Medicaid Behavioral Health: CMS Guidelines Needed To Better Align Demo Payment Rates With Costs And Avoid Duplication


What GAO found

In 2016, the Department of Health and Human Services (HHS) selected eight states to participate in a time-limited protest to establish Certified Community Behavioral Health Clinics (CCBHC). These states, in turn, have certified 66 behavioral health clinics as CCBHCs. Compelled to provide a wide range of behavioral health services – mental health and addiction services – CCBHCs are reimbursed by state Medicaid programs using clinic-specific rates designed to cover expected costs. As part of the demonstration, states are receiving increased federal funding for CCBHC services provided to Medicaid recipients.

GAO found that five of the eight demonstration states reported an overall increase in state spending on CCBHCs, which officials in those states attributed to an increased number of people receiving treatment, an increased range of services. provided, or both. In contrast, officials from the other three participating states did not indicate that the protest resulted in increased state spending. Officials from two of those states noted that the protest resulted in reduced spending, citing factors such as increased federal Medicaid funding for the protest. The remaining state officials said the effects on spending were unknown. In addition, four of the eight states assessed the potential cost savings of the demonstration resulting from reduced use of more expensive care, such as emergency department visits. Officials in three of the four states viewed the results of their assessments as suggesting potential cost savings, while officials in the fourth state did not.

GAO’s review of the payment guidelines for the demonstration from the Centers for Medicare & Medicaid Services (CMS), an HHS agency that oversees Medicaid at the federal level, found that the guidelines lacked clear and consistent information on better alignment of CCBHC payment rates with costs and avoid duplicate payments. For example:

The CMS guidelines give States the option to rebase their initial payment rates after the first year of demonstration (v. CMS officials said the rebasing would mean that States would not have to rely on them. anticipated costs and customer visit data after the first year, and would align tariffs more closely with costs. While officials said CMS expected all states to rebase their tariffs at some point, CMS guidelines do not reflect this expectation, nor do they provide details on relining, such as suggested timelines.

CMS guidelines conflict over whether CCBHCs that are also federally accredited health centers (FQHCs) – safety net providers who typically provide behavioral health services – should receive CCBHC payments. and FQHC for the same client on the same day if the services provided overlap.

Addressing these weaknesses is important to ensure that Medicaid CCBHC payments meet the requirements of Medicaid payments under federal law, including that they are consistent with efficiency, economy and quality of care, and are sufficient to guarantee access to care.

Why GAO did this study

Behavioral health issues affected an estimated 61.2 million adults in 2019. Congress has taken steps to expand access to behavioral health treatments, including allowing the CCBHC demonstration, which aims to improve service availability. community behavioral health.

The CARES Act included a provision for GAO to report on the experiences of states participating in the CCBHC demonstration. Among other goals, this report describes what states reported on how the CCBHC demonstration affected state spending on behavioral health services; and reviews CMS Guidelines for States on Medicaid CCBHC Payments.

GAO reviewed the documentation and interviewed Medicaid and behavioral health officials from the eight CCBHC demonstration states, as well as federal officials responsible for monitoring demonstrations. GAO also reviewed the literature and interviewed officials for a non-generalizable sample of three CCBHCs, which GAO selected for a number of reasons, including variation in geographic location.

About Matthew R. Dailey

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