Certified Community 

Behavioral Health 

Clinics Demonstration 

Program

Report to Congress, 2017 

U.S. Department of Health and Human Services 

Alex Azar 

Secretary 

Substance Abuse and Mental Health Services Administration 

Elinore F. McCance-Katz, M.D., Ph.D. 

Assistant Secretary for Mental Health and Substance Use 

Center for Mental Health Services 

Paolo del Vecchio, M.S.W. 

Director 

Division of Service and Systems Improvement 

Luis A. Vasquez, LICSW 

Director 

Community Support Programs Branch 

Cynthia Kemp, M.A., LPC 

Chief 

David Morrissette, Ph.D., LCSW, Captain, USPHS 

Social Science Analyst 

Joanna Wise Barnes 

Special Expert 

Certified Community Behavioral Health Clinics Demonstration Program, Report to Congress, 2017 was 

written by staff at Advocates for Human Potential, Inc., pursuant to a contract with The Bizzell Group 

(contract number HHSS280201400002C) under the direction of the Community Support Programs 

Branch, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 

U.S. Department of Health and Human Services.
 

 

 

 

NorthEast Treatment (NET) 

Center facility, a CCBHC 

in Pennsylvania 

TABLE OF CONTENTS

EXECUTIVE SUMMARY ................................................................... 1 

INTRODUCTION.................................................................................. 2 

BACKGROUND..................................................................................... 4 

Coordination of Care ................................................................................. 5 

Access and Availability of Care ................................................................ 6 

Quality of Care and Scope of Services...................................................... 7 

PART I: AUTHORIZATION OF SECTION 223 ............................ 8 

PENNSYLVANIA: ACHIEVING INTEGRATION........................ 8 

PART II: IMPLEMENTATION OF SECTION 223...................... 10 

Established Criteria to Certify Community 

Behavioral Health Clinics ....................................................................... 10 

Released Data and Reporting Requirements............................................ 12 

Issued Guidance on the Development of a 

Prospective Payment System ................................................................... 12 

Awarded Grants to States to Plan for the Demonstration Program ......... 14 

Prepared to Evaluate the Demonstration Program................................... 16 

Selected States to Participate in the Demonstration Program.................. 18 

OKLAHOMA: A DECADE-LONG QUEST .................................. 20 

PART III: THE DEMONSTRATION PROGRAM ...................... 21 

Anticipated Impact of Participation......................................................... 21 

Data and Reporting Requirements........................................................... 22 

CCBHC Service Recipients Projected to be Served................................ 22 

Diversity of Proposed CCBHCs and Service Areas ................................ 24 

Withdrawal of Clinics.............................................................................. 26 

Scope of Services..................................................................................... 26 

PPS Methodology of Demonstration States............................................. 27 

Launch of Demonstration Programs........................................................ 28 

FURTHER CONSIDERATIONS........................................................ 29 

Community-Based, Whole-Person Care.................................................. 29 

Value-based Purchasing ........................................................................... 30 

Effective Practices.................................................................................... 30 

Sustaining Excellence in Mental Health.................................................. 32 
FIGURES 

FIGURE A: CCBHC Range of Services.................................................. 3 

FIGURE B: States Awarded Planning Grants........................................ 14 

FIGURE C: Spending on CCBHC Planning Grant Activities............... 15 

FIGURE D: Conceptual Model for 

CCBHC Demonstration Evaluation......................................................... 16 

FIGURE E: States Selected to Participate 

in the Demonstration Program................................................................. 19 

FIGURE F: Map of State Areas Covered by CCBHCs ......................... 24 

TABLES 

Table 1: CCBHC Criteria Areas...............................................................11 

Table 2: Eligible Measures For Quality Bonus Payments...................... 13 

Table 3: Application Components........................................................... 18 

Table 4: Selected Goals by State............................................................. 21 

Table 5: Projected Number of Individuals to be 

Served by CCBHCs ................................................................................. 23 

Table 6: CCBHC Profiles by Demonstration State ................................. 25 

Table 7: EBPs Most Commonly Used by Number 

of Demonstration States........................................................................... 27 

Table 8: Methods for Incorporating CC PPS Rates into 

Managed Care Capitation ........................................................................ 28 

Appendix A: State Snapshots............................................................... 33 

Appendix B: Glossary of Acronyms .................................................... 49 

References............................................................................................... 50 
1 

EXECUTIVE SUMMARY

Millions of Americans and thousands of communities in the United States are affected by mental illness 

and substance use disorders. It is estimated that more than 10 million adults 18 and older had a serious 

mental illness (SMI) in the past year, more than 17 million adults misused prescription drugs in the past 

year, and about 20 million adults had an illicit drug or alcohol use disorder in the past year (SAMHSA, 

Center for Behavioral Health Statistics 

and Quality, September 2017). While 

effective treatment and supportive 

services exist, too few individuals with 

behavioral health conditions receive the 

help they need. 

Section 223 of the Protecting Access to 

Medicare Act (PAMA) of 2014 (Public 

Law 113-93) authorizes demonstration 

programs in up to eight states to improve 

community behavioral health services 

by establishing and evaluating certified 

community behavioral health clinics 

(CCBHCs). It is expected that the 

emphasis on quality of services will 

manifest in the following ways: 

• Service recipients will receive whole-person care, avoiding disjointed, duplicative services 

and services with potentially poor outcomes. 

– Care coordination is the linchpin of the CCBHC model of integrating physical and behavioral 

health to serve the whole person. Constant and consistent communication among providers is 

the hallmark of care coordination. 

• Service recipients will have better access to services when they need them and where they 

need them. 

– Individuals will have immediate and timely access to treatment through a single point of 

entry. Furthermore, CCBHCs cannot refuse services due to an individual’s place of residence 

or inability to pay. CCBHC service recipients include individuals who are eligible under 

Medicaid fee-for-service, managed care, and dually eligible programs. Section 223 calls 

for crisis management services that are available and accessible 24 hours a day.

• Service recipients will choose from a comprehensive range of high-quality services. 

– CCBHCs are required to provide substance use treatment and mental health services across the 

lifespan, either directly or through formal relationships with other high-quality providers known 

as designated collaborating organizations (DCOs).

Syracuse Behavioral Healthcare in Syracuse, New York—one of six 

CCBHCs serving upstate New York
2 

 

– Emphasis is placed on quality and positive outcomes. As a condition of participating in the 

demonstration program, services must incorporate a minimum set of evidence-based practices 

(EBPs) established by states and based on community needs. Some states also recommended 

additional EBPs that their CCBHCs had the option to implement. 

• Providers will receive payments that reimburse the expected cost of demonstration services. 

– The services and supports noted above are paid using a Prospective Payment System (PPS) 

that is a clinic-specific encounter rate paid daily or monthly. The rate is intended to reimburse 

CCBHCs their expected cost of care. The Centers for Medicare & Medicaid Services (CMS) 

provided technical assistance to states on how to determine the PPS rates. 

This report discusses these points in relation to the impetus of the demonstration program, its 

authorization, and its implementation. It provides a profile of the eight states awarded demonstration 

grants and spotlights participation in the demonstration program as the culmination of states’ efforts 

to transform their behavioral health systems. 

INTRODUCTION

The Protecting Access to Medicare Act (PAMA) of 2014 (Public Law 113-93) authorizes the creation and 

evaluation of demonstration programs to improve behavioral health services1

 through certified community 

behavioral health clinics (CCBHCs). 

CCBHCs provide a comprehensive range of services directly or through referral to designated

collaborating organizations (DCOs) (see Figure A on page 3). The eight states conducting demonstration

programs certified providers as CCBHCs based on their capacity to meet criteria authorized by Section

223. CCBHCs are expected to provide coordinated care using designated evidence-based practices (EBPs).

Certified clinics receive Medicaid payment through a daily or monthly Prospective Payment System 

(PPS) rate that is clinic-specific and reimburses the expected cost of demonstration services. Clinics must 

serve all clinic users, not just Medicaid beneficiaries, and cannot refuse services due to an individual’s 

place of residence or ability to pay. The statute specifies that clinics must accept payment on a sliding fee 

scale basis (PAMA of 2014 Section 223, (a)(2)(B)).

This report focuses on the statutory requirements of Section 223, its implementation, the planning 

grant that helped states prepare, and the selection of the states to participate in demonstration programs, 

including activities associated with launching the demonstration programs. Because states launched their 

CCBHCs in mid-2017, more data will be included in future annual reports. 

1 Except in cases of direct quotes from other sources, the term “behavioral health” is used to inclusively refer to mental disorders, 

substance misuse, and co-occurring mental and substance use disorders.
3 

 

Subsequent annual reports will include an analysis of available data demonstrating the impact of 

CCBHCs on the delivery of behavioral health care in the demonstration states. As required by statute, 

the reports will detail use of funds provided under Section 223, as well as an assessment of the following:

• access to community-based mental health services under the Medicaid program in the area or areas 

of a state targeted by a demonstration program compared to other areas of the state,

• quality and scope of services provided by CCBHCs compared to community-based mental 

health services provided in states not participating in a demonstration program and in areas of a 

demonstration state that are not participating in the demonstration program, and

• impact of the demonstration programs on the federal and state costs of a full range of mental health 

services (including inpatient, emergency, and ambulatory services). 

In addition to the four annual reports to Congress, a final report with recommendations for continuation, 

expansion, modification, or termination of demonstration projects under Section 223 will be submitted to 

Congress no later than December 2021.

FIGURE A: CCBHC Range 

of Services 

2 As further defined in Criteria for the Demonstration Program to Improve Community Mental Health Centers and to Establish 

Certified Community Behavioral Health Clinics (SAMHSA, n.d., p. 37): “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 state-sanctioned alternative acting as a DCO, available services must include 24-hour mobile crisis teams, emergency 

crisis intervention services, and crisis stabilization.”
4 

BACKGROUND

Nationwide, it is estimated that more than 10 million adults 18 and older had a serious mental illness 

(SMI) in the past year, more than 17 million adults misused prescription drugs in the past year, and 

about 20 million adults had an illicit drug or alcohol use disorder in the past year (Substance Abuse and 

Mental Health Services Administration [SAMHSA], Center for Behavioral Health Statistics and Quality, 

September 2017). Although alarming, these numbers fail to convey the full scope of the problem. Costs 

associated with mental and substance use disorders run into the hundreds of billions. 

• At $201 billion, mental disorder costs far exceed spending on heart conditions ($147 billion), trauma

in the form of fractures and wounds ($143 billion), and cancer ($122 billion) (Roehrig, 2016). 

• Another $417 billion in health care, lost work productivity, and crime is attributed to substance use 

(National Institute on Drug Abuse, 2015). 

The prevalence of serious emotional disturbance (SED) 

among youth is less well known than SMI among adults,

Suicide is the but the National Comorbidity Survey Adolescent Cohort

second-leading found that approximately 18 percent of youth (ages 13–17)

cause of death experience mental disorders with moderate or severe 

among youth and young impairment in any area of living (SAMHSA, Center for 

adults (ages 10–34). Behavioral Health Statistics and Quality, June 2016). 

Youth with SED have higher risk of substance use (Wu et (Centers for Disease Control al., 2008; Center for Mental Health Services, 2014), as do and Prevention, 2014) adults with SMI. Adults with SMI are significantly more 

likely to engage in heavy marijuana use, heavy alcohol use, 

and smoking than the general population (Hartz et al., 2014). 

Co-occurring disorders—the coexistence of both a mental disorder and substance use disorder—affect 

more than 8 million adults 18 or older in the U.S. (SAMHSA, Center for Behavioral Health Statistics and 

Quality, September 2017). 

Nearly 12 million adults in this country misuse opioids annually (SAMHSA, Center for Behavioral 

Health Statistics and Quality, January 2017). A study on using an interim buprenorphine treatment regime 

with individuals awaiting comprehensive treatment in an area where demand for treatment is greater 

than supply noted reductions among participants in not only opioid use but also in symptoms of anxiety 

and depression (Bercaw, 2016). Of note, almost all states and the District of Columbia report higher 

medication-assisted treatment (MAT) need than capacity (Jones, Campopiano, Baldwin, & McCanceKatz, 2015). Need exceeding capacity is not unique to this epidemic.

$78.5 BILLION

Estimated economic burden of the opioid crisis to the U.S. 

(Florence, Zhou, Luo, & Xu, 2016) 
5 

 

Coordination of Care 

In the early 2000s, the President’s New Freedom Commission on Mental

Health (2002) described the fragmented mental health delivery system in

this country. Numerous providers (e.g., government and private sector,

hospitals, community clinics, private offices, schools, businesses) offered

various services and supports (e.g., treatment, rehabilitation, housing,

employment) using multiple sources of funding (e.g., Medicaid, Medicare,

state or local agency, foundation, private insurance). Services and supports

were described by the Commission as disconnected and insufficient for

meeting the needs of those with mental and substance use disorders.

The demand for coordinated, integrated, cost-effective, and quality 

health care has been growing and is being incorporated into delivery and 

payment systems. The current focus on value-based purchasing demands 

that services provide a higher quality of care for individuals and result in 

better health for populations at lower costs.

Coordinated care must involve providers of physical and behavioral 

healthcare services. Physical and behavioral conditions often go hand in 

hand but are seldom diagnosed and treated simultaneously. For example, 

some type of mental disorder was the primary diagnosis for 61.7 million 

individuals visiting physicians’ offices in a single year (Hing, Rui, & 

Palso, 2013), but many go undetected or unaddressed due to lack of 

provider training about overlapping symptoms or time to manage multiple 

issues (Druss & Walker, 2011). Lack of provider training was also cited in 

a study that found substance use services sometimes less well integrated 

with primary care than mental health services (Urada, Teruya, Gelberg, & 

Rawson, 2014). Aside from workforce development, policy suggestions 

emanating from this study call for restructured billing and payment 

reform, which are important aims of Section 223. 

CCBHC staff of Berks Counseling Center in Pennsylvania

WHAT IS CARE

COORDINATION?

“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 that 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, and effective 

care to the patient.”

(Agency for Healthcare 

Research and Quality, 2014) 
6 

Care coordination is the linchpin holding together primary aspects of the CCBHC model, which include 

integration of behavioral health with physical health care (SAMHSA, n.d.). This movement toward 

integrated care is a reversal of a late-twentieth century trajectory of addressing substance use separately 

from primary care. Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and 

Health commented that this separation “created unintended and enduring impediments to the quality 

and range of care options,” including rising negativity toward those living with substance use disorders 

and less aggressive development of new medicine to treat substance use. In some cases, primary care 

providers who did not recognize substance misuse in their patients prescribed medicine for a medical 

condition that proved to be deadly (Health and Human Services [HHS] Office of the Surgeon General, 

2016, p. 1-19–1-20).

Access and Availability of Care 

More than half of adults with any mental illness and approximately one-third of adults with SMI did 

not receive treatment in the past year (SAMHSA, Center for Behavioral Health Statistics and Quality, 

September 2017). Similarly, fewer than half of teens with mental disorders receive any form of service, 

with youth of color receiving fewer specialty mental health services than white youth (Costello, He, 

Sampson, Kessler, & Merikangas, 2014). In 2016, 10 percent (2 million people) of the 21 million people 

age 12 or older who needed substance use treatment received treatment at a specialty facility in the past 

year, which means that almost 90 percent of them did not receive specialty treatment (SAMHSA, Center 

for Behavioral Health Statistics and Quality, September 2017). 

Failure to access services when they are available may be partially attributable to long-standing public 

attitudes surrounding behavioral health. Approximately 9 percent of adults with a perceived need for 

mental disorder treatment or services and more than 12 percent of adults with a perceived need for 

substance use treatment reported not seeking services because it “might cause neighbors/community to 

have negative opinions.” Not knowing where to go for services was cited as a common reason for not 

receiving services for adults feeling a need for treatment for either mental health issues (26 percent) or 

substance use disorders (19 percent). Meanwhile, 11 percent of adults with a perceived unmet need for 

mental health services did not receive services because of confidentiality concerns. (SAMHSA, Center 

for Behavioral Health Statistics and Quality, September 2017). Co-locating services in a central location 

where patients receive multiple types of service, such as a CCBHC, may reduce patient concerns about 

inadvertently disclosing the nature of their visit.

“The CCBHC payment system is a historic 

development. Integrated payment models 

are essential to supporting expansion and 

sustainability of integrated treatment models.” 

— Demonstration State Lead 
7 

Quality of Care and Scope of Services 

The U.S. Surgeon General echoed the call for “a cultural shift in how 

we think about addiction” while encouraging the use of evidence-based 

interventions (HHS Office of the Surgeon General, 2016, p. v) to increase 

scope of services and improve quality of care. In the years following 

deinstitutionalization and the rise in community care, various models of 

care emerged, some of which stood up to rigorous testing for effectiveness 

(Drake & Latimer, 2012). 

The value of EBPs is well established, and states participating in the Section

223 demonstration program are expected to “ensure the continual integration

of new evidence-based practices” (SAMHSA, n.d., p. 33). Instituting an

EBP involves building support for change, revising policies and procedures,

identifying funding issues, assessing training needs, and monitoring and

evaluating implementation regularly, all of which can take a year or more

(SAMHSA, 2009b; Drake & Latimer, 2012).

Consistent use of EBPs is one aspect of the drive to achieve excellence 

in behavioral health; another key aspect is breadth of services. On their 

journey to wellness, individuals with complex mental and substance use 

disorders require a comprehensive array of services and supports, such as 

crisis response, integrated health care, care coordination, and treatment. 

As required by statute, CCBHCs provide a continuum of coordinated 

services and supports, including rapid-response 24/7 crisis services in 

supportive settings, peer and family support, specific support for active 

and veteran military, targeted case management, clinical outpatient 

psychotherapeutic interventions, and timely screening and assessment 

of behavioral health and physical needs. 

“The change that has 

occurred as a result 

of being part of the 

CCBHC planning and 

demonstration program

is remarkable. Our state 

was ripe for innovation, 

and the CCBHC initiative 

has been the conduit 

for the changes that 

were needed.” 

— Demonstration State Lead 
8 

PART I: AUTHORIZATION OF SECTION 223

CCBHCs are the next step in the transformative effort states are pursuing to better meet the behavioral 

health, fiscal, and system needs of individuals, providers, and communities. The demonstration program 

authorized by Section 223 of PAMA offers states an opportunity to improve the quality, scope, and 

financing of community-based mental and substance use disorder supports and treatment. What 

distinguishes this program from other efforts to provide behavioral health services to Medicaid 

beneficiaries is its (1) emphasis on coordinated care across the full spectrum of high-quality and 

accessible behavioral and physical health care and (2) a restructured payment system allowing clinics 

to deliver high-quality services. 

To implement Section 223, HHS was authorized to complete the following activities: 

• By September 1, 2015, publish criteria that states would use to certify community behavioral 

health clinics for a 2-year demonstration program. 

• By September 1, 2015, issue guidance to states on the development of a PPS for CCBHC services 

provided by certified clinics.

• By January 1, 2016, award planning grants to states for developing proposals to participate in 

demonstration programs.

• By September 1, 2017, select up to eight states to participate in 2-year demonstration programs.

• Pay states participating in demonstration programs federal matching funds equivalent to the 

standard used by the Children’s Health Insurance Program (CHIP) to pay for services provided to 

currently enrolled Medicaid beneficiaries.

• Evaluate the demonstration programs and prepare annual reports and a final report to Congress.

PENNSYLVANIA: ACHIEVING INTEGRATION

CCBHCs are the capstone of Pennsylvania’s behavioral health transformation efforts to focus on the 

whole person. Twenty years ago, Pennsylvania implemented HealthChoices Behavioral Health (HC-BH) 

to integrate mental health and substance use services in five counties. Ten years ago, the state announced 

that it had integrated the behavioral health system in all of its counties. Now, it is furthering the vision and 

goals of the HC-BH program through the CCBHC demonstration program’s emphasis on service integration with primary care. 

“We are committed to getting individuals we serve the care they need,” says Dale K. Adair, M.D. and 

CCBHC Lead at Pennsylvania’s Office of Mental Health and Substance Abuse Services (OMHSAS). 

“Treating the whole person involves integrating behavioral and physical health care. The CCBHC 

demonstration program brings those two systems together.” 

Passion for an integrated approach runs high throughout the state. When the opportunity to apply 

for a Section 223 planning grant was announced in 2015, state legislators wrote to the governor, 

formally expressing their desire for Pennsylvania to participate. During the planning year, hundreds 
9 

of stakeholders—community members, clinic representatives, consumers and their families, county 

representatives, managed care organizations (MCOs), and statewide groups—attended forums held in 

numerous locations. Pennsylvania also engaged a steering committee of 25 invited stakeholders representing consumers, families, youth, providers, counties, MCOs, and state entities representing veterans, 

substance use, child welfare, and corrections. Public meetings of the steering committee were regularly 

attended by 40 individuals. Stakeholders on the steering committee commented on the openness and 

transparency of the entire process, from planning to developing the application. 

The demonstration program both harnesses this excitement and builds on other initiatives in 

Pennsylvania’s journey to integrated care, which includes the following: 

• The Serious Mental Illness (SMI) Innovations Project piloted integrated healthcare services 

for adult Medicaid beneficiaries with SMI and co-occurring physical health conditions.

• Pennsylvania’s Centers of Excellence, established to help people struggling with opioids, pursues 

the “explicit goal of integrating behavioral health and primary care” (Pennsylvania Department of 

Human Services, n.d.). 

• Pennsylvania was one of six states to participate in CMS’ Medicaid Innovation Accelerator 

Program – Substance Use Disorders High Intensity Learning Collaborative to support integration 

of physical and mental health care. 

Pennsylvania has laid the groundwork for several 

other aspects of the demonstration program by 

expanding the use of recovery-oriented services, 

initiating pay-for-performance programs, 

developing telemedicine payment policies, and 

promoting the Medicaid electronic health record 

incentive program. 

Ellen DiDomenico, who assumed leadership of 

the demonstration program when it launched in 

July 2017, observes, “We have a robust system 

of services, typically falling within the top five 

states in terms of per capita spending on 

behavioral health issues. But there is always 

room for improvement to help more people more 

effectively. The CCBHC demonstration program 

provides an opportunity to make change and to show how the change makes a difference.” 

The Pennsylvania team offers an innovative method for capturing this difference. It developed a “quality 

dashboard” for providers through which CCBHCs can upload process performance measures and receive 

near real-time feedback on their performance. Charts tracking data month to month are generated from the 

data elements of the dashboard. “We use dashboards in other OMHSAS work,” notes Adair, “so this is yet 

another example of the interconnectedness of our efforts to serve the whole person.” 

A CCBHC in Pennsylvania
10 

PART II: IMPLEMENTATION OF SECTION 223

Three HHS agencies partnered to ensure the success of the demonstration program: the Substance Abuse 

and Mental Health Services Administration (SAMHSA), the Centers for Medicare & Medicaid Services 

(CMS), and the Office of the Assistant Secretary of Planning and Evaluation (ASPE). This section of the 

report describes combined efforts to implement Section 223 of PAMA of 2014. 

Established Criteria to Certify Community Behavioral Health Clinics 

Over the past several decades, behavioral health centers adapted to the individual licensing laws within 

their states; funding priorities of state and local government; and requirements of commercial and 

government insurers, Medicare and Medicaid, CHIP, and managed care companies. As a result, 

community behavioral health centers are configured and operate differently in each state. 

With this in mind, SAMHSA developed criteria for certifying community behavioral health clinics in 

compliance with the statutory requirements outlined under Section 223 of PAMA (a)2. They are based on 

a review of State Medicaid Plans, standards for federally qualified health centers (FQHCs) and Medicaid 

health homes, accreditation standards, and quality measures currently in use by states. Over a period 

of 5 months, SAMHSA gathered public input on the draft criteria through a national listening session, 

consultation with tribal leaders, written public comments, and solicitation for public response on its 

website. The criteria (Table 1 on page 11) were released as Appendix II to SAMHSA’s Planning Grants 

for Certified Community Behavioral Health Clinics (CCBHCs Planning Grants) Request for Applications 

(RFA) in May 2015. 

CPC Behavioral Healthcare, a CCBHC in New Jersey
11 

 

 

TABLE 1: CCBHC CRITERIA AREAS 

Staffing 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. 

Availability & 

accessibility of 

services 

The clinic provides 24-hour crisis management services, a sliding scale for payment, and does 

not reject or limit services by the patient’s ability to pay or place of residence. 

Care coordination Coordinated care across settings and providers ensures seamless transitions for patients 

across the full spectrum of health services, including physical and behavioral health needs. 

The clinics maintain partnerships or formal contracts with the following: 

• FQHCs and rural health clinics (as applicable) 

• Inpatient psychiatric facilities and substance use detoxification, post-detoxification 

step-down services, and residential programs 

• 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 

• U.S. Department of Veterans Affairs medical centers, independent outpatient clinics, and 

drop-in centers3 

• Inpatient acute care hospitals and hospital outpatient clinics 

Scope of services— • Crisis mental health services, including 24-hour mobile crisis teams, emergency crisis 

delivered directly by intervention services, and crisis stabilization4 

CCBHCs only • Screening, assessment, and diagnosis, including risk assessment 

• Patient-centered treatment planning or similar processes, including risk assessment 

and crisis planning 

• Outpatient mental health and substance use services 

Scope of services— • Outpatient clinic primary care screening and monitoring of key health indicators and 

delivered directly by health risk 

CCBHCs or through 

referral with DCOs 

• Targeted case management 

• Psychiatric rehabilitation services 

• Peer support and counselor services and family supports 

• Intensive, community-based mental health care for members of the armed forces 

and veterans, particularly those members and veterans located in rural areas 

Quality and other 

reporting 

The clinic reports encounter data, clinical outcomes data, quality data, and such other data 

as the Secretary requires. 

Organizational The clinic is a nonprofit or part of a local government behavioral health authority or operated 

authority under the authority of the Indian Health Service, an Indian tribe, or a tribal organization 

pursuant to a contract, grant, cooperative agreement, or compact with the Indian Health 

Service pursuant to the Indian Self-Determination Act or an urban Indian organization pursuant 

to a grant or contract with the Indian Health Service. 

3 In collaboration with SAMHSA, the U.S. Department of Veterans Affairs developed and distributed a template for coordination 

of care agreements with CCBHCs to their Veterans Integrated Service Networks.

4 As further defined in Criteria for the Demonstration Program to Improve Community Mental Health Centers and to Establish 

Certified Community Behavioral Health Clinics, “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 state-sanctioned alternative 

acting as a DCO, available services must include 24-hour mobile crisis teams, emergency crisis intervention services, and 

crisis stabilization.”
12 

Released Data and Reporting Requirements 

Following extensive input from stakeholders, 21 quality measures were identified as required reporting 

elements under the demonstration program. To support state efforts to collect and submit the quality 

and other reporting criteria, the federal partners made available Office of Management and Budget 

(OMB)-approved technical specifications and reporting templates for quality measures. The technical 

specifications provide states and other interested parties with detailed information regarding the 

calculation of the required quality measures, and the reporting template provides a standardized format 

for the reporting of the quality measures. To further support state efforts to plan for the collection and 

reporting of the quality measures, the federal partners have provided detailed technical assistance to 

states through a series of quality measurement webinars and individual responses to state queries. 

Issued Guidance on the Development of a Prospective Payment System 

As required under PAMA, Section 223, 2(b), CMS issued guidance for states to use in establishing PPS 

rates for payment of demonstration services. Under the PPS methodology, Medicaid payment is based on 

individual clinic’s expected cost of care.

To support states in determining these clinic-specific rates, CMS provided extensive technical assistance 

through webinars, publicly posted questions and answers on Medicaid.gov, held calls with individual 

states, and responded to 1,100 detailed questions submitted to the CMS CCBHC PPS electronic mailbox. 

CMS also provided states the opportunity to use an OMB-approved CCBHC Cost Report and CCBHC 

Cost Report Instructions created expressly for this demonstration. Designed to allow providers to capture 

the expected cost of care as well as document current costs, the CCBHC Cost Report was finalized after 

obtaining public comment solicited through a notice in the Federal Register. States had the option of using 

this cost report or a state-developed reporting tool.

Section 223 Demonstration Programs to Improve 

Community Mental Health Services Prospective Payment 

System (PPS) Guidance was released as Appendix III 

to the CCBHCs Planning Grants RFA noted above. 

The guidance provided information on identifying, 

reporting, and allocating allowable costs for two 

CCBHC PPS methodology options:

• Certified Clinic Prospective Payment System 

(CC PPS-1) uses a daily PPS methodology, 

which means that CCBHCs receive a fixed daily, 

clinic-specific rate when at least one of the nine 

required demonstration services has been 

provided to a Medicaid beneficiary. The rate is 

intended to reimburse providers their expected 

cost of care.

Under this methodology, a state may choose to offer a quality bonus payment (QBP). In order to 

receive a QBP, the CCBHC must demonstrate that it has achieved the required quality measures 

noted in Table 2 on page 13. The state can issue QBPs using additional measures but only after the 

certified clinic has met state-determined performance goals for the required set of bonus measures. 

Workgroup of staff members from CCBHCs and state offices 

in Minnesota 
13 

 

TABLE 2: ELIGIBLE MEASURES FOR QUALITY BONUS PAYMENTS REQUIRED 

Follow-up After Hospitalization for Mental Illness (adult age groups) Yes 

Follow-up After Hospitalization for Mental Illness (child/adolescents) Yes 

Adherence to Antipsychotics for Individuals with Schizophrenia Yes 

Initiation and Engagement of Alcohol and Other Drug Dependence Treatment Yes 

Adult Major Depressive Disorder: Suicide Risk Assessment Yes 

Child and Adolescent Major Depressive Disorder: Suicide Risk Assessment Yes 

Follow-up Care for Children Prescribed ADHD Medication No 

Screening for Clinical Depression and Follow-up Plan No 

Antidepressant Medication Management No 

Plan All-cause Readmission Rate No 

Depression Remission at 12 Months-Adults No 

• CC PPS Alternative (CC PPS-2) uses a monthly PPS methodology that is paid when at least one 

of the nine demonstration services has been delivered during the month. The rate is intended to 

reimburse CCBHCs their expected cost of care. Under the CC PPS-2 methodology, each clinic 

will be assigned at least two monthly PPS rates: (1) a monthly PPS rate for demonstration services 

provided to clinic users who are not necessarily part of a higher need population, and (2) a monthly 

PPS rate to reimburse CCBHCs for the increased costs associated with providing services to higher 

need/special populations. Higher need populations that a state may identify include: adults with 

SMI, children with SED, those with long-term and serious substance misuse, and those with mental 

and substance use disorders. States have flexibility in defining the populations for which separate 

CC PPS-2 rates will be established. Under CC PPS-2, the state is required to incorporate a QBP 

and make a separate outlier payment for reimbursement of costs more than the state’s identified 

threshold. 

A state may choose to update demonstration year (DY) 2 CCBHC PPS rates by rebasing with data 

obtained during DY1 or by trending DY1 rates using the Medicare Economic Index (MEI). The state 

must use either CC PPS-1 or CC PPS-2 for its entire demonstration program, and payment may be made 

fee-for-service or through managed care. 

CMS funds a portion of a state’s Medicaid costs according to federal medical assistance percentages

(FMAPs) calculated by HHS. This rate varies by state and by types of services. During the demonstration,

participating states’ demonstration expenditures will be eligible for an “enhanced FMAP” (the percentage

equivalent to the state’s rates for CHIP services) for covered services delivered to Medicaid beneficiaries

by CCBHCs. To the extent CCBHC services are provided to newly eligible Medicaid beneficiaries

enrolled in the New Adult Eligibility Group, expenditures will be matched at the applicable FMAP.

Expenditures for services to American Indians and Alaska Natives furnished by CCBHCs that are Indian

Health Service or tribal facilities are matched at 100 percent. Finally, for services provided to targeted

low-income children in a CHIP Medicaid expansion program, expenditures are matched at the enhanced

FMAP, including the 23 percent point increase in effect October 1, 2015, to September 30, 2019. CMS has

provided states detailed guidance on how to report demonstration expenditures.
14 

Awarded Grants to States to Plan for the Demonstration Program 

In May 2015, SAMHSA announced the availability of funding to support states in certifying community

behavioral health clinics, establishing PPS rates for Section 223 reimbursable services, soliciting 

stakeholder input, preparing to collect data for the evaluation, and preparing applications to participate 

in a 2-year demonstration program. Many states applied for planning grants and their applications were 

reviewed by a panel of subject matter experts external to the federal government. In October 2015, HHS 

awarded a total of $22.9 million in planning grants to 24 states based on the strength of their applications 

(Figure B). 

24 Planning Grant States 

MA 

NY 

PA 

MI 

IL IN

MO 

IA 

MN 

CO 

OR 

NV 

CA 

AK 

NM 

TX 

OK 

VA 

NC 

KY 

RI 

NJ 

MD 

CT 

FIGURE B: States Awarded Planning Grants 
15 

FIGURE C: Spending 

on CCBHC Planning 

Grant Activities 

Figure C illustrates spending on activities as a proportion of total CCBHC planning grant spending for all 

24 states. States spent most (27 percent) of their grant funding on hiring actuarial firms to establish the 

PPS and nearly the same (26 percent) on training staff and providing other support to clinics to prepare 

for certification. 

The 24 planning grant states devoted 21 percent of their grant funds to data collection and reporting. 

This was primarily to enhance information technology (IT) capabilities for reporting on quality measures 

and other information required of the states participating in the demonstration. During the planning 

grant year, states were also required to electronically enter data on eight grant indicators. Results from 

that data reveal important accomplishments during the planning grant year, well before the CCBHC 

demonstration began. 

Most of the planning grant states implemented 

behavioral health-related training programs during 

the planning grant year. Hundreds of organizations 

participated, increasing the number of credentialed 

or certified staff to provide mental and substance 

use disorder-related services to children and adults 

in community and mobile settings. Certifications/

credentials were in the disciplines of psychiatry 

and psychiatric rehabilitation, social work, 

nursing, pharmacy, case management, and 

peer support. 

Stakeholders participating in a round-table discussion 

of CCBHC work at a behavioral health integration 

event in Oregon 

Twelve percent of planning grant funds were used to engage stakeholders and coordinate statewide efforts 

during the planning grant year. Notably, one-third of the members of the 24 states’ workgroups and 

advisory groups were consumers or the family members of consumers. 

During the 1-year planning period, HHS staff coordinated technical assistance to help states prepare for 

the demonstration program. Staff from ASPE, CMS, and SAMHSA delivered 34 webinars. One-third of 

the webinars were devoted to issues specific to PPS; another third to quality measures, data collection, 

and reporting; and the final third to certifying clinics. HHS staff also distributed 26 technical assistance 

briefs and instruments, hosted numerous cross-agency conference calls with states, and responded to more 

than 1,400 technical questions (combined across all three federal agencies) on a wide range of topics.
16 

 

Prepared to Evaluate the Demonstration Program 

With input from SAMHSA and CMS and reflecting comments received from stakeholders, ASPE 

developed plans to evaluate the demonstration program. As described in the Analysis Plan for the 

Evaluation of the Certified Community Behavioral Health Clinic Demonstration (Brown et al., 2017), 

the evaluation framework reflects structures and processes supporting intended outcomes of the 

demonstration (Figure D). 

STRUCTURES 

Scope of Services 

• Crisis services*

• Screening, assessment,

and diagnosis

• Patient-centered

treatment planning

• Outpatient mental health

and substance use

services

• Outpatient primary care

screening and monitoring*

• Targeted case

management*

• Psychiatric rehabilitation

services*

• Peer suppor t and

family suppor ts*

• Services of armed forces

and veterans

Clinic and State Structures 

• Governance

• Clinical par tnerships

• Prospective payment rates

• Billing systems to suppor t

payment model

PROCESSES 

Improving Access to Care 

• Client outreach

• Care coordination

• Providing care to

underserved groups

• Accessing social services

Monitoring and 

Improving Quality of Care

• Mental health care

• Substance use disorder

treatment

• Physical health care

• Chronic conditions

• CCBHC repor ting to

states/SAMHSA

• Using quality measures

to improve care

Cost Reporting 

• CCBHC cost repor ting

to states

OUTCOMES 

Utilization of Services 

• Outpatient visits

• Inpatient visits

• Emergency depar tment visits

Costs 

• Adequacy of payment rate

• State Medicaid costs

• Federal Medicaid costs

Consumer and Family 

Experiences with Care 

• Getting care when needed

• Perceptions of care

received by CCBHCs

* Service may be delivered by DCOs.

Please see footnote number 4

on page 11.

FIGURE D: Conceptual Model for CCBHC Demonstration Evaluation 
17 

The evaluation will respond to the following five overarching questions:

1. What activities do CCBHCs implement to improve access to care (including participation in 

assisted outpatient treatment)? How does access to care in the demonstration area(s) compare to 

access to care in other parts of the state? 

2. How do CCBHCs implement the full scope of services and maintain the certification requirements 

throughout the demonstration? How does the scope of services provided to CCBHC service 

recipients compare with that provided to other populations and in other service settings? 

3. What is the quality of care provided to CCBHC service recipients? How does the quality of care 

compare with that provided to other populations and in other service settings? 

4. Do the PPS models cover the full cost of care for the CCBHCs? What changes do states make in 

their PPS rates over the course of the demonstration? 

5. What is the impact of the demonstration on inpatient, emergency, and ambulatory service utilization 

rates and state and federal Medicaid costs relative to comparison groups?

To answer these questions, the evaluation team will conduct telephone interviews with state officials and 

representatives of service recipients and family organizations, as well as visit clinics in several states 

and review cost reports, CCBHC quality measures, and Medicaid fee-for-service claims and managed 

care encounters. 

The Puerto Rican Organization to Motivate, Enlighten, and Serve Addicts, Inc. (Promesa) — 

a CCBHC serving downstate New York 
18 

 

 

Selected States to Participate in the Demonstration Program 

Planning grant states were expected to apply to participate in the 2-year 223 demonstration program 

by October 31, 2016. In January 2016, HHS provided planning grantees guidance as they completed 

their applications. The guidance included specific criteria HHS would use to evaluate and score 

applications. At the end of the planning grant period, 19 of the 24 states submitted competitive 

applications to participate in the demonstration program.5 

Applications consisted of three parts, as noted in Table 3.

TABLE 3: APPLICATION COMPONENTS 

Component Contents 

1: Required 

Attachments 

• Verification that CCBHCs will be compliant with CCBHC criteria

• Description of Medicaid populations to be served 

• List of participating CCBHCs and DCOs

• Verification of state agreement to pay for services at the PPS rate

• Description of the scope of services 

• Projection of unexpended funds and how they will be used 

2: Program 

Narrative 

• State’s readiness to participate in the demonstration program 

• Solicitation of input by stakeholders in developing CCBHCs 

• Certification of clinics as CCBHCs

• Development of enhanced data collection and reporting capacity 

• Participation in the national evaluation 

• Projection of the impact of participating in the demonstration program 

3: PPS Methodology 

Description 

• CCBHC PPS rate-setting methodology options 

• Payment to CCBHCs that are FQHCs, clinics, or tribal facilities 

• Cost reporting and documentation requirements 

• Managed care considerations 

• Funding question 

5 Five of the original planning grant states did not pursue the demonstration phase of the grant, citing reasons of discrepancies 

between the CCHBC model and efforts currently underway in the state, too few personnel for an expanded service population, 

too little time for crisis services development, inadequate funding and time to establish and maintain the CCBHC model, 

infeasibility of integrating CCBHCs into managed care, and unanticipated staff turnover.
19 

 

A team of 21 staff from SAMHSA, CMS, and ASPE with expertise in behavioral health service delivery, 

payment, and evaluation objectively reviewed the applications to participate in the demonstration program 

with respect to the criteria provided in the evaluation and scoring guidance. Reviewers assessed strengths 

and weaknesses of each application. The eight states with the highest scores were selected to participate 

in the demonstration program. A key consideration in the selection process was that participating states 

represented a diverse selection of geographic areas, including rural and underserved areas as required 

by statute. SAMHSA notified all applicants about the outcome and provided each applicant a document 

summarizing the application’s strengths and weaknesses. In December 2016, HHS announced the states 

selected to participate in the demonstration: Minnesota, Missouri, Nevada, New Jersey, New York, 

Oklahoma, Oregon, and Pennsylvania (Figure E). 

FIGURE E: States Selected to Participate in the Demonstration Program 
20 

OKLAHOMA: A DECADE-LONG QUEST

With a launch date 3 months earlier than most of the demonstration states, Oklahoma was one of two 

states to initiate CCBHC services on April 1, 2017. “Our clinics were eager and ready to go,” notes Jackie 

Shipp, CCBHC Project Director at the Oklahoma Department of Mental Health and Substance Abuse 

Services, “but remember, this has been a decade-long quest for us. We’ve been working at a system-wide 

level to change our operations and culture for years. Our successes and our lessons learned, combined 

with strong leadership, let us run with new initiatives.”

The implementation of health homes in January 2015 paved the way for Oklahoma’s participation in the 

CCBHC demonstration. Their CCBHCs are health homes that have now been implementing integrated 

care for over 2 years. The three Oklahoma CCBHCs together manage 19 service locations covering 

one-third of the state. Under the CMS-approved model for CCBHCs, they can receive bonus payments 

based on treatment outcomes. This change has promoted a “do whatever it takes” approach to improving 

treatment outcomes for clients and their families. CCBHCs will allow the state and its providers to take 

this philosophy to the next level. Shipp stated, “We chose 

the payment methodology that pushes the hardest on 

providers to really change the business model.” 

North Care Adult Services in Oklahoma City—

one of three CCBHCs in Oklahoma

Two of Oklahoma’s community mental health centers now 

operating as CCBHCs—Grand Lake and NorthCare—

are also recipients of SAMHSA Primary and Behavioral 

Health Care Integration Grants, which seek to improve 

the overall wellness of people with serious mental illness 

(SMI) through provision of primary care services in 

community behavioral health settings. To allow clients 

to easily connect with providers in times of crisis or to 

initiate therapy, the Grand Lake clinic distributes Health 

Insurance Portability and Accountability Act (HIPAA)-

compliant tablet computers configured for that purpose 

only. Law enforcement agencies, juvenile detention facilities, and hospital emergency departments also 

receive the specially configured tablet computers to consult with Grand Lake staff. 

Building on a long-standing tradition of training its clinical staff on trauma-focused cognitive behavioral 

therapy, Oklahoma included it as a required treatment practice to be available at all CCBHCs. Clinics 

are now required to screen for trauma among children and adults. 

Providers’ commitment to change and excitement about the CCBHC demonstration program have 

strengthened in the months since its launch. Informal feedback from provider agencies reveals that 

staff are trained on new processes to ensure the paradigm shift and on the client report card as a tool 

for tracking consumer and agency progress. The report card provides key health indicators, including 

a toxicology/hematology lab test. If results indicate that medication regimes are either not effective or 

not being followed, changes can be implemented in a timely and responsive fashion. 

Staff now feel empowered to provide people with what they need. Most importantly, consumer 

satisfaction of services is higher than ever. Shipp observes, “Consumers and staff have given us 

positive feedback since the CCBHC demonstration program began.” 
21 

 

 

 

 

 

 

 

PART III: THE DEMONSTRATION PROGRAM

This section of the report highlights the applications of the eight states awarded demonstration grants, as 

well as activities associated with the launch of the demonstration programs. For more information about 

the demonstration program in each state, see Appendix A: State Snapshots. 

Anticipated Impact of Participation 

In their demonstration applications, states were required to identify one or more impacts the program will 

have on their system, provider organizations, and individuals receiving services as related to the following 

goals listed in the statute (PAMA of 2014 Section 223, (d)(4)): 

1. Provide the most complete scope of services to individuals eligible for medical assistance under the 

state Medicaid program. 

2. Improve availability of, access to, and participation in services to individuals eligible for medical 

assistance under the state Medicaid program. 

3. Improve availability of, access to, and participation in assisted outpatient mental health treatment in 

the state. 

4. Demonstrate the potential to expand available mental health services in a demonstration area and 

increase the quality of such services without increasing net federal spending. 

States were asked to project the impact of their participation in the demonstration program by 

listing specific measures to show impact, providing baseline data on these measures, explaining the 

data collection and analysis plan, and projecting the impact from baseline to the completion of the 

demonstration program. As depicted in Table 4, most of the demonstration states will show the impact of 

their participation on providing the most complete scope of services (Goal 1) and improving availability 

and access to services (Goal 2). 

TABLE 4: SELECTED GOALS BY STATE 

GOAL STATE 

Goal 1: Complete Scope Minnesota Missouri New Jersey Oklahoma Oregon Pennsylvania 

Goal 2: Improve Access Minnesota Missouri Nevada New Jersey Oklahoma Oregon Pennsylvania 

Goal 3: Improve Access to AOT* Missouri Oklahoma 

Goal 4: Contain Costs New York Pennsylvania 

*Assisted Outpatient Treatment
22 

Data and Reporting Requirements 

In their applications to participate in the demonstration program, states were required to outline plans to 

collect and report data related to 21 required quality measures relevant to the CCBHC criteria. Twelve of 

the quality measures will be calculated by the states using claims and encounter data, and 9 of the quality 

measures will be collected and calculated by participating CCBHCs. 

CCBHC Service Recipients Projected to be Served 

All states awarded demonstration grants included adults with SMI, children with SED, and those with 

substance use disorders in their targeted Medicaid population for CCBHC services. Several states further 

specifically identified subpopulations to receive priority.

• People with opioid use disorders, individuals experiencing homelessness, and veterans are noted in 

several applications. 

• Three of the eight demonstration states focus on the vulnerability of youth who are either in state 

custody, of transition age and at risk of or experiencing an initial onset of psychiatric illnesses and 

substance misuse, or involved with the juvenile justice system. 

• States note the importance of serving individuals with comorbid health conditions by screening 

for multiple key health indicators, including obesity, diabetes, hypertension, and cardiovascular 

conditions in children and adults. 

Based on statute, CCBHCs have a no-refusal policy, meaning that anyone who needs services cannot

be refused service based on their inability to pay or place of residence.

Adolescent room at a Nevada CCBHC
23 

 

The projected number of individuals expected to be served by CCBHCs in each state that received 

a demonstration grant is noted in Table 5.

TABLE 5: PROJECTED NUMBER OF INDIVIDUALS TO BE SERVED BY CCBHCS 

State 

State 

Population 

(in millions) 

CCBHCs 

CCBHC 

Service 

Locations 

DY1 – Total to Receive 

CCBHC Services 

(all pay sources) 

DY1 – Projected 

CCBHC Consumers 

who are Medicaid 

Recipients* 

Minnesota 5.52 6 22 17,600 15,000 

Missouri 6.09 15 201 127,083 87,284 

Nevada 2.94 4 5 7,305 5,844 

New Jersey 8.94 7 20 79,782 50,882 

New York 19.75 13 77 40,000 32,000 

Oklahoma 3.92 3 19 23,076 11,077 

Oregon 4.09 12 21 61,700 50,000 

Pennsylvania 12.80 7 7 24,800 17,800 

Total: 64.05 67 372 381,346 269,887 

*These estimates may include dual-eligible Medicaid and Medicare recipients.

Bridge Counseling Associates in Las Vegas—one of four CCBHCs in Nevada
24 

 

Diversity of Proposed CCBHCs and Service Areas 

The total number of CCBHCs launched is 67, ranging from three to 15 per state. These numbers belie the 

true magnitude of service delivery, however, since CCBHC services are provided at 372 locations in 190 

counties in the eight states (Figure F).

FIGURE F: Map of State Areas Covered by CCBHCs 
25 

 

The CCBHCs include nonprofit and government entities, and many of them are also qualified as health 

homes. Likewise, the number of DCOs engaged by CCBHCs varies across the states. Two states list 

eight DCOs, whereas another state has none. Table 6 lists CCBHCs by type and population density. 

TABLE 6: CCBHC PROFILES BY DEMONSTRATION STATE 

Demonstration 

State 

Number 

of 

CCBHCs* 

Population Density 

of Clinic Service Area 

Organizational 

Structure 

CCBHCs that are 

also certified as...

Number 

of DCOs 

in State 

(numbers 

may 

change) 

Urban Urban/ 

Rural 

Rural/ 

Frontier 

Gov’trun Nonprofit 

Organizations 

Federally 

Qualified

Health 

Centers 

Health 

Homes 

Minnesota 

(CC PPS-1) 6 3 1 2 1 5 0 4 5 

Missouri 

(CC PPS-1) 15 4 5 6 0 15 4 15 3 

Nevada 

(CC PPS-1) 4 2 0 2 0 4 0 0 0 

New Jersey 

(CC PPS-2) 7 6 1 0 1 6 0 5 8 

New York 

(CC PPS-1) 13 6 6 1 0 13 0 0 4 

Oklahoma 

(CC PPS-2) 3 1 1 1 0 3 0 3 2 

Oregon 

(CC PPS-1) 12 4 5 3 3 9 0 0 5 

Pennsylvania 

(CC PPS-1) 7 4 3 0 0 7 0 0 8 

Total: 8 67 30 22 15 5 62 4 27 35 

*

Number in state as of launch date

The selected states included CCBHCs in areas designated by the Health Resources and Services 

Administration (HRSA) as a medically underserved area (MUA), medically underserved population 

(MUP), or mental health professional shortage area (MHPSA). Several states had far greater 

representation of geographic diversity than required. In addition to urban and rural areas, three 

states—Nevada, Oregon, and Minnesota—identified frontier areas that will be served by CCBHCs.6 

• All CCBHCs in three of the funded states (Minnesota, New York, and Oklahoma) will provide 

services to counties designated as either MUA or MUP. 

• In Missouri, 81 percent of the CCBHCs are associated with service areas designated as MUA, 

just under 60 percent of Oregon’s CCBHCs are in a MUA, and 50 percent of the counties where 

CCBHCs operate in New Jersey are in a MUA. 

• All prospective CCBHCs in Nevada are in areas where the entire population lives in a MHPSA. 

Three of Pennsylvania’s CCBHCs are in MHPSAs. 

6 The U.S. Department of Agriculture’s Economic Research Service defines frontier as “territory characterized by some 

combination of low population size and high geographic remoteness.” 
26 

Withdrawal of Clinics 

Originally, states proposed certifying 76 clinics by their respective launch dates. In the months 

between application and launch, a few clinics withdrew from participation for various reasons, including 

the following:

• A hospital-affiliated clinic concluded that it would receive lower reimbursement rates under a 

PPS than it currently receives through the hospital.

• A clinic with multiple service locations was unable to certify them all by the launch date. 

• Two clinics experienced financial losses preventing them from risking involvement in a 

demonstration program. 

• Several clinics were unable to institute IT systems sufficient for billing and data collection by 

the launch date. 

• Several clinics were unable to provide services across the life span and to include both substance 

use and mental disorder treatment by the launch date. 

Scope of Services 

Requirement 4 of the Criteria for the Demonstration Program addresses the scope of services to be 

provided by CCBHCs, either directly or through referral to or formal partnerships with DCOs. Building 

on the common assumption that services will be delivered “in a person-centered and family-centered 

manner,” states conducted needs assessments of the communities to be served by prospective CCBHCs 

to identify cultural and linguistic needs, as well as the types of EBPs that will best meet the needs of 

their population of focus. 

Under the criteria, EBPs that CCBHCs were required to deliver were to be determined by the state. 

The number of EBPs associated with treatment required by each state ranged from two to 18, averaging 

seven per state. In total, 47 different EBPs (31 associated with treatment and 16 associated with 

assessment) were required by the demonstration states; an additional 27 were made optional by the 

demonstration states. EBPs required or made 

optional by at least half of the demonstration 

states are described in Table 7. 

A CCBHC in Trenton, Missouri
27 

TABLE 7: EBPS MOST COMMONLY USED BY NUMBER OF DEMONSTRATION STATES 

Evidence-based Practice (EBP) 

# of States 

Requiring 

EBP 

# of States 

with EBP 

Optional 

Motivational interviewing helps clinicians engage people with mental and substance 

use disorders by expressing empathy and avoiding arguing, developing discrepancy, 

rolling with resistance, and supporting self-efficacy (SAMHSA-HRSA Center for 

Integrated Health Solutions, n.d. a). 

8 0 

Cognitive behavioral therapy teaches individuals in treatment how to recognize 

and stop negative patterns of thinking and behavior (SAMHSA, August 2016). 

6 1 

Trauma treatment that meets the needs of the population of focus includes 

the following: 

• Trauma-focused cognitive behavioral therapy integrates trauma interventions 

with cognitive, behavioral, interpersonal, and family therapy principles to treat 

posttraumatic stress and related emotional and behavioral problems. 

• Trauma-informed care teaches service providers and their organizations about 

the triggers and vulnerabilities of trauma survivors and effective interventions. 

5 2 

Integrated treatment for co-occurring disorders addresses both mental illness 

and substance use, each in the context of the other disorder, through consumercentered treatment planning (SAMHSA, October 2015). 

4 0 

Medication-assisted treatment combines behavioral therapy and medications to 

treat substance use, such as opioids (SAMHSA, November 2016). 

4 0 

Illness management and recovery incorporates strategies for avoiding illness, 

dealing with symptoms, and working with providers on growing beyond mental illness 

(SAMHSA, 2009a). 

2 3 

Assertive Community Treatment offers community-based treatment and support to 

individuals with SMI (SAMHSA, 2008). 

1 3 

Four states required or recommended EBPs on suicide and suicidality, including 

Collaborative Assessment and Management of Suicidality (assesses suicidal risk 

and manages “driver-oriented” treatment), Zero Suicide (relies on a system-wide 

approach to patient safety), and Cognitive Therapy for Suicide Prevention (teaches 

alternative ways of thinking during crises and helps build supportive networks). 

3 1 

PPS Methodology of Demonstration States 

As noted above, two PPS rate methodologies were offered to applicants: the daily rate CC PPS-1 and the 

monthly rate CC PPS-2. All but two of the demonstration states chose CC PPS-1. Five of the six states 

pursuing CC PPS-1 are offering QBPs based on a variety of formulas, including the following: 

• at least 1 percent of total PPS payments;

• approximately 3 percent of total PPS payments;

• 5 percent of total CCBHC payments;
28 

 

• 3.84 percent of total PPS payments for CCBHC services, MCO payments for CCBHC services, 

and applicable wraparound payments; or 

• 10 percent of annual PPS payments in DY1 and up to 15 percent in DY2.

In addition to meeting the required set of quality measures noted in Table 2, three of the CC PPS-1 

demonstration states offering QBPs require other measures, such as adult major depressive disorder 

(suicide risk assessment), adherence to antipsychotics for individuals with schizophrenia, plan all-cause 

readmission rate, suicide attempts, and deaths by suicide. 

The two states pursuing CC PPS-2 do not require additional quality measures. One of those states weighs 

Initiation and Engagement of Alcohol and Other Drug Dependence Treatment more heavily than the other 

required quality measures. 

In their PPS methodology discussions, states also explained the source(s) of cost and visit data used 

to determine the rate for DY1 and how those rates would be updated in DY2. Half of the states 

(Minnesota, Missouri, New York, and Oregon) will update their rates per the MEI; the other half 

(Nevada, Pennsylvania, New Jersey, and Oklahoma) will rebase their PPS rates.

Another aspect of PPS methodology is how the PPS rate will be incorporated into managed care. 

With some exceptions,7

 states selected the choice noted in Table 8. 

TABLE 8: METHODS FOR INCORPORATING CC PPS RATES INTO MANAGED CARE CAPITATION 

Method State 

Require managed care plans to pay a rate to the CCBHCs that other

providers would receive for similar services and then use a supplemental 

payment (wraparound) to ensure payment to CCBHCs is equal to the PPS.

Minnesota 

Nevada 

New York 

Oregon 

Fully incorporate the PPS payment into the managed care capitation rate 

and require the managed care plans to pay the full PPS or its actuarial 

equivalent. 

Missouri 

Pennsylvania 

Launch of Demonstration Programs 

Following the selection and announcement of the demonstration states in December 2016, states needed 

time to complete planning and begin implementing the demonstration program. For some states, that 

meant revising their fiscal year state Medicaid budget and obtaining legislative approval before launching 

the program. To align with the fiscal year calendar, HHS permitted states flexibility in selecting a start 

date of the demonstration program up to July 1, 2017. Oklahoma and Oregon launched their CCBHC 

programs statewide on April 1, and the remaining six states launched theirs on July 1, 2017. Activities 

associated with the launch are described in Appendix A. 

7 Oklahoma indicated that it does not currently have managed care arrangements in its Medicaid program. 

New Jersey does not include behavioral health in most managed care contracts. Medicaid enrollees receiving behavioral 

health benefits through managed Long Term Services and Supports or the Division of Developmental Disabilities in New 

Jersey who do receive services through managed care represent less than 0.5 percent of Medicaid enrollees and were thereby 

excluded from the CCBHC demonstration. 
29 

FURTHER CONSIDERATIONS

The Section 223 demonstration program, slated to end by July 1, 2019, provides states with enhanced 

federal funding to support the provision of EBPs and a comprehensive package of services that are key to 

reducing the burden of care for Medicaid beneficiaries with SMI and substance use disorders. Moreover, 

enhanced funding supports improved quality of care through payment to providers for the achievement

of quality measures. Carefully selected by a team of quality and behavioral health experts, the measures

used for this demonstration quantify the improvement in quality. In turn, providers receive payment for

better care, not just more care. There is good reason to be optimistic as the demonstration features a

comprehensive and integrated array of evidence-based services, reimbursed through a PPS.

Community-Based, Whole-Person Care 

The CCBHC demonstration program is a unique opportunity for participating states to provide 

coordinated community-based mental and substance use disorder services that treat the whole person, 

using a bundled payment methodology and applying EBPs on a consistent basis. Clinic users have access 

to a broad range of primary care and behavioral health services that are comprehensive and integrated.

Comprehensive 

The uniquely broad range of services offered by CCBHCs—from 24-hour crisis services to treatment 

planning, from screening to psychiatric rehabilitation—helps ensure that individuals of all ages and at all 

points in their wellness journey receive the help they need. Comprehensive approaches such as this have 

proven effective. For example, participants of a comprehensive approach to first-episode psychosis 

that incorporates medication management, family psychoeducation, resilience-focused individual therapy, 

and supported employment and education were more likely to remain in treatment, have an improved 

quality of life, and be engaged in work and school than those receiving standard care (Kane et al., 2016). 

A system of care framework—one that offers “a comprehensive spectrum of mental health and other 

necessary services and supports organized into a coordinated network”—for children with SEDs 

has a demonstrated impact on multiple levels. Individually, children receiving these services 

experienced improvements in behavioral and emotional symptoms (e.g., aggression, rule-breaking, 

depression, anxiety), as well as in school attendance and academic performance (Center for Mental 

Health Services, 2014, p. 2). At the family level, caregiving became less burdensome. Community-wide, 

expenses associated with juvenile justice services, residential treatment, and hospitalization decreased. 

Integrated 

In the 1980s, studies of co-occurring mental and substance use disorders resulted in recommendations 

for integrated treatment that addressed both disorders (Drake, Mercer-McFadden, Mueser, McHugo, 

& Bond, 1998). After years of evolution, integrated care is now increasingly used to describe the 

coordination of mental health and substance use care with primary care, noted as “the most effective 

approach to caring for people with multiple healthcare needs” (SAMHSA–HRSA Center for Integrated 

Health Solutions, n.d. b). 
30 

• The American Hospital Association (2012) reported that adults receiving integrated care had 

42 percent fewer visits to the emergency department. Integrated care reduced readmission rates 

to psychiatric hospitals from 17.7 percent to 10.4 percent. Patients with SMI who received 

integrated care instead of usual care were more likely to be screened for cholesterol, hypertension, 

and diabetes; to have their blood pressure tested; to have received a flu vaccine; to be educated 

about smoking, nutrition, and exercise; and to have their medications listed in their chart. Patients 

with depressive disorders who received collaborative care had better functional outcomes than 

those who received usual care. 

• A long-term study of more than 100,000 adult patients who received care from team-based 

providers versus traditional practices revealed that team-based care resulted in higher rates of 

screening for depression, greater adherence to diabetes care protocols, and greater use of selfcare plans. Patients receiving team-based care experienced fewer emergency room visits, 

hospital admissions, and primary care physician encounters (Reiss-Brennan et al., 2016). 

As noted in the Criteria for the Demonstration Program, CCBHCs seek to advance the integration of 

behavioral health and physical health care. 

Value-based Purchasing 

The eight states selected to participate in the Section 223 demonstration program are regarded as 

early adopters of an approach to behavioral health care that is made possible, in part, by a payment 

methodology long used in physical health care that promotes value over volume. Building on its initial 

use of PPS with hospitals in 1983, Medicare now applies PPS to a host of settings: acute inpatient 

hospitals, home health agencies, hospice, hospital outpatient, inpatient psychiatric facilities, inpatient 

rehabilitation facilities, long-term care hospitals, and skilled nursing facilities. Regardless of the setting, 

a PPS promotes equity by ensuring that providers are reimbursed according to the resources actually 

used in providing care. The PPS-2 also limits disincentives to provide care to more costly patients 

because these individuals are allocated more resources. Likewise, access to treatment may improve when 

incentives to turn away patients that may require more resources are removed. Quality is also promoted 

using QBPs that incentivize appropriate treatment and limit disincentives to skimp on treatment.

Effective Practices

CCBHCs’ scope of services draws on a history of what works. In an analysis of lessons learned from 

the evolution of community mental health care over the past 50 years, Drake and Latimer (2012) 

identify several “robust and durable concepts.” These include psychiatric rehabilitation and peer 

support—both of which are incorporated in the CCBHC criteria. The authors list recovery as another 

lesson learned, singling out the role of choice and self-determination. These concepts are intrinsic to 

the patient-centered care in CCBHC criteria. Team-based care speaks to two CCBHC criteria areas: 

staffing and care coordination.
31 

EBPs do not go unmentioned in the list of lessons learned. In the mission to provide high-quality services,

states participating in the CCBHC demonstration program have established required and optional EBPs that

best meet the needs of the people the CCBHCs serve. The majority of the commonly selected EBPs noted

in this report (see page 27) have been considered essential community mental health for the past 20 years

(Drake & Latimer, 2012) and are backed by substantive research.

• Motivational interviewing positively contributes to the treatment of alcohol, tobacco, and 

cannabis use; depression, anxiety, and mood disorders; and numerous physical health issues, 

including medication adherence. Studies show motivational interviewing to be effective for a range 

of ages, from adolescent to elderly patients (Riper et al., 2014; Satre et al., 2016; Dean, 

Britt, Bell, Stanley, & Collings, 2016; Lundah et al., 2013; Moral et al., 2015).

• A review of more than 100 meta-analytic studies on cognitive behavioral therapy revealed its 

significant positive effects on anxiety disorders, somatoform disorders, bulimia, anger control 

problems, and general stress, as well as effectiveness in treating some addiction disorders, positive 

symptoms and secondary outcomes of schizophrenia, and depression (Hofmann, Asnaani, Vonk, 

Sawyer, & Fang, 2012).

• Najavits and Hien’s review of the treatment outcome literature on substance use and posttraumatic 

stress disorder (PTSD) cites more than 20 research studies of trauma-focused cognitive 

behavioral therapy bringing about improvement in PTSD symptoms (2013). Trauma-informed 

care is a cost-effective approach associated with decreases in psychiatric symptoms and substance 

use, improvements in daily functioning, and decreases in hospitalizations and crisis interventions 

(Hopper, Bassuk, & Oliver, 2010).

• Since the 1990s, evidence of the value of integrated treatment for co-occurring disorders 

has grown steadily (McGovern, Lambert-Harris, Gotham, Claus, & Xie, 2014). A 2017 study of 

residential integrated treatment shows a drop in emergency room visits and hospital admissions 

for medical, mental health, and substance use problems from 2,725 visits in the 6 months prior to 

receiving treatment to 901 visits and admissions in the 6 months following treatment. Healthcare 

costs decreased by approximately $3 million (Morse & Bride, 2017).
32 

• Randomized trials, meta-analyses, and large-scale longitudinal studies show that medicationassisted treatment reduces illicit drug use, is cost-effective, and leads to better health (Nosyk 

et al., 2013). A study of deaths from heroin overdose over a 14-year period indicated a 

statistically significant drop in such deaths upon the expansion of opioid agonist treatment 

(Schwartz et al., 2013). 

• A review of 40 controlled studies summarizes that illness management and recovery (IMR) has 

been successfully implemented in a variety of treatment settings, improves service recipients’

ability to manage illness more readily than other services, and reduces the use of high-cost 

psychiatric services (Mueser, 2013). Hospitalizations for psychiatric or physical reasons were 

significantly fewer among studied adults over 50 with SMI who participated in IMR than those 

who received regular care (Bartels et al., 2014).

• Assertive Community Treatment was found most effective in terms of cutting hospital use 

and promoting community reintegration among service recipients with SMI who had frequent 

psychiatric hospitalizations (Bond & Drake, 2015). Another study found assertive community 

treatment was instrumental in increasing service recipients’ ability to navigate a fragmented 

mental health system (Drukker et al., 2014). 

Sustaining Excellence in Mental Health 

Although the demonstration states are currently focused on successfully implementing the demonstration,

many of them are planning to sustain certain aspects of the model beyond the demonstration period. 

This may require additional state funding and changes to a state’s Medicaid program, as the enhanced 

FMAP will expire. The EBPs and services implemented by CCBHCs will no longer be supported by 

Medicaid unless they are covered in the state Medicaid plan. States will no longer be compelled to 

collect quality measures on CCBHCs or use them for QBPs. Lastly, states will no longer need to adhere 

to practice standards for CCBHCs as intended by Congress. To reduce these impacts, state behavioral 

health agencies are meeting with Medicaid officials to extend Medicaid payment for services beyond 

the demonstration period through waiver authority or amending the Medicaid state plan, seeking state 

legislative appropriation to continue state Medicaid matching funds for 2019, and collecting returnon-investment data, particularly on electronic patient registries, data collection, and service costs.
33 

APPENDIX A: STATE SNAPSHOTS

The CCBHCs 

Minnesota’s six CCBHCs offer services at 22 locations, covering 18 

urban, rural, and frontier counties. Nearly all sites are in medically 

underserved areas (MUAs) and mental health professional shortage 

areas (MHPSAs). Five of the CCBHCs are operated by nonprofit 

organizations, and one is operated by a local government agency.

Improving Quality and Access 

Minnesota hopes to improve behavioral healthcare access to veterans, 

tribal entities, persons of color, and non-native English speakers 

during the demonstration. Minnesota’s goal is to provide access to all 

nine CCBHC services within 10 days. It is expected that the number 

of consumers served will increase by approximately 10 percent 

with the launch of CCBHCs. To meet CCBHC standards, one of the 

clinics added children’s services and two sought state certification in 

children’s therapeutic treatment, another became licensed to provide 

treatment for substance use disorders, and all six clinics added 

substance use withdrawal management services. The CCBHCs hired 

many licensed professionals and certified peer specialists, increased 

the use of telemedicine in rural and urban clinics, and engaged 

more providers to deliver additional services, such as primary care 

screening and care coordination.

Paying for CCBHC Services 

Minnesota chose the Certified Clinic Prospective Payment System 

(CC PPS-1) for the demonstration and will offer quality bonus 

payments to CCBHCs that achieve six required quality measures. 

The state recently added $50 million in funding for behavioral health 

services and is developing legislation to support the continuation of 

CCBHCs when the 2-year demonstration ends. 

Concurrent State Initiatives 

Four of Minnesota’s CCBHCs are certified as health homes. CCBHC 

consumers who also receive services through the health homes 

will be identified through the state’s Mental Health Information 

System. This reporting system measures changes in employment 

and living situation, diagnostic information, and health indicators. 

Other concurrent state initiatives include training on person-centered 

planning and the integration of the state mental health and substance 

use disorder authority. 

MINNESOTA 

Snapshot of Minnesota’s Demonstration Program and 

Measurement of its Impact 
34 

Projecting the Impact of the State’s Participation in Demonstration Program 

In response to the state’s CCBHC needs assessment, Minnesota will demonstrate the impact of CCBHCs 

on the scope of and access to behavioral health services using the measures below.

Scope of services: 

• The proportion of encounters and persons served by peer services in CCBHCs

Access: 

• The percentage of persons of color and Latinos/Hispanics receiving CCBHC services versus the 

percentage of Medicaid population in the CCBHC service areas

• The percentage of non-primary English speakers receiving CCBHC services versus the percentage 

of Medicaid population in the CCBHC service area

• The number of persons served by telemedicine for allowable services in CCBHCs

• The mean number of days between initial contact and evaluation of new clients

• The percentage of all clients receiving two or more services within 2 months of initial assessment

• The percentage of clients who are persons of color and Latinos/Hispanics receiving two or more 

services within 2 months of initial assessment

• The percentage of non-primary English speaking clients receiving two or more services within 

2 months of initial assessment
35 

The CCBHCs 

The Missouri Department of Behavioral Health (DBH) certified 

15 CCBHCs covering both rural and urban service areas. Three designated collaborating organizations (DCOs) are working with CCBHCs 

in the state to deliver the full scope of services.

Improving Quality and Access 

Through outreach and improved access to services, Missouri estimates 

a 4 percent growth in number of people served. All CCBHCs are 

required to adopt a trauma-informed approach to care by participating 

in a state-led Trauma-informed Care Learning Collaborative or by 

participating in a related DBH-approved initiative. 

Paying for CCBHC Services 

Missouri selected the Certified Clinic Prospective Payment System 

(CC PPS-1) and will make quality bonus payments to CCBHCs 

contingent upon their meeting goals for six measures that demonstrate 

quality and access to care. Clinics that meet or exceed the measures 

will be eligible to receive at least an additional 1 percent of the total 

PPS payments. A PPS daily blended rate provides the specialized array 

of services used to treat adults with serious mental illness (SMI) and 

children and adolescents with serious emotional disturbance (SED). 

Concurrent State Initiatives 

To meet the CCBHC primary care screening and monitoring 

certification criteria, the state required that all clinics be recognized as 

community mental health center healthcare homes under the Medicaid 

health home option. Three of Missouri CCBHCs are also grantees of 

SAMHSA’s Primary and Behavioral Health Care Integration Grants. 

Projecting the Impact of the State’s Participation in 

Demonstration Program 

reduce hospitalizations, homelessness, incarceration, and interaction 

with the criminal justice system while improving the health and 

social outcomes of the patient.” 

Missouri will demonstrate the impact of CCBHCs on the scope 

and availability of, access to, and participation in community 

behavioral health services. The state will also demonstrate the 

impact of CCBHCs on the goal of assisted outpatient treatment “to 

MISSOURI 

Snapshot of Missouri’s Demonstration Program and 

Measurement of its Impact 
36 

The following measures will be used to demonstrate impact.

Scope of services: 

The percentage of CCBHC service areas where 

• certified peer specialists are employed by a CCBHC;

• family support providers are employed by a CCBHC;

• outpatient substance use treatment services are accredited or comply with state certification 

standards; 

• physicians are trained in providing medication-assisted treatment (MAT);

• buprenorphine prescription billings occur;

• the CCBHC is adopting or has adopted Integrated Treatment for Co-occurring Disorders to fidelity;

• clinicians are trained in the use of Eye Movement Desensitization and Reprocessing (an evidencebased practice to treat trauma disorders); 

• a clinician is trained as a tobacco treatment specialist; 

• CCBHCs are engaged in a state-approved Trauma-informed Care Initiative; and 

• CCBHCs are engaged in the Suicide Prevention Learning Collaborative.

Access: 

• The number of certified peer specialists employed by CCBHCs

• The number of family support providers employed by CCBHCs

• The number of unduplicated persons receiving individual peer support services

• The number of unduplicated families receiving individual family support services

• The number of individuals receiving outpatient substance use disorder treatment

• The number of individuals prescribed buprenorphine

• The number of individuals who received metabolic screening 

• The number of individuals served with Medicaid, Medicare, and state funding

Availability of, access to, and participation in services that meet assisted outpatient 

treatment goals: 

• Number of individuals engaged in treatment

• Reduced emergency room visits

• Reduced hospitalizations 

• Reduced homelessness 

• Reduced unemployment 

• Reduced number of arrests
37 

The CCBHCs 

Nevada’s multi-phase application process culminated in the selection 

of four clinics to be certified as CCBHCs and participate in the 

demonstration program—two serve urban counties and two serve 

rural/frontier counties. 

Improving Quality and Access 

Staff training and core treatment requirements of Nevada’s CCBHCs 

have emphasized quality of care and delivery of evidence-based 

practices. Participation in the demonstration program has enabled 

Nevada, through CCBHCs, to increase access to whole health care 

through integrated primary and behavioral health services onsite and 

through the expanded use of telemedicine. 

Paying for CCBHC Services 

Nevada selected the Certified Clinic Prospective Payment System 

(CC PPS-1) and offers quality bonus payments to CCBHCs that meet 

or exceed the six PPS-required quality measures, plus one of the 

following: 

• child and adolescent major depressive disorder suicide 

risk assessment, 

• major depressive disorder suicide risk assessment, 

• antipsychotic medication adherence, 

• adult follow-up after hospital,

• child follow-up after hospital, 

• initiating and engaging in alcohol and other drug 

dependence treatment, or 

• hospitalization readmission rates. 

Nevada requires its managed care plans to pay a rate to CCBHCs that 

other providers would receive for similar services. To reach the level 

of the PPS rate, CCBHCs are paid the base managed care plan rate 

plus a supplemental or wraparound payment to ensure that payments 

are equivalent to the PPS rate. 

NEVADA 

Snapshot of Nevada’s Demonstration Program and 

Measurement of its Impact 
38 

Concurrent State Initiatives 

Several initiatives have prepared and continue to support Nevada and its CCBHCs for the integration 

of care, payment reform, and data collection systems required for the demonstration. In 2014, Nevada 

received a $2 million State Innovation Model (SIM) Grant through the Center for Medicare and Medicaid Innovation. The SIM Project focused on whole-health integrated care across a multipayer system. In 

2015, Nevada’s Division of Child and Family Services received a Children’s Behavioral Health System 

of Care Grant to help develop a comprehensive behavioral health service delivery model for improving 

outcomes through care coordination and evidence-based practices (EBPs). In 2016, Nevada was awarded 

intensive technical assistance on integrating primary and mental health care through the Medicaid 

Innovation Accelerator Program. 

Projecting the Impact of the State’s Participation in Demonstration Program 

Nevada will demonstrate the impact of CCBHCs on the availability of, access to, and participation in 

behavioral health services. The state will measure the

• number of individuals with substance use disorders who have received targeted case management 

services and who report positive outcomes, improved functioning, social connectedness, positive 

quality and appropriateness of care, general satisfaction with services, as well as including status, 

living arrangements, number of arrests in the past 30 days, and frequency of attendance to self-help 

programs;

• number and percent of new clients with an initial evaluation provided within 10 business days and 

the mean number of days until initial evaluation for new clients; 

• frequency of use of crisis services and number of emergency room visits by adult and child 

consumers of the CCBHC;

• percentage of CCBHC members who received follow-up within 7 days and within 30 days of 

discharge following hospitalization for mental illness;

• number of inpatient psychiatric discharges that were followed by an unplanned acute readmission 

for any diagnosis within 30 days of the initial discharge; and 

• percentage of individuals and families who rate their participation in treatment as positive.
39 

The CCBHCs 

New Jersey’s seven CCBHCs are in five urban counties and one 

mixed urban and rural county. CCBHCs collaborate with eight designated collaborating organizations (DCOs) that provide mobile crisis 

services, supported education and employment services, and specialty 

substance use treatment. 

Improving Quality and Access 

New Jersey’s CCBHC design and scope of services align with the 

state’s vision to develop an integrated model of care providing 

comprehensive physical and behavioral health services to children, 

youth, and adults with mental and substance use disorders and to 

improve the availability of, access to, and participation in CCBHC 

services for populations of focus. New Jersey’s CCBHCs are also 

expected to meet service gaps for individuals with substance use 

disorders, expand the use of peer support specialists among that 

population, and increase use of evidence-based practices (EBPs) in 

the counties they serve. 

Paying for CCBHC Services 

New Jersey is one of two states that selected the monthly selected the 

monthly Certified Clinic Prospective Payment System Alternative (CC 

PPS-2). CCBHCs must report all six quality bonus payment (QBP) 

measures to be eligible for a payment and will receive a QBP for 

meeting or exceeding national standards established by the Healthcare 

Effectiveness Data and Information Set. To address the state’s broader 

goal of addressing addictions, New Jersey will weigh measures 

related to the initiation and treatment of substance use more heavily 

in the calculation for QBPs. The cumulative funding of QBPs for all 

clinics is $350,000. 

Concurrent State Initiatives 

New Jersey received $1 million from SAMHSA’s Grants to Prevent 

Prescription Drug/Opioid Overdose-related Deaths in 2016. The state 

is leveraging this opportunity to provide training to the CCBHC staff 

and make naloxone kits available. New Jersey implemented an opioid 

overdose recovery program (OORP) in 11 counties and will expand 

the program to 10 more through SAMHSA’s State Targeted Response 

to the Opioid Crisis Grant. CCBHCs operate in six counties where 

the OORPs are located. Two CCBHCs have received grants to 

integrate care under SAMHSA’s Primary and Behavioral Health 

Care Integration Program. 

NEW JERSEY 

Snapshot of New Jersey’s Demonstration Program and 

Measurement of its Impact 
40 

Projecting the Impact of the State’s Participation in Demonstration Program 

New Jersey chose to demonstrate impact in terms of scope of services and access to services. 

The following measures will be used to demonstrate impact. 

Scope of services: 

• Preventive care and screening: tobacco use—screening and cessation intervention 

• Preventive care and screening: unhealthy alcohol use—screening and brief counseling 

• Number/percent of consumers receiving primary health screens on key indicators 

• Number/percent of consumers receiving a peer recovery support service while in treatment 

• Number/percent of consumers receiving targeted case management 

• Number/percent of families receiving intensive family support services

• Number/percent of consumers receiving supported employment services

• Number/percent of peers employed by agency for mental illness and substance use treatment

• Number/percent of opiate-addicted individuals receiving medication-assisted treatment (MAT) 

Access: 

• Number of new consumers with initial evaluations provided within 10 business days 

• Initiation and engagement of alcohol and other drug dependence treatment

• Follow-up after emergency department visit for mental health-related issues

• Follow-up after emergency department visit for alcohol or other dependence

• Number/percent of treatment admissions into CCBHCs from opioid overdose recovery programs 

• Number/percent of treatment admissions by target group 

• Percent of opioid-addicted individuals receiving MAT

• Number/percent of consumers remaining in treatment for 21 days (engagement)

• Number/percent of consumers remaining in treatment for 90 days (retention) 

• Number/percent of consumers who drop out of treatment 
41 

The CCBHCs 

Twenty-nine provider agencies applied to become CCBHCs in the 

state and 13 completed the process to become certified. Of the 13 

CCBHCs, one serves a rural area, six serve urban areas, and six serve 

mixed urban and rural areas of the state. 

Improving Quality and Access 

New York’s 13 CCBHCs include 77 service locations assisted by 

four designated collaborating organizations to deliver comprehensive 

behavioral health care. Planning grant funds were used to provide 

training to CCBHC staff on evidence-based services and culturally 

appropriate practices. With training and preparation, CCBHCs and 

their staff obtained additional certifications to provide treatment for 

mental and substance use disorders across the life cycle. 

Paying for CCBHC Services 

The state selected the Certified Clinic Prospective Payment System 

(CC PPS-1) and will offer quality bonus payments to CCBHCs that 

meet or exceed the six required quality measures plus three staterequired additional measures. CCBHCs will receive reimbursement 

equal to the PPS rate through a negotiated managed care rate 

supplemented by a state wraparound payment. 

Concurrent State Initiatives 

New York’s 1115 Medicaid waiver includes housing, education, and 

employment for adults with serious mental illness (SMI) and for 

children with serious emotional disturbance (SED). These are the 

same groups of individuals to be served by CCBHCs. New York is 

strengthening its behavioral health safety net by establishing Health 

and Recovery Plans that improve care management for those with 

SMI (also a population of focus for CCBHCs). The state is developing 

health homes with care coordination, which also underpins CCBHCs, 

facilitating strong partnerships with hospitals, primary care providers, 

and community-based behavioral health agencies. 

NEW YORK 

Snapshot of New York’s Demonstration Program and 

Measurement of its Impact 
42 

Projecting the Impact of the State’s Participation in Demonstration Program 

New York will demonstrate the impact of CCBHCs to expand available services and increase their quality 

without increasing net federal spending. Specific measures related to this goal include the following. 

Expand available services: 

• Number/percent of new clients with initial evaluation provided within 10 business days, and mean 

number of days until initial evaluation for new clients

• Number of buprenorphine treatment slots 

• Number of consumers maintained on medication-assisted treatment (MAT)

• Number of emergency department visits for mental and substance use disorders

Increase service quality: 

• Diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic 

medications 

• Follow-up after hospitalization for mental illness

• Follow-up care for children prescribed attention-deficit hyperactivity disorder (ADHD) 

medication 

• Antidepressant medication management

• Initiation and engagement of alcohol and other drug dependence treatment
43 

The CCBHCs 

Oklahoma selected three community mental health centers in areas 

with the highest population densities in the state: two in the central 

region and one in the northeastern region of the state. These three 

CCBHCs cover 17 counties through 19 service locations, including 

one urban, four urban/rural, and 13 rural/frontier areas. 

Improving Quality and Access 

CCBHCs have undertaken several important steps to improve access 

and quality of services for Oklahomans who are American Indians; 

veterans; Hispanic; or lesbian, gay, bisexual, or transgender, including 

staff training, expanding the bilingual workforce and use of translation 

services, and establishing processes for referrals and linkage with the 

Indian Health Service. CCBHCs are making changes to improve the 

physical accessibility of sites, such as installing automated doors for 

people in wheelchairs. Two of the three CCBHCs are issuing specially 

configured and HIPAA-compliant tablet computers to consumers, 

emergency rooms, and police departments to enhance coordinated 

care and connectedness. 

Paying for CCBHC Services 

Oklahoma selected the Certified Clinic Prospective Payment System 

Alternative (CC PPS-2) and set aside $1 million for quality bonus 

payments (QBPs). Under the PPS-2 methodology, QBPs will be paid 

to CCBHCs that meet or exceed PPS-required quality measures. 

Concurrent State Initiatives 

Health home services were authorized under a state plan amendment 

approved by CMS in January 2015 for adults with a serious mental 

illness (SMI) and for children with serious emotional disturbance 

(SED). Clinics had begun implementing integrated care approaches 

as health homes or through SAMHSA Primary and Behavioral Health 

Care Integration Grants before they became CCBHCs.

OKLAHOMA 

Snapshot of Oklahoma’s Demonstration Program and 

Measurement of its Impact 
44 

Projecting the Impact of the State’s Participation in Demonstration Program 

Oklahoma chose three demonstration goals for its program. The first two goals—complete scope of 

services and availability of, access to, and participation in services—are being evaluated in tandem:

• Increase the number of services to adults age 16–25, ensuring age-appropriate services are being 

provided and addressing gaps identified through the needs assessments.

• Increase the number of substance use services provided.

• Increase the number of mobile crisis services, targeting the span of services that the needs 

assessment identified as lacking in the treatment system.

• Increase the number of memoranda of understanding or other formal agreements with consulting 

physicians, ensuring coordination with and inclusion of primary care in the CCBHCs.

• Increase the number of clients served, demonstrating the improved availability to persons who may 

not have been able to access services in the past. 

• Increase the number of clients receiving peer recovery support services.

• Increase the number of clients engaging in treatment as defined by a third and fourth service within 

30 days of the second service, ensuring improved participation in services.

• Increase the number of veterans and military personnel served.

• Increase the number of Hispanics served.

• Increase the number of LGBT individuals served, addressing underserved populations identified 

through the needs assessments.

The third goal—improving the availability of, access to, and participation in assisted outpatient mental 

health treatment—will be measured separately by the following data elements:

• increase in treatment adherence for persons served through the assisted outpatient treatment 

(AOT) program,

• reduction of inpatient hospitalizations for persons served through the AOT program,

• reduction in homelessness for persons served through the AOT program, and

• reduction in arrests/incarceration for persons served through the AOT program to address 

treatment adherence and the desired outcomes of the AOT programs.
45 

The CCBHCs 

Oregon added nine state standards adapted from the health home 

model to the federal CCBHC criteria to certify clinics in the state. 

Through extensive site visits and interviews, 12 clinics were selected 

and certified as CCBHCs. The 12 CCBHCs have 21 service locations 

in 12 counties: four urban, five rural, and three frontier counties. One 

of the CCBHCs is using five designated collaborating organizations 

(DCOs) to deliver services.

Improving Quality and Access 

Oregon expects their CCBHCs to serve 20 to 30 percent more 

individuals than in previous years. The state will focus on providing 

new services at all CCBHCs, including outreach and primary care. 

Paying for CCBHC Services 

The state is using the Certified Clinic Prospective Payment System 

(CC PPS-1). Managed care organizations (MCOs) will pay CCBHCs 

the same rates as other providers and the state will reimburse 

CCBHCs up to the PPS rate. The state did not opt to provide quality 

bonus payments (QBPs) to clinics. 

Concurrent State Initiatives 

The CCBHC demonstration program aligns with Oregon’s Behavioral 

Health Strategic Plan, with a shared focus on the integration of 

behavioral health and primary health care and the use of peer services. 

Projecting the Impact of the State’s Participation in 

Demonstration Program 

Oregon selected goals of providing the most complete scope of 

services and improving availability of, access to, and participation 

in services. 

Scope of services: 

Oregon will measure the number and type of services offered 

by each CCBHC. By tracking both total claims and claims per 

consumer for each clinic by category, Oregon will determine how 

service types have expanded throughout the course of the CCBHC 

demonstration program. The types of services to be tracked are

• crisis; 

• screening, assessment, and diagnosis, including 

risk assessment; 

OREGON 

Snapshot of Oregon’s Demonstration Program and 

Measurement of its Impact 
46 

• patient-centered treatment planning or similar processes, including risk assessment and

crisis planning;

• outpatient mental health and substance use services; 

• outpatient clinic primary care screening and monitoring of key health indicators and health risk;

• targeted case management;

• psychiatric rehabilitation services; and 

• peer support and counselor services and family supports. 

Access: 

• Number of Medicaid patients served (through billing claims)

• Number of staff by clinic and number of staff added as a result of the needs assessment

• Number of new clients who received an initial evaluation within 10 business days

• The mean number of days a client had to wait until receiving an initial evaluation
47 

The CCBHCs 

Pennsylvania selected 16 clinics to participate in the planning grant 

from the 76 that were interested in becoming CCBHCs. Of those, 

seven clinics were certified as CCBHCs. CCBHCs are in urban and 

in mixed urban/rural areas of the state. Some of the CCBHCs have 

formal agreements with designated collaborating organizations 

(DCOs) to provide services. 

Improving Quality and Access 

The vision of Pennsylvania’s behavioral health program is to increase 

access to services, improve quality of care, and contain costs. The 

state will assess the value and cost effectiveness of CCBHCs during 

the demonstration program to test whether primary care screening 

and integrated care with value-based purchasing strategies should be 

extended statewide. 

Paying for CCBHC Services 

Pennsylvania is using the Certified Clinic Prospective Payment System

(CC PPS-1). The state is implementing quality bonus payments

(QBPs) for CCBHCs. CCBHCs must meet or exceed PPS quality

measures as validated by an external quality review organization.

The state’s share of the PPS rate and QBPs will be funded from an

appropriation by the state legislature to the state Medicaid agency.

Concurrent State Initiatives 

The demonstration provides Pennsylvania with an exceptional 

opportunity to test its vision of improving access and quality while 

containing costs. 

Projecting the Impact of the State’s Participation in 

Demonstration Program 

Pennsylvania seeks to demonstrate improved scope of services 

and access to services while expanding mental health services and 

containing costs by measuring improvements in the following areas. 

Scope of services: 

• Number of clinical staff providing the nine core services

per quarter 

• Number of full-time equivalent clinical staff by professional 

category providing the nine core services per quarter

• Number of referrals to specialty providers per month

• Number of referrals for veterans per month

PENNSYLVANIA 

Snapshot of Pennsylvania’s Demonstration Program and 

Measurement of its Impact 
48 

Access: 

• Number of hours of service provided outside of core business hours per month

• Number of units of each service provided per month, including peer support services, certified 

recovery specialist services, and telehealth 

• Number of children who receive at least one CCBHC service in most recent 12 months

• Number of adults who receive at least one CCBHC service in most recent 12 months

• Number of new individuals contacting the CCBHC per month 

• Number of new individuals per month who receive an initial evaluation within 10 days

• Percentage of timely initial evaluations per month

• Average number of days between contact and initial evaluation per month 

• Number of initial depression screenings per month for members 12–17 years using a standardized/ 

validated child depression tool 

• Number of initial depression screenings per month for CCBHC members over age 18 using a 

standardized/validated adult depression tool 

• Number of initial depression screenings with positive results (members over 12 years)

• Number of initial positive screens (members over age 12) with a follow-up plan documented the 

same day in the record 

• Number of unique individuals receiving outpatient drug and alcohol services per month

• Percentage of drug and alcohol outpatient services recipients per month

• Number of unique individuals receiving intensive outpatient drug and alcohol services per month

• Percentage of intensive outpatient drug and alcohol service recipients per month

Expand and increase quality of services without increasing net federal spending: 

• Individual and family satisfaction with services received at the CCBHC, including convenience 

of provider location, satisfaction with provider services, and timeliness and availability of 

appointments 

• Number of evidence-based practices (EBPs) provided each month

• Number of individuals receiving EBPs per month

• Number of staff credentialed to practice each of the EBPs
49 

 

 

 

 

APPENDIX B: GLOSSARY OF ACRONYMS

ADHD Attention-deficit hyperactivity disorder

AOT Assisted outpatient treatment

ASPE Assistant Secretary of Planning and Evaluation 

CCBHC Certified community behavioral health clinic

CC PPS Certified Clinic Prospective Payment System

CHIP Children’s Health Insurance Program

CMS Centers for Medicare & Medicaid Services

DCO Designated collaborating organizations

DY Demonstration year 

EBP Evidence-based practice 

FMAP Federal medical assistance percentage

FQHC Federally qualified health center

HHS Department of Health and Human Services

HIPAA Health Insurance Portability and Accountability Act 

HRSA Health Resources and Services Administration 

IT Information technology 

MAT Medication-assisted treatment 

MCO Managed care organization

MEI Medicare Economic Index 

MHPSA Mental health professional shortage area

MUA Medically underserved area 

MUP Medically underserved population 

OMB Office of Management and Budget

OMHSAS Office of Mental Health and Substance Abuse Services 

PAMA Protecting Access to Medicare Act 

PPS Prospective Payment System 

QBP Quality bonus payment 

SAMHSA Substance Abuse and Mental Health Services Administration 

SED Serious emotional disturbance 

SMI Serious mental illness 
50 

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