Attn: Comments on the Prospective Payment System for the CCBHC Demonstration

December 22, 2014 Ms. Cindy Mann Deputy Administrator and Director for Center for Medicaid & CHIP Services Centers for Medicare & Medicaid Services Department of Health and Human Services 200 Independence Avenue, SW Washington, DC 20201 Attn: Comments on the Prospective Payment System for the CCBHC Demonstration Dear Ms. Mann: On behalf of the nation s Medicaid Directors, we appreciate the opportunity to provide you with input as the Center for Medicaid and CHIP Services (CMCS) develops the prospective payment system (PPS) for the Certified Community Behavioral Health Clinic (CCBHC) Demonstration, enacted under the Protecting Access to Medicare Act. Our preliminary comments focus on aligning this demonstration with existing state initiatives, minimizing the administrative burden and maximizing success for those states interested in leveraging this opportunity to build capacity and advance practice transformation in their behavioral health systems. As you know, Medicaid Directors across the country are advancing efforts to improve quality and deliver person-centered care to those with behavioral health needs, such as by improving care coordination, enhancing care management and integrating physical and behavioral health services. These delivery reforms are being coupled with the widespread movement toward payment models that reward value, such as risk-based payment arrangements. States have recognized 444 North Capitol Street, NW, Suite 524 Washington, DC 20001 Phone: 202.403.8620 www.medicaiddirectors.org

that these types of innovative payment reforms are necessary to usher in a modern delivery model that best meets of the needs of beneficiaries, including those with behavioral health diagnoses. Our initial comments focus on three main requests, listed below. These are detailed further in the enclosed document: 1. We respectfully request that CMS use the full extent of its authority under the statute to allow states to align the demonstration PPS with their existing payment strategies that reward value and drive high quality care. The payment methodology options and guidance to states should promote efficiency and value. The demonstration should not create more fragmentation and separate the behavioral health population into an antiquated payment approach that incentivizes volume of services rather than quality. 2. The PPS must be nimble enough to reflect differences across states; states need to shape the PPS in the context of their program and target populations. For example, meaningful differences exist between state agency structures, provider capacity, information and administrative systems, managed care penetration, licensing authority, covered services and other components of the Medicaid delivery system. 3. We recognize the respective expertise and areas of authority of SAMHSA and CMS, and ask the agencies to continue to work closely together to align all aspects of the demonstration. Due to the strong link between delivery and payment, the criteria and oversight mechanisms for CCBHCs cannot be developed or assessed in isolation. As noted above, we have enclosed comments on specific aspects of the PPS. We also hope that CMS will work with NAMD and our members to have more focused discussion on these complex payment and service delivery issues. Page 2 of 19

We look forward to continuing to work with you on the implementation of this demonstration to afford states another viable option to improve care and drive value for Medicaid-eligible individuals with behavioral health needs. Sincerely, Darin J. Gordon TennCare Director Department of Finance and Administration State of Tennessee President, NAMD Thomas J. Betlach Arizona Health Care Cost Containment System Director State of Arizona Vice-President, NAMD Encs. (2): Preliminary Recommendations for Developing the CCBHC Demonstration PPS November 26, 2014 letter to SAMHSA Regarding CCBHC Criteria Cc: Pamela Hyde, J.D., Administrator, Substance Abuse and Mental Health Services Administration Shantanu Agawal, M.D., Deputy Administrator and Director, Center for Program Integrity Page 3 of 19

Preliminary Recommendations for Developing the CCBHC Demonstration PPS Alternative Payment Models 1. CMS should provide maximum flexibility for states in the design of their PPS, including through the use of alternative payment models. States need the flexibility to align the PPS, to the greatest extent possible, with other existing payment approaches in their state s delivery system. This will help to facilitate timely implementation and drive coherence rather than fragmentation. One example of this flexibility might include the option to use a flat-rate per day to cover all behavioral health issues, rather than a specific fee for each intervention, which could grant more flexibility to the provider and deliver a whole-person focus. In addition, CMS should permit alternative payment models which reward high quality care and hold underperforming providers accountable. Many states are currently using these payment models to drive widespread improvement for other beneficiaries in Medicaid. The demonstration should not force states to isolate individuals with behavioral health conditions from these advances in payment and care delivery. Managed Care 2. CMS should ensure states have the option to propose a demonstration approach to implement the PPS in a managed care environment, where applicable. Variations in managed care models, population served, and geographic characteristics are just some of the variables that affect the structure and feasibility of this demonstration in managed care. Rather than prohibiting managed care arrangements or prescribing a one-sizedfits all approach that does not take into account these variables, states should be permitted to determine how the PPS will be implemented in its Page 4 of 19

managed care framework during the application phase. This will provide CMS and SAMHSA with an opportunity to review the approaches when states submit their application. Further, when the demonstration is underway, states and federal officials will have an opportunity to assess a range of strategies for implementing the PPS in managed care. This information could help inform model state practices and future policy initiatives. 3. CMS should provide technical assistance to states in developing specific contracting approaches that maximize budget certainty, protect program integrity and minimize administrative burden. States are concerned that under some contracting approaches, the PPS could increase uncertainty in budgeting for the costs of care for Medicaid beneficiaries served by CCBHCs. For instance, MCOs may negotiate a rate with CCBHCs, but states would be obligated to pay the difference between MCO payment and PPS rate. States would not be able to budget for these additional payments, which raises significant uncertainty for states around the cost of care. In addition, administering wrap payments presents a sizable administrative burden to states. This is especially true in the initial transition to managed care where encounters are lagged as the MCOs build up their systems. We urge CMS to provide states with technical assistance, such as sample contract language, to support states in implementing appropriate and effective contracting approaches to address these concerns. PPS Adjustments 4. States should be permitted to determine the adjustments to basic rates to account for variability in the intensity of services offered by CCBHCs and to account for geographic disparities. Because of the variations between state Medicaid programs, eligible populations, delivery models, and geographic characteristics, states will need flexibility to build in certain Page 5 of 19

adjustments to the PPS. These adjustments will be necessary regardless of the basic unit used to establish the PPS for behavioral health services. In addition, states would welcome technical assistance from CMS on the front end to help identify appropriate adjustments that should be incorporated in the PPS. Allowable Costs 5. The cost of services for uninsured individuals should be built into the PPS, taking into consideration any other state or federal reimbursement intended to offset the cost of uncompensated care. Section 223 of the Protecting Access to Medicare Act of 2014 requires that CCBHCs not reject or limit services based on a patient s ability to pay. This is similar to requirements maintained under the Section 330 grants for FQHCs. However, unlike the 330 grant funds for the FQHC program, the Act does not provide for another source of payment in addition to the prospective payment to cover the cost of services to uninsured individuals. To ensure that the CCBHC model is viable, states must be able to build the costs of serving uninsured individuals into the PPS unless federal authorities provide for these costs through some other means. 6. States must have flexibility to include ongoing training and information technology costs in their proposed prospective payment rate. Implementation of the PPS will require significant initial and ongoing training to prepare, and continue to improve, both state and CCBHC staff in developing and managing the new system. The demonstration will also require initial and ongoing development and maintenance of electronic medical records (EMRs) at both the state and CCBHC levels in order to extract the data necessary for providing comprehensive care coordination, and for evaluation of the demonstration. While the planning grant will help to cover some of the initial training and HIT costs, there will be ongoing training and information technology costs for CCBHCs that states Page 6 of 19

must be able to incorporate into the PPS. 7. States should be able to include the cost of providing new services into their PPS. In order to certify CCBHCs under the criteria included in the Act, states participating in the PPS may be required to add new services not previously covered under a state s Medicaid Plan. Likewise, in order to deliver quality care and improved outcomes, states may find it advantageous to require CCBHCs to provide services that are not currently covered under the state plan. However, Section 223(d)(5)(C)(i) of the Act requires, in part, that payment shall be made under this paragraph to a State only for mental health services for which payment is available under the State Medicaid program. We urge CMS, working with its colleagues at SAMSHA, to clarify the payment and service requirements. We request that CMS use the fullest extent of its authority to extend states the flexibility to include the costs of services not previously covered in the State Plan into the payment methodology. This would promote financial viability for the model and ensure CCBHCs deliver high quality care that meets the needs of the target population. Cost Reporting 8. CMS should provide states with a cost report template, rather than a mandatory format, which they can adapt for use in their demonstration program. A sample cost report template could assist states in implementing this demonstration within the short timeframe allotted. States should be permitted to tailor this cost report template, as necessary, to meet the needs of their respective demonstration programs and to align with similar service delivery priorities. Page 7 of 19

9. The cost reporting process should incorporate periodic rebasing of the PPS. We recognize that the need for rebasing may be contingent, at least in part, on the length of the state s demonstration program and the flexibility states have around developing the initial PPS. However, states may still wish to implement a policy for regular intervals for rebasing, beyond the interim and final rate setting. This would be consistent with state Medicaid programs that currently rebase payments on a regular basis for other providers, such as hospitals and nursing homes. A similar rebasing approach should be applied to the CCBHC PPS to ensure payment accurately reflects the costs of services delivered. Rebasing should be the basis for increasing payment under the PPS; there should not be a default payment adjustment upward each year. This will protect the integrity of the program and guard against fraud, waste and abuse that may otherwise occur in the demonstration. Service Areas 10. States should have the authority to establish the CCBHC service areas, in consultation with providers, and only require CCBHCs to deliver crisis response/emergency and stabilization services to individuals residing outside of their region. Many states currently rely on catchment or service areas for community mental health service providers and have a delivery system structured around this model. In states that rely on these catchment areas, state flexibility is needed to define service areas that would apply to the PPS. This approach would require CCBHCs to provide crisis services to all individuals regardless of place of residence, while the CCBHC from a given individual s region would be responsible for providing all required ongoing care. We urge CMS to afford states maximum flexibility to ensure the CCBHC model can fit within the context of state behavioral health delivery systems that are structured around service areas as well as to best Page 8 of 19

utilize the capacity of CCBHCs. Operational Challenges of the Two-Year Demonstration Duration 11. CMS should develop a template or other appropriate resources, to assist states that wish to use Section 1115 waiver authority, or other authorities as appropriate, to extend their PPS methodology beyond the initial two years of the demonstration. Changing a payment methodology requires considerable resources and time on the part of states and providers. Specifically, states would have to plan for and implement the new PPS methodology, including making programming changes in their systems, and providers would have to make changes to their billing system, retrain staff, and plan for changes in cash flow. Likewise, during the two year period for this demonstration, states would have to start preparing to switch back to a non-pps payment methodology approximately 12 months into the demonstration. It may be a disincentive for states and providers to participate in the demonstration if CMS does not give assurances that the PPS payment methodology could continue at the standard state match rate beyond the two year demonstration. Articulating a longer-term pathway by which states may choose to continue the demonstration concept may also result in better outcome data and a more robust evaluation of the demonstration. In the initial two-year timeframe, it is unlikely that any reliable and meaningful outcome data on the impact of the payment methodology will be gleaned. Typically, the first 12 to 18 months of any large delivery and payment transformation are not representative of the changing outcomes that result from a mature and fully operational program. For example, the Medicaid Emergency Psychiatric Demonstration faced such similar challenges in evaluating outcome data after only two years. Page 9 of 19

Nov. 26, 2014 Ms. Pamela Hyde Administrator Substance Abuse and Mental Health Services Administration 1 Choke Cherry Road Rockville, MD 20857 Attn: Certified Community Behavioral Health Clinic Comments (Docket Number 2014-25822) Dear Ms. Hyde: On behalf of the nation s Medicaid Directors, we appreciate the opportunity to comment on the criteria for the state-certified community behavioral health clinic (CCBHC) demonstration enacted under Sec. 223 of the Protecting Access to Medicare Act of 2014. Our comments focus on maximizing participation and success for those states interested in leveraging this opportunity to build capacity and advance practice transformation in their behavioral health systems. NAMD is a bipartisan, professional, nonprofit organization representing the nation s 56 state and territorial Medicaid agencies, including the District of Colombia, whose mission is to represent and serve state Medicaid Directors. NAMD works closely with our members to provide a focused, coordinated voice for the Medicaid program in national policy discussion and to effectively meet the needs of our member states now and in the future. Medicaid Directors across the country are advancing efforts to improve quality and deliver person-centered care to those with behavioral health needs, such as by improving care coordination, enhancing care management and integrating physical and behavioral health services. Many states are approaching this work through bi-directional, large scale initiatives that aim to facilitate a more rational, accessible and cost-effective delivery system for those with behavioral health diagnoses. States are coupling this work with broader state payment reform efforts that incentivize the delivery of high quality care, rather than volume of services delivered. It is necessary to keep in mind the context for this and any demonstration involving state Medicaid programs. Meaningful differences exist between state structures, systems, managed care penetration, licensing authority, and other components of the Medicaid delivery system. As a result, states are pursuing a range of strategies to better coordinate, integrate, and coherently deliver physical and behavioral health care. Page 10 of 19

NAMD and its members share SAMHSA s goal for evolving the behavioral health infrastructure to provide coordinated, high-quality cost-effective care. With this goal in mind, we urge SAMHSA to provide states flexibility to propose demonstrations that will advance a more coherent system of care for consumers in their communities. Parameters for the CCBHC demonstration should, at a minimum, permit and ideally will encourage states to build on their existing initiatives. We believe successful demonstration programs will be those that align with emerging and effective state models. A program which ultimately compels states to create a distinct system of care that bifurcates services for those with behavioral health needs would be a step backwards. Instead, in many areas of the discussion topics SAMHSA identified, state flexibility would promote alignment with existing work, and lead to greater learning for your agency, other federal partners and states. We believe SAMHSA should issue a request for applications that encourages a wide range of approaches within the statutory framework and select those approaches it believes are most promising to test, including applications that also look to provide services beyond the four walls of a clinic and are focused on providing services in the home and community. By testing variations on the structure and payment for the CCBHC model, SAMHSA, states and other stakeholders will have greater data and insight into the successful strategies to improve the delivery of care. It is also important to recognize that existing innovative models and service coordination approaches are evolving, and the CCBHCs must be able to adapt along with this broader progress in the delivery system. In addition to flexibility, we urge SAMHSA, in all aspects of the demonstration, to minimize the administrative requirements on participating states and providers. Establishing a prospective payment system (PPS), evaluating providers and services, and identifying and effectuating systems-related changes are just some of the many complex tasks states will face in standing up a CCBHC demonstration in a short period of time. Further, quality reporting requirements and quality reporting systems for this demonstration will add a new administrative burden on states and providers. Therefore, SAMHSA must seek to minimize reporting requirements and systems changes during the time-limited demonstration including by focusing on a menu set of measures that states can tailor to meet their Medicaid program s goals and approach. The limited demonstration time also requires federal agencies and participating states to set realistic goals and expectations for participants. In particular, the short timeframe to plan for and carry out this demonstration requires practical approaches to goal-setting and outcomes measurement, as well as expectations around practice transformation. Page 11 of 19

We also ask that SAMHSA provide states with direction regarding the target populations for this initiative. Such direction would enhance states ability to evaluate their interest in the model and develop a successful proposal. For example, we urge the agency to use as a model the information provided to states regarding the target populations for Medicaid health homes under Section 2703 of the Affordable Care Act. SAMHSA s guidance could help states appropriately tailor this demonstration to specific populations, such as children with severe emotional disturbances; super-utilizers; or adults with chronic or chronic and episodic severe and persistent mental illness. Finally, due to the strong link between delivery and payment, the criteria and oversight mechanisms for CCBHCs cannot be developed or assessed in isolation. While we recognize the respective expertise and areas of authority of SAMHSA and CMS, the agencies must continue to work closely together to align all aspects of the demonstration. We are particularly interested in ensuring that the demonstration not segment the behavioral health population into an antiquated payment model. Therefore, we ask SAMHSA and CMS to use the full extent of their authority to ensure the payment methodology options promote efficiency and value and do not impede participating states evolving delivery system and payment transformations to move away from volume-based payment. We appreciate the opportunity to comment on the CCBHC demonstration, and have enclosed responses to your specific discussion questions. We separately hope to work with the Centers for Medicaid and CHIP Services to inform your agencies thinking on how to best structure the PPS and provide for alternative payment methodologies under the demonstration. We look forward to continuing to work with you around the implementation of this demonstration to ensure it improves care and drives value for individuals with behavioral health needs in Medicaid. Sincerely, Darin J. Gordon TennCare Director Department of Finance and Administration State of Tennessee President, NAMD Thomas J. Betlach Arizona Health Care Cost Containment System Director State of Arizona Vice-President, NAMD Enclosure: Response to SAMHSA s Guiding Questions on CCBHC Criteria Page 12 of 19

Response to SAMHSA s Guiding Questions on CCBHC Criteria Quality and Other Reporting 1. SAMHSA should develop a menu of quality measures, aligned to the greatest degree possible with the quality measures in existing Medicaid initiatives, that states would select to report. We urge the agency to balance the need for a federal quality framework in this demonstration with state flexibility to drive improvement in the context of their delivery model and existing initiatives for Medicaid beneficiaries with behavioral health conditions. We believe this can be achieved through a menu approach where states would select quality measures from among a core set of federally-specified measures, and have the option to identify additional measures pertinent to their population, services and related factors. This selection would take place as part of their proposal to participate in the demonstration, which would provide SAMHSA with the opportunity to evaluate the appropriateness of the measures selected. It is also vital that the measures in the menu align with the quality measures for other Medicaid initiatives, such as health homes, the electronic health records meaningful use incentive program, federally qualified health centers, Medicare-Medicaid demonstrations, and other key efforts. Such alignment is necessary to bring coherence with other innovative delivery models and behavioral health care improvement efforts in Medicaid, and minimize administrative burden on states and providers. Further, the number of measures states must report on from within this menu should be kept to a manageable number and readily available from current data sources in Medicaid. 2. The outcomes of interest should focus on the coherence of physical and behavioral health care delivery and should be specified by states as part of their application to participate in the demonstration. As states advance delivery reforms to promote a coordinated system of care, including through integration approaches, it is important that the outcomes sought under this demonstration align with that work. As such, SAMHSA should require states to identify the outcomes in the application process and prioritize those focused on targeting key concerns in the state around creating a coherent system of care and driving quality improvement for beneficiaries. States should be permitted to identify various ways of measuring outcomes for this population in their application. For example, states could use pay-for-performance contracts that target the population of a CCBHC and measure compliance with guidelines for the treatment of chronic illnesses, such as diabetes, which are a valid method of measuring integration. The differences in behavioral health delivery Page 13 of 19

systems and variations in Medicaid s approach to this work make this flexibility necessary. Scope of Services 3. States should propose the scope of services that CCBHCs will provide as part of the application to participate in the demonstration and should have the option to require inclinic primary care services. States would construct and propose their approach to services in accordance with the statute. States understand their health care landscapes, the availability of providers, the existing delivery models and situations where it is only feasible to partner with a provider for the provision of services. This knowledge is necessary to develop a framework that ensures CCBHC are a viable and effective model in the state. Further, it is important that the scope of services align with existing work in the state to create a coherent, person-centered model of care. Likewise, SAMHSA should refrain from providing detailed service definitions beyond what is provided in statute that could threaten the feasibility of the demonstration. For example, states use different terminology to describe certain services. States also may define terms slightly differently, for example care coordination, and a single federal definition would be problematic to adopt for this time-limited demonstration. 4. States selected to participate in the demonstration should have the flexibility to determine that in a specific case, a particular CCBHC is not required to provide or arrange for a specific service. In general, we believe that CCBHCs will provide or arrange for the provision of all of the services included in the Scope of Services described in Section 223(a)(2)(D) of the Act. However, it might be possible for a specific CCBHC to demonstrate that a specific service included in the Scope of Services is not needed or appropriate given the specific circumstances of that CCBHC, target population or other state-specific program parameters. Further, we believe an exceptions process is necessary to ensure states can still advance services that meet consumers where they are, including by delivering in-home or telehealth services. States that propose to exercise this option should describe the criteria they propose to use in order to authorize exceptions to the general expectation that CCBHCs provide or arrange for the full array of services. 5. States should have the option to require a certified CCBHC to enter into a contract with other providers for the provision of required services. CCBHCs should add to the creation of a coherent delivery system, whether the state has implemented medical homes, accountable care organizations, or other delivery models. States must have the ability to engage CCBHCs in these other existing efforts and similarly CCBHCs should be willing to participate in such efforts, where appropriate. Page 14 of 19

Further, states have found that formal agreements and contracts are usually but not always necessary to provide services through other providers, depending on the nature of relationships and provider profiles in the community. Presumably, CCBHC would have to pay a partnering organization in accordance with the prospective payment since the CCBHC will be receiving the prospective payment for that service. States should document the accountability and oversight mechanism that will be used to ensure this payment can take place. Staffing 6. Federal requirements around provider licensing and credentialing or cultural and linguistic training are not appropriate and will be determined by the states. Concerns around these issues, which were raised in SAMHSA s guiding questions, are already addressed under existing Medicaid statute. In order to receive payment under Medicaid, providers must be licensed and credentialed or practice under a provider who is licensed and credentialed in the state. The providers in the CCBHC receiving the Medicaid PPS are covered by these existing requirements, and additional licensure or certification requirements are not necessary. In addition, Medicaid programs, managed care plans and providers already operate according to the statutory requirement that services be culturally and linguistically appropriate. The provision of CCBHC services under this demonstration will be covered under these existing requirements. Additional provisions above and beyond existing statute are unnecessary and would place undue administrative burden on states and providers. It is appropriate for states to specify how these requirements are determined and oversight procedures. 7. States should be required to outline the array of staff required in a CCBHCs in their application to participate in the demonstration. Like other aspects of this demonstration framework, the type, number and disciplinary backgrounds of the CCBHC staff is impacted by the nature of state delivery models and the available workforce in a particular community. The staffing model in a rural CCBHCs will differ from a CCBHC in a state with multiple medical schools and urban areas. Detailed staff requirements, such as requiring the CCBHC to have a medical director who is a psychiatrist, will preclude many states from participating in this demonstration simply due to its geographic features and not based on the its ability to improve quality and drive value for those with behavioral health conditions through a CCBHC model. Page 15 of 19

8. States should be permitted to use peer support specialists under appropriate supervision by a licensed health professional as part of their CCBHC staffing model. Many states have found the use of these non-licensed providers are a key component of care for those with behavioral health conditions. Though state capacity to incorporate peer support specialists and their availability may differ, states should be afforded the flexibility to incorporate this optional staffing component into their proposed CCBHC model, which SAMHSA will evaluate in reviewing the demonstration proposals. Accessibility and Availability of Services 9. States should have the flexibility to propose additional approaches, such as telemedicine, to assure the availability and accessibility of CCBHC services and additional 24 hour capabilities as part of their application to participate in the PPS demonstrations. For Medicaid Directors, access is one of several fundamental components of the program. States manage this issue using a range of strategies tailored to address challenges, such as significant limitations in the supply of providers in locals and in some specialties. In some of these problematic areas where access is also usually a challenge for individuals with other types of public and private coverage states have designed innovative service delivery systems and payment models to ensure access to quality care. The CCBHC demonstration provides an opportunity to drive further innovation around accessibility and availability of behavioral health services. State innovation is best achieved through creative problem-solving within the context of a state s existing behavioral and physical health delivery system and available workforce. By evaluating various accessibility standards and approaches under the demonstration, SAMHSA can promote innovation and identify new methods of ensuring access for those with behavioral health conditions. 10. CCBHCs should be permitted, at state option, to deliver services in community-based settings. Office-based settings are not always the most appropriate place to deliver care for certain populations with behavioral health conditions, including children with severe emotional disturbances and homeless individuals with substance use or mental health conditions. Because of this, states should have the option to allow CCBHCs to provide care in the community or home, as appropriate under the state proposal. Care Coordination Page 16 of 19

11. States should define care coordination to align with definitions and expectations across their program. As states advance behavioral health reforms and other care delivery improvements across their programs, care coordination is a central tenant of these efforts, whether in health homes, Medicare-Medicaid integration efforts, or managed care reforms. States have significant experience in outlining and structuring care coordination approaches, including approaches to coordinate social services and supports, and tailoring care linkages to meet the needs of the population. The state application to participate in the demonstration provides an opportunity for states to describe how care will be coordinated, including how the state will ensure that care coordination includes recovery support services, such as housing and employment supports. States can draw from their significant experience and expertise in this area and propose an approach that includes the specific care coordination activities and the infrastructure that will enable care coordination. States can also articulate any entities, including those listed in statute, that will be care coordination partners under the demonstration. SAMHSA and CMS can evaluate the adequacy of the proposed care coordination approach as part of the state selection process for the demonstration. 12. States should be permitted to require CCBHCs to have partnerships with a variety of physical health providers. It is important that CCBHCs are able to seamlessly connect beneficiaries with physical health services when such services are not available in the CCBHC. In particular, coordination with primary care services is essential. Additionally, partnerships with large provider delivery systems are critical in addressing patient transitions and access to appropriate levels of care. As such, states must be permitted to require CCBHCs coordinate with a diverse array of physical health providers, extending beyond federally-qualified health centers. This is necessary to ensure the CCBHC model effectively treats the whole person, including both their physical and behavioral health needs. 13. CCBHCs must be permitted to provide care coordination activities through partnerships, and not only contracts, with the entities outlined in statute. Partnerships offer an ideal pathway for CCBHCs to build linkages between services, while minimizing the administrative burden of developing formal contracts. It is important to limit this burden in order to ensure CCBHCs have linkages with the broadest scope and number of providers. Partnerships should also be broadly defined to allow states to demonstrate a variety of ways that they have established relationships with the providers listed in statute. For example, CCBHCs could submit letters of support from a wide array of health care, social service (including vocational rehabilitation), and community organizations as Page 17 of 19

part of the certification process to demonstrate the existence of partnerships. On the other hand, requiring formal contracts with care coordination partners is both unnecessary and impractical. Developing a good working relationship with a wide range of community organizations takes time and is not enhanced by formal contracts. Formal contracts are also impractical because CCBHCs would have to develop such agreements with a large number of entities. Likewise, it is impractical because while a CCBHC may be willing to enter into such agreements, other providers and community organizations may not even though they will continue to make and accept referrals. 14. SAMHSA should partner with demonstration states to enhance the relationship between the state, CCBHCs, the Department of Veterans Affairs and the Indian Health Service. States welcome assistance from SAMHSA to develop linkages and a solid relationship with the Department of Veterans Affairs and the Indian Health Service and their medical centers, outpatient clinics, drop-in centers, and other facilities. 15. CMS and SAMHSA should allow demonstration states to pilot data sharing across physical and behavioral health providers. To date, states have identified major concerns with the ability to deliver a cohesive, coordinated set of services due to separate health information privacy requirements for substance use disorder treatment. As a result, it is significantly less likely that people with substance use disorders, including Medicaid beneficiaries, receive the attention and time to support continuing remission. It also makes it less likely that these individuals have early recurrence identified, which is routinely provided to those with other chronic medical conditions. We believe this demonstration offers an ideal vehicle for the federal agencies to pilot an approach through which states could exchange data across providers and would align with the objectives of this federal demonstration. Organizational Authority 16. States should be permitted to exercise oversight authority and promote program integrity among CCBHCs. States are statutorily charged with preventing fraud, waste and abuse in Medicaid and ensuring that the program is operated efficiently. In this demonstration, states must be able to exercise oversight authority over CCBHCs as the agency would over all other Medicaid providers. CCBHCs should be required to report accurate and timely data to states and managed care plans. In addition, CCBHCs must be subject to audit requirements established by the state. Page 18 of 19

17. States should propose to SAMHSA what, if any, additional requirements they expect of entities that would serve as CCBHCs in a demonstration. Key differences in the delivery system can greatly impact what entities are best positioned to serve as CCBHCs and raise concerns around those entities that should not serve in this role. For example, in a state with many co-located behavioral and physical health providers, these practices may be well suited to serve as CCBHCs whereas another demonstration may hinge on local behavioral health authorities. 18. States should determine CCBHC accreditation requirements. A federal accreditation requirement could be a barrier to achieving the intended goals of the demonstration in the given timeframe in many states. Rather, states should be permitted to use existing accreditation components to deem relevant aspects of CCBHCs, where appropriate. We recognize that work is underway at the national level to develop some type of behavioral health provider accreditation. However, as noted earlier, the timeline to plan and implement this demonstration is challenging, given the complexity of establishing a PPS, certifying entities as CCBHCs, and otherwise standing up a major demonstration. Given this, a uniform federal mandate for accreditation would make this timeline more compressed since no CCBHC accreditation currently exists. Accrediting entities would have to develop a CCBHC accreditation, which would slow down state efforts to stand up the demonstration. Page 19 of 19