SF4820

Purpose

• Provide a framework to reimburse Certified Community Behavioral Health Clinics (CCBHCs) for medical assistance (Medicaid) using a daily bundled rate system, with ongoing rebasing, quality incentives, and related administration changes. The bill aims to adjust how CCBHCs are paid, how rates are calculated and updated, and how claims and wrap payments are handled.

Main Provisions

• Establish a CCBHC daily bundled rate system for medical assistance payments.
  • Reimburse each CCBHC on a per-day basis for eligible services delivered.
  • Include a quality incentive payment in the daily bundled rate.
  • No county share is required for medical assistance when paid through the daily bundled rate.
• Define and mandate rate calculations and adjustments.
  • The daily bundled rate is provider-specific and based on the daily cost of providing CCBHC services and total annual allowable CCBHC costs divided by the total annual visits (including both medical assistance and non-medical assistance visits).
  • The rate includes costs such as salaries, benefits, insurance, and supplies needed to provide CCBHC services.
  • A single payment per day per eligible enrollee is allowed when an eligible CCBHC service is provided.
• Rebasing and rate adjustments.
  • Initial rates for newly certified CCBHCs are set using audited historical cost data, adjusted for expected costs, with estimates subject to state review.
  • Rates must be rebased every two years, and at least 12 months after an initial rebasing or a change in service scope.
  • For CCBHCs certified in specific windows, there are transitional rules to determine rebasing timing (including applying the 2023 rate for services through 2026 and rebasing for services after 2027).
  • A 60-day appeals process is provided after rebasing results.
• Adjustments for changes in scope.
  • If changes in the scope of services are expected to change the rate by 2.5% or more, a rate adjustment can be requested (no more than once per year between rebasing periods), with adjustments effective on the date of the annual rate update.
• Coordination with managed care and wrap payments.
  • Managed care plans and county-based purchasing plans must reimburse at the CCBHC daily bundled rate.
  • The bill directs monitoring of access implications and provides a mechanism to adjust capitation rates if federal approval for this provision is not received (the provision expires if federal approval is not obtained).
  • The state must complete the phaseout of CCBHC wrap payments within 60 days of implementing the daily bundled rate in the Medicaid Management Information System (MMIS) and settle final payments to CCBHCs within 18 months.
• Claims processing and timing.
  • All claims for CCBHC services under this section must be submitted to and paid by the commissioner if a managed care plan fails to pay clean claims within federal guidelines, with specifics on timing depending on when the failure occurs.
• Quality and data reporting.
  • Implement a quality incentive payment program with predefined performance metrics set by the commissioner; eligibility requires CCBHC certification and enrollment for the entire measurement year.
  • CCBHCs must provide cost and visit data annually via a cost report.
  • The daily bundled rate is updated annually by trending the provider-specific rate using the Medicare Economic Index (MEI) for primary care services, between rebasing periods.
• Peer services.
  • Peer services provided by a CCBHC can be a covered medical assistance service when determined medically necessary by a licensed professional or counselor, and eligibility for peer services supersedes certain other eligibility standards.
• General administration.
  • CCBHCs must deliver data and maintain documentation as required, and the commissioner has authority to make and adjust implementations to ensure proper administration and compliance.

Rate Structure and Rebasing Details

• Per-day bundled rate is provider-specific and based on:
  • Daily cost of delivering CCBHC services.
  • Total annual allowable CCBHC costs divided by total annual visits (including non-Medicaid visits).
• Initial rates for newly certified CCBHCs use audited historical cost data, adjusted for expected costs; estimates subject to review.
• Rebasing occurs every two years, with minimum 12 months between rebases after a rate change or scope change.
• For certain certified dates, transitional rebasing rules apply (e.g., applying 2023 rate through 2026, then rebasing in 2027).
• 60-day appeals window after rebasing results.
• MEI-based updates to provider-specific daily rates occur yearly between rebasing periods.

Payment, Claims, and Access

• All CCBHC claims to managed care plans or county-based purchasing plans are paid by the commissioner if plans fail to pay clean claims timely, subject to federal requirements.
• If federal approval for certain provisions is not received, corresponding adjustments to capitation rates may be required, and the provision may expire without approval.
• Phaseout of CCBHC wrap payments to be completed within 60 days of daily bundled rate implementation, with final settlements due within 18 months.
• A 60-day appeals process applies to rebasing outcomes.

Quality Incentives and Data

• A separate quality incentive payment program rewards CCBHCs meeting predefined performance metrics.
• Eligibility for incentive payments requires full-year certification and enrollment.
• CCBHCs must receive notice of data criteria well before measurement and must submit necessary data within a defined period; performance results and incentive amounts are communicated within a year after the measurement year.
• CCBHCs must report cost and visit data annually via the mandated cost report.

Scope of Services and Eligibility

• Peer services under CCBHCs are covered when medically necessary, with eligibility determinations superseding certain other eligibility standards in specified state statutes.

Effective Date and Implementation

• The bill outlines schedule-based rebasing, MEI updates, and phased implementation tied to MMIS updates and federal approvals where applicable.

Significance and Potential Impacts

• Introduces a new, cost-based, per-day reimbursement model for CCBHCs, shifting away from prior payment methods (where applicable) to a bundled rate structure.
• Emphasizes data reporting, cost transparency, and performance-based incentives.
• Ties rate updates to MEI and scheduled rebases, with mechanisms to adjust for service scope changes.
• Aims to strengthen payment integrity and timely claims processing, while phasing out wrap payments tied to CCBHCs.
• Could affect how managed care plans compensate CCBHCs and how quickly access to services changes, depending on federal approvals and implementation timelines.

Relevant Terms - CCBHC (Certified Community Behavioral Health Clinic) - Medical assistance (Medicaid) - Daily bundled rate / CCBHC daily bundled rate - Provider-specific rate - Rebasing (every two years) - Initial rate and audited cost reports - Total annual costs and total annual visits - MEI (Medicare Economic Index) for primary care services - Cost report - Quality incentive payment program - Phaseout of CCBHC wrap payments - Managed care plans / county-based purchasing plans - Clean claims - Scope of services changes and rate adjustments (up to 2.5%) - Peer services - Eligibility and enrollment requirements for incentive payments - Appeals process for rebasing results