Q1: What are the primary funding sources for Minnesota CCBHCs?
A: Minnesota has three primary funding sources for CCBHCs:
Q2: What is the status of the federal Section 223 demonstration?
A: Congress has extended the Sec. 223 demonstration until September 30, 2023. The demonstration is limited to 6 clinics which began 7/1/17. The extension provides continued Medicaid funding for these 6 clinics based on Sec. 223 requirements.
Q3: What is the status of Minnesota’s Medicaid State Plan Amendment (SPA)?
A: The CCBHC SPA was submitted to CMS October 23, 2020 after a public comment period. Since a number of other states have already received approval for similar SPAs, DHS is confident that Minnesota’s SPA will be approved, retroactive to October 1, 2020.
Q1: What is the CCBHC PPS rate?
A: The PPS 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 (see below). The rate is based on a cost report from each clinic, using federal cost reporting rules. The cost report 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 encounters arrive at a PPS rate per encounter.
Q2: What is a qualifying encounter?
A: 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.
Q3: How do CCBHCs bill for PPS payment?
A: CCBHCs follow the usual billing policies that apply to each of the procedure codes which are included in the Scope of Services table. Minnesota does not use a separate procedure code for CCBHC encounters. CCBHCs bill for each procedure code at their usual and customary charge.
Q4: Which services are eligible for PPS payment?
A: The Scope of Services table describes which services are eligible for PPS payment.
Q5: What does the Q2 modifier mean?
A: In the Scope of Service table, the Q2 modifier is used to indicate changes in coverage policy that took effect when the CCBHC project began in 2017. For example, certain procedure codes that are usually only allowable for children became available to adult CCBHC clients. All of the procedure codes on the CCBHC Scope of Services list are eligible for PPS whether or not they have the Q2 modifier – in fact, most CCBHC procedure codes do not use Q2.
Q6: Are there additional requirements which determine when an Evaluation and Management (E&M) procedure code is eligible for PPS payment?
A: In order for an E&M code to be eligible for PPS, it must be provided by a child psychiatrist, psychiatrist, nurse practitioner or clinical nurse specialist with mental health certification. The purpose of this limitation is to exclude E&M services which are primary care or other non-behavioral health services. It is the responsibility of the CCBHC to ensure that DHS Provider Enrollment has up-to-date information regarding licensure and certification status of their E&M providers.
Q7: Will eligible CCBHC procedure codes change? How often?
A: DHS expects 3 types of changes in the list of eligible CCBHC procedures:
Whenever there is a change in CCBHC procedure codes, DHS will send an updated version of these documents to MCOs and CCBHCs with as much lead time as possible.
Q9: MH-TCM is billed at a monthly rate. How does this fit with the daily CCBHC encounter rate?
A: Since the billable unit for MH-TCM is a month, only the first MH-TCM billable service per month is eligible for a PPS payment. The date of that first service per month is considered the date of service for the PPS. In all other aspects, MH-TCM is treated like any other CCBHC service for the PPS payment.
Q10: Should CCBHCs continue to negotiate MH-TCM rates with their counties?
A: Yes! The county-negotiated rate should be used when billing counties for MH-TCM services for persons not eligible for MA, as well as for CCBHC billing to MMIS and the MCOs for persons who are eligible for MA. The PPS system will consider all other services received by that client on that date (i.e. the date of the first MH-TCM service in a month) and make the appropriate PPS payment.
Q11: Can a county use the CCBHCs’ PPS rate as the MH-TCM rate?
A: DHS does not recommend using the PPS rate as the MH-TCM rate. The PPS rate reflects the average for an integrated set of all CCBHC services (over 60 procedure codes, including MH-TCM), whereas the TCM rate is a monthly rate for one procedure code. Therefore, the TCM rate and the CCBHC encounter rate are not comparable. The county should continue negotiating a TCM rate as they have in the past.
Q12: Since the TCM claim is for the entire month, does that affect PPS for other services during that month?
A: For purposes of calculating the PPS, DHS considers the single date of the first billable MH-TCM service per month to be the date of service for the MH-TCM encounter. The MH-TCM payment does not affect PPS payment for any other dates of service within that month.
Q13: If a CCBHC bills services that are not on the list, does it receive the fee schedule or PPS rate?
A: Non PPS eligible services will continue to be paid at the same rates as all other non-CCBHC MA covered services.
Q14: Can PPS payments be greater than billed charges?
A: The PPS rate is an average bundled rate that reflects the cost of providing all CCBHC services for a client on a given day. CCBHC providers bill for CCBHC procedure codes at the usual and customary rates. There are days where the PPS payment is greater than the billed charges and days when the billed charges are greater than the PPS payment.
Q1: How does PPS payment work for the Demonstration CCBHCs?
A: Demo CCBHCs receive an initial payment from MMIS and the MCOs through the normal claims process, followed by a wrap payment which is calculated by DHS and a contracted vendor. For dates of service after September 1, 2019, the wrap payment for managed care enrollees is made by the MCOs, based on amounts specified by DHS. For additional details, see the DHS CCBHC Wrap Payment (PDF).
Q2: Now that Congress has extended the Sec. 223 demo until September 30, 2023, do you expect any changes in the payment system for the Demonstration CCBHCs?
A: Not in the immediate future. If any changes are needed, this significant extension of the demo allows time for proper consultation and planning with all stakeholders before any changes are made.
Q1: How many CCBHCs have been approved for SPA PPS payment?
A: Only Western Mental Health Center and Human Development Center have been approved for SPA PPS payment. These centers were certified as CCBHCs in 2018 as SAMHSA grantees (see below). They were approved for SPA PPS payment after their SAMHSA grants ended.
Q2: When do you expect more SPA CCBHCs?
A: After CMS approves the SPA, DHS will proceed with the certification and rate-setting process for additional SPA CCBHCs. DHS has provided planning grants to three organizations to become SPA CCBHCs, SAMHSA has provided CCBHC grants to two organizations, and DHS is providing technical assistance to a number of other organizations.
Q3: How does Fee-for-Service PPS payment work for the SPA CCBHCs?
A: Until MMIS is ready to implement PPS claims processing (currently projected for June 2021), PPS payment for fee-for-service (FFS) clients served by SPA CCBHCs is similar to the payment system that is used for Demo CCBHCs. SPA CCBHCs receive an initial payment from MMIS through the normal claims process, followed by a wrap payment which is calculated by DHS and a contracted vendor.
When MMIS implements the full PPS payment for FFS clients served by SPA CCBHCs, the process will be similar to the MCO PPS claims processing system described below.
Q4: How does MCO PPS claims processing work for the SPA CCBHCs?
A: SPA CCBHCs should continue to follow the usual billing policies that apply to each of the procedure codes which are included in the CCBHC Scope of Services table, as well as the additional policies applicable to the Q2 modifier for CCBHC expanded services, as described in the MHCP Provider Manual. Each MCO determines whether the claim qualifies for PPS payment. See PPS Payment process for more information.
Q5: When did the MCOs implement PPS claims processing for the SPA CCBHCs?
A: MCOs implemented PPS claims processing early January 2021. The MCOs will reprocess HDC & Western PPS-eligible claims retroactive to October 1, 2020.
Q6: What makes a SPA CCBHC claim eligible for PPS payment?
A: SPA CCBHC claims must meet the following requirements to be eligible for CCBHC payment:
Q7: Can DHS explain more about the exclusion of claims where Medicare is primary? Does it matter if the service is covered under Medicare? What does this mean for MSHO and other plans where Medicare and Medicaid funds are integrated?
A: If Medicare is primary, the claim type is typically a Medicare crossover claim. If the service is provided by a SPA CCBHC, these claims will not receive the PPS rate for Medicare-covered services provided to full benefit dual eligibles.
If a service is not covered by Medicare, Medicare would not be considered to be primary. For example, TCM and Adult Mental Health Rehabilitative Services (ARMHS) are not covered by Medicare and therefore Medicare is not primary in those situations.
MSHO plans are responsible for paying the PPS rate for services NOT covered by Medicare.
MSHO plans should NOT pay the PPS rate for services that are covered by Medicare.
Q8: Which major programs are eligible for a SPA PPS payment, and which of these programs will affect MCOs? How does this differ from the Sec 223 demonstration?
A: In the Sec 223 demonstration, the only major programs eligible for PPS payment were MA and QM. For SPA CCBHCs, QM is no longer eligible since it only applies in situations where Medicare is primary (see previous question). The following additional major programs are eligible for SPA CCBHCs: IM, NM, RM and EH. The only additional program that affects MCOs is Program IM. The other additional programs are not included in managed care contracts.
Q9: How can the MCO identify CCBHC claims eligible for PPS payment when multiple locations share an NPI?
A: Each CCBHC has one rate for all of its CCBHC services, including all NPIs and all locations which are included in the CCBHC’s certification. DHS has added the ESP-Ind = 20 to the PECD file by individual service location as identified by NPI and the address fields. The ESP-Ind value ‘20’ denotes the NPI/service-locations that are participating CCBHC clinics. MCOs are expected to do whatever is necessary in their systems to ensure that PPS payments are made for eligible services provided at these locations. If the service location on the claim is blank, the MCO should assume that the service location is the same as the billing location. These locations can include provision of telehealth services according to policies described in the MHCP Provider Manual.
The PECD is an electronic file which DHS provides to MCOs. The file includes information regarding all providers who are enrolled with DHS Provider Enrollment.
Q10: Why does the PECD file User guide list Address Line 1 as an address, when we are seeing that non-address information is being added to this field?
A: Address line 1 and address line 2 are used to identify the provider’s primary office location information.
This information can include street address, extension address (floors, suites, locations in the building), and may also include identifying information as needed for the provider to identify specific services.
Q11: Is the PECD file the source of truth for the designation of a CCBHC?
A: Yes, the PECD file has the current information from DHS Provider Enrollment. CCBHCs under SPA authority are designated with ESPInd number = 20. The file is updated twice a month.
Q12: How do the concepts of CCBHC service area and service location apply to non-clinic based services?
A: Services which are provided at clinic locations outside the CCBHC’s approved service area are not included in the CCBHC certification and are not eligible for PPS payment. CCBHC 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 considered to be in- area services and therefore eligible for PPS payment.
Q13: Will the implementation date for changes in rates, locations or procedure codes be based on the claim date of service or the date the change is entered into each MCO’s system? How quickly does DHS expect MCOs to make the necessary system adjustments?
A: Changes which affect payment will be based on claim date of service. DHS expects that adjustments such as certification and enrollment of a new provider, adding a new location for an existing CCBHC or rate changes should be feasible within 60 days. In some cases, the changes may need to be applied retroactively.
Q14: How will the MCOs know when PPS rates are changed?
A: DHS will promptly communicate any rate changes to MCOs. Typically, these changes will only occur once a year. DHS has provided MCOs with PPS rates and approved provider enrollment information for HDC and Western effective Oct 1, 2020. A rate grid has been provided. The grid has the location info for the CCBHCs, NPI, PPS rate, and effective period for the rate. Rates are scheduled to be annual rates. DHS is working towards an annual timeline that coincides with the annual MCO contract process.
Q15: Will locations eligible for the rates also only be added annually? For example, for now, Western just has the one. If they wanted more locations added, would that only happen to coincide with the above?
A: During the first two years of the CCBHC demo, the current 6 clinics added about 15 new service locations. Some of these were moves, i.e. replacements for previous locations, and some were new, e.g. newly developed SUD treatment locations. After the first two years, the current 6 clinics stabilized, with very few new locations being added.
As we develop additional CCBHCs, we expect a similar experience. New locations will be added to the PECD file as they are developed and approved for CCBHC certification.
DHS is working with Western MHC to enroll additional locations as eligible Minnesota Health Care Program (MHCP) CCBHC locations. The enrollment process can take up to 30 days, so it may be February before the additional locations show up in the PECD file. DHS will provide an updated CCBHC rate grid as soon as the additional locations are enrolled and approved as CCBHC locations.
Q16: MCOs will compute the PPS payment for the first claim. What if the MCO receives a second claim two weeks later for a service that is on the CCBHC list? If the MCO had already assessed a copay, would the MCO have to reassess the second claim because of the allowable?
A: All subsequent claims will need to consider action already taken on the first claim. If a PPS has already been paid on the first claim and the subsequent claims are not a void or replacement of the first claim, subsequent claims which meet CCBHC criteria should be paid zero. If the subsequent claim has a copay or TPL, there is no need to go back and adjust the payment for the first claim.
Q17: DHS has indicated that third party payments, client spenddowns, copays and deductibles should be subtracted from the PPS rate. What if the sum of those subtractions is greater than the PPS rate?
A: If the sum of those items is greater than the PPS rate, the MCO should pay zero.
Q18: After MCO implementation of PPS claims processing, what will be continued outside of managed care? i.e. ambulatory withdrawal management (AWM)?
A: DHS has proposed inclusion of AWM in its CCBHC SPA. The impact of inclusion of this service was deemed immaterial during the 2021 MCO rate setting process. DHS will provide guidance on inclusion of the service once state plan approval is received.
Q19: How will quality bonus payments work for SPA CCBHCs?
A: DHS calculates quality bonuses as annual lump sum payments based on specific performance measures. DHS will notify the MCO that a CCBHC earned an annual incentive payment and will notify the MCO of the amount to be paid. First payments would be made at the end of 2022 for services rendered in 2021. Total quality bonus payments cannot exceed 5% of the total of PPS payments to all SPA CCBHCs. DHS determines the methodology and will communicate the amounts to the MCOs. The lump sum payment per CCBHC will be allocated between FFS and managed care and among MCOs based on utilization.
Q1: What are CCBHC SAMHSA Expansion grants?
A: These are time-limited grants which are awarded directly by the federal Substance Abuse and Mental Health Services Administration (SAMHSA) to local providers. These grants pay for services and clients who are not covered by the funding normally received by outpatient behavioral health providers.
Q2: How many CCBHC SAMHSA grants do we have in Minnesota?
A: Two CCBHCs received SAMHSA grants in 2018. Those grants expired and those two CCBHCs (Western and HDC) have received approval to convert to SPA CCBHCs as of October 1, 2020. During 2020, these two SPA clinics were re-certified as CCBHCs according to state requirements and completed the cost reporting process in order to receive a clinic-specific PPS rate.
Two additional providers, Northland Counseling Center and Wayside Recovery Center, received
SAMHSA grants in a second CCBHC expansion grant funding opportunity in August of 2020. These clinics do not have an approved Medicaid PPS rate.
Q3: Will there be an opportunity for more SAMHSA grants?
A: According to a recent communication (December 2020) from the National Council for Behavioral Health, the recently passed omnibus appropriations/COVID relief includes $850 million in grant funding for CCBHC expansion grants. Some of this will fund continuations for current grantees. Of the remainder, it’s possible SAMHSA could opt to fund applications from the previous round that did not get funded—and in addition (or instead) they could also issue a new Funding Opportunity Announcement (FOA). Since that communication, SAMHSA has issued a new FOA, with a deadline of March 1, 2021.