CCBHC Prospective Payment System (PPS)
Pending CMS approval of the CCBHC SPA, CCBHCs are eligible to receive up to two kinds of MHCP payment for CCBHC services:
- PPS payment for covered CCBHC services, including CCBHC expanded services and the other CCBHC covered services which are described above.
- Quality bonus payments averaging up to 5 percent of the other payments previously described.
CCBHCs receive a cost-based prospective payment system (PPS) rate for each clinic. The rate is based on a cost report from each clinic, using federal cost reporting rules. The cost report includes estimated changes in costs, which are necessary costs to comply with CCBHC criteria. The report also includes historical and projected numbers of qualifying encounters or visits. DHS reviews all cost reports to determine individual rates for each CCBHC. Total approved costs for a year divided by total anticipated encounters arrive at a PPS rate per encounter. The rate represents an average cost per encounter for all clients receiving CCBHC services from a particular CCBHC. The rate includes the cost of providing services listed in the Scope of Services table (PDF).
A qualifying encounter is the first billable unit for a CCBHC service on a given service date, for dates of service on or after the effective date of the PPS rate. Billable unit is defined by billing policies that apply to each procedure code. Since MH-TCM is currently paid in monthly units, only one service date per month counts as a qualifying CCBHC encounter. Likewise, other services (such as extended diagnostic assessments) that may involve more than one day of actual service, but only one billing unit, are counted as one encounter for purposes of the PPS payment. Staff travel (H0046) is included only if it is required to provide a CCBHC service.
CCBHCs should follow billing policies described above to submit a claim for PPS payment. CCBHCs should include their usual and customary charge for each procedure code. Regardless of the charge on the claim, DHS and the MCOs determine the PPS payment as follows:
- The full PPS rate is assigned to the first qualifying encounter (that is, one service date per client)
- Additional CCBHC services provided by that CCBHC for that same client and same date of service are paid zero.
- The PPS rate is offset by all other payments received by that CCBHC for all CCBHC services on that date of service for that client, including spenddown, family deductibles, third party liability, etc.
CCBHCs are not eligible for PPS payment if Medicare is primary. In fee-for-service, this means that Medicare crossover claims are not eligible for PPS payment. Instead of PPS, MA pays the copays and deductibles that would normally apply to a Medicare crossover.
Services which are provided at clinic locations outside the CCBHC’s approved service area are not eligible for PPS payment. Services which are appropriately billed from locations within the CCBHC service area, such as crisis calls, home-based services, case management follow-up and school-based services, are not considered to be outside the service area.
Quality bonus payments for SPA CCBHCs
SPA CCBHCs are eligible for a quality incentive payment based on reaching specific numeric thresholds on state identified performance metrics pending State Plan approval. Quality incentive payments are in addition to payments under the bundled rate and are paid to CCBHCs that achieve specific performance targets identified by the state agency. The department will notify each CCBHC of the criteria for receiving incentive payments in writing prior to the measurement year. Performance targets must be developed with input from clinical experts and stakeholders and may include factors affecting specific providers.
The measurement year shall be the calendar year. CCBHC providers will be notified of their performance on the required measures and the incentive payment amount by the 12th month following the measurement year. CCBHCs must provide the department with data needed to determine incentive payment eligibility within 6 months following the measurement year. CCBHCs must be certified and enrolled as CCBHC providers for the entire measurement year to be eligible for incentive payments. Total payments for each award year may not exceed 5 percent of CCBHC payments to eligible clinics during the measurement year. Subject to CMS approval of the SPA, providers participating in the Section 223 Demonstration Program may receive prorated incentive payments for a portion of the measurement year remaining after conversion from demonstration to SPA status.
Quality bonus payments for SPA CCBHCs will be pro-rated between fee-for-service and the MCOs based on the proportion of claims paid by each.