCs. Use of 

the term “patient” is restricted to areas where the statutory or other language is 

being quoted. Elsewhere, the word “consumer” is used. 

Cultural and linguistic competence: Culturally and linguistically appropriate 

services are respectful of and responsive to the health beliefs, practices and 

needs of diverse consumers (Office of Minority Health [2014]). 
5

Designated Collaborating Organization (DCO): A DCO is an entity that is not under 

the direct supervision of the CCBHC but is engaged in a formal relationship with 

the CCBHC and delivers services under the same requirements as the CCBHC. 

Payment for DCO services is included within the scope of the CCBHC PPS, and 

DCO encounters will be treated as CCBHC encounters for purposes of the PPS. 

The CCBHC maintains clinical responsibility for the services provided for CCBHC 

consumers by the DCO. To the extent that services are required that cannot be 

provided by either the CCBHC directly or by a DCO, referrals may be made to 

other providers or entities. The CCBHC retains responsibility for care 

coordination including services to which it refers consumers. Payment for those 

referred services is not through the PPS but is made through traditional 

mechanisms within Medicaid.

Engagement: Engagement includes a set of activities connecting consumers with 

needed services. This involves the process of making sure consumers and 

families are informed about and initiate access with available services and, once 

services are offered or received, individuals and families make active decisions 

to continue receipt of the services provided. Activities such as outreach and 

education can serve the objective of engagement. Conditions such as 

accessibility, provider responsiveness, availability of culturally and linguistically 

competent care, and the provision of quality care, also promote consumer 

engagement.

Family: Families of both adult and child consumers are important components of 

treatment planning, treatment and recovery. Families come in different forms 

and, to the extent possible, the CCBHC should respect the individual consumer’s 

view of what constitutes their family. Families can be organized in a wide variety 

of configurations regardless of social or economic status. Families can include 

biological parents and their partners, adoptive parents and their partners, foster 

parents and their partners, grandparents and their partners, siblings and their 

partners, care givers, friends, and others as defined by the family. 

Family-centered: The Health Resources and Services Administration defines familycentered care, sometimes referred to as “family-focused care,” as “an approach 

to the planning, delivery, and evaluation of health care whose cornerstone is 

active participation between families and professionals. Family-centered care 

recognizes families are the ultimate decision-makers for their children, with 

children gradually taking on more and more of this decision-making themselves.

When care is family-centered, services not only meet the physical, emotional, 

developmental, and social needs of children, but also support the family’s 

relationship with the child’s health care providers and recognize the family’s 
6

customs and values” (Health Resources and Services Administration [2004]). 

More recently, this concept was broadened to explicitly recognize family-centered 

services are both developmentally appropriate and youth guided (American 

Academy of Child & Adolescent Psychiatry [2009]). Family-centered care is 

family-driven and youth-driven. 

Formal relationships: As used in the context of scope of services and the 

relationships between the CCBHC and DCOs, a formal relationship is evidenced 

by a contract, Memorandum of Agreement (MOA), Memorandum of Understanding 

(MOU), or such other formal arrangements describing the parties’ mutual 

expectations and establishing accountability for services to be provided and 

funding to be sought and utilized. This formal relationship does not extend to 

referrals for services outside either the CCBHC or DCO, which are not 

encompassed within the reimbursement provided by the PPS. 

Limited English Proficiency (LEP): LEP includes individuals who do not speak 

English as their primary language or who have a limited ability to read, write, 

speak, or understand English and who may be eligible to receive language 

assistance with respect to the particular service, benefit, or encounter. 

Peer Support Services: Peer support services are services designed and delivered 

by individuals who have experienced a mental or substance use disorder and are 

in recovery. This also includes services designed and delivered by family 

members of those in recovery. 

Peer Support Specialist: A peer provider (e.g., peer support specialist, recovery 

coach) is a person who uses their lived experience of recovery from mental or 

substance use disorders or as a family member of such a person, plus skills 

learned in formal training, to deliver services in behavioral health settings to 

promote recovery and resiliency. In states where Peer Support Services are 

covered through the state Medicaid Plans, the title of “certified peer specialist” 

often is used. SAMHSA recognizes states use different terminology for these 

providers.

Person-centered care: Person-centered care is aligned with the requirements of 

Section 2402(a) of the Patient Protection and Affordable Care Act, as 

implemented by the Department of Health & Human Services Guidance to HHS 

Agencies for Implementing Principles of Section 2403(a) of the Affordable Care 

Act: Standards for Person-Centered Planning and Self-Direction in Home and 

Community-Based Services Programs (Department of Health & Human Services 

[June 6, 2014]). That guidance defines “person-centered planning” as a process 

directed by the person with service needs which identifies recovery goals, 
7

objectives and strategies. If the consumer wishes, this process may include a 

representative whom the person has freely chosen, or who is otherwise 

authorized to make personal or health decisions for the person. Person-centered 

planning also includes family members, legal guardians, friends, caregivers, and 

others whom the person wishes to include. Person-centered planning involves 

the consumer to the maximum extent possible. Person-centered planning also 

involves self- direction, which means the consumer has control over selecting 

and using services and supports, including control over the amount, duration, 

and scope of services and supports, as well as choice of providers (Department 

of Health & Human Services [June 6, 2014]). 

Practitioner or Provider: Any individual (practitioner) or entity (provider) engaged in 

the delivery of health care services and who is legally authorized to do so by the 

state in which the individual or entity delivers the services (42 CFR § 400.203).

Recovery: Recovery is defined as “a process of change through which individuals 

improve their health and wellness, live a self-directed life, and strive to reach 

their full potential.” The 10 guiding principles of recovery are: hope; persondriven; many pathways; holistic; peer support; relational; culture; addresses 

trauma; strengths/responsibility; and respect. Recovery includes: Health 

(abstinence, ”making informed healthy choices that support physical and 

emotional wellbeing”); Home (safe, stable housing); Purpose (“meaningful daily 

activities ... and the independence, income and resources to participate in 

society”); and Community (“relationships and social networks that provide 

support, friendship, love, and hope”) (Substance Abuse and Mental Health 

Services Administration [2012]). 

Recovery-oriented care: Recovery-oriented care is oriented toward promoting and 

sustaining a person's recovery from a behavioral health condition. Care 

providers identify and build upon each individual’s assets, strengths, and areas of 

health and competence to support the person in managing their condition while 

regaining a meaningful, constructive sense of membership in the broader 

community (Substance Abuse and Mental Health Services Administration 

[2015]). 

Shared Decision-Making (SDM): SDM is an approach to care through which 

providers and consumers of health care come together as collaborators in 

determining the course of care. Key characteristics include having the health 

care provider, consumer, and sometimes family members and friends acting 

together, including taking steps in sharing a treatment decision, sharing 
8

information about treatment options, and arriving at consensus regarding 

preferred treatment options (Schauer, Everett, delVecchio, & Anderson [2007]). 

Targeted case management: Targeted case management is case management, as 

defined above, directed at specific groups, which may vary by state. CMS 

defines targeted case management as case management furnished without 

regard to requirements of statewide provision of service or comparability that 

typically apply for Medicaid reimbursement. 42 CFR § 440.169(b). Examples of 

groups that might be targeted for case management are children with serious 

emotional disturbance, adults with serious mental and/or substance use 

disorders, pregnant women who meet risk criteria, individuals with HIV, and such 

other groups as a state might identify as in need of targeted case management. 

See also the definition of “case management.”

Trauma-informed: A trauma-informed approach to care “realizes the widespread 

impact of trauma and understands potential paths for recovery; recognizes the 

signs and symptoms of trauma in clients, families, staff, and others involved in 

the system; and responds by fully integrating knowledge about trauma into 

policies, procedures, and practices, and seeks to actively resist retraumatization.” The six key principles of a trauma-informed approach include: 

safety; trustworthiness and transparency; peer support; collaboration and 

mutuality; empowerment, voice and choice; and cultural, historical and gender 

issues (Substance Abuse and Mental Health Services Administration [2014]).
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Program Requirement 1: STAFFING

Within the bounds of state licensure and certification regulations, CCBHC staffing will 

include Medicaid-enrolled providers who adequately address the needs of the consumer 

population served. Credentialed, certified, and licensed professionals with adequate 

training in person-centered, family-centered, trauma-informed, culturally-competent and 

recovery-oriented care will help ensure this objective is attained. Care meeting these 

standards will further help the CCBHCs achieve integrated and high quality care. 

Authority: Section 223 (a)(2)(A) of PAMA 

The statute requires the published criteria to include criteria with respect to the 

following: 

“Staffing requirements, including criteria that staff have diverse disciplinary 

backgrounds, have necessary State required license and accreditation, and are 

culturally and linguistically trained to serve the needs of the clinic’s patient population.”

Criteria 1.A: General Staffing Requirements 

1.a.1 

As part of the process leading to certification, the state will prepare an 

assessment of the needs of the target consumer population and a staffing 

plan for prospective CCBHCs. The needs assessment will include cultural, 

linguistic and treatment needs. The needs assessment is performed prior to 

certification of the CCBHCs in order to inform staffing and services. After 

certification, the CCBHC will update the needs assessment and the staffing 

plan, including both consumer and family/caregiver input. The needs 

assessment and staffing plan will be updated regularly, but no less 

frequently than every three years. 

1.a.2 

The staff (both clinical and non-clinical) is appropriate for serving the 

consumer population in terms of size and composition and providing the 

types of services the CCBHC is required to and proposes to offer. 

Note: See criteria 4.K relating to required staffing of services for veterans. 
10

Criteria 1.A: General Staffing Requirements 

1.a.3

The Chief Executive Officer (CEO) of the CCBHC maintains a fully staffed 

management team as appropriate for the size and needs of the clinic as 

determined by the current needs assessment and staffing plan. The 

management team will include, at a minimum, a CEO or Executive 

Director/Project Director, and a psychiatrist as Medical Director. The 

Medical Director need not be a full-time employee of the CCBHC. 

Depending on the size of the CCBHC, both positions (CEO/Executive 

Director/Project Director and the Medical Director) may be held by the same 

person. The Medical Director will ensure the medical component of care and 

the integration of behavioral health (including addictions) and primary care 

are facilitated. 

Note: If a CCBHC is unable, after reasonable and consistent efforts, to 

employ or contract with a psychiatrist as Medical Director because of a 

documented behavioral health professional shortage in its vicinity (as 

determined by the Health Resources and Services Administration (HRSA) 

(Health Resources and Services Administration [2015]), psychiatric 

consultation will be obtained on the medical component of care and the 

integration of behavioral health and primary care, and a medically trained 

behavioral health care provider with appropriate education and licensure with 

prescriptive authority in psychopharmacology who can prescribe and 

manage medications independently pursuant to state law will serve as the 

Medical Director. 

1.a.4 The CCBHC maintains liability/malpractice insurance adequate for the 

staffing and scope of services provided. 
11

Criteria 1.B: Licensure and Credentialing of Providers 

1.b.1 

All CCBHC providers who furnish services directly, and any Designated 

Collaborating Organization (DCO) providers that furnish services under 

arrangement with the CCBHC, are legally authorized in accordance with 

federal, state and local laws, and act only within the scope of their respective 

state licenses, certifications, or registrations and in accordance with all 

applicable laws and regulations, including any applicable state Medicaid 

billing regulations or policies. Pursuant to the requirements of the statute 

(PAMA § 223 (a)(2)(A)), CCBHC providers have and maintain all necessary 

state-required licenses, certifications, or other credentialing, with providers 

working toward licensure, and appropriate supervision in accordance with 

applicable state law. 
12

Criteria 1.B: Licensure and Credentialing of Providers

1.b.2

The CCBHC staffing plan meets the requirements of the state behavioral 

health authority and any accreditation standards required by the state, is 

informed by the state’s initial needs assessment, and includes clinical and 

peer staff. In accordance with the staffing plan, the CCBHC maintains a core 

staff comprised of employed and, as needed, contracted staff, as appropriate 

to the needs of CCBHC consumers as stated in consumers’ individual 

treatment plans and as required by program requirements 3 and 4 of these 

criteria. States specify which staff disciplines they will require as part of 

certification but must include a medically trained behavioral health care 

provider, either employed or available through formal arrangement, who can 

prescribe and manage medications independently under state law, including 

buprenorphine and other medications used to treat opioid and alcohol use 

disorders. The CCBHC must have staff, either employed or available through 

formal arrangements, who are credentialed substance abuse specialists. 

Providers must include individuals with expertise in addressing trauma and 

promoting the recovery of children and adolescents with serious emotional 

disturbance (SED) and adults with serious mental illness (SMI) and those with 

substance use disorders. Examples of staff the state might require include a 

combination of the following: (1) psychiatrists (including child, adolescent, and 

geriatric psychiatrists), (2) nurses trained to work with consumers across the 

lifespan, (3) licensed independent clinical social workers, (4) licensed mental 

health counselors, (5) licensed psychologists, (6) licensed marriage and family 

therapists, (7) licensed occupational therapists, (8) staff trained to provide 

case management, (9) peer specialist(s)/recovery coaches, (10) licensed 

addiction counselors, (11) staff trained to provide family support, (12) medical 

assistants, and (13) community health workers. The CCBHC supplements its 

core staff, as necessary given program requirements 3 and 4 and individual 

treatment plans, through arrangements with and referrals to other providers. 

Note: Recognizing professional shortages exist for many behavioral health 

providers: (1) some services may be provided by contract or part-time or as 

needed; (2) in CCBHC organizations comprised of multiple clinics, providers 

may be shared among clinics; and (3) CCBHCs may utilize telehealth/ 

telemedicine and on-line services to alleviate shortages. CCBHCs are not 

precluded by anything in this criterion from utilizing providers working towards 

licensure, provided they are working under the requisite supervision. 
13

1.c.2 

The CCBHC assess the skills and competence of each individual furnishing 

services and, as necessary, provides in-service training and education 

programs. The CCBHC has written policies and procedures describing its 

method(s) of assessing competency and maintains a written accounting of 

the in-service training provided during the previous 12 months. 

1.c.3 The CCBHC documents in the staff personnel records that the training and 

demonstration of competency are successfully completed. 

1.c.4 Individuals providing staff training are qualified as evidenced by their 

education, training and experience.

Criteria 1.C: Cultural Competence and Other Training

1.c.1

The CCBHC has a training plan, for all employed and contract staff, and for 

providers at DCOs who have contact with CCBHC consumers or their 

families, which satisfies and includes requirements of the state behavioral 

health authority and any accreditation standards on training which may be 

required by the state. Training must address cultural competence; personcentered and family-centered, recovery-oriented, evidence-based and 

trauma-informed care; and primary care/behavioral health integration. This 

training, as well as training on the clinic’s continuity plan, occurs at orientation 

and thereafter at reasonable intervals as may be required by the state or 

accrediting agencies. At orientation and annually thereafter, the CCBHC 

provides training about: (1) risk assessment, suicide prevention and suicide 

response; (2) the roles of families and peers; and (3) such other trainings as 

may be required by the state or accrediting agency on an annual basis. If 

necessary, trainings may be provided on-line. 

Cultural competency training addresses diversity within the organization’s 

service population and, to the extent active duty military or veterans are being 

served, must include information related to military culture. Examples of 

cultural competency training and materials include, but are not limited to, 

those available through the website of the US Department of Health & Human 

Services (DHHS), the SAMHSA website through the website of the DHHS, 

Office of Minority Health, or through the website of the DHHS, Health 

Resources and Services Administration. 

Note: See criteria 4.K relating to cultural competency requirements in 

services for veterans.
14

Criteria 1.D: Linguistic Competence

1.d.1

If the CCBHC serves individuals with Limited English Proficiency (LEP) or 

with language-based disabilities, the CCBHC takes reasonable steps to 

provide meaningful access to their services. 

1.d.2

Interpretation/translation service(s) are provided that are appropriate and 

timely for the size/needs of the LEP CCBHC consumer population (e.g., 

bilingual providers, onsite interpreters, language telephone line). To the 

extent interpreters are used, such translation service providers are trained to 

function in a medical and, preferably, a behavioral health setting. 

1.d.3 

Auxiliary aids and services are readily available, Americans With Disabilities 

Act (ADA) compliant, and responsive to the needs of consumers with 

disabilities (e.g., sign language interpreters, teletypewriter (TTY) lines). 

1.d.4 

Documents or messages vital to a consumer’s ability to access CCBHC 

services (for example, registration forms, sliding scale fee discount schedule, 

after-hours coverage, signage) are available for consumers in languages 

common in the community served, taking account of literacy levels and the 

need for alternative formats (for consumers with disabilities). Such materials 

are provided in a timely manner at intake. The requisite languages will be 

informed by the needs assessment prepared prior to certification, and as 

updated. 

1.d.5 

The CCBHC’s policies have explicit provisions for ensuring all employees, 

affiliated providers, and interpreters understand and adhere to confidentiality 

and privacy requirements applicable to the service provider, including but not 

limited to the requirements of Health Insurance Portability and Accountability 

Act (HIPAA) (Pub. L. No. 104-191, 110 Stat. 1936 (1996)), 42 CFR Part 2, 

and other federal and state laws, including patient privacy requirements 

specific to the care of minors. The HIPAA Privacy Rule allows routine – and 

often critical – communications between health care providers and a 

consumer's family and friends, so long as the consumer consents or does not 

object. If a consumer is amenable and has the capacity to make health care 

decisions, health care providers may communicate with a consumer's family 

and friends. 
15

Program Requirement 2: AVAILABILITY 

AND ACCESSIBILITY OF SERVICES

CCBHC will offer services in a manner accessible and available to individuals in their 

community. Significant aspects of accessibility and availability include the need for 

access at times and places convenient for those served, prompt intake and engagement 

in services, access regardless of ability to pay and place of residence, access to 

adequate crisis services, and consumer choice in treatment planning and services. 

Because the emergency department (ED) is often a source of crisis care, CCBHCs 

must have clearly established relationships with local EDs to facilitate care coordination, 

discharge and follow-up, as well as relationships with other sources of crisis care. Use 

of peer, recovery, and clinical supports in the community and increased access through 

the use of telehealth/telemedicine and mobile in-home supports also will further the 

statutory objective of availability and access to services. 

Authority: Section 223 (a)(2)(B) of PAMA 

The statute requires the published criteria to include criteria with respect to the 

following: 

“Availability and accessibility of services, including: crisis management services that 

are available and accessible 24 hours a day, the use of a sliding scale for payment, and 

no rejection for services or limiting of services on the basis of a patient’s ability to pay or 

a place of residence.”
16

Criteria 2.A: General Requirements of Access and Availability 

2.a.1

The CCBHC provides a safe, functional, clean, and welcoming environment, 

for consumers and staff, conducive to the provision of services identified in 

program requirement 4. 

2.a.2

The CCBHC provides outpatient clinical services during times that ensure 

accessibility and meet the needs of the consumer population to be served, 

including some nights and weekend hours. 

2.a.3

The CCBHC provides services at locations that ensure accessibility and meet 

the needs of the consumer population to be served. 

2.a.4

To the extent possible within the state Medicaid program or other funding or 

programs, the CCBHC provides transportation or transportation vouchers for 

consumers. 

2.a.5

To the extent possible within the state Medicaid program and as allowed by 

state law, CCBHCs utilize mobile in-home, telehealth/telemedicine, and online treatment services to ensure consumers have access to all required 

services. 

2.a.6

The CCBHC engages in outreach and engagement activities to assist 

consumers and families to access benefits, and formal or informal services to 

address behavioral health conditions and needs. 

2.a.7

Services are subject to all state standards for the provision of both voluntary 

and court-ordered services. 

2.a.8 CCBHCs have in place a continuity of operations/disaster plan. 
17

Criteria 2.B: Requirements for Timely Access to Services and Initial and 

Comprehensive Evaluation for New Consumers 

2.b.1 

All new consumers requesting or being referred for behavioral health services 

will, at the time of first contact, receive a preliminary screening and risk 

assessment to determine acuity of needs. That screening may occur 

telephonically. The preliminary screening will be followed by: (1) an initial 

evaluation, and (2) a comprehensive person-centered and family-centered 

diagnostic and treatment planning evaluation, with the components of each 

specified in program requirement 4. Each evaluation builds upon what came 

before it. Subject to more stringent state, federal, or applicable accreditation 

standards: 

 If the screening identifies an emergency/crisis need, appropriate action 

is taken immediately, including any necessary subsequent outpatient 

follow-up. 

 If the screening identifies an urgent need, clinical services are 

provided and the initial evaluation completed within one business day 

of the time the request is made. 

 If the screening identifies routine needs, services will be provided and 

the initial evaluation completed within 10 business days. 

 For those presenting with emergency or urgent needs, the initial 

evaluation may be conducted telephonically or by 

telehealth/telemedicine but an in-person evaluation is preferred. If the 

initial evaluation is conducted telephonically, once the emergency is 

resolved the consumer must be seen in person at the next subsequent 

encounter and the initial evaluation reviewed. 

Subject to more stringent state, federal or applicable accreditation standards, 

all new consumers will receive a more comprehensive person-centered and 

family-centered diagnostic and treatment planning evaluation to be 

completed within 60 calendar days of the first request for services. This 

requirement that the comprehensive evaluation be completed within 60 

calendar days does not preclude either the initiation or completion of the 

comprehensive evaluation or the provision of treatment during the 60 day 

period. 

Note: Requirements for these screenings and evaluations are specified in 

criteria 4.D. 
18

Criteria 2.B: Requirements for Timely Access to Services and Initial and 

Comprehensive Evaluation for New Consumers 

2.b.2 

The comprehensive person-centered and family-centered diagnostic and 

treatment planning evaluation is updated by the treatment team, in 

agreement with and endorsed by the consumer and in consultation with the 

primary care provider (if any), when changes in the consumer’s status, 

responses to treatment, or goal achievement have occurred. The 

assessment must be updated no less frequently than every 90 calendar days 

unless the state has established a standard that meets the expectation of 

quality care and that renders this time frame unworkable, or state, federal, or 

applicable accreditation standards are more stringent. 

2.b.3

Outpatient clinical services for established CCBHC consumers seeking an 

appointment for routine needs must be provided within 10 business days of 

the requested date for service, unless the state has established a standard 

that meets the expectation of quality care and that renders this time frame 

unworkable, or state, federal, or applicable accreditation standards are more 

stringent. If an established consumer presents with an emergency/crisis 

need, appropriate action is taken immediately, including any necessary 

subsequent outpatient follow-up. If an established consumer presents with an 

urgent need, clinical services are provided within one business day of the 

time the request is made. 
19

Criteria 2.C: 24/7 Access to Crisis Management Services 

2.c.1 

In accordance with the requirements of program requirement 4, the CCBHC 

provides crisis management services that are available and accessible 24-

hours a day and delivered within three hours. 

2.c.2 

The methods for providing a continuum of crisis prevention, response, and 

postvention services are clearly described in the policies and procedures of 

the CCBHC and are available to the public. 

2.c.3 

Individuals who are served by the CCBHC are educated about crisis 

management services and Psychiatric Advanced Directives and how to 

access crisis services, including suicide or crisis hotlines and warmlines, at 

the time of the initial evaluation. This includes individuals with LEP or 

disabilities (i.e., CCBHC provides instructions on how to access services in 

the appropriate methods, language(s), and literacy levels in accordance with 

program requirement 1). 

2.c.4 

In accordance with the requirements of program requirement 3, CCBHCs 

maintain a working relationship with local EDs. Protocols are established for 

CCBHC staff to address the needs of CCBHC consumers in psychiatric crisis 

who come to those EDs. 

2.c.5 

Protocols, including protocols for the involvement of law enforcement, are in 

place to reduce delays for initiating services during and following a psychiatric 

crisis. 

Note: See criterion 3.c.5 regarding specific care coordination requirements 

related to discharge from hospital or ED following a psychiatric crisis. 

2.c.6 

Following a psychiatric emergency or crisis involving a CCBHC consumer, in 

conjunction with the consumer, the CCBHC creates, maintains, and follows a 

crisis plan to prevent and de-escalate future crisis situations, with the goal of 

preventing future crises for the consumer and their family. 

Note: See criterion 3.a.4 where precautionary crisis planning is addressed. 
20

Criteria 2.D: No Refusal of Services due to Inability to Pay 

2.d.1 

The CCBHC ensures: (1) no individuals are denied behavioral health care 

services, including but not limited to crisis management services, because of 

an individual’s inability to pay for such services (PAMA § 223 (a)(2)(B)), and 

(2) any fees or payments required by the clinic for such services will be 

reduced or waived to enable the clinic to fulfill the assurance described in 

clause (1). 

2.d.2 

The CCBHC has a published sliding fee discount schedule(s) that includes all 

services the CCBHC proposes to offer pursuant to these criteria. Such fee 

schedule will be included on the CCBHC website, posted in the CCBHC 

waiting room and readily accessible to consumers and families. The sliding 

fee discount schedule is communicated in languages/formats appropriate for 

individuals seeking services who have LEP or disabilities. 

2.d.3 

The fee schedules, to the extent relevant, conform to state statutory or 

administrative requirements or to federal statutory or administrative 

requirements that may be applicable to existing clinics; absent applicable 

state or federal requirements, the schedule is based on locally prevailing 

rates or charges and includes reasonable costs of operation. 

2.d.4 

The CCBHC has written policies and procedures describing eligibility for and 

implementation of the sliding fee discount schedule. Those policies are 

applied equally to all individuals seeking services. 
21

Criteria 2.E: Provision of Services Regardless of Residence 

2.e.1 

The CCBHC ensures no individual is denied behavioral health care services, 

including but not limited to crisis management services, because of place of 

residence or homelessness or lack of a permanent address. 

2.e.2 

CCBHCs have protocols addressing the needs of consumers who do not live 

close to a CCBHC or within the CCBHC catchment area as established by 

the state. CCBHCs are responsible for providing, at a minimum, crisis 

response, evaluation, and stabilization services regardless of place of 

residence. The required protocols should address management of the 

individual’s on-going treatment needs beyond that. Protocols may provide for 

agreements with clinics in other localities, allowing CCBHCs to refer and track 

consumers seeking non-crisis services to the CCBHC or other clinic serving 

the consumer’s county of residence. For distant consumers within the 

CCBHC’s catchment area, CCBHCs should consider use of 

telehealth/telemedicine to the extent practicable. In no circumstances (and in 

accordance with PAMA § 223 (a)(2)(B)), may any consumer be refused 

services because of place of residence. 
22

Program Requirement 3: CARE 

COORDINATION 

Care coordination is the linchpin of the CCBHC program. The Agency for Healthcare 

Research and Quality (2014) defines care coordination as involving “deliberately 

organizing patient care activities and sharing information among all of the participants 

concerned with a patient’s care to achieve safer and more effective care. This means 

the patient’s needs and preferences are known ahead of time and communicated at the 

right time to the right people, and this information is used to provide safe, appropriate, 

and effective care to the patient.” CCBHCs should be guided by this definition as they 

provide integrated and coordinated care to address all aspects of a person’s health. 

Person-centered and family-centered care is aligned with the requirements of Section 

2402(a) of the Patient Protection and Affordable Care Act, as implemented by the 

Department of Health & Human Services Guidance to HHS Agencies for Implementing 

Principles of Section 2403(a) of the Affordable Care Act: Standards for PersonCentered Planning and Self-Direction in Home and Community-Based Services 

Programs (Department of Health & Human Services [June 6, 2014]). Person-centered 

and family-centered care considers the consumer’s choice in care services provided, as 

well as the physical, behavioral health, and social service needs of each individual as 

these factors influence the well-being of the whole person. Whether services are 

provided directly by CCBHC staff or through collaboration with medical or other service 

providers in the community, adequate communication and collaboration between 

providers are essential to best address the consumer’s needs and preferences. 
23

Authority: Section 223 (a)(2)(C) of PAMA 

The statute requires the published criteria to include criteria with respect to the 

following: 

“Care coordination, including requirements to coordinate care across settings and 

providers to ensure seamless transitions for patients across the full spectrum of health 

services, including acute, chronic, and behavioral health needs. Care coordination 

requirements shall include partnerships or formal contracts with the following: 

(i) Federally-qualified health centers (and as applicable, rural health clinics) to 

provide Federally-qualified health center services (and as applicable, rural 

health clinic services) to the extent such services are not provided directly 

through the certified community behavioral health clinic. 

(ii) Inpatient psychiatric facilities and substance use detoxification, postdetoxification step-down services, and residential programs. 

(iii) Other community or regional services, supports, and providers, including 

schools, child welfare agencies, and juvenile and criminal justice agencies and 

facilities, Indian Health Service youth regional treatment centers, State licensed 

and nationally accredited child placing agencies for therapeutic foster care 

service, and other social and human services. 

(iv) Department of Veterans Affairs medical centers, independent outpatient clinics, 

drop-in centers, and other facilities of the Department as defined in section 

1801 of title 38, United States Code. 

(v) Inpatient acute care hospitals and hospital outpatient clinics.”
24

Criteria 3.A: General Requirements of Care Coordination 

3.a.1 

Based on a person and family-centered plan of care aligned with the 

requirements of Section 2402(a) of the ACA and aligned with state 

regulations and consistent with best practices, the CCBHC coordinates care 

across the spectrum of health services, including access to high-quality 

physical health (both acute and chronic) and behavioral health care, as well 

as social services, housing, educational systems, and employment 

opportunities as necessary to facilitate wellness and recovery of the whole 

person. 

Note: See criteria 4.K relating to care coordination requirements for veterans. 

3.a.2 

The CCBHC maintains the necessary documentation to satisfy the 

requirements of HIPAA (Pub. L. No. 104-191, 110 Stat. 1936 (1996)), 42 

CFR Part 2, and other federal and state privacy laws, including patient 

privacy requirements specific to the care of minors. The HIPAA Privacy Rule 

allows routine – and often critical – communications between health care 

providers and a consumer's family and friends. Health care providers may 

always listen to a consumer’s family and friends. If a consumer consents and 

has the capacity to make health care decisions, health care providers may 

communicate protected health care information to a consumer's family and 

friends. Given this, the CCBHC ensures consumers’ preferences, and those 

of families of children and youth and families of adults, for shared information 

are adequately documented in clinical records, consistent with the philosophy 

of person and family-centered care. Necessary consent for release of 

information is obtained from CCBHC consumers for all care coordination 

relationships. If CCBHCs are unable, after reasonable attempts, to obtain 

consent for any care coordination activity specified in program requirement 3, 

such attempts must be documented and revisited periodically. 

3.a.3 

Consistent with requirements of privacy, confidentiality, and consumer 

preference and need, the CCBHC assists consumers and families of children 

and youth, referred to external providers or resources, in obtaining an 

appointment and confirms the appointment was kept. 
25

Criteria 3.A: General Requirements of Care Coordination 

3.a.4 

Care coordination activities are carried out in keeping with the consumer’s 

preferences and needs for care and, to the extent possible and in accordance 

with the consumer’s expressed preferences, with the consumer’s 

family/caregiver and other supports identified by the consumer. So as to 

ascertain in advance the consumer’s preferences in the event of psychiatric 

or substance use crisis, CCBHCs develop a crisis plan with each consumer. 

Examples of crisis plans may include a Psychiatric Advanced Directive or 

Wellness Recovery Action Plan. 

3.a.5 

Appropriate care coordination requires the CCBHC to make and document 

reasonable attempts to determine any medications prescribed by other 

providers for CCBHC consumers and, upon appropriate consent to release of 

information, to provide such information to other providers not affiliated with 

the CCBHC to the extent necessary for safe and quality care. 

3.a.6 

Nothing about a CCBHC’s agreements for care coordination should limit a 

consumer’s freedom to choose their provider with the CCBHC or its DCOs. 

Criteria 3.B: Care Coordination and Other Health Information Systems 

3.b.1 

The CCBHC establishes or maintains a health information technology (IT) 

system that includes, but is not limited to, electronic health records. The 

health IT system has the capability to capture structured information in 

consumer records (including demographic information, diagnoses, and 

medication lists), provide clinical decision support, and electronically transmit 

prescriptions to the pharmacy. To the extent possible, the CCBHC will use 

the health IT system to report on data and quality measures as required by 

program requirement 5. 

3.b.2 

The CCBHC uses its existing or newly established health IT system to 

conduct activities such as population health management, quality 

improvement, reducing disparities, and for research and outreach. 
26

Criteria 3.B: Care Coordination and Other Health Information Systems 

3.b.3 

If the CCBHC is establishing a health IT system, the system will have the 

capability to capture structured information in the health IT system (including 

demographic information, problem lists, and medication lists). CCBHCs 

establishing a health IT system will adopt a product certified to meet 

requirements in 3.b.1, to send and receive the full common data set for all 

summary of care records and be certified to support capabilities including 

transitions of care and privacy and security. CCBHCs establishing health IT 

systems will adopt a health IT system that is certified to meet the “Patient List 

Creation” criterion (45 CFR §170.314(a)(14)) established by the Office of the 

National Coordinator (ONC)4for ONC’s Health IT Certification Program. 

3.b.4 

The CCBHC will work with DCOs to ensure all steps are taken, including 

obtaining consumer consent, to comply with privacy and confidentiality 

requirements, including but not limited to those of HIPAA (Pub. L. No. 104-

191, 110 Stat. 1936 (1996)), 42 CFR Part 2, and other federal and state laws, 

including patient privacy requirements specific to the care of minors.

3.b.5 

Whether a CCBHC has an existing health IT system or is establishing a new 

health IT system, the CCBHC will develop a plan to be produced within the 

two-year demonstration program time frame to focus on ways to improve 

care coordination between the CCBHC and all DCOs using a health IT 

system. This plan shall include information on how the CCBHC can support 

electronic health information exchange to improve care transition to and from 

the CCBHC using the health IT system they have in place or are 

implementing for transitions of care. 

 

4

 See Table 1 and Table 3 respectively in Certification Guidance for EHR Technology Developers Serving Health 

Care Providers Ineligible for Medicare and Medicaid EHR Incentive Payments, which lists specific criteria related to 

transitions of care and privacy and security. 
27

Criteria 3.C: Care Coordination Agreements

3.c.1

The CCBHC has an agreement establishing care coordination expectations 

with Federally-Qualified Health Centers (FQHCs) (and, as applicable, Rural 

Health Clinics [RHCs]) to provide health care services, to the extent the 

services are not provided directly through the CCBHC. For consumers who 

are served by other primary care providers, including but not limited to FQHC 

Look-Alikes and Community Health Centers, the CCBHC has established 

protocols to ensure adequate care coordination. 

Note: If an agreement cannot be established with a FQHC or, as applicable, 

an RHC (e.g., a provider does not exist in their service area), or cannot be 

established within the time frame of the demonstration project, justification is 

provided to the certifying body and contingency plans are established with 

other providers offering similar services (e.g., primary care, preventive 

services, other medical care services). 

Note: CCBHCs are expected to work toward formal contracts with entities 

with which they coordinate care if they are not established at the beginning of 

the demonstration project. 
28

Criteria 3.C: Care Coordination Agreements

3.c.2

The CCBHC has an agreement establishing care coordination expectations 

with programs that can provide inpatient psychiatric treatment, with 

ambulatory and medical detoxification, post-detoxification step-down 

services, and residential programs to provide those services for CCBHC 

consumers. The CCHBC is able to track when consumers are admitted to 

facilities providing the services listed above, as well as when they are 

discharged, unless there is a formal transfer of care to a non-CCBHC entity. 

The CCBHC has established protocols and procedures for transitioning 

individuals from EDs, inpatient psychiatric, detoxification, and residential 

settings to a safe community setting. This includes transfer of medical 

records of services received (e.g., prescriptions), active follow-up after 

discharge and, as appropriate, a plan for suicide prevention and safety, and 

provision for peer services. 

Note: For these services, if an agreement cannot be established, or cannot 

be established within the time frame of the demonstration project, justification 

is provided and contingency plans are developed and the state will make a 

determination whether the contingency plans are sufficient or require further 

efforts. 
29

Criteria 3.C: Care Coordination Agreements

3.c.3

The CCBHC has an agreement establishing care coordination expectations 

with a variety of community or regional services, supports, and providers. 

Services and supports to collaborate with which are identified by statute 

include: 

 Schools; 

 Child welfare agencies; 

 Juvenile and criminal justice agencies and facilities (including drug, 

mental health, veterans and other specialty courts); 

 Indian Health Service youth regional treatment centers; 

 State licensed and nationally accredited child placing agencies for 

therapeutic foster care service; and

 Other social and human services. 

The CCBHC has, to the extent necessary given the population served and 

the needs of individual consumers, an agreement with such other community 

or regional services, supports, and providers as may be necessary, such as 

the following:

 Specialty providers of medications for treatment of opioid and alcohol 

dependence; 

 Suicide/crisis hotlines and warmlines; 

 Indian Health Service or other tribal programs; 

 Homeless shelters; 

 Housing agencies; 

 Employment services systems; 

 Services for older adults, such as Aging and Disability Resource 

Centers; and

 Other social and human services (e.g., domestic violence centers, 

pastoral services, grief counseling, Affordable Care Act navigators, 

food and transportation programs). 

Note: For these services, if an agreement cannot be established, or cannot 

be established within the time frame of the demonstration project, justification 

is provided and contingency plans are developed and the state will make a 

determination whether the contingency plans are sufficient or require further 

efforts. 
30

Criteria 3.C: Care Coordination Agreements

3.c.4

The CCBHC has an agreement establishing care coordination expectations 

with the nearest Department of Veterans Affairs' medical center, independent 

clinic, drop-in center, or other facility of the Department. To the extent 

multiple Department facilities of different types are located nearby, the 

CCBHC should explore care coordination agreements with facilities of each 

type. 

Note: For these services, if an agreement cannot be established, or cannot 

be established within the time frame of the demonstration project, justification 

is provided and contingency plans are developed and the state will make a 

determination whether the contingency plans are sufficient or require further 

efforts. 
31

Criteria 3.C: Care Coordination Agreements

3.c.5

The CCBHC has an agreement establishing care coordination expectations 

with inpatient acute-care hospitals, including emergency departments, 

hospital outpatient clinics, urgent care centers, residential crisis settings, 

medical detoxification inpatient facilities and ambulatory detoxification 

providers, in the area served by the CCBHC, to address the needs of CCBHC 

consumers. This includes procedures and services, such as peer bridgers, to 

help transition individuals from the ED or hospital to CCBHC care and 

shortened time lag between assessment and treatment. The agreement is 

such that the CCBHC can track when their consumers are admitted to 

facilities providing the services listed above, as well as when they are 

discharged, unless there is a formal transfer of care to another entity. The 

agreement also provides for transfer of medical records of services received 

(e.g., prescriptions) and active follow-up after discharge. 

The CCBHC will make and document reasonable attempts to contact all 

CCBHC consumers who are discharged from these settings within 24 hours 

of discharge. For all CCBHC consumers being discharged from such 

facilities who presented to the facilities as a potential suicide risk, the care 

coordination agreement between these facilities and the CCBHC includes a 

requirement to coordinate consent and follow-up services with the consumer 

within 24 hours of discharge, and continues until the individual is linked to 

services or assessed to be no longer at risk. 

Note: For these services, if an agreement cannot be established, or cannot 

be established within the time frame of the demonstration project, justification 

is provided and contingency plans are developed and the state will make a 

determination whether the contingency plans are sufficient or require further 

efforts. 
32

Criteria 3.D: Treatment Team, Treatment Planning and Care Coordination 

Activities 

3.d.1 

The CCBHC treatment team includes the consumer, the family/caregiver of 

child consumers, the adult consumer’s family to the extent the consumer 

does not object, and any other person the consumer chooses. All treatment 

planning and care coordination activities are person-centered and familycentered and aligned with the requirements of Section 2402(a) of the 

Affordable Care Act. All treatment planning and care coordination activities 

are subject to HIPAA (Pub. L. No. 104-191, 110 Stat. 1936 (1996)), 42 CFR 

Part 2, and other federal and state laws, including patient privacy 

requirements specific to the care of minors. The HIPAA Privacy Rule does 

not cut off all communication between health care professionals and the 

families and friends of consumers. As long as the consumer consents, 

health care professionals covered by HIPAA may provide information to a 

consumer’s family, friends, or anyone else identified by a consumer as 

involved in their care. 

3.d.2 

As appropriate for the individual’s needs, the CCBHC designates an 

interdisciplinary treatment team that is responsible, with the consumer or 

family/caregiver, for directing, coordinating, and managing care and services 

for the consumer. The interdisciplinary team is composed of individuals who 

work together to coordinate the medical, psychosocial, emotional, 

therapeutic, and recovery support needs of CCBHC consumers, including, as 

appropriate, traditional approaches to care for consumers who may be 

American Indian or Alaska Native. 

Note: See criteria 4.K relating to required treatment planning services for 

veterans.

3.d.3 

The CCBHC coordinates care and services provided by DCOs in accordance 

with the current treatment plan. 

Note: See program requirement 4 related to scope of service and personcentered and family-centered treatment planning. 
33

Program Requirement 4: SCOPE OF 

SERVICES

Person-centered care is care aligned with the requirements of Section 2402(a) of the 

Affordable Care Act, and is care in which the consumer is actively involved and has the 

ability to self-direct services received, having maximum choice and control over their 

services, “including the amount, duration, and scope of services and supports as well as 

choice of provider(s)” (Department of Health & Human Services [June 6, 2014]). 

CCBHCs are required by PAMA to provide directly, or provide through referral or formal 

relationships with other providers, a broad array of services to meet the needs of the 

population served and to do so in a person-centered and family-centered manner. 

These criteria establish the concept of DCOs with whom the CCBHC will have formal 

relationships to provide, in conjunction with the CCBHC, many of the requisite services. 

Even if, however, a DCO supplies some aspect of required services, the CCBHC is still 

regarded as providing the service and is clinically responsible for the services provided. 

Although the statute lists minimum requirements that will need to be met, states also will 

have flexibility to shape the scope of services within the required areas to be aligned 

with their state Medicaid Plans and other state regulations. There is no requirement for 

the state to amend its Medicaid state plan for any CCBHC service provided by a 

certified clinic through this demonstration program. This applies to services currently 

authorized in the Medicaid state plan and to additional services made available through 

this demonstration. The intention and expectation is that states will establish scope of 

service requirements which encourage CCBHCs to expand the availability of highquality integrated person-centered and family-centered care as envisioned by the 

statute, and to ensure the continual integration of new evidence-based practices. 
34

Authority: Section 223 (a)(2)(D) of PAMA 

The statute requires the published criteria to include criteria with respect to the 

following: 

“Provision (in a manner reflecting person-centered care) of the following services which, 

if not available directly through the certified community behavioral health clinic, are 

provided or referred through formal relationships with other providers: 

 (i) Crisis mental health services, including 24-hour mobile crisis teams, 

emergency crisis intervention services, and crisis stabilization. 

(ii) Screening, assessment, and diagnosis, including risk assessment. 

(iii) Patient-centered treatment planning or similar processes, including risk 

assessment and crisis planning. 

(iv) Outpatient mental health and substance use services. 

(v) Outpatient clinic primary care screening and monitoring of key health 

indicators and health risk. 

 (vi) Targeted case management. 

(vii) Psychiatric rehabilitation services. 

(viii) Peer support and counselor services and family supports. 

(ix) 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.”
35

Criteria 4.A: General Service Provisions 

4.a.1 

CCBHCs are responsible for the provision of all care specified in PAMA, 

including, as more explicitly provided and more clearly defined below in 

criteria 4.B through 4.K, crisis services; screening, assessment and 

diagnosis; person-centered treatment planning; outpatient behavioral health 

services; outpatient primary care screening and monitoring; targeted case 

management; psychiatric rehabilitation; peer and family supports; and 

intensive community-based outpatient behavioral health care for members of 

the US Armed Forces and veterans. As provided in criteria 4.B through 4.K, 

many of these services may be provided either directly by the CCBHC or 

through formal relationships with other providers that are DCOs. Whether 

directly supplied by the CCBHC or by a DCO, the CCBHC is ultimately 

clinically responsible for all care provided. The decision as to the scope of 

services to be provided directly by the CCBHC, as determined by the state 

and clinics as part of certification, reflects the CCBHC’s responsibility and 

accountability for the clinical care of the consumers. Despite this flexibility, it 

is expected CCBHCs will be designed so most services are provided by the 

CCBHC rather than by DCOs, as this will enhance the ability of the CCBHC 

to coordinate services. 

Note: See CMS PPS guidance regarding payment. 

4.a.2 

The CCBHC ensures all CCBHC services, if not available directly through the 

CCBHC, are provided through a DCO, consistent with the consumer’s 

freedom to choose providers within the CCBHC and its DCOs. This 

requirement does not preclude the use of referrals outside the CCBHC or 

DCO if a needed specialty service is unavailable through the CCBHC or DCO 

entities. 

4.a.3 

With regard to either CCBHC or DCO services, consumers will have access 

to the CCBHC’s existing grievance procedures, which must satisfy the 

minimum requirements of Medicaid and other grievance requirements such 

as those that may be mandated by relevant accrediting entities. 

4.a.4 

DCO-provided services for CCBHC consumers must meet the same quality 

standards as those provided by the CCBHC. 

4.a.5 

The entities with which the CCBHC coordinates care and all DCOs, taken in 

conjunction with the CCBHC itself, satisfy the mandatory aspects of these 

criteria. 
36

Criteria 4.B: Requirement of Person-Centered and Family-Centered Care 

4.b.1 

The CCBHC ensures all CCBHC services, including those supplied by its 

DCOs, are provided in a manner aligned with the requirements of Section 

2402(a) of the Affordable Care Act, reflecting person and family-centered, 

recovery-oriented care, being respectful of the individual consumer’s needs, 

preferences, and values, and ensuring both consumer involvement and selfdirection of services received. Services for children and youth are familycentered, youth-guided, and developmentally appropriate. 

Note: See program requirement 3 regarding coordination of services and 

treatment planning. See criteria 4.K relating specifically to requirements for 

services for veterans. 

4.b.2 

Person-centered and family-centered care includes care which recognizes 

the particular cultural and other needs of the individual. This includes but is 

not limited to services for consumers who are American Indian or Alaska 

Native (AI/AN), for whom access to traditional approaches or medicines may 

be part of CCBHC services. For consumers who are AI/AN, these services 

may be provided either directly or by formal arrangement with tribal providers. 
37

Criteria 4.C: Crisis Behavioral Health Services 

4.c.1 

Unless there is an existing state-sanctioned, certified, or licensed system or 

network for the provision of crisis behavioral health services that dictates 

otherwise, the CCBHC will directly provide robust and timely crisis behavioral 

health services. Whether provided directly by the CCBHC or by a statesanctioned alternative acting as a DCO, available services must include the 

following: 

 24 hour mobile crisis teams, 

 Emergency crisis intervention services, and 

 Crisis stabilization. 

PAMA requires provision of these three crisis behavioral health services. As 

part of the certification process, the states will clearly define each term as 

they are using it but services provided must include suicide crisis response 

and services capable of addressing crises related to substance abuse and 

intoxication, including ambulatory and medical detoxification. States may 

elect to require the employment of peers on crisis teams. CCBHCs will have 

an established protocol specifying the role of law enforcement during the 

provision of crisis services. 

Note: See program requirement 2 related to crisis prevention, response and 

postvention services and criterion 3.c.5 regarding coordination of services 

and treatment planning, including after discharge from a hospital or ED 

following a psychiatric crisis. 
38

Criteria 4.D: Screening, Assessment, and Diagnosis 

4.d.1 

The CCBHC directly provides screening, assessment, and diagnosis, 

including risk assessment, for behavioral health conditions. In the event 

specialized services outside the expertise of the CCBHC are required for 

purposes of screening, assessment or diagnosis (e.g., neurological testing, 

developmental testing and assessment, eating disorders), the CCBHC 

provides or refers them through formal relationships with other providers, or 

where necessary and appropriate, through use of telehealth/telemedicine 

services. 

Note: See program requirement 3 regarding coordination of services and 

treatment planning. 

4.d.2 

Screening, assessment, and diagnosis are conducted in a time frame 

responsive to the individual consumer’s needs and are of sufficient scope to 

assess the need for all services required to be provided by CCBHCs. 

4.d.3 

The initial evaluation (including information gathered as part of the preliminary 

screening and risk assessment), as required in program requirement 2,

includes, at a minimum, (1) preliminary diagnoses; (2) the source of referral; 

(3) the reason for seeking care, as stated by the consumer or other 

individuals who are significantly involved; (4) identification of the consumer’s 

immediate clinical care needs related to the diagnosis for mental and 

substance use disorders; (5) a list of current prescriptions and over-thecounter medications, as well as other substances the consumer may be 

taking; (6) an assessment of whether the consumer is a risk to self or to 

others, including suicide risk factors; (7) an assessment of whether the 

consumer has other concerns for their safety; (8) assessment of need for 

medical care (with referral and follow-up as required); and (9) a determination 

of whether the person presently is or ever has been a member of the U.S. 

Armed Services. As needed, releases of information are obtained. 
39

Criteria 4.D: Screening, Assessment, and Diagnosis 

4.d.4 

As required in program requirement 2, a comprehensive person-centered and 

family-centered diagnostic and treatment planning evaluation is completed 

within 60 days by licensed behavioral health professionals who, in 

conjunction with the consumer, are members of the treatment team, 

performing within their state’s scope of practice. Information gathered as part 

of the preliminary screening and initial evaluation may be considered a part of 

the comprehensive evaluation. This requirement that the comprehensive 

evaluation be completed within 60 calendar days does not preclude either the 

initiation or completion of the comprehensive evaluation or the provision of 

treatment during the intervening 60 day period. 
40

Criteria 4.D: Screening, Assessment, and Diagnosis 

4.d.5 

Although a comprehensive diagnostic and treatment planning evaluation is 

required for all CCBHC consumers, the extent of the evaluation will depend 

on the individual consumer and on existing state, federal, or applicable 

accreditation standards. As part of certification, states will establish the 

requirements for these evaluations; factors states should consider requiring 

include: (1) reasons for seeking services at the CCBHC, including information 

regarding onset of symptoms, severity of symptoms, and circumstances 

leading to the consumer’s presentation to the CCBHC; (2) a psychosocial 

evaluation including housing, vocational and educational status, 

family/caregiver and social support, legal issues, and insurance status; (3) 

behavioral health history (including trauma history and previous therapeutic 

interventions and hospitalizations); (3) a diagnostic assessment, including 

current mental status, mental health (including depression screening) and 

substance use disorders (including tobacco, alcohol, and other drugs); (4) 

assessment of imminent risk (including suicide risk, danger to self or others, 

urgent or critical medical conditions, other immediate risks including threats 

from another person); (5) basic competency/cognitive impairment screening 

(including the consumer’s ability to understand and participate in their own 

care); (6) a drug profile including the consumer’s prescriptions, over-thecounter medications, herbal remedies, and other treatments or substances 

that could affect drug therapy, as well as information on drug allergies; (7) a 

description of attitudes and behaviors, including cultural and environmental 

factors, that may affect the consumer’s treatment plan; (8) the consumer’s 

strengths, goals, and other factors to be considered in recovery planning; (9)

pregnancy and parenting status; (10) assessment of need for other services 

required by the statute (i.e., peer and family/caregiver support services, 

targeted case management, psychiatric rehabilitation services, LEP or 

linguistic services); (11) assessment of the social service needs of the 

consumer, with necessary referrals made to social services and, for pediatric 

consumers, to child welfare agencies as appropriate; and (12) depending on 

whether the CCBHC directly provides primary care screening and monitoring 

of key health indicators and health risk pursuant to criteria 4.G, either: (a) an 

assessment of need for a physical exam or further evaluation by appropriate 

health care professionals, including the consumer’s primary care provider 

(with appropriate referral and follow-up), or (b) a basic physical assessment 

as required by criteria 4.G. All remaining necessary releases of information 

are obtained by this point. 
41

Criteria 4.D: Screening, Assessment, and Diagnosis 

4.d.6 

Screening and assessment by the CCBHC related to behavioral health 

include those for which the CCBHC will be accountable pursuant to program 

requirement 5 and Appendix A of these criteria. The CCBHC should not take 

non-inclusion of a specific metric in Appendix A as a reason not to provide 

clinically indicated behavioral health screening or assessment and the state 

may elect to require specific other screening and monitoring to be provided by 

the CCBHCs beyond those listed in criterion 4.d.5 or Appendix A. 

4.d.7 The CCBHC uses standardized and validated screening and assessment 

tools and, where appropriate, brief motivational interviewing techniques. 

4.d.8 

The CCBHC uses culturally and linguistically appropriate screening tools, and 

tools/approaches that accommodate disabilities (e.g., hearing disability, 

cognitive limitations), when appropriate. 

4.d.9 

If screening identifies unsafe substance use including problematic alcohol or 

other substance use, the CCBHC conducts a brief intervention and the 

consumer is provided or referred for a full assessment and treatment, if 

applicable. 
42

Criteria 4.E: Person-Centered and Family-Centered Treatment Planning 

4.e.1 

The CCBHC directly provides person-centered and family-centered treatment 

planning or similar processes, including but not limited to risk assessment 

and crisis planning. Person-centered and family-centered treatment planning 

satisfies the requirements of criteria 4.e.2 – 4.e.8 below and is aligned with 

the requirements of Section 2402(a) of the Affordable Care Act, including 

consumer involvement and self-direction. 

Note: See program requirement 3 related to coordination of care and 

treatment planning. 

4.e.2 

An individualized plan integrating prevention, medical and behavioral health 

needs and service delivery is developed by the CCBHC in collaboration with 

and endorsed by the consumer, the adult consumer’s family to the extent the 

consumer so wishes, or family/caregivers of youth and children, and is 

coordinated with staff or programs necessary to carry out the plan. 

Note: States may wish to access additional resources related to personcentered treatment planning found in the CMS Medicaid Home and 

Community Based Services regulations at 42 C.F.R. Part 441, Subpart M, or 

in the CMS Medicare Conditions of Participation for Community Mental 

Health Centers regulations at 42 C.F.R. Part 485. 

4.e.3 The CCBHC uses consumer assessments to inform the treatment plan and 

services provided. 

4.e.4 

Treatment planning includes needs, strengths, abilities, preferences, and 

goals, expressed in a manner capturing the consumer’s words or ideas and, 

when appropriate, those of the consumer’s family/caregiver.

4.e.5 

The treatment plan is comprehensive, addressing all services required, with 

provision for monitoring of progress towards goals. The treatment plan is built 

upon a shared decision-making approach. 

4.e.6 

Where appropriate, consultation is sought during treatment planning about 

special emphasis problems, including for treatment planning purposes (e.g., 

trauma, eating disorders). 

4.e.7 The treatment plan documents the consumer’s advance wishes related to 

treatment and crisis management and, if the consumer does not wish to 

share their preferences, that decision is documented. 
43

Criteria 4.E: Person-Centered and Family-Centered Treatment Planning 

4.e.8 Consistent with the criteria in 4.e.1 through 4.e.7, states should specify other 

aspects of consumer, person-centered and family-centered treatment 

planning they will require based upon the needs of the population served. 

Treatment planning components that states might consider include: 

prevention; community inclusion and support (housing, employment, social 

supports); involvement of family/caregiver and other supports; recovery 

planning; safety planning; and the need for specific services required by the 

statute (i.e., care coordination, physical health services, peer and family 

support services, targeted case management, psychiatric rehabilitation 

services, accommodations to ensure cultural and linguistically competent 

services). 

Criteria 4.F: Outpatient Mental Health and Substance Use Services 

4.f.1 

The CCBHC directly provides outpatient mental and substance use disorder 

services that are evidence-based or best practices, consistent with the needs 

of individual consumers as identified in their individual treatment plan. In the 

event specialized services outside the expertise of the CCBHC are required 

for purposes of outpatient mental and substance use disorder treatment (e.g., 

treatment of sexual trauma, eating disorders, specialized medications for 

substance use disorders), the CCBHC makes them available through referral 

or other formal arrangement with other providers or, where necessary and 

appropriate, through use of telehealth/telemedicine services. The CCBHC 

also provides or makes available through formal arrangement traditional 

practices/treatment as appropriate for the consumers served in the CCBHC 

area. 

Note: See also program requirement 3 regarding coordination of services and 

treatment planning. 
44

Criteria 4.F: Outpatient Mental Health and Substance Use Services 

4.f.2 

Based upon the findings of the needs assessment as required in program 

requirement 1, states must establish a minimum set of evidence-based 

practices required of the CCBHCs. Among those evidence-based practices 

states might consider are the following: Motivational Interviewing; Cognitive 

Behavioral individual, group and on-line Therapies (CBT); Dialectical 

Behavior Therapy (DBT); addiction technologies; recovery supports; first 

episode early intervention for psychosis; Multi-Systemic Therapy; Assertive 

Community Treatment (ACT); Forensic Assertive Community Treatment (FACT); evidence-based medication evaluation and management (including but 

not limited to medications for psychiatric conditions, medication assisted 

treatment for alcohol and opioid substance use disorders (e.g., 

buprenorphine, methadone, naltrexone (injectable and oral), acamprosate, 

disulfiram, naloxone), prescription long-acting injectable medications for both 

mental and substance use disorders, and smoking cessation medications); 

community wrap-around services for youth and children; and specialty clinical 

interventions to treat mental and substance use disorders experienced by 

youth (including youth in therapeutic foster care). This list is not intended to 

be all-inclusive and the states are free to determine whether these or other 

evidence-based treatments may be appropriate as a condition of certification. 

4.f.3 

Treatments are provided that are appropriate for the consumer’s phase of life 

and development, specifically considering what is appropriate for children, 

adolescents, transition age youth, and older adults, as distinct groups for 

whom life stage and functioning may affect treatment. Specifically, when 

treating children and adolescents, CCHBCs provide evidenced-based 

services that are developmentally appropriate, youth guided, and 

family/caregiver driven with respect to children and adolescents. When 

treating older adults, the individual consumer’s desires and functioning are 

considered and appropriate evidence-based treatments are provided. When 

treating individuals with developmental or other cognitive disabilities, level of 

functioning is considered and appropriate evidence-based treatments are 

provided. These treatments are delivered by staff with specific training in 

treating the segment of the population being served. 
45

Criteria 4.F: Outpatient Mental Health and Substance Use Services 

4.f.4 

Children and adolescents are treated using a family/caregiver-driven, youth 

guided and developmentally appropriate approach that comprehensively 

addresses family/caregiver, school, medical, mental health, substance abuse, 

psychosocial, and environmental issues. 

Criteria 4.G: Outpatient Clinic Primary Care Screening and Monitoring 

4. g.1

The CCBHC is responsible for outpatient clinic primary care screening and 

monitoring of key health indicators and health risk. Whether directly provided 

by the CCBHC or through a DCO, the CCBHC is responsible for ensuring 

these services are received in a timely fashion. Required primary care 

screening and monitoring of key health indicators and health risk provided by 

the CCBHC include those for which the CCBHC will be accountable pursuant 

to program requirement 5 and Appendix A of these criteria. The CCBHC 

should not take non-inclusion of a specific metric in Appendix A as a reason 

not to provide clinically indicated primary care screening and monitoring and 

the state may elect to require specific other screening and monitoring to be 

provided by the CCBHCs. The CCBHC ensures children receive age 

appropriate screening and preventive interventions including, where 

appropriate, assessment of learning disabilities, and older adults receive age 

appropriate screening and preventive interventions. Prevention is a key 

component of primary care services provided by the CCBHC. Nothing in 

these criteria prevent a CCBHC from providing other primary care services. 

Note: See also program requirement 3 regarding coordination of services and 

treatment planning. 
46

Criteria 4.H: Targeted Case Management Services 

4.h.1 

The CCBHC is responsible for high quality targeted case management 

services that will assist individuals in sustaining recovery, and gaining access 

to needed medical, social, legal, educational, and other services and 

supports. Targeted case management should include supports for persons 

deemed at high risk of suicide, particularly during times of transitions such as 

from an ED or psychiatric hospitalization. Based upon the needs of the 

population served, states should specify the scope of other targeted case 

management services that will be required, and the specific populations for 

which they are intended. 

Criteria 4.I: Psychiatric Rehabilitation Services 

4.i.1 

The CCBHC is responsible for evidence-based and other psychiatric 

rehabilitation services. States should specify which evidence-based and 

other psychiatric rehabilitation services they will require based upon the 

needs of the population served. Psychiatric rehabilitation services that might 

be considered include: medication education; self-management; training in 

personal care skills; individual and family/caregiver psycho-education; 

community integration services; recovery support services including Illness 

Management & Recovery; financial management; and dietary and wellness 

education. States also may wish to require the provision of supported 

services such as housing, employment, and education, the latter in 

collaboration with local school systems. 

Note: See program requirement 3 regarding coordination of services and 

treatment planning. 
47

Criteria 4.J: Peer Supports, Peer Counseling and Family/Caregiver Supports 

4.j.1 

The CCBHC is responsible for peer specialist and recovery coaches, peer 

counseling, and family/caregiver supports. States should specify the scope of 

peer and family services they will require based upon the needs of the 

population served. Peer services that might be considered include: peer‐run 

drop‐in centers, peer crisis support services, peer bridge services to assist 

individuals transitioning between residential or inpatient settings to the 

community, peer trauma support, peer support for older adults or youth, and 

other peer recovery services. Potential family/caregiver support services that 

might be considered include: family/caregiver psycho-education, parent 

training, and family-to-family/caregiver support services. 

Note: See program requirement 3 regarding coordination of services and 

treatment planning. 

Criteria 4.K: Intensive, Community-Based Mental Health Care for Members of the 

Armed Forces and Veterans 

4.k.1 

The CCBHC is responsible for intensive, community-based behavioral health 

care for certain members of the U.S. Armed Forces and veterans, particularly 

those Armed Forces members located 50 miles or more (or one hour’s drive 

time) from a Military Treatment Facility (MTF) and veterans living 40 miles or 

more (driving distance) from a VA medical facility, or as otherwise required by 

federal law. Care provided to veterans is required to be consistent with 

minimum clinical mental health guidelines promulgated by the Veterans 

Health Administration (VHA), including clinical guidelines contained in the 

Uniform Mental Health Services Handbook of such Administration. The 

provisions of these criteria in general and, specifically, in criteria 4.K, are 

designed to assist CCBHCs in providing quality clinical behavioral health 

services consistent with the Uniform Mental Health Services Handbook. 

Note: See program requirement 3 regarding coordination of services and 

treatment planning. 
48

Criteria 4.K: Intensive, Community-Based Mental Health Care for Members of the 

Armed Forces and Veterans 

4.k.2 

All individuals inquiring about services are asked whether they have ever 

served in the U.S. military. 

Current Military Personnel: Persons affirming current military service will be 

offered assistance in the following manner:

(1) Active Duty Service Members (ADSM) must use their servicing MTF, 

and their MTF Primary Care Managers (PCMs) are contacted by the 

CCBHC regarding referrals outside the MTF.

(2) ADSMs and activated Reserve Component (Guard/Reserve) 

members who reside more than 50 miles (or one hour’s drive time) 

from a military hospital or military clinic enroll in TRICARE PRIME 

Remote and use the network PCM, or select any other authorized 

TRICARE provider as the PCM. The PCM refers the member to 

specialists for care he or she cannot provide; and works with the 

regional managed care support contractor for referrals/authorizations.

(3) Members of the Selected Reserves, not on Active Duty (AD) orders, 

are eligible for TRICARE Reserve Select and can schedule an 

appointment with any TRICARE-authorized provider, network or nonnetwork. 

Veterans: Persons affirming former military service (veterans) are offered 

assistance to enroll in VHA for the delivery of health and behavioral health 

services. Veterans who decline or are ineligible for VHA services will be 

served by the CCBHC consistent with minimum clinical mental health 

guidelines promulgated by the VHA, including clinical guidelines contained in 

the Uniform Mental Health Services Handbook as excerpted below (from 

VHA Handbook 1160.01, Principles of Care found in the Uniform Mental 

Health Services in VA Centers and Clinics). 

Note: See also program requirement 3 requiring coordination of care across 

settings and providers, including facilities of the Department of Veterans 

Affairs. 
49

Criteria 4.K: Intensive, Community-Based Mental Health Care for Members of the 

Armed Forces and Veterans 

4.k.3

In keeping with the general criteria governing CCBHCs, CCBHCs ensure 

there is integration or coordination between the care of substance use 

disorders and other mental health conditions for those veterans who 

experience both and for integration or coordination between care for 

behavioral health conditions and other components of health care for all 

veterans.

4.k.4

Every veteran seen for behavioral health services is assigned a Principal 

Behavioral Health Provider. When veterans are seeing more than one 

behavioral health provider and when they are involved in more than one 

program, the identity of the Principal Behavioral Health Provider is made clear 

to the veteran and identified in the medical record. The Principal Behavioral 

Health Provider is identified on a consumer tracking database for those 

veterans who need case management. The Principal Behavioral Health 

Provider ensures the following requirements are fulfilled:

(1) Regular contact is maintained with the veteran as clinically indicated 

as long as ongoing care is required.

(2) A psychiatrist, or such other independent prescriber as satisfies the 

current requirements of the VHA Uniform Mental Health Services 

Handbook, reviews and reconciles each veteran’s psychiatric 

medications on a regular basis. 

(3) Coordination and development of the veteran’s treatment plan 

incorporates input from the veteran (and, when appropriate, the family 

with the veteran’s consent when the veteran possesses adequate 

decision-making capacity or with the veteran’s surrogate decisionmaker’s consent when the veteran does not have adequate decisionmaking capacity).

(4) Implementation of the treatment plan is monitored and documented. 

This must include tracking progress in the care delivered, the 

outcomes achieved, and the goals attained.

(5) The treatment plan is revised, when necessary.
50

Criteria 4.K: Intensive, Community-Based Mental Health Care for Members of the 

Armed Forces and Veterans 

4.k.4 

(contin

ued) 

(6) The principal therapist or Principal Behavioral Health Provider 

communicates with the veteran (and the veteran's authorized 

surrogate or family or friends when appropriate and when veterans 

with adequate decision-making capacity consent) about the treatment 

plan, and for addressing any of the veteran’s problems or concerns 

about their care. For veterans who are at high risk of losing decisionmaking capacity, such as those with a diagnosis of schizophrenia or 

schizoaffective disorder, such communications need to include 

discussions regarding future behavioral health care treatment (see 

information regarding Advance Care Planning Documents in VHA 

Handbook 1004.2).

(7) The treatment plan reflects the veteran’s goals and preferences for 

care and that the veteran verbally consents to the treatment plan in 

accordance with VHA Handbook 1004.1, Informed Consent for Clinical 

Treatments and Procedures. If the Principal Behavioral Health 

Provider suspects the veteran lacks the capacity to make a decision 

about the mental health treatment plan, the provider must ensure the 

veteran’s decision-making capacity is formally assessed and 

documented. For veterans who are determined to lack capacity, the 

provider must identify the authorized surrogate and document the 

surrogate’s verbal consent to the treatment plan.
51

Criteria 4.K: Intensive, Community-Based Mental Health Care for Members of the 

Armed Forces and Veterans 

4.k.5

In keeping with the general criteria governing CCBHCs, behavioral health 

services are recovery-oriented. The VHA adopted the National Consensus 

Statement on Mental Health Recovery in its Uniform Mental Health Services 

Handbook. SAMHSA has since developed a working definition and set of 

principles for recovery updating the Consensus Statement. Recovery is 

defined as “a process of change through which individuals improve their 

health and wellness, live a self-directed life, and strive to reach their full 

potential.” The following are the 10 guiding principles of recovery: 

 Hope

 Person-driven 

 Many pathways 

 Holistic 

 Peer support 

 Relational 

 Culture 

 Addresses trauma 

 Strengths/responsibility 

 Respect

(Substance Abuse and Mental Health Services Administration [2012]). 

As implemented in VHA recovery, the recovery principles also include the 

following: 

 Privacy 

 Security 

 Honor 

Care for veterans must conform to that definition and to those principles in 

order to satisfy the statutory requirement that care for veterans adheres to 

guidelines promulgated by the VHA. 
52

Criteria 4.K: Intensive, Community-Based Mental Health Care for Members of the 

Armed Forces and Veterans 

4.k.6

In keeping with the general criteria governing CCBHCs, all behavioral health 

care is provided with cultural competence. 

(1) Any staff who is not a veteran has training about military and veterans’ 

culture in order to be able to understand the unique experiences and 

contributions of those who have served their country. 

(2) All staff receives cultural competency training on issues of race, 

ethnicity, age, sexual orientation, and gender identity. 

4.k.7 In keeping with the general criteria governing CCBHCs, there is a behavioral 

health treatment plan for all veterans receiving behavioral health services. 

(1) The treatment plan includes the veteran’s diagnosis or diagnoses and 

documents consideration of each type of evidence-based intervention 

for each diagnosis. 

(2) The treatment plan includes approaches to monitoring the outcomes 

(therapeutic benefits and adverse effects) of care, and milestones for 

reevaluation of interventions and of the plan itself. 

(3) As appropriate, the plan considers interventions intended to 

reduce/manage symptoms, improve functioning, and prevent relapses 

or recurrences of episodes of illness. 

(4) The plan is recovery oriented, attentive to the veteran’s values and 

preferences, and evidence-based regarding what constitutes effective 

and safe treatments. 

(5) The treatment plan is developed with input from the veteran, and when 

the veteran consents, appropriate family members. The veteran’s 

verbal consent to the treatment plan is required pursuant to VHA 

Handbook 1004.1. 
53

Program Requirement 5: QUALITY 

AND OTHER REPORTING

Data collection, use and reporting are vital for assessment and improvement of program 

quality. As a condition of participation in the demonstration program, the statute 

requires states to collect and report on encounter, clinical outcomes, and quality 

improvement data. The statute also requires annual reporting by the states that will 

entail collection of data which can be used to assess the impact of the demonstration 

program on: (1) access to community-based behavioral health services “in the area or 

areas of a state targeted by a demonstration program compared to other areas of the 

state”; (2) quality and scope of services provided by CCBHCs compared with nonCCBHC providers; and (3) federal and state costs of a full range of behavioral health 

services (including inpatient, emergency, and ambulatory services) (PAMA § 

223(d)(7)(A)). The criteria related to this program requirement are designed to elicit the 

data needed to ensure improved access to care, high-quality services and appropriate 

state reporting. States also may wish to encourage the use of consumer and family led 

evaluations of the CCBHCs to ensure consumers and families are involved in this 

aspect of service design and delivery. 

Authority: Section 223 (a)(2)(E) of PAMA 

The statute requires the published criteria to include criteria with respect to the 

following: 

“Reporting of encounter data, clinical outcomes data, quality data, and such other 

data as the Secretary requires.”
54

Criteria 5.A: Data Collection, Reporting and Tracking 

5.a.1 

The CCBHC has the capacity to collect, report, and track encounter, 

outcome, and quality data, including but not limited to data capturing: (1) 

consumer characteristics; (2) staffing; (3) access to services; (4) use of 

services; (5) screening, prevention, and treatment; (6) care coordination; 

(7) other processes of care; (8) costs; and (9) consumer outcomes. Data 

collection and reporting requirements are elaborated below and in 

Appendix A. 

5.a.2 

Reporting is annual and data are required to be reported for all CCBHC 

consumers, or where data constraints exist (for example, the measure is 

calculated from claims), for all Medicaid enrollees in the CCBHCs. 

5.a.3 

To the extent possible, these criteria assign to the state responsibility for 

data collection and reporting where access to data outside the CCBHC is 

required. Data to be collected and reported and quality measures to be 

reported, however, may relate to services CCBHC consumers receive 

through DCOs. Collection of some of the data and quality measures that 

are the responsibility of the CCBHC may require access to data from 

DCOs and it is the responsibility of the CCBHC to arrange for access to 

such data as legally permissible upon creation of the relationship with 

DCOs and to ensure adequate consent as appropriate and that releases of 

information are obtained for each affected consumer. 
55

Criteria 5.A: Data Collection, Reporting and Tracking 

5.a.4 

As specified in Appendix A, some aspects of data reporting will be the 

responsibility of the state, using Medicaid claims and encounter data. 

States must provide CCHBC-level Medicaid claims or encounter data to 

the evaluators of this demonstration program annually. At a minimum, 

consumer and service-level data should include a unique consumer 

identifier, unique clinic identifier, date of service, CCBHC-covered service 

provided, units of service provided and diagnosis. These data must be 

reported through MMIS/T-MSIS in order to support the state’s claim for 

enhanced federal matching funds made available through this 

demonstration program. For each consumer, the state must obtain and 

link the consumer level administrative Uniform Reporting System (URS) 

information to the claim (or be able to link by unique consumer identifier). 

CCBHC consumer claim or encounter data must be linkable to the 

consumer’s pharmacy claims or utilization information, inpatient and 

outpatient claims, and any other claims or encounter data necessary to 

report the measures identified in Appendix A. These linked claims or 

encounter data must also be made available to the evaluator. In addition 

to data specified in this program requirement and in Appendix A that the 

state is to provide, the state will provide such other data, including 

Treatment Episode Data Set (TEDS) data and data from comparison 

settings, as may be required for the evaluation to HHS and the national 

evaluation contractor annually. To the extent CCBHCs are responsible for 

provision of data, the data will be provided to the state and, as may be 

required elsewhere, to HHS and the evaluator. If requested, CCBHCs will 

participate in discussions with the national evaluation team. 

5.a.5 

CCBHCs annually submit a cost report with supporting data within six 

months after the end of each demonstration year to the state. The state will 

review the submission for completeness and submit the report and any 

additional clarifying information within nine months after the end of each 

demonstration year to CMS. 

Note: In order for a clinic to receive payment using the CCBHC PPS, it 

must be certified as a CCBHC. 
56

Criteria 5.B: Continuous Quality Improvement (CQI) Plan 

5.b.1 

The CCBHC develops, implements, and maintains an effective, CCBHCwide data-driven continuous quality improvement (CQI) plan for clinical 

services and clinical management. The CQI projects are clearly defined, 

implemented, and evaluated annually. The number and scope of distinct 

CQI projects conducted annually are based on the needs of the CCBHC’s 

population and reflect the scope, complexity and past performance of the 

CCBHC’s services and operations. The CCBHC-wide CQI plan addresses 

priorities for improved quality of care and client safety, and requires all 

improvement activities be evaluated for effectiveness. The CQI plan 

focuses on indicators related to improved behavioral and physical health 

outcomes, and takes actions to demonstrate improvement in CCBHC 

performance. The CCBHC documents each CQI project implemented, the 

reasons for the projects, and the measurable progress achieved by the 

projects. One or more individuals are designated as responsible for 

operating the CQI program. 

5.b.2 

Although the CQI plan is to be developed by the CCBHC and reviewed and 

approved by the state during certification, specific events are expected to be 

addressed as part of the CQI plan, including: (1) CCBHC consumer suicide 

deaths or suicide attempts; (2) CCBHC consumer 30 day hospital 

readmissions for psychiatric or substance use reasons; and (3) such other 

events the state or applicable accreditation bodies may deem appropriate 

for examination and remediation as part of a CQI plan. 
57

Program Requirement 6: 

ORGANIZATIONAL AUTHORITY, 

GOVERNANCE AND ACCREDITATION 

It is envisioned the organizations meeting the CCBHC standards will be able to provide 

comprehensive and high quality services in a manner reflecting evidence based and 

best practices in the field. Combined with the other program requirements of Section 

223, the criteria within this section are meant to bolster states’ ability to identify and 

support organizations with demonstrated capacity and capability to meet the CCBHC 

criteria. 

Authority: Section 223 (a)(2)(F) of PAMA 

The statute requires the published criteria to include criteria with respect to the 

following:

“Criteria that a clinic be a nonprofit or part of a local government behavioral health 

authority or operated under the authority of the Indian Health Service, an Indian Tribe, 

or Tribal organization pursuant to a contract, grant, cooperative agreement, or compact 

with the Indian Health Service pursuant to the Indian Self-Determination Act (25 U.S.C. 

450 et seq.), or an urban Indian organization pursuant to a grant or contract with the 

Indian Health Service under title V of the Indian Health Care Improvement Act (25 

U.S.C. 1601 et seq.).”
58

Criteria 6.A: General Requirements of Organizational Authority and Finances 

6.a.1 

The CCBHC maintains documentation establishing the CCBHC conforms to 

at least one of the following statutorily established criteria: 

 Is a non-profit organization, exempt from tax under Section 501(c)(3) of 

the United States Internal Revenue Code; 

 Is part of a local government behavioral health authority; 

 Is operated under the authority of the Indian Health Service, an Indian 

tribe, or tribal organization pursuant to a contract, grant, cooperative 

agreement, or compact with the Indian Health Service pursuant to the 

Indian Self-Determination Act (25 U.S.C. 450 et seq.); 

 Is an urban Indian organization pursuant to a grant or contract with the 

Indian Health Service under Title V of the Indian Health Care 

Improvement Act (25 U.S.C. 1601 et seq.). 

Note: A CCBHC is considered part of a local government behavioral health 

authority when a locality, county, region or state maintains authority to 

oversee behavioral health services at the local level and utilizes the clinic to 

provide those services. 

6.a.2 

To the extent CCBHCs are not operated under the authority of the Indian 

Health Service, an Indian tribe, or tribal or urban Indian organization, states, 

based upon the population the prospective CCBHC may serve, should 

require CCBHCs to reach out to such entities within their geographic service 

area and enter into arrangements with those entities to assist in the provision 

of services to AI/AN consumers and to inform the provision of services to 

those consumers. To the extent the CCBHC and such entities jointly provide 

services, the CCBHC and those collaborating entities shall, as a whole, 

satisfy the requirements of these criteria. 

6.a.3 

An independent financial audit is performed annually for the duration of the 

demonstration in accordance with federal audit requirements, and, where 

indicated, a corrective action plan is submitted addressing all findings, 

questioned costs, reportable conditions, and material weakness cited in the 

Audit Report. 
59

Criteria 6.B: Governance 

6.b.1 

As a group, the CCBHC’s board members are representative of the 

individuals being served by the CCBHC in terms of demographic factors such 

as geographic area, race, ethnicity, sex, gender identity, disability, age, and 

sexual orientation, and in terms of types of disorders. The CCBHC will 

incorporate meaningful participation by adult consumers with mental illness, 

adults recovering from substance use disorders, and family members of 

CCBHC consumers, either through 51 percent of the board being families, 

consumers or people in recovery from behavioral health conditions, or 

through a substantial portion of the governing board members meeting this 

criteria and other specifically described methods for consumers, people in 

recovery and family members to provide meaningful input to the board about 

the CCBHC’s policies, processes, and services. 

6.b.2 

The CCBHC will describe how it meets this requirement or develop a 

transition plan with timelines appropriate to its governing board size and 

target population to meet this requirement.

6.b.3 

To the extent the CCBHC is comprised of a governmental or tribal entity or a 

subsidiary or part of a larger corporate organization that cannot meet these 

requirements for board membership, the state will specify the reasons why 

the CCBHC cannot meet these requirements and the CCBHC will have or 

develop an advisory structure and other specifically described methods for 

consumers, persons in recovery, and family members to provide meaningful 

input to the board about the CCBHC's policies, processes, and services. 

6.b.4 

As an alternative to the board membership requirement, any organization 

selected for this demonstration project may establish and implement other 

means of enhancing its governing body’s ability to insure that the CCBHC is 

responsive to the needs of its consumers, families, and communities. Efforts 

to insure responsiveness will focus on the full range of consumers, services 

provided, geographic areas covered, types of disorders, and levels of care 

provided. The state will determine if this alternative approach is acceptable 

and, if it is not, will require that additional or different mechanisms be 

established to assure that the board is responsive to the needs of CCBHC 

consumers and families. Each organization will make available the results of 

their efforts in terms of outcomes and resulting changes. 
60

Criteria 6.B: Governance 

6.b.5 

Members of the governing or advisory boards will be representative of the 

communities in which the CCBHC's service area is located and will be 

selected for their expertise in health services, community affairs, local 

government, finance and banking, legal affairs, trade unions, faith 

communities, commercial and industrial concerns, or social service agencies 

within the communities served. No more than one half (50 percent) of the 

governing board members may derive more than 10 percent of their annual 

income from the health care industry. 

6.b.6 

States will determine what processes will be used to verify that these 

governance criteria are being met. 

Criteria 6.C: Accreditation 

6.c.1 

CCBHCs will adhere to any applicable state accreditation, certification, and/or 

licensing requirements. 

6.c.2 

States are encouraged to require accreditation of the CCBHCs by an 

appropriate nationally-recognized organization (e.g., the Joint Commission, 

the Commission on Accreditation of Rehabilitation Facilities [CARF], the 

Council on Accreditation [COA], the Accreditation Association for Ambulatory 

Health Care [AAAHC]). Accreditation does not mean “deemed” status.
61

References

Agency for Healthcare Research and Quality. Care Coordination. Rockville, MD, 

October 2014. Available at http://www.ahrq.gov/professionals/prevention-chroniccare/improve/coordination/index.html

American Academy of Child & Adolescent Psychiatry. Family and Youth Participation in 

Clinical Decision-Making. Washington, D.C., October 2009. Available at 

http://www.aacap.org/AACAP/Policy_Statements/2009/Family_and_Youth_Partici

pation_in_Clinical_Decision_Making.aspx 

Centers for Medicare & Medicaid Services, Department of Health and Human Services, 

General Provisions, Definitions Specific to Medicaid, 42 CFR § 400.203.

Centers for Medicare & Medicaid Services, Department of Health and Human Services, 

Medical Assistance Programs, Services: General Provisions, 42 CFR § 440.169.

Conditions of Participation: Community Mental Health Centers (CMHCs) Rule, 42 CFR 

§§ 485.900 et seq. (2014).

Department of Health & Human Services. Guidance to HHS Agencies for Implementing 

Principles of Section 2403(a) of the Affordable Care Act: Standards for PersonCentered Planning and Self-Direction in Home and Community-Based Services 

Programs (June 6, 2014). Available at 

http://www.acl.gov/Programs/CDAP/OIP/docs/2402-a-Guidance.pdf 

Health Resources and Services Administration. Find Shortage Areas: HPSA by State & 

County. Health Resources and Services Administration, Rockville, MD, 2015. 

Available at http://hpsafind.hrsa.gov/

Health Resources and Services Administration (November 2014/FY2015). Health 

Center Program Site Visit guide for HRSA Health Center Program Grantees and 

Look-Alikes. Health Resources and Services Administration, Rockville, MD. 

Available at http://bphc.hrsa.gov/administration/visitguidepdf.pdf

Health Resources and Services Administration, Maternal and Child Health Bureau. The 

National Survey of Children with Special Health Care Needs Chartbook 2001. Rockville, 

Maryland: U.S. Department of Health and Human Services, 2004. Available at 

http://www.mchb.hrsa.gov/chscn/index.htm

National Association of State Mental Health Program Directors. Glossary. Alexandria, 

VA: National Association of State Mental Health Program Directors. 2014. 

Available at http://www.nasmhpd.org/GeneralInfo/ContactUs.aspx
62

Office of Minority Health. Cultural and Linguistic Competency. Rockville, MD: U.S. 

Department of Health and Human Services, December 12, 2014. Available at 

http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=1&lvlid=6 

Protecting Access to Medicare Act of 2014 (PAMA), § 223. 

SAMHSA-HRSA Center for Integrated Health Solutions. Glossary. Rockville, MD: 

Substance Abuse and Mental Health Services Administration, 2015. Available at 

http://www.integration.samhsa.gov/glossary 

Schauer C, Everett A, del Vecchio P, et al. Promoting the value and practice of shared 

decision-making in mental health care. Psych Rehab J 2007: 31(1): 54-61.

Social Security Act, 42 U.S.C. 1396 et seq. 

Substance Abuse and Mental Health Services Administration. Glossary of Recovery 

Terms. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2015. Available at 

http://media.samhsa.gov/recoverytopractice/glossaryofterms.aspx

Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of 

Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. 

(SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2014. Available at http://store.samhsa.gov/product/SAMHSA-sConcept-of-Trauma-and-Guidance-for-a-Trauma-Informed-Approach/SMA14-4884

Substance Abuse and Mental Health Services Administration. SAMHSA’s Working 

Definition of Recovery. Rockville, MD: Substance Abuse and Mental Health 

Services Administration, 2012. Available at 

http://store.samhsa.gov/shin/content//PEP12-RECDEF/PEP12-RECDEF.pdf 
63

Appendix A: Quality Measures and 

Other Reporting Requirements

UPDATED 5-1-2016 

Appendix A of the Criteria for the Demonstration Program to Improve Community Mental Health 

Centers and to Establish Certified Community Behavioral Health Clinics (published with the Request 

for Applications SM16-001 Planning Grants for CCBHCs) alerted readers that the list of required 

quality measures may change. This updated chart replaces the original Appendix A. The change 

column below identifies measures that are no longer required and modifications that were made to 

the required measures. Please note that experience of care is counted as one measure but 

collected separately for patients and families. 

Appendix A contains the data and quality measures required to be reported as part 

of these criteria.5. The requirements are based on the measurement landscape as 

of the time the CCBHC criteria were drafted (March 2015) and, given the rapid 

change occurring in the measurement field, might change, particularly if altering 

these quality measures enables better alignment with other reporting requirements. 

For the same reason, Quality Bonus Measures (QBMs) are not specified in these 

criteria or Appendix, rather they are established by CMS as part of the PPS. 

Appendix A is divided into data/measures required to be reported by the CCBHCs 

(Table 1) and those required to be reported by the states (Table 2). Reporting is 

annual and data are required to be reported for all CCBHC consumers, or where 

data constraints exist, for all Medicaid enrollees in the CCBHCs. In addition to these 

reporting requirements, the demonstration program evaluator will require the 

reporting of additional data to be used as part of the project evaluation. Those 

additional data are not specified in these criteria. All data collected and reported by 

the state must be flagged to distinguish the individual CCBHCs and consumers 

served by CCBHCs, as well as a comparison group of clinics and consumers. In 

addition, the consumer’s unique Medicaid identifier must be attached.

 

5

 See also program requirement 5 for additional information on required reporting. 
64

UPDATED Table 1. CCBHC Reported Measures (9 Required)

Potential 

Source of 

Data

Measure or Other Reporting Requirement NQF 

Endors

ed

Change Cou

nt

Electronic 

scheduler 

Number/Percent of clients requesting services 

who were determined to need routine care

N/A Not 

Required 

EHR, 

Patient 

records, 

Electronic 

scheduler 

Number/percent of new clients with initial 

evaluation provided within 10 business days, 

and mean number of days until initial evaluation 

for new clients

N/A

1

EHR, 

Patient 

records, 

Electronic 

scheduler 

Mean number of days before the comprehensive 

person-centered and family centered diagnostic 

and treatment planning evaluation is performed 

for new clients

N/A Not 

Required

EHR, 

Patient 

records

Number of Suicide Deaths by Patients Engaged 

in Behavioral Health (CCBHC) Treatment 

N/A Not 

Required 

EHR, 

Patient 

records

Documentation of Current Medications in the 

Medical Records 

0419 Not 

Required 

MHSIP 

surveys 

 

Patient experience of care survey 

N/A 

Moved to

state 

reported 

measures 

Family experience of care survey 

EHR, 

Patient 

records 

Preventive Care and Screening: Adult Body 

Mass Index (BMI) Screening and Follow-Up

0421 2 

EHR, 

Encounter 

data 

Weight Assessment and Counseling for Nutrition 

and Physical Activity for Children/Adolescents 

(WCC) (see Medicaid Child Core Set) 

0024 3 

EHR, 

Encounter 

data

Controlling High Blood Pressure (see Medicaid 

Adult Core Set)

0018 Not 

Required 

EHR, 

Encounter 

data

Preventive Care & Screening: Tobacco Use: 

Screening & Cessation Intervention

0028 4

EHR, 

Patient 

records

Preventive Care and Screening: Unhealthy 

Alcohol Use: Screening and Brief Counseling

2152 5

EHR, 

Patient 

Initiation and engagement of alcohol and other 

drug dependence treatment (see Medicaid Adult 

0004 Moved to

state 
65

Potential 

Source of 

Data

Measure or Other Reporting Requirement NQF 

Endors

ed

Change Cou

nt

records Core Set) reported 

measures 

EHR, 

Patient 

records

Child and adolescent major depressive disorder 

(MDD): Suicide Risk Assessment (see Medicaid 

Child Core Set) 

1365 6

EHR, 

Patient 

records

Adult major depressive disorder (MDD): Suicide 

risk assessment (use EHR Incentive Program 

version of measure)

0104 7

EHR, 

Patient 

records

Screening for Clinical Depression and Follow-Up 

Plan (see Medicaid Adult Core Set)

0418 8

EHR, 

Patient 

records 

Consumer 

follow-up 

with 

standardize

d measure 

(PHQ-9)

Depression Remission at 12 months 0710 9
66

UPDATED Table 2. State Reported Measures (12 Required) 

Potential 

Source of 

Data

Measure or Other Reporting Requirement NQF 

Endorsed

Change Cou

nt 

URS Housing Status (Residential Status at 

Admission or Start of the Reporting Period 

Compared to Residential Status at Discharge 

or End of the Reporting Period)

N/A 1

Claims 

data/ 

encounter 

data

Number of Suicide Attempts Requiring 

Medical Services by Patients Engaged in 

Behavioral Health (CCBHC) Treatment

N/A Not 

Required

Claims

data/encou

nter data

Follow-Up After 

Discharge from 

the Emergency 

Department for 

Mental Health or 

Alcohol or Other 

Dependence

Follow-Up After 

Emergency Department 

for Mental Health

2605 Original 

Measure 

split

2

Follow-Up After 

Emergency Department 

for Alcohol or Other 

Dependence 

2605 Original 

Measure 

split 

3 

Claims 

data/ 

encounter 

data

Plan All-Cause Readmission Rate (PCR-AD) 

(see Medicaid Adult Core Set)

1768 4 

Claims 

data/ 

encounter 

data

Diabetes Screening for People with 

Schizophrenia or Bipolar Disorder who Are 

Using Antipsychotic Medications

1932 5

Claims 

data/ 

encounter 

data

Diabetes Care for People with Serious Mental 

Illness: Hemoglobin A1c (HbA1c) Poor 

Control (>9.0%)

2607 Not 

Required 

Claims 

data/ 

encounter 

data

Metabolic Monitoring for Children and 

Adolescents on Antipsychotics

No Not 

Required 

Claims 

data/ 

encounter 

data

Cardiovascular health screening for people 

with schizophrenia or bipolar disorder who are 

prescribed antipsychotic medications

1927 Not 

Required 

Claims 

data/ 

encounter 

data

Cardiovascular health monitoring for people 

with cardiovascular disease and 

schizophrenia 

1933 Not 

Required 
67

Potential 

Source of 

Data 

Measure or Other Reporting Requirement NQF 

Endorsed 

Change Cou

nt 

Claims 

data/ 

encounter 

data

Adherence to Mood Stabilizers for Individuals 

with Bipolar I Disorder

1880 Not 

Required 

Claims 

data/ 

encounter 

data

Adherence to Antipsychotic Medications for 

Individuals with Schizophrenia (see Medicaid 

Adult Core Set)

No 6

Claims 

data/ 

encounter 

data

Follow-Up After Hospitalization for Mental 

Illness, ages 21+ (adult) (see Medicaid Adult 

Core Set)

0576 7

Claims 

data/ 

encounter 

data

Follow-Up After Hospitalization for Mental 

Illness, ages 6 to 21 (child/adolescent) (see 

Medicaid Child Core Set)

0576 8

Claims 

data/ 

encounter 

data

Follow-up care for children prescribed ADHD 

medication (see Medicaid Child Core Set)

0108 9

Claims 

data/ 

encounter 

data

Antidepressant Medication Management (see 

Medicaid Adult Core Set)

0105 10

EHR, 

Patient 

records 

Initiation and engagement of alcohol and 

other drug dependence treatment (see 

Medicaid Adult Core Set) 

0004 Moved 

from 

CCBHC 

reported 

measures 

11

MHSIP 

Survey 

 

Patient experience of care survey N/A Moved 

from 

CCBHC 

reported 

measures 

and 

counted 

as one 

12

Family experience of care survey