Certified Community Behavioral 

Health Clinic (CCBHC) 

CERTIFICATION CRITERIA

Updated March 2023
Certified Community Behavioral Health Clinic Certification Criteria Page i

Acknowledgments

Preparation Notice

The revised Certified Community Behavioral Health Center (CCBHC) certification criteria were developed 

by the Substance Abuse and Mental Health Services Administration (SAMHSA) through the Center for 

Behavioral Health Financing and Integration task order (HHSS283201700031I/75S20322F42003) with 

Westat. 

Electronic Access

This publication can be downloaded at Certified Community Behavioral Health Clinics (CCBHCs) | 

SAMHSA.

Public Domain Notice

All material appearing in this publication is in the public domain and may be reproduced or copied 

without permission from SAMHSA, or the Department of Health and Human Services. Citation of this 

document is appreciated.

Suggested Citation

Substance Abuse and Mental Health Services Administration. Certified Community Behavioral Health 

Center (CCBHC) Certification Criteria. Published February 2023. Accessed [insert access date] at Certified 

Community Behavioral Health Clinics (CCBHCs) | SAMHSA. 
Certified Community Behavioral Health Clinic Certification Criteria Page ii

Table of Contents

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

CCBHC Background and History............................................................................................................ 2 

Development and Expansion of the CCBHC Program........................................................................... 3 

Revised CCBHC Criteria ......................................................................................................................... 4 

The Structure of the Revised Criteria ................................................................................................... 5 

Program Requirement 1: Staffing ................................................................................................................. 6 

Criteria 1.A: General Staffing Requirements ........................................................................................ 6 

Criteria 1.B: Licensure and Credentialing of Providers......................................................................... 7 

Criteria 1.C: Cultural Competence and Other Training......................................................................... 8 

Criteria 1.D: Linguistic Competence ................................................................................................... 10

Program Requirement 2: Availability and Accessibility of Services............................................................ 11

Criteria 2.A: General Requirements of Access and Availability .......................................................... 11

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

Evaluation........................................................................................................................................ 12

Criteria 2.C: 24/7 Access to Crisis Management Services................................................................... 13

Criteria 2.D: No Refusal of Services due to Inability to Pay ................................................................ 14

Criteria 2.E: Provision of Services Regardless of Residence ............................................................... 15

Program Requirement 3: Care Coordination.............................................................................................. 16

Criteria 3.A: General Requirements of Care Coordination ................................................................. 17

Criteria 3.B: Care Coordination and Other Health Information Systems ...........................................18

Criteria 3.C: Care Coordination Partnerships...................................................................................... 20

Criteria 3.D: Care Treatment Team, Treatment Planning, and Care Coordination Activities.............24

Program Requirement 4: Scope of Services................................................................................................ 25

Criteria 4.A: General Service Provisions ............................................................................................. 26

Criteria 4.B: Requirement of Person-Centered and Family-Centered Care........................................26

Criteria 4.C: Crisis Behavioral Health Services.................................................................................... 27

Criteria 4.D: Screening, Assessment, and Diagnosis........................................................................... 29

Criteria 4.E: Person-Centered and Family Centered Treatment Planning..........................................32

Criteria 4.F: Outpatient Mental Health and Substance Use Services.................................................33

Criteria 4.G: Outpatient Clinic Primary Care Screening and Monitoring............................................34

 
Certified Community Behavioral Health Clinic Certification Criteria Page iii

Criteria 4.H: Targeted Case Management Services............................................................................ 36

Criteria 4.I: Psychiatric Rehabilitation Services .................................................................................. 36

Criteria 4.J: Peer Supports, Peer Counseling, and Family/Caregiver Supports...................................37

Criteria 4.K: Intensive, Community-Based Mental Health Care for Members of the Armed Forces 

and Veterans.................................................................................................................................... 38

Program Requirement 5: Quality and Other Reporting.............................................................................. 42

Criteria 5.A: Data Collection, Reporting, and Tracking ....................................................................... 42

Criteria 5.B: Continuous Quality Improvement (CQI) Plan ................................................................. 44

Program Requirement 6: Organizational Authority, Governance, and Accreditation................................45

Criteria 6.A: General Requirements of Organizational Authority and Finances................................. 45

Criteria 6.B: Governance..................................................................................................................... 46

Criteria 6.C: Accreditation................................................................................................................... 48

Appendix A. Terms and Definitions ............................................................................................................ 49

Appendix B. Behavioral Health Clinic Quality Measures ............................................................................ 58

Clinic-Collected Measures .................................................................................................................. 58

State-Collected Measures................................................................................................................... 59

 
Certified Community Behavioral Health Clinic Certification Criteria Page 1

Introduction

The Protecting Access to Medicare Act of 2014 (PAMA, P.L. 113-93), Section 223, directed the 

Department of Health and Human Services (HHS) to publish criteria for clinics to be certified as Certified 

Community Behavioral Health Clinics (CCBHCs). In 2015, HHS issued the original CCBHC certification 

criteria. The criteria established a set of uniform standards that providers must meet to be a CCBHC. By 

meeting these criteria, CCBHCs across the country are transforming systems by providing

comprehensive, coordinated, trauma-informed, and recovery-oriented care for mental health and 

substance use conditions. 

The standards were used by the initial eight states participating in the Section 223 CCBHC 

Demonstration program to certify 67 CCBHCs in 2016. Since then, the CCBHC Section 223 CCBHC 

Demonstration has expanded to two additional states, HHS has supported the development of CCBHCs

through the SAMHSA CCBHC Expansion Grant Program, which was established in 2018, and states have 

supported the development of CCBHCs separate from the Section 223 CCBHC Demonstration. Today, 

there are over 500 CCBHCs across 48 U.S. states, territories, and the District of Columbia. 

What is a Certified Community Behavioral Health Center?

CCBHCs provide:

• Comprehensive, coordinated mental health and substance 

use services appropriate for individuals across the life span

• Increased access to high-quality community mental health 

and substance use care, including crisis care

• Integrated person- and family-centered services, driven by 

the needs and preferences of people receiving services

and their families 

• A range of evidence-based practices, services, and supports 

to meet the needs of their communities

• Services to anyone seeking help for a mental health or substance use condition, regardless of their 

diagnosis, place of residence, or ability to pay. 

Since 2015, a lot has been learned about implementing the CCBHC model. Developments and 

advancements in the mental health and substance use disorder field have also created a need to update 

the criteria in several areas. As a result, HHS is releasing this updated version of the criteria. 

Updates were informed by written feedback from the public, CCBHCs, and states; listening sessions 

where the public, people with lived experience of mental health and substance use conditions, and 

CCBHC stakeholders provided input; and findings from the Section 223 CCBHC Demonstration

evaluation. The updated criteria will guide existing and future CCBHCs. These criteria will ensure that 

individuals who seek CCBHC services can expect the same quality, comprehensive, coordinated care 

regardless of where they reside.

 
Certified Community Behavioral Health Clinic Certification Criteria Page 2

CCBHC Background and History

On April 1, 2014, PAMA was signed into law, establishing the Section 223 CCBHC Demonstration.

1

 A 

cross-HHS partnership supports the CCBHC initiative, including the Substance Abuse and Mental Health 

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

Assistant Secretary of Planning and Evaluation (ASPE). 

PAMA included program requirements that have served as the organizing framework for the CCBHC 

certification criteria. These requirements also guide the updated criteria and include:

1. Staffing 

2. Availability and Accessibility of Services 

3. Care Coordination

4. Scope of Services

5. Quality and Other Reporting

6. Organizational Authority and Governance

PAMA makes clear that, regardless of condition, CCBHCs must provide services to anyone seeking help

for a mental health or substance use condition, regardless of their place of residence, ability to pay, or

age. This includes any individual with a mental or substance use disorder who seeks care, including 

those with serious mental illness (SMI); substance use disorder (SUD) including opioid use disorder and 

severe SUD; children and adolescents with serious emotional disturbance (SED); individuals with cooccurring mental and substance disorders (COD); and individuals experiencing a mental health or 

substance use-related crisis. It also specifies that CCBHCs provide nine required services. 

1 Protecting Access to Medicare Act of 2014.

 
Certified Community Behavioral Health Clinic Certification Criteria Page 3

Development and Expansion of the CCBHC Program

The original CCBHC certification criteria, released in 2015, were based primarily on the requirements in 

PAMA. They were informed by review of state Medicaid Plans, standards for Federally Qualified Health 

Centers and Medicaid Health Homes, and state quality measures. The criteria were refined and finalized 

through a public process that included national listening sessions; consultation with tribal, state, and 

federal leadership; and written public comments. The original criteria were written for states 

participating in the Section 223 CCBHC Demonstration. 

Since then, other funding sources for CCBHCs have emerged. In 2018, SAMHSA was appropriated 

funding for the CCBHC-Expansion Grant Program. Unlike the Section 223 CCBHC Demonstration, which 

was administered through states, the CCBHC-Expansion grants are awarded directly from SAMHSA to 

community provider organizations. Some states are also using existing Medicaid authorities to allow 

CMS-approved payments to CCBHCs that are certified by states but outside of the Section 223 CCBHC 

Demonstration. 

As of September 2022, CCBHCs are primarily funded through three separate funding streams:

1. CCBHCs funded by the Section 223 CCBHC Demonstration. These CCBHCs are managed through 

state Section 223 CCBHC Demonstration programs. They are certified by the state as being in 

compliance with the CCBHC Certification Criteria and are reimbursed via a prospective payment 

system (PPS) for 9 required services defined in the criteria. These CCBHCs may also receive 

SAMHSA expansion grants. 

2. CCBHC-Es funded by SAMHSA expansion grants. These CCBHCs are supported through direct 

SAMHSA grants to the provider organization and the grantee self-attests to compliance with the 

certification criteria. There is no PPS for services provided as a part of the expansion grants and 

there is no required oversight by their state, tribe, or territory. These CCBHCs fund their 

activities using a combination of grant funds and other funding sources (e.g., Medicaid, 

Medicare, state and local funding, other third-party payment). In FY 2022, the expansion grant 

program was divided into two tracks: Planning, Development, and Implementation (PDI) grants 

for new CCBHCs and Improvement and Advancement (IA) grants for existing CCBHCs. 

3. CCBHCs funded through state Medicaid programs separate from the Section 223 CCBHC 

Demonstration. These states use Medicaid state plan or section 1115 demonstration authority, 

not the Section 223 CCBHC Demonstration, to define the CCBHC array of services and payment 

for CCBHC services. These CCBHCs are subject to state oversight through their Medicaid 

programs and may also receive SAMHSA expansion grants.

 
Certified Community Behavioral Health Clinic Certification Criteria Page 4

Revised CCBHC Criteria

The revised CCBHC criteria are applicable to all CCBHCs, regardless of state, tribe, territory, or funding 

stream. The criteria maintain the six program requirements and nine services that anchor the 2015 

criteria. 

The criteria continue to emphasize 

the principles embedded in PAMA, 

including the provision of 

coordinated, person-and familycentered care to help individuals 

recover, be healthy, and live fully 

within their communities. These 

criteria are intended to empower 

people and families to engage with 

their communities in the ways that 

they choose. These criteria are also

designed to support effective 

community-based care that meets 

the legal obligation to provide 

services in the least restrictive 

setting possible. 

In December 2022, HHS released a 

draft of the updated CCBHC Criteria 

after receiving input on the 2015 

criteria from the public, key 

stakeholders, and federal partners. 

After additional public input on 

these draft revised criteria2

, HHS 

developed the version of the 

criteria that is included in this 

document. 

CCBHC Milestones

2014 Initially authorized through Protecting 

Access to Medicare Act of 2014

2015 Released original Certification Criteria, 24 

State Planning Grants awarded

2016

8 States selected to participate in the 

Section 223 CCBHC Demonstration (MN, 

MO, NY, NJ, NV, OK, OR, and PA)

2018

First 52 CCBHC-Expansion Grants awarded 

under Section 520A (42 USC 290bb–32) of 

the Public Health Service Act, as amended

2020-21

2 Additional States added to the Section 

223 CCBHC Demonstration (KY and MI, 

authorized by Coronavirus Aid, Relief, and 

Economic Security Act)

2022

Bipartisan Safer Communities Act 

authorizes addition of up to 10 states to 

the Demonstration every two years

2023 Up to 15 Planning Grants awarded and 

updated Certification Criteria released

2024 Up to 10 States Additional Demonstration 

States Added 

2026+ Additional Demonstration States added The rev every two years ised criteria seek to 

strengthen and update the criteria 

without significantly adding to state 

or clinic burden. SAMHSA updated and revised the criteria to 1) respond to developments in the field 

(e.g., newer terminology, 988 and the crisis continuum, emerging best practices, workforce shortages), 

2) update criteria that are no longer current (e.g., reference to outdated electronic health record 

standards), and 3) address areas suggested by CCBHCs, states, and other stakeholders. 

2 Federal Register :: Request for comments on the initial revised draft of the Update to the Certified Community 

Behavioral Health Clinics certification criteria. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 5

The Structure of the Revised Criteria

The criteria continue to use the six program requirements from PAMA as an organizing structure. At the 

beginning of each program requirement section, the PAMA language is included in a text box. Each of 

the program requirements are numbered, as in the original criteria. In some program requirement 

sections, the numbering of the criteria has changed due to the deletion or addition of criteria. As in the 

original criteria, “notes” are embedded into the criteria to provide clarifications or additional 

information. 

Identifying State Roles and Concerns

A green dot identifies the few criteria, or parts of criteria, that are relevant to 

demonstration states that certify CCBHCs. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 6

Program Requirement 1: Staffing

This program requirement describes: 

a. General staffing requirements, community needs assessment, and staffing plan

b. Licensure and credentialing of providers

c. Training related to cultural competence, trauma-informed care, and other areas

d. Linguistic competence

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

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

“Staffing requirements, including criteria that staff have diverse disciplinary backgrounds, 

have necessary State required license and accreditation, and are culturally and linguistically 

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

Criteria 1.A: General Staffing Requirements 

1.a.1 As part of the process leading to certification and recertification, and before certification or 

attestation, a community needs assessment (see Appendix A: Terms and Definitions for 

required components of the community needs assessment) and a staffing plan that is 

responsive to the community needs assessment are completed and documented. The needs 

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

three years. 

Certifying states may specify additional community needs assessment requirements. 

1.a.2 The staff (both clinical and non-clinical) is appropriate for the population receiving services, 

as determined by the community needs assessment, in terms of size and composition and 

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

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

1.a.3 The Chief Executive Officer (CEO) of the CCBHC, or equivalent, maintains a fully staffed 

management team as appropriate for the size and needs of the clinic, as determined by the 

current community needs assessment and staffing plan. The management team will include, 

at a minimum, a CEO or equivalent/Project Director and a psychiatrist as Medical Director. 

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

Depending on the size of the CCBHC, both positions (CEO or equivalent and the Medical 

Director) may be held by the same person. The Medical Director will provide guidance 

regarding behavioral health clinical service delivery, ensure the quality of the medical 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 7

component of care, and provide guidance to foster the integration3 and coordination of 

behavioral health and primary care. 

Note: If a CCBHC is unable, after reasonable efforts, to employ or contract with a psychiatrist 

as Medical Director, a medically trained behavioral health care professional with prescriptive 

authority and appropriate education, licensure, and experience in psychopharmacology, and 

who can prescribe and manage medications independently, pursuant to state law, may serve 

as the Medical Director. In addition, if a CCBHC is unable to hire a psychiatrist and hires 

another prescriber instead, psychiatric consultation will be obtained regarding behavioral 

health clinical service delivery, quality of the medical component of care, and integration and 

coordination of behavioral health and primary care.

1.a.4 The CCBHC maintains liability/malpractice insurance adequate for the staffing and scope of 

services provided. 

Criteria 1.B: Licensure and Credentialing of Providers

1.b.1 All CCBHC providers who furnish services directly, and any Designated Collaborating 

Organization (DCO) providers that furnish services under arrangement with the CCBHC, are 

legally authorized in accordance with federal, state, and local laws, and act only within the 

scope of their respective state licenses, certifications, or registrations and in accordance 

with all applicable laws and regulations. This includes any applicable state Medicaid billing 

regulations or policies. Pursuant to the requirements of the statute (PAMA § 223 (a)(2)(A)), 

CCBHC providers must have and maintain all necessary state-required licenses, 

certifications, or other credentialing. When CCBHC providers are working toward licensure, 

appropriate supervision must be provided in accordance with applicable state laws. 

1.b.2 The CCBHC staffing plan meets the requirements of the state behavioral health authority 

and any accreditation standards required by the state. The staffing plan is informed by the 

community needs assessment and includes clinical, peer, and other staff. In accordance with 

the staffing plan, the CCBHC maintains a core workforce comprised of employed and

contracted staff. Staffing shall be appropriate to address the needs of people receiving 

services at the CCBHC, as reflected in their treatment plans, and as required to meet

program requirements of these criteria. 

CCBHC staff must include a medically trained behavioral health care provider, either 

employed or available through formal arrangement, who can prescribe and manage 

medications independently under state law, including buprenorphine and other FDAapproved medications used to treat opioid, alcohol, and tobacco use disorders. This would

not include methadone, unless the CCBHC is also an Opioid Treatment Program (OTP). If the 

3 While CCBHCs are not required to provide primary care services, they are required to provide Primary Care 

Screening and Monitoring (See 4.g). CCBHCs may not pay for primary care services under the Section 223 CCBHC 

Demonstration PPS beyond those defined under 4.g. CCBHCs should coordinate with primary care providers to 

support integrated provision of primary and behavioral health care.

 
Certified Community Behavioral Health Clinic Certification Criteria Page 8

CCBHC does not have the ability to prescribe methadone for the treatment of opioid use 

disorder directly, it shall refer to an OTP (if any exist in the CCBHC service area) and provide

care coordination to ensure access to methadone. The CCBHC must have staff, either 

employed or under contract, who are licensed or certified substance use treatment

counselors or specialists. If the Medical Director is not experienced with the treatment of 

substance use disorders, the CCBHC must have experienced4 addiction medicine physicians 

or specialists on staff, or arrangements that ensure access to consultation on addiction 

medicine for the Medical Director and clinical staff. The CCBHC must include staff with 

expertise in addressing trauma and promoting the recovery of children and adolescents with 

serious emotional disturbance (SED) and adults with serious mental illness (SMI). Examples 

of staff include a combination of the following: (1) psychiatrists (including general adult 

psychiatrists and subspecialists), (2) nurses, (3) licensed independent clinical social workers, 

(4) licensed mental health counselors, (5) licensed psychologists, (6) licensed marriage and 

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

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

addiction counselors, (11) certified/trained family peer specialists, (12) medical assistants, 

and (13) community health workers. 

The CCBHC supplements its core staff as necessary in order to adhere to program 

requirements 3 and 4 and individual treatment plans, through arrangements with and 

referrals to other providers. 

Note: Recognizing professional shortages exist for many behavioral health providers5

: (1) 

some services may be provided by contract or part-time staff as needed; (2) in CCBHC 

organizations comprised of multiple locations, providers may be shared across locations; and 

(3) the CCBHC may utilize telehealth/telemedicine, video conferencing, patient monitoring, 

asynchronous interventions, and other technologies, to the extent possible, to alleviate 

shortages, provided that these services are coordinated with other services delivered by the 

CCBHC. The CCBHC is not precluded by anything in this criterion from utilizing providers 

working towards licensure if they are working under the requisite supervision. 

Certifying states should specify which staff disciplines they will require as part of 

certification. 

Criteria 1.C: Cultural Competence and Other Training

1.c.1 The CCBHC has a training plan for all CCBHC employed and contract staff who have direct 

contact with people receiving services or their families. The training plan satisfies and 

includes requirements of the state behavioral health authority and any accreditation 

4 CCBHCs should seek practitioners with experience in the assessment and diagnosis of SUD, substance 

intoxication and withdrawal; pharmacological management of intoxication, withdrawal, and SUDs; ambulatory 

withdrawal management; outpatient addiction treatment; toxicology testing; and pharmacodynamics of 

commonly used substances. 5 Find Shortage Areas by State & County, see HPSA Find (hrsa.gov).

 
Certified Community Behavioral Health Clinic Certification Criteria Page 9

standards on training required by the state. At orientation and at reasonable intervals 

thereafter, the CCBHC must provide training on:

• Evidence-based practices

• Cultural competency (described below)

• Person-centered and family-centered, recovery-oriented planning and services

• Trauma-informed care

• The clinic’s policy and procedures for continuity of operations/disasters 

• The clinic’s policy and procedures for integration and coordination with primary 

care

• Care for co-occurring mental health and substance use disorders

At orientation and annually thereafter, the CCBHC must provide training on risk assessment; 

suicide and overdose prevention and response; and the roles of family and peer staff. 

Trainings may be provided on-line. 

Training shall be aligned with the National Standards for Culturally and Linguistically 

Appropriate Services (CLAS)6 to advance health equity, improve quality of services, and 

eliminate disparities. To the extent active-duty military or veterans are being served, such 

training must also include information related to military culture. Examples of training and 

materials that further the ability of the clinic to provide tailored training for a diverse 

population include, but are not limited to, those available through the HHS website, the 

SAMHSA website,7 the HHS Office of Minority Health, or through the website of the Health 

Resources and Services Administration. 

Note: See criteria 4.k relating to cultural competency requirements in services for veterans. 

1.c.2 The CCBHC regularly assesses the skills and competence of each individual furnishing 

services and, as necessary, provides in-service training and education programs. The CCBHC 

has written policies and procedures describing its method(s) of assessing competency and 

maintains a written accounting of the in-service training provided for the duration of 

employment of each employee who has direct contact with people receiving services. 

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

competency are successfully completed. CCBHCs are encouraged to provide ongoing 

coaching and supervision to ensure initial and ongoing compliance with, or fidelity to, 

evidence-based, evidence-informed, and promising practices. 

6 Access standards at, What is CLAS? - Think Cultural Health (hhs.gov) and Behavioral Health Implementation 

Guide for the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care 

at National Minority Mental Health Awareness Month — New CLAS Implementation Guide (hhs.gov). 7 Suggested resources include the African American Behavioral Health Center of Excellence, LGBTQ+ Behavioral 

Health Equity Center of Excellence, Engage, Educate, Empower for Equity: E4 Center of Excellence for Behavioral 

Health Disparities in Aging, and Asian American, Native Hawaiian, and Pacific Islander Behavioral Health Center 

of Excellence. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 10

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

and experience.

Criteria 1.D: Linguistic Competence

1.d.1 The CCBHC takes reasonable steps to provide meaningful access to services, such as 

language assistance, for those with Limited English Proficiency (LEP) and/or language-based 

disabilities. 

1.d.2 Interpretation/translation service(s) are readily available and appropriate for the size/needs 

of the LEP CCBHC population (e.g., bilingual providers, onsite interpreters, language video or 

telephone line). To the extent interpreters are used, such translation service providers are 

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

1.d.3 Auxiliary aids and services are readily available, Americans with Disabilities Act (ADA) 

compliant, and responsive to the needs of people receiving services with physical, cognitive, 

and/or developmental disabilities (e.g., sign language interpreters, teletypewriter (TTY) 

lines). 

1.d.4 Documents or information vital to the ability of a person receiving services to access CCBHC 

services (e.g., registration forms, sliding scale fee discount schedule, after-hours coverage, 

signage) are available online and in paper format, in languages commonly spoken within the 

community served, taking account of literacy levels and the need for alternative formats. 

Such materials are provided in a timely manner at intake and throughout the time a person 

is served by the CCBHC. Prior to certification, the needs assessment will inform which 

languages require language assistance, to be updated as needed.

1.d.5 The CCBHC’s policies have explicit provisions for ensuring all employees, affiliated providers, 

and interpreters understand and adhere to confidentiality and privacy requirements 

applicable to the service provider. These include, but are not limited to, the requirements of 

the Health Insurance Portability and Accountability Act (HIPAA) (Pub. L. No. 104-191, 110 

Stat. 1936 (1996)), 42 CFR Part 2, and other federal and state laws, including patient privacy 

requirements specific to the care of minors. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 11

Program Requirement 2: Availability and Accessibility 

of Services

This program requirement describes: 

a. General requirements of access and availability

b. Requirements for timely access to services and assessment

c. Access to Crisis Management Services

d. Provision of services regardless of ability to pay and residence

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

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

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

available and accessible 24 hours a day, the use of a sliding scale for payment, and no 

rejection for services or limiting of services on the basis of a patient’s ability to pay or a place 

of residence.”

Criteria 2.A: General Requirements of Access and Availability

2.a.1 The CCBHC provides a safe, functional, clean, sanitary, and welcoming environment for 

people receiving services and staff, conducive to the provision of services identified in 

program requirement 4. CCBHCs are encouraged to operate tobacco-free campuses. 

2.a.2 Informed by the community needs assessment, the CCBHC ensures that services are 

provided during times that facilitate accessibility and meet the needs of the population 

served by the CCBHC, including some evening and weekend hours.

2.a.3 Informed by the community needs assessment, the CCBHC provides services at locations 

that ensure accessibility and meet the needs of the population to be served, such as settings 

in the community (e.g., schools, social service agencies, partner organizations, community 

centers) and, as appropriate and feasible, in the homes of people receiving services. 

2.a.4 The CCBHC provides transportation or transportation vouchers for people receiving services

to the extent possible with relevant funding or programs in order to facilitate access to 

services in alignment with the person-centered and family-centered treatment plan. 

2.a.5 The CCBHC uses telehealth/telemedicine, video conferencing, remote patient monitoring, 

asynchronous interventions, and other technologies, to the extent possible, in alignment 

with the preferences of the person receiving services to support access to all required 

services. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 12

2.a.6 Informed by the community needs assessment, the CCBHC conducts outreach, engagement, 

and retention activities to support inclusion and access for underserved individuals and

populations.

8

2.a.7 Services are subject to all state standards for the provision of both voluntary and courtordered services.

2.a.8 The CCBHC has a continuity of operations/disaster plan. The plan will ensure the CCBHC is 

able to effectively notify staff, people receiving services, and healthcare and community 

partners when a disaster/emergency occurs or services are disrupted. The CCBHC, to the 

extent feasible, has identified alternative locations and methods to sustain service delivery 

and access to behavioral health medications during emergencies and disasters. The plan also 

addresses health IT systems security/ransomware protection and backup and access to 

these IT systems, including health records, in case of disaster. 

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

Comprehensive Evaluation

2.b.1 All people new to receiving services, whether requesting or being referred for behavioral 

health services at the CCBHC, will, at the time of first contact, whether that contact is inperson, by telephone, or using other remote communication, receive a preliminary triage, 

including risk assessment, to determine acuity of needs. That preliminary triage may occur 

telephonically. If the triage identifies an emergency/crisis need, appropriate action is taken 

immediately (see 4.c.1 for crisis response timelines and detail about required services), 

including plans to reduce or remove risk of harm and to facilitate any necessary subsequent 

outpatient follow-up. 

• If the triage identifies an urgent need, clinical services are provided, including an

initial evaluation within one business day of the time the request is made. 

• If the triage identifies routine needs, services will be provided and the initial 

evaluation completed within 10 business days.

• For those presenting with emergency or urgent needs, the initial evaluation may be 

conducted by phone or through use of technologies for telehealth/telemedicine 

and video conferencing, but an in-person evaluation is preferred. If the initial 

evaluation is conducted telephonically, once the emergency is resolved, the person 

receiving services must be seen in person at the next subsequent encounter and 

the initial evaluation reviewed. 

8 Underserved individuals and populations includes communities as defined in Federal Register: Advancing Racial 

Equity and Support for Underserved Communities Through the Federal Government as well as individuals or 

populations that have unmet needs for mental health and substance use disorder treatment and supports. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 13

The preliminary triage and risk assessment will be followed by: (1) an initial evaluation and 

(2) a comprehensive evaluation, with the components of each specified in program 

requirement 4. At the CCBHC’s discretion, recent information may be reviewed with the 

person receiving services and incorporated into the CCBHC health records from outside 

providers to help fulfill these requirements. Each evaluation must build upon what came 

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

new people receiving services will receive a comprehensive evaluation to be completed 

within 60 calendar days of the first request for services. If the state has established 

independent screening and assessment processes for certain child and youth populations or 

other populations, the CCBHC should establish partnerships to incorporate findings and 

avoid duplication of effort. This requirement does not preclude the initiation or completion 

of the comprehensive evaluation, or the provision of treatment during the 60-day period. 

Note: Requirements for these screenings and evaluations are specified in criteria 4.d. 

2.b.2 The person-centered and family-centered treatment plan is reviewed and updated as 

needed by the treatment team, in agreement with and endorsed by the person receiving 

services. The treatment plan will be updated when changes occur with the status of the 

person receiving services, based on responses to treatment or when there are changes in 

treatment goals. The treatment plan must be reviewed and updated no less frequently than 

every 6 months, unless the state, federal, or applicable accreditation standards are more 

stringent.

2.b.3 People who are already receiving services from the CCBHC who are seeking routine 

outpatient clinical services must be provided an appointment within 10 business days of the 

request for an appointment, unless the state, federal, or applicable accreditation standards 

are more stringent. If a person receiving services presents with an emergency/crisis need, 

appropriate action is taken immediately based on the needs of the person receiving 

services, including immediate crisis response if necessary. If a person already receiving 

services presents with an urgent, non-emergency need, clinical services are generally 

provided within one business day of the time the request is made or at a later time if that is 

the preference of the person receiving services. Same-day and open access scheduling are 

encouraged. 

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

2.c.1 In accordance with program requirement 4.c, the CCBHC provides crisis management 

services that are available and accessible 24 hours a day, seven days a week. 

2.c.2 A description of the methods for providing a continuum of crisis prevention, response, and 

postvention services shall be included in the policies and procedures of the CCBHC and 

made available to the public. 

2.c.3 Individuals who are served by the CCBHC are educated about crisis planning, psychiatric 

advanced directives, and how to access crisis services, including the 988 Suicide & Crisis 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 14

Lifeline (by call, chat, or text) and other area hotlines and warmlines, and overdose 

prevention, if risk is indicated, at the time of the initial evaluation meeting following the 

preliminary triage. Please see 3.a.4. for further information on crisis planning. This includes 

individuals with LEP or disabilities (i.e., CCBHC provides instructions on how to access 

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

program requirement 1.d). 

2.c.4 In accordance with program requirement 3, the CCBHC maintains a working relationship 

with local hospital emergency departments (EDs). Protocols are established for CCBHC staff 

to address the needs of CCBHC people receiving services in psychiatric crisis who come to 

those EDs.

2.c.5 Protocols, including those for the involvement of law enforcement, are in place to reduce 

delays for initiating services during and following a behavioral health crisis. Shared protocols 

are designed to maximize the delivery of recovery-oriented treatment and services. The

protocols should minimize contact with law enforcement and the criminal justice system, 

while promoting individual and public safety, and complying with applicable state and local 

laws and regulations. 

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

discharge from hospital or ED following a psychiatric crisis. 

2.c.6 Following a psychiatric emergency or crisis, in conjunction with the person receiving 

services, the CCBHC creates, maintains, and follows a crisis plan to prevent and de-escalate 

future crisis situations, with the goal of preventing future crises. 

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

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

2.d.1 The CCBHC ensures: (1) no individuals are denied behavioral health care services, including 

but not limited to crisis management services, because of an individual’s inability to pay for 

such services (PAMA § 223 (a)(2)(B)); and (2) any fees or payments required by the clinic for 

such services will be reduced or waived to enable the clinic to fulfill the assurance described 

in clause (1). 

2.d.2 The CCBHC has a published sliding fee discount schedule(s) that includes all services the 

CCBHC offers pursuant to these criteria. Such fee schedules will be included on the CCBHC 

website, posted in the CCBHC waiting room and readily accessible to people receiving 

services and families. The sliding fee discount schedule is communicated in 

languages/formats appropriate for individuals seeking services who have LEP, literacy 

barriers, or disabilities.

2.d.3 The fee schedules, to the extent relevant, conform to state statutory or administrative 

requirements or to federal statutory or administrative requirements that may be applicable 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 15

to existing clinics; absent applicable state or federal requirements, the schedule is based on 

locally prevailing rates or charges and includes reasonable costs of operation.

2.d.4 The CCBHC has written policies and procedures describing eligibility for and implementation 

of the sliding fee discount schedule. Those policies are applied equally to all individuals 

seeking services. 

Criteria 2.E: Provision of Services Regardless of Residence

2.e.1 The CCBHC ensures no individual is denied behavioral health care services, including but not 

limited to crisis management services, because of place of residence, homelessness, or lack 

of a permanent address. 

2.e.2 The CCBHC has protocols addressing the needs of individuals who do not live close to the

CCBHC or within the CCBHC service area. The CCBHC is responsible for providing, at a 

minimum, crisis response, evaluation, and stabilization services in the CCBHC service area 

regardless of place of residence. The required protocols should address management of the 

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

with clinics in other localities, allowing the CCBHC to refer and track individuals seeking noncrisis services to the CCBHC or other clinics serving the individual’s area of residence. For 

individuals and families who live within the CCBHC’s service area but live a long distance 

from CCBHC clinic(s), the CCBHC should consider use of technologies for 

telehealth/telemedicine, video conferencing, remote patient monitoring, asynchronous 

interventions, and other technologies in alignment with the preferences of the person 

receiving services, and to the extent practical. These criteria do not require the CCBHC to 

provide continuous services including telehealth to individuals who live outside of the 

CCBHC service area. CCBHCS may consider developing protocols for populations that may 

transition frequently in and out of the services area such as children who experience out-ofhome placements and adults who are displaced by incarceration or housing instability. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 16

Program Requirement 3: Care Coordination

This section describes the requirements for:

a. General requirements of care coordination

b. Health information systems

c. Agreements to support care coordination

d. Treatment team, planning, and care coordination activities

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

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

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

ensure seamless transitions for patients across the full spectrum of health services, including 

acute, chronic, and behavioral health needs. Care coordination requirements shall include 

partnerships or formal contracts with the following: 

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

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

services) to the extent such services are not provided directly through the certified 

community behavioral health clinic. 

• Inpatient psychiatric facilities and substance use detoxification, post detoxification 

step-down services, and residential programs. 

• Other community or regional services, supports, and providers, including schools, child 

welfare agencies, and juvenile and criminal justice agencies and facilities, Indian 

Health Service youth regional treatment centers, State licensed and nationally 

accredited child placing agencies for therapeutic foster care service, and other social 

and human services. 

• Department of Veterans Affairs medical centers, independent outpatient clinics, dropin centers, and other facilities of the Department as defined in Section 1801 of title 38, 

United States Code. 

• Inpatient acute care hospitals and hospital outpatient clinics.”

 
Certified Community Behavioral Health Clinic Certification Criteria Page 17

Criteria 3.A: General Requirements of Care Coordination

3.a.1 Based on a person-centered and family-centered treatment plan aligned with the 

requirements of Section 2402(a) of the Affordable Care Act and aligned with state 

regulations and consistent with best practices, the CCBHC coordinates care across the 

spectrum of health services. This includes access to high-quality physical health (both acute 

and chronic) and behavioral health care, as well as social services, housing, educational 

systems, and employment opportunities as necessary to facilitate wellness and recovery of 

the whole person. The CCBHC also coordinates with other systems to meet the needs of the 

people they serve, including criminal and juvenile justice and child welfare.9

 

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

3.a.2 The CCBHC maintains the necessary documentation to satisfy the requirements of HIPAA 

(Pub. L. No. 104-191, 110 Stat. 1936 (1996)), 42 CFR Part 2, and other federal and state 

privacy laws, including patient privacy requirements specific to the care of minors. To 

promote coordination of care, the CCBHC will obtain necessary consents for sharing 

information with community partners where information is not able to be shared under 

HIPAA and other federal and state laws and regulations. If the CCBHC is unable, after 

reasonable attempts, to obtain consent for any care coordination activity specified in 

program requirement 3, such attempts must be documented and revisited periodically. 

Note: CCBHCs are encouraged to explore options for electronic documentation of consent 

where feasible and responsive to the needs and capabilities of the person receiving services. 

See standards within the Interoperability Standards Advisory.10 

3.a.3 Consistent with requirements of privacy, confidentiality, and the preferences and needs of 

people receiving services, the CCBHC assists people receiving services and the families of 

children and youth referred to external providers or resources in obtaining an appointment 

and tracking participation in services to ensure coordination and receipt of supports. 

3.a.4 The CCBHC shall coordinate care in keeping with the preferences of the person receiving 

services and their care needs. To the extent possible, care coordination should be provided, 

as appropriate, in collaboration with the family/caregiver of the person receiving services

and other supports identified by the person. To identify the preferences of the person in the 

event of psychiatric or substance use crisis, the CCBHC develops a crisis plan with each 

person receiving services. At minimum, people receiving services should be counseled about 

the use of the National Suicide & Crisis Lifeline, local hotlines, warmlines, mobile crisis, and 

9 For additional information on care coordination, see Care Coordination | Agency for Healthcare Research and 

Quality (ahrq.gov). 10 The Interoperability Standards Advisory (ISA) process represents the model by which the Office of the National 

Coordinator for Health Information Technology (ONC) will coordinate the identification, assessment, and 

determination of "recognized" interoperability standards and implementation specifications for industry use to 

fulfill specific clinical health IT interoperability needs. More information can be found at Interoperability 

Standards Advisory (ISA) | HealthIT.gov. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 18

stabilization services should a crisis arise when providers are not in their office. Crisis plans 

may support the development of a Psychiatric Advanced Directive, if desired by the person 

receiving services.

11 Psychiatric Advance Directives, if developed, are entered in the 

electronic health record of the person receiving services so that the information is available 

to providers in emergency care settings where those electronic health records are 

accessible. 

3.a.5 Appropriate care coordination requires the CCBHC to make and document reasonable 

attempts to determine any medications prescribed by other providers. To the extent that 

state laws allow, the state Prescription Drug Monitoring Program (PDMP) must be consulted 

before prescribing medications. The PDMP should also be consulted during the 

comprehensive evaluation. Upon appropriate consent to release of information, the CCBHC 

is also required to provide such information to other providers not affiliated with the CCBHC 

to the extent necessary for safe and quality care. 

3.a.6 Nothing about a CCBHC’s agreements for care coordination should limit the freedom of a 

person receiving services to choose their provider within the CCBHC, with its DCOs, or with 

any other provider. 

3.a.7 The CCBHC assists people receiving services and families to access benefits, including 

Medicaid, and enroll in programs or supports that may benefit them.

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

3.b.1 The CCBHC establishes or maintains a health information technology (IT) system that 

includes, but is not limited to, electronic health records.

3.b.2 The CCBHC uses its secure health IT system(s) and related technology tools, ensuring

appropriate protections are in place, to conduct activities such as population health 

management, quality improvement, quality measurement and reporting, reducing 

disparities, outreach, and for research. When CCBHCs use federal funding to acquire, 

upgrade, or implement technology to support these activities, systems should utilize 

nationally recognized, HHS-adopted standards, where available, to enable health 

information exchange.12 For example, this may include simply using common terminology 

mapped to standards adopted by HHS to represent a concept such as race, ethnicity, or 

other demographic information. While this requirement does not apply to incidental use of 

11 Psychiatric Advance Directives are legal instruments that may be used to document a competent person’s 

specific instructions or preferences regarding future mental health treatment. Psychiatric Advance Directives can 

be used to plan for the possibility that someone may lose capacity to give or withhold informed consent to 

treatment during acute episodes of psychiatric illness. For more information visit NRC PAD | National Resource 

Center on Psychiatric Advance Directives (nrc-pad.org). 12 Pursuant to HHS Health IT Alignment policy and Section 13112 of the HITECH Act, recipients and subrecipients of 

award funding which involves acquiring, upgrading and implementing health IT must utilize health IT that meets 

standards and implementation specifications adopted by HHS in 45 CFR part 170, Subpart B, if such standards 

and implementation specifications can support the award activity. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 19

existing IT systems to support these activities when there is no targeted use of program 

funding, CCBHCs are encouraged to explore ways to support alignment with standards 

across data-driven activities.

3.b.3 The CCBHC uses technology that has been certified to current criteria13 under the ONC 

Health IT Certification Program for the following required core set of certified health IT 

capabilities (see footnotes for citations to the required health IT certification criteria and 

standards) that align with key clinical practice and care delivery requirements for CCBHCs:14 

• Capture health information, including demographic information such as race, 

ethnicity, preferred language, sexual and gender identity, and disability status (as 

feasible).15

• At a minimum, support care coordination by sending and receiving summary of 

care records.16

• Provide people receiving services with timely electronic access to view, download, 

or transmit their health information or to access their health information via an API 

using a personal health app of their choice.

17

• Provide evidence-based clinical decision support.18

• Conduct electronic prescribing.19

Note: Under the CCBHC program, CCBHCs are not required to have all these capabilities in 

place when certified or when submitting their attestation but should plan to adopt and use 

technology meeting these requirements over time, consistent with any applicable program 

timeframes. In addition, CCBHCs do not need to adopt a single system that provides all these 

certified capabilities but can adopt either a single system or a combination of tools that 

provide these capabilities. Finally, CCBHC providers who successfully participate in the 

Promoting Interoperability Performance Category of the Quality Payment Program will 

already have health IT systems that successfully meet all the core certified health IT 

capabilities.

3.b.4 The CCBHC will work with DCOs to ensure all steps are taken, including obtaining consent 

from people receiving services, to comply with privacy and confidentiality requirements. 

13 As of February 2023, current criteria are the 2015 Edition of health IT certification criteria, as updated according 

to the 2015 Edition Cures Update. 14 Additional information about health IT products certified to these criteria is available on the Certified Health IT 

Product List (CHPL). 15 United States Core Data for Interoperability (USCDI) standard at 45 CFR 170.213 and “Demographics” criterion at 

§ CFR 170.315(a)(5). 16 “Transitions of care” criterion at § 170.315(b)(1)). 17 “Application access – patient selection” criterion at § 170.315(g)(7); “Application access – all data request” 

criterion at § 170.315(g)(9) and “Standardized API for patient and population services” criterion at § 

170.315(g)(10). 18 “Clinical decision support” criterion at § 170.315(a)(9). 19 “Electronic prescribing” criterion at § 170.215(b)(3).

 
Certified Community Behavioral Health Clinic Certification Criteria Page 20

These include, but are not limited to, those of HIPAA (Pub. L. No. 104-191, 110 Stat. 1936 

(1996)), 42 CFR Part 2, and other federal and state laws, including patient privacy 

requirements specific to the care of minors. 

3.b.5 The CCBHC develops and implements a plan within two-years from CCBHC certification or 

submission of attestation to focus on ways to improve care coordination between the 

CCBHC and all DCOs using a health IT system. This plan includes information on how the 

CCBHC can support electronic health information exchange to improve care transition to 

and from the CCBHC using the health IT system they have in place or are implementing for 

transitions of care. To support integrated evaluation planning, treatment, and care 

coordination, the CCBHC works with DCOs to integrate clinically relevant treatment records 

generated by the DCO for people receiving CCBHC services and incorporate them into the 

CCBHC health record. Further, all clinically relevant treatment records maintained by the 

CCBHC are available to DCOs within the confines of federal and/or state laws governing 

sharing of health records. 

Criteria 3.C: Care Coordination Partnerships

3.c.1 The CCBHC has a partnership establishing care coordination expectations with Federally 

Qualified Health Centers (FQHCs) (and, as applicable, Rural Health Clinics (RHCs)) to provide 

health care services, to the extent the services are not provided directly through the CCBHC. 

For people receiving services who are served by other primary care providers, including but 

not limited to FQHC Look-Alikes and Community Health Centers, the CCBHC has established 

protocols to ensure adequate care coordination. 

Note: These partnerships should be supported by a formal, signed agreement detailing the 

roles of each party. If the partnering entity is unable to enter into a formal agreement, the 

CCBHC may work with the partner to develop unsigned joint protocols that describe 

procedures for working together and roles in care coordination. At a minimum, the CCBHC 

will develop written protocols for supporting coordinated care undertaken by the CCBHC and 

efforts to deepen the partnership over time so that jointly developed protocols or formal 

agreements can be developed. All partnership activities should be documented to support 

partnerships independent of any staff turnover.

3.c.2 The CCBHC has partnerships that establish care coordination expectations with programs 

that can provide inpatient psychiatric treatment, OTP services, medical withdrawal 

management facilities and ambulatory medical withdrawal management providers for 

substance use disorders, and residential substance use disorder treatment programs (if any 

exist within the CCBHC service area). These include tribally operated mental health and 

substance use services including crisis services that are in the service area. The clinic tracks 

when people receiving CCBHC services are admitted to facilities providing the services listed 

above, as well as when they are discharged, unless there is a formal transfer of care to a 

non-CCBHC entity. The CCBHC has established protocols and procedures for transitioning 

individuals from EDs, inpatient psychiatric programs, medically monitored withdrawal 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 21

management services, and residential or inpatient facilities that serve children and youth 

such as Psychiatric Residential Treatment Facilities and other residential treatment facilities, 

to a safe community setting. This includes transfer of health records of services received 

(e.g., prescriptions), active follow-up after discharge, and, as appropriate, a plan for suicide 

prevention and safety, overdose prevention, and provision for peer services. 

Note: These partnerships should be supported by a formal, signed agreement detailing the 

roles of each party. If the partnering entity is unable to enter into a formal agreement, the 

CCBHC may work with the partner to develop unsigned joint protocols that describe 

procedures for working together and roles in care coordination. At a minimum, the CCBHC 

will develop written protocols for supporting coordinated care undertaken by the CCBHC and 

efforts to deepen the partnership over time so that jointly developed protocols or formal 

agreements can be developed. All partnership activities should be documented to support 

partnerships independent of any staff turnover.

Certifying states are encouraged to find ways to incentivize inpatient treatment 

facilities to partner with CCBHCs to establish protocols and procedures for 

transitioning individuals, including real time notification of discharge and record 

transfers that support the seamless delivery of care, maintain recovery, and reduce 

the risk of relapse and injury during transitions. 

3.c.3 The CCBHC has partnerships with a variety of community or regional services, supports, and 

providers. Partnerships support joint planning for care and services, provide opportunities 

to identify individuals in need of services, enable the CCBHC to provide services in 

community settings, enable the CCBHC to provide support and consultation with a 

community partner, and support CCBHC outreach and engagement efforts. CCBHCs are 

required by statute to develop partnerships with the following organizations that operate 

within the service area: 

• Schools 

• Child welfare agencies 

• Juvenile and criminal justice agencies and facilities (including drug, mental 

health, veterans, and other specialty courts)

• Indian Health Service20 youth regional treatment centers 

• State licensed and nationally accredited child placing agencies for therapeutic 

foster care service

• Other social and human services

CCBHCs may develop partnerships with the following entities based on the population 

served, the needs and preferences of people receiving services, and/or needs identified in 

20 The Indian Health Service is an Operating Division within HHS, responsible for providing federal health services 

to American Indians and Alaska Natives.

 
Certified Community Behavioral Health Clinic Certification Criteria Page 22

the community needs assessment. Examples of such partnerships include (but are not 

limited to) the following

• Specialty providers including those who prescribe medications for the treatment 

of opioid and alcohol use disorders 

• Suicide and crisis hotlines and warmlines

• Indian Health Service or other tribal programs 

• Homeless shelters

• Housing agencies

• Employment services systems 

• Peer-operated programs 

• Services for older adults, such as Area Agencies on Aging 

• Aging and Disability Resource Centers 

• State and local health departments and behavioral health and developmental 

disabilities agencies

• Substance use prevention and harm reduction programs

• Criminal and juvenile justice, including law enforcement, courts, jails, prisons, 

and detention centers

• Legal aid

• Immigrant and refugee services

• SUD Recovery/Transitional housing 

• Programs and services for families with young children, including Infants & 

Toddlers, WIC, Home Visiting Programs, Early Head Start/Head Start, and Infant 

and Early Childhood Mental Health Consultation programs

• Coordinated Specialty Care programs for first episode psychosis

• Other social and human services (e.g., intimate partner violence centers, 

religious services and supports, grief counseling, Affordable Care Act Navigators, 

food and transportation programs) 

In addition, the CCBHC has a care coordination partnership with the 988 Suicide & Crisis 

Lifeline call center serving the area in which the CCBHC is located.

Note: These partnerships should be supported by a formal, signed agreement detailing the 

roles of each party or unsigned joint protocols that describe procedures for working together 

and roles in care coordination. At a minimum, the CCBHC will develop written protocols for 

supporting coordinated care undertaken by the CCBHC and efforts to deepen the partnership 

over time so that jointly developed protocols or formal agreements can be developed. All 

partnership activities should be documented to support partnerships independent of any 

staff turnover.

Certifying states may require CCBHCs to establish additional partnerships. 

3.c.4 The CCBHC has partnerships with the nearest Department of Veterans Affairs' medical 

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

 
Certified Community Behavioral Health Clinic Certification Criteria Page 23

multiple Department facilities of different types are located nearby, the CCBHC should work 

to establish care coordination agreements with facilities of each type. 

Note: These partnerships should be supported by a formal, signed agreement detailing the 

roles of each party. If the partnering entity is unable to enter into a formal agreement, the 

CCBHC may work with the partner to develop unsigned joint protocols that describe 

procedures for working together and roles in care coordination. At a minimum, the CCBHC 

will develop written protocols for supporting coordinated care undertaken by the CCBHC and 

efforts to deepen the partnership over time so that jointly developed protocols or formal 

agreements can be developed. All partnership activities should be documented to support 

partnerships independent of any staff turnover.

3.c.5 The CCBHC has care coordination partnerships establishing expectations with inpatient 

acute-care hospitals in the area served by the CCBHC and their associated services/facilities, 

including emergency departments, hospital outpatient clinics, urgent care centers, and 

residential crisis settings. This includes procedures and services, such as peer recovery 

specialist/coaches, to help individuals successfully transition from ED or hospital to CCBHC 

and community care to ensure continuity of services and to minimize the time between 

discharge and follow up. Ideally, the CCBHC should work with the discharging facility ahead 

of discharge to assure a seamless transition. These partnerships shall support tracking when 

people receiving CCBHC services are admitted to facilities providing the services listed 

above, as well as when they are discharged. The partnerships shall also support the transfer 

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

discharge. CCBHCs should request of relevant inpatient and outpatient facilities, for people

receiving CCBHC services, that notification be provided through the Admission-DischargeTransfer (ADT) system. 

The CCBHC will make and document reasonable attempts to contact all people receiving 

CCBHC services who are discharged from these settings within 24 hours of discharge. For all 

people receiving CCBHC services being discharged from such facilities who are at risk for 

suicide or overdose, the care coordination agreement between these facilities and the 

CCBHC includes a requirement to coordinate consent and follow-up services with the person 

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

services or assessed to be no longer at risk. 

Note: These partnerships should be supported by a formal, signed agreement detailing the 

roles of each party. If the partnering entity is unable to enter into a formal agreement, the 

CCBHC may work with the partner to develop unsigned joint protocols that describe 

procedures for working together and roles in care coordination. At a minimum, the CCBHC 

will develop written protocols for supporting coordinated care undertaken by the CCBHC and 

efforts to deepen the partnership over time so that jointly developed protocols or formal 

agreements can be developed. All partnership activities should be documented to support 

partnerships independent of any staff turnover.

 
Certified Community Behavioral Health Clinic Certification Criteria Page 24

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

Activities

3.d.1 The CCBHC treatment team includes the person receiving services and their 

family/caregivers, to the extent the person receiving services desires their involvement or 

when they are legal guardians, and any other people the person receiving services desires to 

be involved in their care. All treatment planning and care coordination activities are personand family-centered and align with the requirements of Section 2402(a) of the Affordable 

Care Act. All treatment planning and care coordination activities are subject to HIPAA (Pub. 

L. No. 104-191, 110 Stat. 1936 (1996)), 42 CFR Part 2, and other federal and state laws, 

including patient privacy requirements specific to the care of minors. 

3.d.2 The CCBHC designates an interdisciplinary treatment team that is responsible, with the 

person receiving services and their family/caregivers, to the extent the person receiving 

services desires their involvement or when they are legal guardians, for directing, 

coordinating, and managing care and services. The interdisciplinary team is composed of 

individuals who work together to coordinate the medical, psychiatric, psychosocial, 

emotional, therapeutic, and recovery support needs of the people receiving services, 

including, as appropriate and desired by the person receiving services, traditional 

approaches to care for people receiving services who are American Indian or Alaska Native

or from other cultural and ethnic groups. 

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

3.d.3 The CCBHC coordinates care and services provided by DCOs in accordance with the current 

treatment plan. 

Note: See program requirement 4 related to scope of service and person-centered and 

family-centered treatment planning. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 25

Program Requirement 4: Scope of Services

This program requirement 

describes the nine services 

delivered by the CCBHC directly or 

through its DCOs, in a manner 

reflecting person-centered and 

family-centered care. 

1. Crisis Services

2. Screening, Assessment, 

and Diagnosis 

3. Person-Centered and 

Family-Centered 

Treatment Planning

4. Outpatient Mental Health 

and Substance Use 

Services 

5. Primary Care Screening 

and Monitoring

6. Targeted Case 

Management Services

7. Psychiatric Rehabilitation 

Services 

8. Peer Supports and 

Family/Caregiver Supports

9. Community Care for 

Uniformed Service 

Members and Veterans

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

The statute requires the published criteria to include criteria 

with respect to the following: 

“Provision (in a manner reflecting person-centered care) of 

the following services which, if not available directly through 

the certified community behavioral health clinic, are provided 

or referred through formal relationships with other providers: 

I. Crisis mental health services, including 24-hour 

mobile crisis teams, emergency crisis intervention 

services, and crisis stabilization. 

II. Screening, assessment, and diagnosis, including risk 

assessment. 

III. Patient-centered treatment planning or similar 

processes, including risk assessment and crisis 

planning. 

IV. Outpatient mental health and substance use 

services. 

V. Outpatient clinic primary care screening and 

monitoring of key health indicators and health risk. 

VI. Targeted case management. 

VII. Psychiatric rehabilitation services. 

VIII. Peer support and counselor services and family 

supports. 

IX. Intensive, community-based mental health care for 

members of the armed forces and veterans, 

particularly those members and veterans located in 

rural areas, provided the care is consistent with 

minimum clinical mental health guidelines 

promulgated by the Veterans Health Administration, 

including clinical guidelines contained in the Uniform 

Mental Health Services Handbook of such 

Administration.” 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 26

Criteria 4.A: General Service Provisions

4.a.1 Whether delivered directly or through a DCO agreement, the CCBHC is responsible for 

ensuring access to all care specified in PAMA. This includes, as more explicitly provided and 

more clearly defined below in criteria 4.c through 4.k the following required services: crisis 

services; screening, assessment and diagnosis; person-centered and family-centered

treatment planning; outpatient behavioral health services; outpatient primary care 

screening and monitoring; targeted case management; psychiatric rehabilitation; peer and 

family supports; and intensive community-based outpatient behavioral health care for 

members of the U.S. Armed Forces and veterans. 

The CCBHC organization will deliver directly the majority (51% or more) of encounters 

across the required services (excluding Crisis Services) rather than through DCOs. 

4.a.2 The CCBHC ensures all CCBHC services, if not available directly through the CCBHC, are 

provided through a DCO, consistent with the freedom of the person receiving services to 

choose providers within the CCBHC and its DCOs. This requirement does not preclude the 

use of referrals outside the CCBHC or DCO if a needed specialty service is unavailable 

through the CCBHC or DCO entities.

4.a.3 With regard to either CCBHC or DCO services, people receiving services will be informed of 

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

minimum requirements of Medicaid and other grievance requirements such as those that 

may be mandated by relevant accrediting entities or state authorities. 

4.a.4 DCO-provided services for people receiving CCBHC services must meet the same quality 

standards as those provided by the CCBHC. The entities with which the CCBHC coordinates 

care and all DCOs, taken in conjunction with the CCBHC itself, satisfy the mandatory aspects 

of these criteria. 

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

4.b.1 The CCBHC ensures all CCBHC services, including those supplied by its DCOs, are provided 

in a manner aligned with the requirements of Section 2402(a) of the Affordable Care Act. 

These reflect person-centered and family-centered, recovery-oriented care; being 

respectful of the needs, preferences, and values of the person receiving services; and 

ensuring both involvement of the person receiving services and self-direction of services 

received. Services for children and youth are family-centered, youth-guided, and 

developmentally appropriate. A shared decision-making model for engagement is the 

recommended approach.

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

planning. See criteria 4.k relating specifically to requirements for services for veterans.

4.b.2 Person-centered and family-centered care is responsive to the race, ethnicity, sexual 

orientation and gender identity of the person receiving services and includes care which 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 27

recognizes the particular cultural and other needs of the individual. This includes, but is not 

limited to, services for people who are American Indian or Alaska Native (AI/AN) or other 

cultural or ethnic groups, for whom access to traditional approaches or medicines may be 

part of CCBHC services. For people receiving services who are AI/AN, these services may be 

provided either directly or by arrangement with tribal organizations. 

Criteria 4.C: Crisis Behavioral Health Services

4.c.1 The CCBHC shall provide crisis services directly or through a DCO agreement with existing 

state-sanctioned, certified, or licensed system or network for the provision of crisis 

behavioral health services. HHS recognizes that state-sanctioned crisis systems may operate 

under different standards than those identified in these criteria. If a CCBHC would like to 

have a DCO relationship with a state-sanctioned crisis system that operates under less 

stringent standards, they must request approval from HHS to do so.21 

Certifying states must request approval from HHS to certify CCBHCs in their states that 

have or seek to have a DCO relationship with a state-sanctioned crisis system with less 

stringent standards than those included in these criteria.22 

PAMA requires provision of these three crisis behavioral health services, whether provided 

directly by the CCBHC or by a DCO: 

• Emergency crisis intervention services: The CCBHC provides or coordinates with 

telephonic, text, and chat crisis intervention call centers that meet 988 Suicide & Crisis 

Lifeline standards for risk assessment and engagement of individuals at imminent risk of 

suicide. The CCBHC should participate in any state, regional, or local air traffic control

(ATC)23 systems which provide quality coordination of crisis care in real-time as well as 

any service capacity registries as appropriate. Quality coordination means that protocols 

have been established to track referrals made from the call center to the CCBHC or its 

DCO crisis care provider to ensure the timely delivery of mobile crisis team response, 

crisis stabilization, and post crisis follow-up care.

• 24-hour mobile crisis teams: The CCBHC provides community-based behavioral health 

crisis intervention services using mobile crisis teams twenty-four hours per day, seven 

days per week to adults, children, youth, and families anywhere within the service area 

including at home, work, or anywhere else where the crisis is experienced. Mobile crisis 

teams are expected to arrive in-person within one hour (2 hours in rural and frontier 

settings) from the time that they are dispatched, with response time not to exceed 3 

hours. Telehealth/telemedicine may be used to connect individuals in crisis to qualified 

21 For questions about this process, please email ccbhc@samhsa.hhs.gov. 22 For questions about this process, please email ccbhc@samhsa.hhs.gov. 23 Air traffic control (ATC) serves as a conceptual model for real-time coordination of crisis care and linkage to crisis 

response services. It may involve real-time connection to GPS-enabled mobile teams, true system-wide access to 

available beds, and outpatient appointment scheduling through the integrated crisis call center. For more 

information see National Guidelines for Behavioral Health Crisis Care | SAMHSA. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 28

mental health providers during the interim travel time. Technologies also may be used 

to provide crisis care to individuals when remote travel distances make the 2-hour 

response time unachievable, but the ability to provide an in-person response must be 

available when it is necessary to assure safety. The CCBHC should consider aligning their 

programs with the CMS Medicaid Guidance on the Scope of and Payments for Qualifying 

Community-Based Mobile Crisis Intervention Services if they are in a state that includes 

this option in their Medicaid state plan.24 

• Crisis receiving/stabilization: The CCBHC provides crisis receiving/stabilization services 

that must include at minimum, urgent care/walk-in mental health and substance use 

disorder services for voluntary individuals. Urgent care/walk-in services that identify the 

individual’s immediate needs, de-escalate the crisis, and connect them to a safe and 

least-restrictive setting for ongoing care (including care provided by the CCBHC). Walk-in 

hours are informed by the community needs assessment and include evening hours that 

are publicly posted. The CCBHC should have a goal of expanding the hours of operation 

as much as possible. Ideally, these services are available to individuals of any level of 

acuity; however, the facility need not manage the highest acuity individuals in this 

ambulatory setting. Crisis stabilization services should ideally be available 24 hours per 

day, 7 days a week, whether individuals present on their own, with a concerned 

individual, such as a family member, or with a human service worker, and/or law 

enforcement, in accordance with state and local laws. In addition to these activities, the 

CCBHC may consider supporting or coordinating with peer-run crisis respite programs. 

The CCBHC is encouraged to provide crisis receiving/stabilization services in accordance 

with the SAMHSA National Guidelines for Behavioral Health Crisis Care.

Services provided must include suicide prevention and intervention, and services capable of 

addressing crises related to substance use including the risk of drug and alcohol related 

overdose and support following a non-fatal overdose after the individual is medically stable.

Overdose prevention activities must include ensuring access to naloxone for overdose 

reversal to individuals who are at risk of opioid overdose, and as appropriate, to their family 

members. The CCBHC or its DCO crisis care provider should offer developmentally 

appropriate responses, sensitive de-escalation supports, and connections to ongoing care, 

when needed. The CCBHC will have an established protocol specifying the role of law 

enforcement during the provision of crisis services. As a part of the requirement to provide 

training related to trauma-informed care, the CCBHC shall specifically focus on the 

application of trauma-informed approaches during crises. 

24 For information on crisis services for children and youth, please see National Guidelines for Child and Youth 

Behavioral Health Crisis Care (samhsa.gov) and A Safe Place to Be: Crisis Stabilization Services and Other 

Supports for Children and Youth (samhsa.gov)

 
Certified Community Behavioral Health Clinic Certification Criteria Page 29

Note: See program requirement 2.c regarding access to crisis services and criterion 3.c.5 

regarding coordination of services and treatment planning, including after discharge from a 

hospital inpatient or emergency department following a behavioral health crisis. 

Criteria 4.D: Screening, Assessment, and Diagnosis

4.d.1 The CCBHC directly, or through a DCO, provides screening, assessment, and diagnosis, 

including risk assessment for behavioral health conditions. In the event specialized services 

outside the expertise of the CCBHC are required for purposes of screening, assessment, or 

diagnosis (e.g., neuropsychological testing or developmental testing and assessment), the 

CCBHC refers the person to an appropriate provider. When necessary and appropriate 

screening, assessment and diagnosis can be provided through telehealth/telemedicine 

services. 

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

planning.

4.d.2 Screening, assessment, and diagnosis are conducted in a time frame responsive to the needs 

and preferences of the person receiving services and are of sufficient scope to assess the 

need for all services required to be provided by the CCBHC. 

4.d.3 The initial evaluation (including information gathered as part of the preliminary triage and 

risk assessment, with information releases obtained as needed), as required in program 

requirement 2, includes at a minimum: 

1. Preliminary diagnoses

2. The source of referral

3. The reason for seeking care, as stated by the person receiving services or other 

individuals who are significantly involved

4. Identification of the immediate clinical care needs related to the diagnosis for mental 

and substance use disorders of the person receiving services

5. A list of all current prescriptions and over-the counter medications, herbal remedies, 

and dietary supplements and the indication for any medications 

6. A summary of previous mental health and substance use disorder treatments with a 

focus on which treatments helped and were not helpful 

7. The use of any alcohol and/or other drugs the person receiving services may be taking 

and indication for any current medications 

8. An assessment of whether the person receiving services is a risk to self or to others, 

including suicide risk factors 

9. An assessment of whether the person receiving services has other concerns for their 

safety, such as intimate partner violence 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 30

10. Assessment of need for medical care (with referral and follow-up as required)

11. A determination of whether the person presently is, or ever has been, a member of the 

U.S. Armed Services 

12. For children and youth, whether they have system involvement (such as child welfare 

and juvenile justice) 

4.d.4 A comprehensive evaluation is required for all people receiving CCBHC services. Subject to 

applicable state, federal, or other accreditation standards, clinicians should use their clinical 

judgment with respect to the depth of questioning within the assessment so that the 

assessment actively engages the person receiving services around their presenting 

concern(s). The evaluation should gather the amount of information that is commensurate 

with the complexity of their specific needs, and prioritize preferences of people receiving 

services with respect to the depth of evaluation and their treatment goals. The evaluation 

shall include: 

1. Reasons for seeking services at the CCBHC, including information regarding onset of 

symptoms, severity of symptoms, and circumstances leading to the presentation to 

the CCBHC of the person receiving services. 

2. An overview of relevant social supports; social determinants of health; and healthrelated social needs such as housing, vocational, and educational status; 

family/caregiver and social support; legal issues; and insurance status. 

3. A description of cultural and environmental factors that may affect the treatment 

plan of the person receiving services, including the need for linguistic services or 

supports for people with LEP.

4. Pregnancy and/or parenting status.

5. Behavioral health history, including trauma history and previous therapeutic 

interventions and hospitalizations with a focus on what was helpful and what was 

not helpful in past treatments. 

6. Relevant medical history and major health conditions that impact current 

psychological status. 

7. A medication list including prescriptions, over-the counter medications, herbal 

remedies, dietary supplements, and other treatments or medications of the person 

receiving services. Include those identified in a Prescription Drug Monitoring 

Program (PDMP) that could affect their clinical presentation and/or 

pharmacotherapy, as well as information on allergies including medication allergies. 

8. An examination that includes current mental status, mental health (including 

depression screening, and other tools that may be used in ongoing measurementbased care) and substance use disorders (including tobacco, alcohol, and other 

drugs). 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 31

9. Basic cognitive screening for cognitive impairment. 

10. Assessment of imminent risk, including suicide risk, withdrawal and overdose risk,

danger to self or others, urgent or critical medical conditions, and other immediate 

risks including threats from another person. 

11. The strengths, goals, preferences, and other factors to be considered in treatment 

and recovery planning of the person receiving services. 

12. Assessment of the need for other services required by the statute (i.e., peer and 

family/caregiver support services, targeted case management, psychiatric 

rehabilitation services). 

13. Assessment of any relevant social service needs of the person receiving services, 

with necessary referrals made to social services. For children and youth receiving 

services, assessment of systems involvement such as child welfare and juvenile 

justice and referral to child welfare agencies as appropriate. 

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

health care professionals, including the primary care provider (with appropriate 

referral and follow-up) of the person receiving services. 

15. The preferences of the person receiving services regarding the use technologies 

such as telehealth/telemedicine, video conferencing, remote patient monitoring,

and asynchronous interventions. 

4.d.5 Screening and assessment conducted by the CCBHC related to behavioral health include 

those for which the CCBHC will be accountable pursuant to program requirement 5 and 

Appendix B of these criteria. The CCBHC should not take non-inclusion of a specific metric in 

Appendix B as a reason not to provide clinically indicated behavioral health screening or 

assessment. 

The state may elect to require specific other screening and monitoring to be provided 

by the CCBHCs beyond those listed in criterion 4.d.4 or Appendix B. 

4.d.6 The CCBHC uses standardized and validated and developmentally appropriate screening and 

assessment tools appropriate for the person and, where warranted, brief motivational 

interviewing techniques to facilitate engagement. 

4.d.7 The CCBHC uses culturally and linguistically appropriate screening tools and approaches that 

accommodate all literacy levels and disabilities (e.g., hearing disability, cognitive 

limitations), when appropriate. 

4.d.8 If screening identifies unsafe substance use including problematic alcohol or other 

substance use, the CCBHC conducts a brief intervention and the person receiving services is 

provided a full assessment and treatment, if appropriate within the level of care of the 

CCBHC, or referred to a more appropriate level of care. If the screening identifies more 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 32

immediate threats to the safety of the person receiving services, the CCBHC will take 

appropriate action as described in 2.b.1. 

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

4.e.1 The CCBHC directly, or through a DCO, provides person-centered and family-centered 

treatment planning, including but not limited to, risk assessment and crisis planning

(CCBHCs may work collaboratively with DCOs to complete these activities). Person-centered 

and family-centered treatment planning satisfies the requirements of criteria 4.e.2 – 4.e.8 

below and is aligned with the requirements of Section 2402(a) of the Affordable Care Act, 

including person receiving services involvement and self-direction. 

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

4.e.2 The CCBHC develops an individualized treatment plan based on information obtained 

through the comprehensive evaluation and the person receiving services’ goals and 

preferences. The plan shall address the person’s prevention, medical, and behavioral health 

needs. The plan shall be developed in collaboration with and be endorsed by the person 

receiving services; their family (to the extent the person receiving services so wishes); and 

family/caregivers of youth and children or legal guardians. Treatment plan development 

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

support care in the least restrictive setting possible. Shared decision making is the preferred 

model for the establishment of treatment planning goals. All necessary releases of 

information shall be obtained and included in the health record as a part of the 

development of the initial treatment plan. 

4.e.3 The CCBHC uses the initial evaluation, comprehensive evaluation, and ongoing screening 

and assessment of the person receiving services to inform the treatment plan and services 

provided. 

4.e.4 Treatment planning includes needs, strengths, abilities, preferences, and goals, expressed in 

a manner capturing the words or ideas of the person receiving services and, when 

appropriate, those of the family/caregiver of the person receiving services. 

4.e.5 The treatment plan is comprehensive, addressing all services required, including recovery 

supports, with provision for monitoring of progress towards goals. The treatment plan is 

built upon a shared decision-making approach. 

4.e.6 Where appropriate, consultation is sought during treatment planning as needed (e.g., eating 

disorders, traumatic brain injury, intellectual and developmental disabilities (I/DD), 

interpersonal violence and human trafficking). 

4.e.7 The person’s health record documents any advance directives related to treatment and 

crisis planning. If the person receiving services does not wish to share their preferences, that 

decision is documented. Please see 3.a.4., requiring the development of a crisis plan with 

each person receiving services. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 33

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

other aspects of person-centered and family-centered treatment planning they will 

require based upon the needs of the population served. Treatment planning 

components that certifying states might consider include: prevention; community 

inclusion and support (housing, employment, social supports); involvement of 

family/caregiver and other supports; recovery planning; and the need for specific 

services required by the statute (i.e., care coordination, physical health services, peer 

and family support services, targeted case management, psychiatric rehabilitation 

services, tailored treatment to ensure cultural and linguistically appropriate services). 

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

4.f.1 The CCBHC directly, or through a DCO, provides outpatient behavioral health care, including 

psychopharmacological treatment. The CCBHC or the DCO must provide evidence-based 

services using best practices for treating mental health and substance use disorders across 

the lifespan with tailored approaches for adults, children, and families. SUD treatment and 

services shall be provided as described in the American Society for Addiction Medicine

Levels 1 and 2.1 and include treatment of tobacco use disorders. In the event specialized or 

more intensive services outside the expertise of the CCBHC or DCO are required for 

purposes of outpatient mental and substance use disorder treatment the CCBHC makes 

them available through referral or other formal arrangement with other providers or, where 

necessary and appropriate, through use of telehealth/telemedicine, in alignment with state

and federal laws and regulations. The CCBHC also provides or makes available through a 

formal arrangement traditional practices/treatment as appropriate for the people receiving 

services served in the CCBHC area. Where specialist providers are not available to provide 

direct care to a particular person receiving CCBHC services, or specialist care is not 

practically available, the CCBHC professional staff may consult with specialized services 

providers for highly specialized treatment needs. For people receiving services with 

potentially harmful substance use, the CCBHC is strongly encouraged to engage the person 

receiving services with motivational techniques and harm reduction strategies to promote 

safety and/or reduce substance use. 

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

planning. 

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

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

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

consider are the following: Motivational Interviewing; Cognitive Behavioral Therapy 

(CBT); Dialectical Behavior Therapy (DBT); Coordinated Specialty Care (CSC) for First 

Episode Psychosis (FEP); Seeking Safety; Assertive Community Treatment (ACT); Forensic 

Assertive Community Treatment (FACT); Long-acting injectable medications to treat 

both mental and substance use disorders; Multi-Systemic Therapy; Trauma-Focused 

Cognitive Behavioral Therapy (TF-CBT); Cognitive Behavioral Therapy for psychosis 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 34

(CBTp); High-Fidelity Wraparound; Parent Management Training; Effective but 

underutilized medications such as clozapine and FDA-approved medications for 

substance use disorders including smoking cessation. This list is not intended to be allinclusive. Certifying states are free to determine whether these or other evidence-based 

treatments may be appropriate as a condition of certification. 

4.f.2 Treatments are provided that are appropriate for the phase of life and development of the 

person receiving services, specifically considering what is appropriate for children, 

adolescents, transition-age youth, and older adults, as distinct groups for whom life stage 

and functioning may affect treatment. When treating children and adolescents, CCBHCs 

must provide evidenced-based services that are developmentally appropriate, youthguided, and family/caregiver-driven. When treating older adults, the desires and functioning

of the individual person receiving services are considered, and appropriate evidence-based 

treatments are provided. When treating individuals with developmental or other cognitive 

disabilities, level of functioning is considered, and appropriate evidence-based treatments 

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

segment of the population being served. CCBHCs are encouraged to use evidence-based

strategies such as measurement-based care (MBC)25 to improve service outcomes. 

4.f.3 Supports for children and adolescents must comprehensively address family/caregiver, 

school, medical, mental health, substance use, psychosocial, and environmental issues. 

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

4.g.1 The CCBHC is responsible for outpatient primary care screening and monitoring of key 

health indicators and health risk. Whether directly provided by the CCBHC or through a DCO, 

the CCBHC is responsible for ensuring these services are received in a timely fashion. 

Prevention is a key component of primary care screening and monitoring services provided 

by the CCBHC. The Medical Director establishes protocols that conform to screening 

recommendations with scores of A and B, of the United States Preventive Services Task 

Force Recommendations (these recommendations specify for which populations screening 

is appropriate) for the following conditions: 

• HIV and viral hepatitis 

• Primary care screening pursuant to CCBHC Program Requirement 5 Quality and 

Other Reporting and Appendix B

• Other clinically indicated primary care key health indicators of children, adults, and 

older adults receiving services, as determined by the CCBHC Medical Director and 

based on environmental factors, social determinants of health, and common 

physical health conditions experienced by the CCBHC person receiving services

population. 

25 Measurement-based care (MBC) is the systematic use of patient-reported information to inform clinical care and 

shared decision-making among clinicians and patients and to individualize ongoing treatment plans: 

Measurement-Based Mental Health Care (va.gov). 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 35

4.g.2 The Medical Director will develop organizational protocols to ensure that screening for 

people receiving services who are at risk for common physical health conditions experienced 

by CCBHC populations across the lifespan. Protocols will include: 

• Identifying people receiving services with chronic diseases; 

• Ensuring that people receiving services are asked about physical health symptoms; 

and 

• Establishing systems for collection and analysis of laboratory samples, fulfilling the 

requirements of 4.g.

In order to fulfill the requirements under 4.g.1 and 4.g.2 the CCBHC should have the ability 

to collect biologic samples directly, through a DCO, or through protocols with an 

independent clinical lab organization. Laboratory analyses can be done directly or through 

another arrangement with an organization separate from the CCBHC. The CCBHC must also 

coordinate with the primary care provider to ensure that screenings occur for the identified 

conditions. If the person receiving services’ primary care provider conducts the necessary 

screening and monitoring, the CCBHC is not required to do so as long as it has a record of 

the screening and monitoring and the results of any tests that address the health conditions 

included in the CCBHCs screening and monitoring protocols developed under 4.g. 

4.g.3 The CCBHC will provide ongoing primary care monitoring of health conditions as identified 

in 4.g.1 and 4.g.2., and as clinically indicated for the individual. Monitoring includes the 

following: 

1. ensuring individuals have access to primary care services; 

2. ensuring ongoing periodic laboratory testing and physical measurement of health 

status indicators and changes in the status of chronic health conditions; 

3. coordinating care with primary care and specialty health providers including 

tracking attendance at needed physical health care appointments; and 

4. promoting a healthy behavior lifestyle. 

Note: The provision of primary care services, outside of primary care screening and 

monitoring as defined in 4.g., is not within the scope of the nine required CCBHC services. 

CCBHC organizations may provide primary care services outside the nine required services, 

but these primary care services cannot be reimbursed through the Section 223 CCBHC 

demonstration PPS. 

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

planning. 

Certifying states may elect to require specific other screening and monitoring to be 

provided by the CCBHCs in addition to the those described in 4.g.

 
Certified Community Behavioral Health Clinic Certification Criteria Page 36

Criteria 4.H: Targeted Case Management Services26

4.h.1 The CCBHC is responsible for providing directly, or through a DCO, targeted case 

management services that will assist people receiving services in sustaining recovery and 

gaining access to needed medical, social, legal, educational, housing, vocational, and other 

services and supports. CCBHC targeted case management provides an intensive level of 

support that goes beyond the care coordination that is a basic expectation for all people 

served by the CCBHC. CCBHC targeted case management should include supports for people

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

from a residential treatment, hospital emergency department, or psychiatric hospitalization.

CCBHC targeted case management should also be used accessible during other critical 

periods, such as episodes of homelessness or transitions to the community from jails or 

prisons. CCBHC targeted case management should be used for individual with complex or 

serious mental health or substance use conditions and for individuals who have a short-term 

need for support in a critical period, such as an acute episode or care transition. Intensive 

case management and team-based intensive services such as through Assertive Community 

Treatment are strongly encouraged but not required as a component of CCBHC services. 

Based upon the needs of the population served, states should specify the scope of 

other CCBHC targeted case management services that will be required, and the specific 

populations for which they are intended.

Criteria 4.I: Psychiatric Rehabilitation Services

4.i.1 The CCBHC is responsible for providing directly, or through a DCO, evidence-based 

rehabilitation services for both mental health and substance use disorders. Rehabilitative 

services include services and recovery supports that help individuals develop skills and 

functioning to facilitate community living; support positive social, emotional, and 

educational development; facilitate inclusion and integration; and support pursuit of their 

goals in the community. These skills are important to addressing social determinants of 

health and navigating the complexity of finding housing or employment, filling out 

paperwork, securing identification documents, developing social networks, negotiating with 

property owners or property managers, paying bills, and interacting with neighbors or coworkers.

27 Psychiatric rehabilitation services must include supported employment programs 

designed to provide those receiving services with on-going support to obtain and maintain 

competitive, integrated employment (e.g., evidence-based supported employment, 

customized employment programs, or employment supports run in coordination with 

26 CCBHC targeted case management services are separate from and do not follow state targeted case 

management rules under the Medicaid state plan or waivers. 27 For more information, see Social Determinants of Health (SDOH) State Health Official (SHO) Letter 

(medicaid.gov). 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 37

Vocational Rehabilitation or Career One-Stop services). Psychiatric rehabilitation services 

must also support people receiving services to:

• Participate in supported education and other educational services;

• Achieve social inclusion and community connectedness;

• Participate in medication education, self-management, and/or individual and 

family/caregiver psycho-education; and

• Find and maintain safe and stable housing.

Other psychiatric rehabilitation services that might be considered include training in 

personal care skills; community integration services; cognitive remediation; facilitated 

engagement in substance use disorder mutual help groups and community supports; 

assistance for navigating healthcare systems; and other recovery support services including 

Illness Management & Recovery, financial management, and dietary and wellness 

education. These services may be provided or enhanced by peer providers. 

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

planning.

Certifying states should specify which evidence-based and other psychiatric 

rehabilitation services they will require based upon the needs of the population served

above the minimum requirements described in 4.i. 

Criteria 4.J: Peer Supports, Peer Counseling, and Family/Caregiver Supports

4.j.1 The CCBHC is responsible for directly providing, or through a DCO, peer supports, including 

peer specialist and recovery coaches, peer counseling, and family/caregiver supports. Peer 

services may include: peer-run wellness and recovery centers; youth/young adult peer 

support; recovery coaching; peer-run crisis respites28; warmlines; peer-led crisis planning; 

peer navigators to assist individuals transitioning between different treatment programs 

and especially between different levels of care; mutual support and self-help groups; peer 

support for older adults; peer education and leadership development; and peer recovery 

services. Potential family/caregiver support services that might be considered include: 

community resources education; navigation support; behavioral health and crisis support; 

parent/caregiver training and education; and family-to-family caregiver support. 

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

planning. 

Certifying states should specify the scope of peer and family services they will require 

based upon the needs of the population served.

28 For more information, see National Guidelines for Behavioral Health Crisis Care. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 38

Criteria 4.K: Intensive, Community-Based Mental Health Care for Members of 

the Armed Forces and Veterans

4.k.1 The CCBHC is responsible for providing directly, or through a DCO, intensive, communitybased behavioral health care for certain members of the U.S. Armed Forces and veterans, 

particularly those Armed Forces members located 50 miles or more (or one hour’s drive 

time) from a Military Treatment Facility (MTF) and veterans living 40 miles or more (driving 

distance) from a VA medical facility, or as otherwise required by federal law. Care provided 

to veterans is required to be consistent with minimum clinical mental health guidelines 

promulgated by the Veterans Health Administration (VHA), including clinical guidelines 

contained in the Uniform Mental Health Services Handbook of such Administration. The 

provisions of these criteria in general and, specifically in criteria 4.k, are designed to assist 

the CCBHC in providing quality clinical behavioral health services consistent with the 

Uniform Mental Health Services Handbook. 

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

planning.

4.k.2 All individuals inquiring about services are asked whether they have ever served in the U.S. 

military. 

Current Military Personnel: Persons affirming current military service will be offered 

assistance in the following manner: 

1. Active Duty Service Members (ADSM) must use their servicing MTF, and their MTF 

Primary Care Managers (PCMs) are contacted by the CCBHC regarding referrals 

outside the MTF. 

2. ADSMs and activated Reserve Component (Guard/Reserve) members who reside 

more than 50 miles (or one hour’s drive time) from a military hospital or military 

clinic enroll in TRICARE PRIME Remote and use the network PCM, or select any 

other authorized TRICARE provider as the PCM. The PCM refers the member to 

specialists for care he or she cannot provide and works with the regional managed 

care support contractor for referrals/authorizations. 

3. Members of the Selected Reserves, not on Active Duty (AD) orders, are eligible for 

TRICARE Reserve Select and can schedule an appointment with any TRICAREauthorized provider, network or non-network. 

Veterans: Persons affirming former military service (veterans) are offered assistance to 

enroll in VHA for the delivery of health and behavioral health services. Veterans who decline 

or are ineligible for VHA services will be served by the CCBHC consistent with minimum 

clinical mental health guidelines promulgated by the VHA. These include clinical guidelines 

contained in the Uniform Mental Health Services Handbook as excerpted below (from VHA 

Handbook 1160.01, Principles of Care found in the Uniform Mental Health Services in VA 

Centers and Clinics). 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 39

Note: See also program requirement 3 requiring coordination of care across settings and 

providers, including facilities of the Department of Veterans Affairs. 

4.k.3 The CCBHC ensures there is integration or coordination between the care of substance use 

disorders and other mental health conditions for those veterans who experience both, and 

for integration or coordination between care for behavioral health conditions and other 

components of health care for all veterans.

4.k.4 Every veteran seen for behavioral health services is assigned a Principal Behavioral Health 

Provider. When veterans are seeing more than one behavioral health provider and when 

they are involved in more than one program, the identity of the Principal Behavioral Health 

Provider is made clear to the veteran and identified in the health record. The Principal 

Behavioral Health Provider is identified on a tracking database for those veterans who need 

case management. The Principal Behavioral Health Provider ensures the following 

requirements are fulfilled: 

1. Regular contact is maintained with the veteran as clinically indicated if ongoing care 

is required. 

2. A psychiatrist or such other independent prescriber as satisfies the current 

requirements of the VHA Uniform Mental Health Services Handbook reviews and 

reconciles each veteran’s psychiatric medications on a regular basis. 

3. Coordination and development of the veteran’s treatment plan incorporates input 

from the veteran (and, when appropriate, the family with the veteran’s consent 

when the veteran possesses adequate decision-making capacity or with the 

veteran’s surrogate decision maker’s consent when the veteran does not have 

adequate decision-making capacity). 

4. Implementation of the treatment plan is monitored and documented. This must 

include tracking progress in the care delivered, the outcomes achieved, and the 

goals attained. 

5. The treatment plan is revised, when necessary.29

6. The principal therapist or Principal Behavioral Health Provider communicates with 

the veteran (and the veteran's authorized surrogate or family or friends when 

appropriate and when veterans with adequate decision-making capacity consent) 

about the treatment plan, and for addressing any of the veteran’s problems or 

concerns about their care. For veterans who are at high risk of losing decision 

making capacity, such as those with a diagnosis of schizophrenia or schizoaffective 

disorder, such communications need to include discussions regarding future 

29 These services must still meet the basic CCBHC requirements to review and update every 6 months in criterion 

2.b.2. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 40

behavioral health care treatment (see information regarding Advance Care Planning 

Documents in VHA Handbook 1004.2). 

7. The treatment plan reflects the veteran’s goals and preferences for care and that 

the veteran verbally consents to the treatment plan in accordance with VHA 

Handbook 1004.1, Informed Consent for Clinical Treatments and Procedures. If the 

Principal Behavioral Health Provider suspects the veteran lacks the capacity to make 

a decision about the mental health treatment plan, the provider must ensure the 

veteran’s decision-making capacity is formally assessed and documented. For 

veterans who are determined to lack capacity, the provider must identify the 

authorized surrogate and document the surrogate’s verbal consent to the treatment 

plan.

4.k.5 Behavioral health services are recovery-oriented. The VHA adopted the National Consensus 

Statement on Mental Health Recovery in its Uniform Mental Health Services Handbook. 

SAMHSA has since developed a working definition and set of principles for recovery 

updating the Consensus Statement. Recovery is defined as “a process of change through 

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

reach their full potential.” The following are the 10 guiding principles of recovery: 

• Hope 

• Person-driven 

• Many pathways 

• Holistic 

• Peer support 

• Relational 

• Culture 

• Addresses trauma 

• Strengths/responsibility 

• Respect30 

As implemented in VHA recovery, the recovery principles also include the following: 

• Privacy 

• Security 

• Honor 

Care for veterans must conform to that definition and to those principles in order to satisfy 

the statutory requirement that care for veterans adheres to guidelines promulgated by the 

VHA. 

30 See SAMHSA’s Working Definition of Recovery. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 41

4.k.6 All behavioral health care is provided with cultural competence. 

1. Any staff who is not a veteran has training about military and veterans’ culture in 

order to be able to understand the unique experiences and contributions of those 

who have served their country. 

2. All staff receive cultural competency training on issues of race, ethnicity, age, sexual 

orientation, and gender identity.

4.k.7 There is a behavioral health treatment plan for all veterans receiving behavioral health 

services. 

1. The treatment plan31 includes the veteran’s diagnosis or diagnoses and documents 

consideration of each type of evidence-based intervention for each diagnosis. 

2. The treatment plan includes approaches to monitoring the outcomes (therapeutic 

benefits and adverse effects) of care, and milestones for reevaluation of 

interventions and of the plan itself. 

3. As appropriate, the plan considers interventions intended to reduce/manage 

symptoms, improve functioning, and prevent relapses or recurrences of episodes of 

illness. 

4. The plan is recovery oriented, attentive to the veteran’s values and preferences, and 

evidence-based regarding what constitutes effective and safe treatments. 

5. The treatment plan is developed with input from the veteran and, when the veteran 

consents, appropriate family members. The veteran’s verbal consent to the 

treatment plan is required pursuant to VHA Handbook 1004.1. 

31 If the treatment plan section of the electronic health record does not include fields for capturing diagnosis, it 

shall be captured in other areas of the electronic health record.

 
Certified Community Behavioral Health Clinic Certification Criteria Page 42

Program Requirement 5: Quality and Other Reporting

This program requirement describes: 

1. Data collection, reporting, and tracking

2. Continuous quality improvement planning

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

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

“Reporting of encounter data, clinical outcomes data, quality data, and such other data as the 

Secretary requires.”

Criteria 5.A: Data Collection, Reporting, and Tracking

5.a.1 The CCBHC has the capacity to collect, report, and track encounter, outcome, and quality 

data, including, but not limited to, data capturing: (1) characteristics of people receiving 

services; (2) staffing; (3) access to services; (4) use of services; (5) screening, prevention, and 

treatment; (6) care coordination; (7) other processes of care; (8) costs; and (9) outcomes of 

people receiving services. Data collection and reporting requirements are elaborated below 

and in Appendix B. Where feasible, information about people receiving services and care 

delivery should be captured electronically, using widely available standards.

Note: See criteria 3.b for requirements regarding health information systems. 

5.a.2 Both Section 223 Demonstration CCBHCs, and CCBHC-Es awarded SAMHSA discretionary 

CCBHC-Expansion grants beginning in 2022, must collect and report the Clinic-Collected 

quality measures identified as required in Appendix B. Reporting is annual and, for ClinicCollected quality measures, reporting is required for all people receiving CCBHC services. 

CCBHCs are to report quality measures nine (9) months after the end of the measurement 

year as that term is defined in the technical specifications. Section 223 Demonstration 

CCBHCs report the data to their states and CCBHC-Es that are required to report quality 

measure data report it directly to SAMHSA.

States participating in the Section 223 Demonstration must report State-Collected 

quality measures identified as required in Appendix B. The State-Collected measures 

are to be reported for all Medicaid enrollees in the CCBHCs, as further defined in the 

technical specifications. Certifying states also may require certified CCBHCs to collect 

and report any of the optional Clinic-Collected measures identified in Appendix B. 

Section 223 Demonstration program states must advise SAMHSA and its CCBHCs 

which, if any, of the listed optional measures it will require (either State-Collected or 

Clinic-Collected). Whether the measures are State- or Clinic-Collected, all must be 

reported to SAMHSA annually via a single submission from the state twelve (12) 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 43

months after the end of the measurement year, as that term is defined in the 

technical specifications. 

States participating in the Section 223 Demonstration program are expected to share 

the results from the State-Collected measures with their Section 223 Demonstration 

program CCBHCs in a timely fashion. For this reason, Section 223 Demonstration 

program states may elect to calculate their State-Collected measures more frequently 

to share with their Section 223 Demonstration program CCBHCs, to facilitate quality 

improvement at the clinic level.

Quality measures to be reported for the Section 223 Demonstration program may 

relate to services individuals receive through DCOs. It is the responsibility of the 

CCBHC to arrange for access to such data as legally permissible upon creation of the 

relationship with DCOs. CCBHCs should ensure that consent is obtained and 

documented as appropriate, and that releases of information are obtained for each 

affected person. CCBHCs that are not part of the Section 223 Demonstration are not 

required to include data from DCOs into the quality measure data that they report.

Note: CCBHCs may be required to report on quality measures through DCOs as a 

result of participating in a state CCBHC program separate from the Section 223 

Demonstration, such as a program to support the CCBHC model through the state 

Medicaid plan. 

5.a.3 In addition to the State- and Clinic-Collected quality measures described above, 

Section 223 Demonstration program states may be requested to provide CCBHCidentifiable Medicaid claims or encounter data to the evaluators of the Section 223 

Demonstration program annually for evaluation purposes. These data also must be 

submitted to CMS through T-MSIS in order to support the state’s claim for enhanced 

federal matching funds made available through the Section 223 Demonstration 

program. At a minimum, Medicaid claims and encounter data provided by the state to 

the national evaluation team, and to CMS through T-MSIS, should include a unique 

identifier for each person receiving services, unique clinic identifier, date of service, 

CCBHC-covered service provided, units of service provided and diagnosis. Clinic site 

identifiers are very strongly preferred.

In addition to data specified in this program requirement and in Appendix B that the 

Section 223 Demonstration state is to provide, the state will provide other data as 

may be required for the evaluation to HHS and the national evaluation contractor 

annually. 

To the extent CCBHCs participating in the Section 223 Demonstration program are 

responsible for the provision of data, the data will be provided to the state and, as 

may be required, to HHS and the evaluator. CCBHC states are required to submit cost 

reports to CMS annually including years where the state’s rates are trended only and 

not rebased. CCBHCs participating in the Section 223 Demonstration program will 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 44

participate in discussions with the national evaluation team and participate in other 

evaluation-related data collection activities as requested. 

5.a.4 CCBHCs participating in the Section 223 Demonstration program annually submit a 

cost report with supporting data within six months after the end of each Section 223 

Demonstration year to the state. The Section 223 Demonstration state will review the 

submission for completeness and submit the report and any additional clarifying 

information within nine months after the end of each Section 223 Demonstration year 

to CMS. 

Note: In order for a clinic participating in the Section 223 Demonstration Program to 

receive payment using the CCBHC PPS, it must be certified by a Section 223 

Demonstration state as a CCBHC. 

Criteria 5.B: Continuous Quality Improvement (CQI) Plan

5.b.1 In order to maintain a continuous focus on quality improvement, the CCBHC develops, 

implements, and maintains an effective, CCBHC-wide continuous quality improvement (CQI) 

plan for the services provided. The CCBHC establishes a critical review process to review CQI 

outcomes and implement changes to staffing, services, and availability that will improve the 

quality and timeliness of services. The CQI plan focuses on indicators related to improved 

behavioral and physical health outcomes and takes actions to demonstrate improvement in 

CCBHC performance. The CQI plan should also focus on improved patterns of care delivery, 

such as reductions in emergency department use, rehospitalization, and repeated crisis 

episodes. The Medical Director is involved in the aspects of the CQI plan that apply to the 

quality of the medical components of care, including coordination and integration with 

primary care.

5.b.2 The CQI plan is to be developed by the CCBHC and addresses how the CCBHC will review

known significant events including, at a minimum: (1) deaths by suicide or suicide attempts

of people receiving services; (2) fatal and non-fatal overdoses; (3) all-cause mortality among 

people receiving CCBHC services; (4) 30 day hospital readmissions for psychiatric or 

substance use reasons; and (5) such other events the state or applicable accreditation 

bodies may deem appropriate for examination and remediation as part of a CQI plan.

5.b.3 The CQI plan is data-driven and the CCBHC considers use of quantitative and qualitative data 

in their CQI activities. At a minimum, the plan addresses the data resulting from the CCBHCcollected and, as applicable for the Section 223 Demonstration, State-Collected, quality 

measures that may be required as part of the Demonstration. The CQI plan includes an 

explicit focus on populations experiencing health disparities (including racial and ethnic 

groups and sexual and gender minorities) and addresses how the CCBHC will use 

disaggregated data from the quality measures and, as available, other data to track and 

improve outcomes for populations facing health disparities. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 45

Program Requirement 6: Organizational Authority, 

Governance, and Accreditation

This program requirement describes: 

1. Organizational Authority and Financing

2. Governance

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

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

“Criteria that a clinic be a nonprofit or part of a local government behavioral health authority or 

operated under the authority of the Indian Health Service, an Indian Tribe, or Tribal organization 

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

pursuant to the Indian Self-Determination Act (25 U.S.C. 450 et seq.), or an urban Indian 

organization pursuant to a grant or contract with the Indian Health Service under title V of the 

Indian Health Care Improvement Act (25 U.S.C. 1601 et seq.)”

Criteria 6.A: General Requirements of Organizational Authority and Finances

6.a.1 The CCBHC maintains documentation establishing the CCBHC conforms to at least one of the 

following statutorily established criteria: 

• Is a non-profit organization, exempt from tax under Section 501(c)(3) of the United 

States Internal Revenue Code

• Is part of a local government behavioral health authority

• Is operated under the authority of the Indian Health Service, an Indian tribe, or tribal 

organization pursuant to a contract, grant, cooperative agreement, or compact with 

the Indian Health Service pursuant to the Indian Self-Determination Act (25 U.S.C. 450 

et seq.)

• Is an urban Indian organization pursuant to a grant or contract with the Indian Health 

Service under Title V of the Indian Health Care Improvement Act (25 U.S.C. 1601 et 

seq.)

Note: A CCBHC is considered part of a local government behavioral health authority when a 

locality, county, region or state maintains authority to oversee behavioral health services at 

the local level and utilizes the clinic to provide those services.

 
Certified Community Behavioral Health Clinic Certification Criteria Page 46

6.a.2 To the extent CCBHCs are not operated under the authority of the Indian Health Service, an 

Indian tribe, or tribal or urban Indian organization, CCBHCs shall reach out to such entities 

within their geographic service area and enter into arrangements with those entities to

assist in the provision of services to tribal members and to inform the provision of services 

to tribal members. To the extent the CCBHC and such entities jointly provide services, the 

CCBHC and those collaborating entities shall, as a whole, satisfy the requirements of these 

criteria. 

6.a.3 An independent financial audit is performed annually for the duration that the clinic is 

designated as a CCBHC in accordance with federal audit requirements, and, where 

indicated, a corrective action plan is submitted addressing all findings, questioned costs, 

reportable conditions, and material weakness cited in the Audit Report. 

Criteria 6.B: Governance

6.b.1 CCBHC governance must be informed by representatives of the individuals being served by 

the CCBHC in terms of demographic factors such as geographic area, race, ethnicity, sex, 

gender identity, disability, age, sexual orientation, and in terms of health and behavioral 

health needs. The CCBHC will incorporate meaningful participation from individuals with 

lived experience of mental and/or substance use disorders and their families, including 

youth. This participation is designed to assure that the perspectives of people receiving 

services, families, and people with lived experience of mental health and substance use 

conditions are integrated in leadership and decision-making. Meaningful participation 

means involving a substantial number of people with lived experience and family members 

of people receiving services or individuals with lived experience in developing initiatives; 

identifying community needs, goals, and objectives; providing input on service development 

and CQI processes; and budget development and fiscal decision making.

32 CCBHCs reflect 

substantial participation by one of two options: 

Option 1: At least fifty-one percent of the CCBHC governing board is comprised of 

individuals with lived experience of mental and/or substance use disorders and families.

Option 2: Other means are established to demonstrate meaningful participation in 

board governance involving people with lived experience (such as creating an advisory 

committee that reports to the board). The CCBHC provides staff support to the 

individuals involved in any alternate approach that are equivalent to the support given 

to the governing board.

Under option 2, individuals with lived experience of mental and/or substance use 

disorders and family members of people receiving services must have representation in 

governance that assures input into:

1. Identifying community needs and goals and objectives of the CCBHC

32 For more information regarding meaningful participation, see Participation Guidelines for Individuals with Lived

Experience and Family | SAMHSA. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 47

2. Service development, quality improvement, and the activities of the CCBHC

3. Fiscal and budgetary decisions

4. Governance (human resource planning, leadership recruitment and selection, 

etc.) 

Under option 2, the governing board must establish protocols for incorporating input 

from individuals with lived experience and family members. Board meeting summaries 

are shared with those participating in the alternate arrangement and recommendations 

from the alternate arrangement shall be entered into the formal board record; a 

member or members of the arrangement established under option 2 must be invited to 

board meetings; and representatives of the alternate arrangement must have the 

opportunity to regularly address the board directly, share recommendations directly 

with the board, and have their comments and recommendations recorded in the board 

minutes. The CCBHC shall provide staff support for posting an annual summary of the 

recommendations from the alternate arrangement under option 2 on the CCBHC 

website. 

6.b.2 If option 1 is chosen, the CCBHC must describe how it meets this requirement, or provide a 

transition plan with a timeline that indicates how it will do so.

If option 2 is chosen, for CCBHCs not certified by the state, the federal grant funding agency

will determine if this approach is acceptable, and, if not, require additional mechanisms that 

are acceptable. The CCBHC must make available the results of its efforts in terms of 

outcomes and resulting changes. 

For certifying states, if option 2 is chosen then states will determine if this approach is 

acceptable, and, if not, require additional mechanisms that are acceptable. The CCBHC 

must make available the results of its efforts in terms of outcomes and resulting 

changes. 

6.b.3 To the extent the CCBHC is comprised of a governmental or tribal organization, subsidiary, 

or part of a larger corporate organization that cannot meet these requirements for board 

membership, the CCBHC will specify the reasons why it cannot meet these requirements. 

The CCBHC will have or develop an advisory structure and describe other methods for 

individuals with lived experience and families to provide meaningful participation as defined 

in 6.b.1. 

6.b.4 Members of the governing or advisory boards will be representative of the communities in 

which the CCBHC's service area is located and will be selected for their expertise in health 

services, community affairs, local government, finance and accounting, legal affairs, trade 

unions, faith communities, commercial and industrial concerns, or social service agencies 

within the communities served. No more than one half (50 percent) of the governing board 

members may derive more than 10 percent of their annual income from the health care 

industry.

 
Certified Community Behavioral Health Clinic Certification Criteria Page 48

Criteria 6.C: Accreditation

6.c.1 The CCBHC enrolled as a Medicaid provider and licensed, certified, or accredited provider of 

both mental health and substance use disorder services including developmentally 

appropriate services to children, youth, and their families, unless there is a state or federal 

administrative, statutory, or regulatory framework that substantially prevents the CCBHC 

organization provider type from obtaining the necessary licensure, certification, or 

accreditation to provide these services. The CCBHC will adhere to any applicable state 

accreditation, certification, and/or licensing requirements. Further, the CCBHC is required to 

participate in SAMHSA Behavioral Health Treatment Locator.

6.c.2 CCBHCs must be certified by their state as a CCBHC or have submitted an attestation to 

SAMHSA as a part of participation in the SAMHSA CCBHC Expansion grant program. Clinics 

that have submitted an attestation to SAMHSA as a part of participation in the SAMHSA 

CCBHC Expansion grant program are designated as CCBHCs only during the period for which 

they are authorized to receive federal funding to provide CCBHC services. CCBHC expansion 

grant recipients are encouraged to seek state certification if they are in a state that certifies 

CCBHCs. 

State-certified clinics are designated as CCBHCs for a period of time determined by the 

state but not longer than three years before recertification. States may decertify 

CCBHCs if they fail to meet the criteria, if there are changes in the state CCBHC 

program, or for other reasons identified by the state. Certifying states may use an 

independent accrediting body as a part of their certification process as long as it 

meets state standards for the certification process and assures adherence to the 

CCBHC Certification Criteria. 

6.c.3 States are encouraged to require accreditation of the CCBHCs by an appropriate 

independent accrediting body (e.g., the Joint Commission, the Commission on Accreditation 

of Rehabilitation Facilities [CARF], the Council on Accreditation [COA], the Accreditation 

Association for Ambulatory Health Care [AAAHC]). Accreditation does not mean “deemed” 

status. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 49

Appendix A. Terms and Definitions

Terms and definitions included in this appendix are meant to guide states, territories, tribes, and 

existing/potential CCBHCs to understand the intent of the CCBHC certification criteria. The terms and 

definitions are not intended to replace state definitions that are more specific or are more broadly 

defined. 

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

the CCBHC and external entities with which care is coordinated. Such an agreement is evidenced by a 

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

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

entity. The agreement describes the parties’ mutual expectations and responsibilities related to care 

coordination.

Behavioral health: Behavioral health is a general term that encompasses the promotion of emotional 

health; the prevention of mental illnesses and substance use disorders; and treatments and services 

for mental and/or substance use disorders.

33

Care coordination: CCBHCs establish activities within their organization and with care coordination 

partners that promote clear and timely communication, deliberate coordination, and seamless 

transition. This may include (but is not limited to): 

• Establishing accountability and agreeing on responsibilities between care coordination 

partners.

• Engaging and supporting people receiving services in and, subject to appropriate consent, 

their family and caregivers, to participate in care planning and delivery and ensuring that 

the supports and services that the person receiving services and family receive are 

provided in the most seamless manner that is practical.

• Communicating and sharing knowledge and information, including the transfer of health 

records and prescriptions, within care teams and other care coordination partners, as 

allowable and agreed upon with the individual being served. 

• Coordinating and supporting transitions of care that include tracking of admission and 

discharge and coordination of specific services if the person receiving services presents as 

a potential suicide or overdose risk. 

• Assessment of the person receiving services needs and goals to create a proactive 

treatment plan and linkage to community resources. 

• Monitoring and follow-up, including adapting supports and treatment plans as needed to 

respond to changes in the needs and preferences of individuals being served.

• Coordinating directly with external providers for appointment scheduling and follow up 

after appointment for any prescription changes or care needs, ‘closing the loop.’

33 Available at Glossary of Terms and Acronyms for SAMHSA Grants | SAMHSA. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 50

• Communicating and sharing knowledge and information to the full extent permissible 

under HIPAA, 42 CFR part 2, and ONC and CMS interoperability regulations on information 

blocking without additional requirements unless based on state law. 

As used here, care coordination applies to activities by CCBHCs that have the purpose of coordinating 

and managing the care and services furnished to each person receiving services as required by PAMA 

(including both behavioral and physical health care), regardless of whether the care and services are 

provided directly by the CCBHC or through referral or other affiliation with care providers and facilities 

outside the CCBHC. Care coordination is regarded as an activity rather than a service.

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

ranging from basic to intensive. The National Association of State Mental Health Program Directors 

(NASMHPD) defines case management as “a range of services provided to assist and support individuals 

in developing their skills to gain access to needed medical, behavioral health, housing, employment, 

social, educational and other services essential to meeting basic human services; linkages and training 

for patient served in the use of basic community resources; and monitoring of overall service delivery”.

34

See also the definition of “targeted case management.”

Certified Community Behavioral Health Clinic (CCBHC) or Clinic: A CCBHC is a qualifying clinic that is 

responsible for providing all nine services in a manner that meets or exceeds CCBHC criteria described 

herein. The qualifying clinic may deliver the nine required services directly or through formal 

agreements with DCOs. The CCBHC must have the capacity to directly provide mental health and 

substance use services to people with serious mental illness and serious emotional disorders as well as 

developmentally appropriate mental health and substance use care for children and youth separate 

from any DCO relationship, unless substantially prohibited by their state because of their provider type. 

A qualifying clinic must be one of the following: a nonprofit organization; part of a local government 

behavioral health authority; an entity operated under authority of the IHS, an Indian tribe, or tribal 

organization pursuant to a contract, grant, cooperative agreement, or compact with the IHS pursuant to 

the Indian Self-Determination Act; or an entity that is an urban Indian organization pursuant to a grant 

or contract with the IHS under Title V of the Indian Health Care Improvement Act (PL 94-437). CCBHC 

and Clinic are used interchangeably to refer to Certified Community Behavioral Health Clinics.

CCBHCs must be certified by their state as a CCBHC or have submitted an attestation to SAMHSA as a 

part of participation in the SAMHSA CCBHC Expansion grant program. State-certified clinics are 

designated as CCBHCs for a period of time determined by the state but not longer than three years. 

CCBHCs must be recertified or submit a new attestation every three years. States may decertify CCBHCs

if they fail to meet the criteria, if there are changes in the state CCBHC program, or for other reasons 

identified by the state.

34 NASMHPD. The Role of Supportive Housing, Case Management, and Employment Services in Reducing the Risk of 

Behavioral Health Crisis. 2022. Accessible at The Role of Supportive Housing, Case Management, and Employment 

Services in Reducing the Risk of Behavioral Health Crisis (nasmhpd.org). 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 51

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

means employees or contract employees within the management structure and, under the direct 

supervision of the CCBHC, deliver the service.

Community Needs Assessment: A systematic approach to identifying community needs and 

determining program capacity to address the needs of the population being served. CCBHCs will conduct 

or collaborate with other community stakeholders to conduct a community needs assessment. The 

assessment should identify current conditions and desired services or outcomes in the community, 

based on data and input from key community stakeholders. Specific CCBHC criteria are tied to the 

community needs assessment including staffing, language and culture, services, locations, service hours 

and evidence- based practices. Therefore, the community needs assessment must be thorough and 

reflect the treatment and recovery needs of those who reside in the service area across the lifespan 

including children, youth, and families. If a separate community needs assessment has been completed 

in the past year, the CCBHC may decide to augment, or build upon the information to ensure that the 

required components of the community needs assessment are collected. 

The community needs assessment is comprised of the following elements: 

1. A description of the physical boundaries and size of the service area, including identification of

sites where services are delivered by the CCBHC, including through DCOs. 

2. Information about the prevalence of mental health and substance use conditions and related 

needs in the service area, such as rates of suicide and overdose. 

3. Economic factors and social determinants of health affecting the population's access to health 

services, such as percentage of the population with incomes below the poverty level, access to 

transportation, nutrition, and stable housing. 

4. Cultures and languages of the populations residing in the service area. 

5. The identification of the underserved population(s) within the service area. 

6. A description of how the staffing plan does and/or will address findings. 

7. Plans to update the community needs assessment every 3 years.

8. Input with regard to: 

• cultural, linguistic, physical health, and behavioral health treatment needs; 

• evidence-based practices and behavioral health crisis services; 

• access and availability of CCBHC services including days, times, and locations, and 

telehealth options; and 

• potential barriers to care such as geographic barriers, transportation challenges, economic 

hardship, lack of culturally responsive services, and workforce shortages. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 52

Input should come from the following entities if they are in the CCBHC service area: 

• People with lived experience of mental and substance use conditions and individuals 

who have received/are receiving services from the clinic conducting the needs 

assessment; 

• Health centers (including FQHCs in the service area); 

• Local health departments (Note: these departments also develop community needs 

assessments that may be helpful); 

• Inpatient psychiatric facilities, inpatient acute care hospitals, and hospital outpatient 

clinics; 

• One or more Department of Veterans Affairs facilities;

• Representatives from local K-12 school systems; and

• Crisis response partners such as hospital emergency departments, emergency 

responders, crisis stabilization settings, crisis call centers and warmlines.

CCBHCs must engage also with other community partners, especially those who also work with 

people receiving services from the CCBHC and populations that historically are not engaging 

with health services, such as: 

• Organizations operated by people with lived experience of mental health and substance 

use conditions; 

• Other mental health and SUD treatment providers in the community;

• Residential programs; 

• Juvenile justice agencies and facilities; 

• Criminal justice agencies and facilities; 

• Indian Health Service or other tribal programs such as Indian Health Service youth 

regional treatment centers as applicable; 

• Child welfare agencies and state licensed and nationally accredited child placing 

agencies for therapeutic foster care service; and 

• Crisis response partners such as hospital emergency departments, crisis stabilization 

settings, crisis call centers and warmlines.

• Specialty providers of medications for treatment of opioid and alcohol use disorders; 

• Peer-run and operated service providers; 

• Homeless shelters and housing agencies; 

• Employment services systems; 

• Services for older adults, such as Area Agencies on Aging; 

• Aging and Disability Resource Centers; and 

• Other social and human services (e.g., domestic violence centers, pastoral services, grief 

counseling, Affordable Care Act navigators, food and transportation programs).

Cultural and linguistic competence: Provide effective, equitable, understandable, and respectful quality 

care and services that are responsive to diverse cultural health beliefs and practices, preferred 

languages, health literacy, and other communication needs. Culturally and linguistically appropriate 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 53

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

consumers.

35

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

supervision of the CCBHC but is engaged in a formal relationship with the CCBHC to deliver one or more

(or elements of) of the required services as described in criteria 4. CCBHC services provided through a 

DCO must conform to the relevant applicable CCBHC criteria. The formal relationship is evidenced by a 

contract, Memorandum of Agreement (MOA), Memorandum of Understanding (MOU), or such other 

formal, legal arrangements describing the parties’ mutual expectations and establishing accountability 

for services to be provided and funding to be sought and utilized. The formal relationship between 

CCBHCs and DCOs creates the platform for seamlessly integrated services delivered across providers 

under the umbrella of a CCBHC. DCO agreements shall include provisions that assure that the required 

CCBHC services that DCOs provide under the CCBHC umbrella are delivered in a manner that meets the 

standards set in the CCBHC certification criteria. To this end, DCOs are more than care coordination or 

referral partners, and there is an expectation that relationships with DCOs will include more regular, 

intensive collaboration across organizations than would take place with other types of care coordination 

partners. 

From the perspective of the person receiving services and their family members, services received 

through a DCO should be part of a coordinated package with other CCBHC services and not simply 

accessing services through another provider organization. To this end, the DCO agreement shall take 

active steps to reduce administrative burden on people receiving services and their family members 

when accessing DCOs services through measures such as coordinating intake process, coordinated 

treatment planning, information sharing, and direct communication between the CCBHC and DCO to 

prevent the person receiving services or their family from having to relay information between the 

CCBHC and DCO. CCBHCs and their DCOs are further directed to work towards inclusion of additional 

integrated care elements (e.g., including DCO providers on CCBHC treatment teams, collocating 

services). Regardless of DCO relationships entered into, the CCBHC maintains responsibility for assuring 

that people receiving services from the CCBHC receive all nine services as needed in a manner that 

meets the requirements of the CCBHC certification criteria. 

In the Section 223 CCBHC Demonstration, payment for DCO services is included within the scope of the 

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

extent that services are needed by a person receiving services or their family that cannot be provided by 

either the CCBHC directly or by a DCO, referrals may be made to other providers or entities. The CCBHC 

retains responsibility for care coordination including services to which it refers consumers. Payment for 

those referred services is not through the PPS but is made through traditional mechanisms within 

Medicaid or other funding sources. 

Engagement: Engagement includes a set of activities connecting people receiving services with needed 

services and supporting their retention services. This involves the process of making sure people

35 Office of Minority Health. Cultural and Linguistic Competency. Rockville, MD: U.S. Department of Health and 

Human Services, December 12, 2014. Available at: Cultural Competency - The Office of Minority Health 

(hhs.gov).

 
Certified Community Behavioral Health Clinic Certification Criteria Page 54

receiving services and families are informed about and are able to access needed services. Activities 

such as outreach and education can serve the objective of engagement. Conditions such as accessibility, 

provider responsiveness, availability of culturally and linguistically competent care, and the provision of 

quality care also promote consumer person receiving services engagement. 

Family: Involvement of families of both adults and children receiving services is important to treatment 

planning, treatment, and recovery. Families come in different forms and, to the extent possible, the 

CCBHC should respect the individual consumer’s view of what constitutes their family. Families can be 

organized in a wide variety of configurations regardless of social or economic status. Families can 

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

their partners, grandparents and their partners, siblings and their partners, extended family members, 

care givers, friends, and others as defined by the family. The CCBHC respects the view of what 

constitutes the family of the individual person receiving services. 

Family-centered: The Health Resources and Services Administration defines family-centered care, 

sometimes referred to as “family-focused care,” as “an approach to the planning, delivery, and 

evaluation of health care whose cornerstone is active participation between families and professionals. 

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

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

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

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

health care providers and recognize the family’s customs and values”.36 More recently, this concept was 

broadened to explicitly recognize that family-centered services should be both developmentally 

appropriate and youth guided.37 Family-centered care is family-driven and youth-driven.

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

CCBHC and DCOs, a formal relationship is evidenced by a contract, Memorandum of Agreement (MOA), 

Memorandum of Understanding (MOU), or such other formal arrangements describing the parties’ 

mutual expectations and establishing accountability for services to be provided and payment to be 

sought and utilized. This formal relationship does not extend to referrals for services outside either the 

CCBHC or DCO, which are not encompassed within the reimbursement provided by the PPS.

Limited English Proficiency (LEP): LEP describes a characteristic of individuals who do not speak English 

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

who may be eligible to receive language assistance with respect to the particular service, benefit, or 

encounter.

Lived Experience: People with lived experience are individuals directly impacted by a social issue or 

combination of issues who share similar experiences or backgrounds and can bring the insights of their 

36 Health Resources and Services Administration, Maternal and Child Health Bureau. The National Survey of 

Children with Special Health Care Needs Chartbook 2001. Rockville, Maryland: U.S. Department of Health and 

Human Services, 2004. Available at Chartbooks | MCHB (hrsa.gov). 37 American Academy of Child & Adolescent Psychiatry. Family and Youth Participation in Clinical Decision-Making. 

Washington, D.C., October 2009. Available at Family and Youth Participation in Clinical Decision-Making 

(aacap.org). 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 55

experience to inform and enhance systems, research, policies, practices, and programs that aim to 

address the issue(s). Because CCBHCs are designed to serve people with mental disorders, adults with 

serious mental illness, children with serious emotional disturbance and their families, and individuals 

with substance use disorders, individuals with lived experiences provide valuable insight to improving 

the delivery of CCBHC services. 

Measurement-Based Care: For purposes of these criteria, measurement-based care (MBC) is the 

systematic use of patient-reported information to inform clinical care and shared decision-making 

among clinicians and patients and to individualize ongoing treatment plans.

Peer/Family/Caregiver Support: A peer support provider is a person who uses their lived experience of 

recovery from mental or substance use disorders or as a family member/caregiver of such a person, plus 

skills learned in formal training, to deliver services to promote recovery and resiliency. Peer providers 

may have titles that may differ from state to state, e.g., certified peer specialist, peer support specialist, 

recovery coach, family partner, parent partner specialist. In states where Peer Support Services are 

covered through the state Medicaid Plans, the title of “certified peer specialist” often is used. SAMHSA 

recognizes states use different terminology for these providers. Peer support may be provided in 

behavioral health, health, and community settings, e.g., mobile crisis outreach, psychiatric 

rehabilitation, outpatient mental health/substance use treatment, emergency rooms, wellness 

programs, peer-operated programs.

Person or People Receiving Services: Within this document, person or people receiving services refers 

to people of all ages (i.e., children, adolescents, transition age youth, adults, and older adults) who are 

receiving one of the nine required services from the CCBHC (including through any DCO arrangements). 

Use of the term “patient” is restricted to areas where the statutory or other language is being quoted. In 

many places in the Certification Criteria, the person receiving services has a role in directing, expressing 

preferences, planning, and coordinating services. In these situations, when there is a legal guardian for 

the person receiving services, these roles shall also be filled by the legal guardian.

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

Patient Protection and Affordable Care Act, as implemented by the Department of Health & Human 

Services Guidance to HHS Agencies for Implementing Principles of Section 2403(a) of the Affordable 

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

Services Programs.

38 That guidance defines “person-centered planning” as a process directed by the 

person with service needs which identifies recovery goals, objectives and strategies. If the person 

receiving services wishes, this process may include a representative whom the person has freely chosen, 

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

planning also includes family members, legal guardians, friends, caregivers, and others whom the person 

wishes to include. Person-centered planning involves the person receiving services to the maximum 

extent possible. Person-centered planning also involves self-direction, which means the person receiving 

38 Department of Health & Human Services. Guidance to HHS Agencies for Implementing Principles of Section 

2403(a) of the Affordable Care Act: Standards for Person Centered Planning and Self-Direction in Home and 

Community-Based Services Programs (June 6, 2014). Available at: Implementing Standards for Person-Centered 

Planning and Self-Direction in Home and Community-Based Services Programs | Guidance Portal (hhs.gov).

 
Certified Community Behavioral Health Clinic Certification Criteria Page 56

services has control over selecting and using services and supports, including control over the amount, 

duration, and scope of services and supports, as well as choice of providers.39

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

health care services and who is legally authorized to do so by the state in which the individual or entity 

delivers the services (42 CFR § 400.203).

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

and wellness, live a self-directed life, and strive to reach their full potential.” The 10 guiding principles of 

recovery are: hope; person-driven; many pathways; holistic; peer support; relational; culture; addresses 

trauma; strengths/responsibility; and respect. Recovery includes: Health (“making informed healthy 

choices that support physical and emotional wellbeing”); Home (safe, stable housing); Purpose 

(“meaningful daily activities ... and the independence, income and resources to participate in society”); 

and Community (“relationships and social networks that provide support, friendship, love, and hope”).

40

Recovery-oriented care: Recovery-oriented care is oriented toward promoting and sustaining a person's 

recovery from a behavioral health condition. Care providers identify and build upon each individual’s 

assets, strengths, and areas of health and competence to support the person in managing their 

condition while regaining a meaningful, constructive sense of membership in the broader community. 

Required services: The nine service areas identified in PAMA, which CCBHCs must provide to people 

receiving services based on their needs (described in Program Requirement 4: Scope of Services), 1. 

Crisis Services; 2. Screening, Assessment, and Diagnosis; 3. Person-Centered and Family-Centered 

Treatment Planning; 4. Outpatient Mental Health and Substance Use Services; 5. Primary Care Screening 

and Monitoring; 6. Targeted Case Management Services; 7. Psychiatric Rehabilitation Services; 8. Peer 

Supports and Family/Caregiver Supports; and 9. Community Care for Uniformed Service Members and 

Veterans. 

Satellite Facility: A satellite facility of a CCBHC is a facility that was established by the CCBHC, operated 

under the governance and financial control of that CCBHC, and provides the following services: crisis 

services; screening, diagnosis, and risk assessment; person and family centered treatment planning; and 

outpatient mental health and substance use services as specified in CCBHC certification criteria Program 

Requirement 4. 

For CCBHCs participating in the Section 223 Demonstration only, the Protecting Access to Medicare Act 

of 2014 stipulates that “no payment shall be made to a satellite facility of a CCBHC established after 

April 1, 2014, under this Demonstration.” This definition does not limit the provision of services in nonclinic settings such as shelters and schools or at other locations managed by the CCBHC that do not meet 

the definition of a satellite facility. 

39 Ibid. 40 Substance Abuse and Mental Health Services Administration. SAMHSA’s Working Definition of Recovery. 

Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012. Available at: SAMHSA's 

Working Definition of Recovery | SAMHSA Publications and Digital Products. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 57

Shared Decision-Making (SDM): Shared decision-making is a best practice in behavioral and physical 

health that aims to help people in treatment and recovery have informed, meaningful, and collaborative 

discussions with providers about their health care services. 

It involves tools and resources that offer objective information upon which people in treatment and 

recovery incorporate their personal preferences and values. Shared decision-making tools empower 

people who are seeking treatment or in recovery to work together with their service providers and be 

active in their own treatment.41

Trauma-informed: A trauma-informed approach to care realizes the widespread impact of trauma and 

understands potential paths for recovery; recognizes the signs and symptoms of trauma in people

receiving services, their families, staff, and others involved in the system; and responds by fully 

integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist 

re-traumatization. The six key principles of a trauma-informed approach include: safety; trustworthiness 

and transparency; peer support; collaboration and mutuality; empowerment, voice and choice; and 

cultural, historical and gender issues.42

41 Substance Abuse and Mental Health Services Administration. Shared Decision-Making Tools. Available at: Shared 

Decision-Making Tools | SAMHSA. 42 Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a 

Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental 

Health Services Administration, 2014. Available at: SAMHSA's Concept of Trauma and Guidance for a TraumaInformed Approach | SAMHSA Publications and Digital Products. 

 
Certified Community Behavioral Health Clinic Certification Criteria Page 58

Appendix B. Behavioral Health Clinic Quality Measures

The Behavioral Health Clinic (BHC) quality measures that CCBHCs will use are being updated in 2023. 

Below is a list, divided into clinic-collected and state-collected measures, required and optional. 

For Section 223 Demonstration or other state-certified CCBHCs, it is a state decision as to whether to 

require reporting of measures designated as optional. For later cohorts of CCBHC-Es that are required to 

report quality measures, only the clinic-collected required measures are mandated.

Color Key: = Required measures 

Clinic-Collected Measures

Measure Name and 

Designated Abbreviation Steward 

CMS 

Medicaid 

Core Set 

(2023)1

Notes

 Time to Services (I-SERV) SAMHSA n/a

Will include sub-measures of 

average time to: Initial 

Evaluation, Initial Clinical 

Services, Crisis Services

 Depression Remission at Six 

Months (DEP-REM-6)

MN Community 

Measurement n/a Changed from the TwelveMonth version of the measure

 Preventive Care and Screening: 

Unhealthy Alcohol Use: Screening 

and Brief Counseling (ASC)

NCQA n/a n/a

 Screening for Clinical Depression 

and Follow-Up Plan (CDF-CH and 

CDF-AD) 

CMS Adult and Child

Child was added to the 

Medicaid Child Core Measure 

Set

 Screening for Social Drivers of 

Health (SDOH)

CMS n/a

Using the 2023 Merit-Based 

Incentive Payment System 

(MIPS) version

Preventive Care & Screening: 

Tobacco Use: Screening & 

Cessation Intervention (TSC)

NCQA n/a n/a

Child and Adolescent Major 

Depressive Disorder (MDD): 

Suicide Risk Assessment (SRA) 

(SRA-A)

Mathematica n/a n/a

 
Certified Community Behavioral Health Clinic Certification Criteria Page 59

Measure Name and 

Designated Abbreviation Steward 

CMS 

Medicaid 

Core Set 

(2023)1

Notes

Adult Major Depressive Disorder: 

Suicide Risk Assessment (SRA)

(SRA-C)

Mathematica n/a n/a

Weight Assessment and 

Counseling for Nutrition and 

Physical Activity for 

children/Adolescents (WCC-CH)

NCQA Child

Measure modified to coincide 

with change in Medicaid Child 

Core Measure Set

Controlling High Blood Pressure 

(CBP-AD) NCQA Adult n/a

1 The CMS Medicaid Core Set describes two separate core sets (the 2023 Child Core Set and the 2023 Adult Core Set). The 

table specifies if a measure is in only one or both of the core sets.

State-Collected Measures

Measure Name and 

Designated Abbreviation Steward 

CMS

Medicaid 

Core Set 

(2023)

Notes

 Patient Experience of Care Survey SAMHSA n/a n/a

 Youth/Family Experience of Care 

Survey

SAMHSA n/a n/a

 Adherence to Antipsychotic 

Medications for Individuals with 

Schizophrenia (SAA-AD) 

CMS Adult n/a

 Follow-Up After Hospitalization 

for Mental Illness, ages 18+ 

(adult) (FUH-AD) 

NCQA Adult n/a

 Follow-Up After Hospitalization 

for Mental Illness, ages 6 to 17 

(child/adolescent) (FUH-CH) 

NCQA Child n/a

 Initiation and Engagement of 

Alcohol and Other Drug 

Dependence Treatment (IET-AD) 

NCQA Adult n/a

 
Certified Community Behavioral Health Clinic Certification Criteria Page 60

Measure Name and 

Designated Abbreviation Steward 

CMS

Medicaid 

Core Set 

(2023)

Notes

 Follow-Up After Emergency 

Department Visit for Mental 

Illness (FUM-CH and FUM-AD)

NCQA Adult & Child

Child was added to the 

Medicaid Child Core Measure 

Set

 Follow-Up After Emergency 

Department Visit for Alcohol and 

Other Drug Dependence (FUA-CH 

and FUA-AD)

NCQA Adult & Child

Child was added to the 

Medicaid Child Core Measure 

Set

 Plan All-Cause Readmissions Rate 

(PCR-AD) NCQA Adult n/a

 Follow-Up Care for Children 

Prescribed Attention-Deficit 

Hyperactivity Disorder (ADHD) 

Medication (ADD-CH)

NCQA Child n/a

 Antidepressant Medication 

Management (AMM-BH) NCQA Adult n/a

 Use of Pharmacotherapy for 

Opioid Use Disorder (OUD-AD) 

CMS Adult n/a

 Hemoglobin A1c Control for 

Patients with Diabetes (HBD-AD) NCQA Adult n/a

Use of First-Line Psychosocial 

Care for Children and Adolescents 

on Antipsychotics (APP-CH)

NCQA Child n/a

Metabolic Monitoring for 

Children and Adolescents on 

Antipsychotics (APM-CH) 

NCQA Child n/a