CMS: Brief summary of proposed updates to CCBHC PPS Guidance

May 16, 2023

Good afternoon,
Background:  NYS recently enacted a new state budget that includes a significant expansion of the NYS CCBHC Federal Demonstration Program.  Over the next two years, the number of participating demo clinics in NY will increase from 13 to 39.

CCBHCs that currently participate in the federal demonstration program are reimbursed through the use of a Prospective Payment System (PPS) rate methodology (rather than APG government rates).  As such, they do not bill Medicaid managed care (MMC) for CCBHC services provided to MMC beneficiaries.  Since the PPS rate does not factor in costs associated with provision of CCBHC services to New Yorkers without insurance, the new state budget also includes a provision that requires the state to apply to CMS for federal matching funds for a new Indigent Care Pool that will assist demo agencies with the costs associated with providing care to these individuals.  If CMS approves the states application, the federal government will participate in the costs associated with the new Pool.  If CMS does not approve, the state will take on the expense of the Indigent Care Pool for eligible CCBHC Demo agencies.

What’s New? In December, CMS implemented an initiative designed to update various components of the CCBHC Federal Demonstration Program.  One of the areas being updated is the PPS technical guidance.   On Friday, HHS’ Center for Medicare and Medicaid Services (CMS) issued proposed updates (see link in first sentence below) to its CCBHC Prospective Payment System guidance.

The NYS Council will again submit formal comments as it did in December during the first public comment period.  Comments are due back to CMS on June 2nd.

CCBHC PPS Guidance: Proposed Updates

Recently the Centers for Medicare & Medicaid Services issued a Notice seeking public comment on proposed updates to the Certified Community Behavioral Health Clinic (CCBHC) Prospective Payment System (PPS) Technical Guidance published as part of the Substance Abuse and Mental Health Services (SAMHSA) CCBHC 2015 Notice of Funding Opportunity.

A summary of the proposed updates includes:

  • Simplifying the PPS-2 methodology to make special population rates optional
  • Addition of two new PPS rate options (PPS-3, daily; PPS-4, monthly) which includes a Special Crisis Service rate component.  NYS Council Note: NYS currently employs the PPS-1 daily rate reimbursement methodology.
  • Updating the quality bonus payment measure-set and providing clarification and examples regarding flexibilities for quality bonus payments.  This would include a tiered payment of bonus payments based on the level of achievement once the minimum threshold to qualify for such payments has been met.    NYS Council Note:  Although discussed in New York’s initial application to be considered for designation as a federal demonstration state, NYS has never implemented the quality bonus payment program.  State agency leads say that none of the participating Demo agencies has met the metrics to receive a quality bonus.  Participating providers have asked for but have not received the data from the state that would support this conclusion. 
  • Updating specific sections of the existing CCBHC PPS Guidance to bring it up-to-date, and provide additional flexibilities as allowable under the Demonstration, and
  • Establishing a standard 3-year cadence for states to rebase clinic-specific PPS rates.