Established by the Excellence in Mental Health and Addiction Treatment Act, Certified Community Behavioral Health Clinics (CCBHCs) are specially designated clinics that provide a comprehensive range of mental health and substance use services. CCBHCs are reimbursed via a cost-based prospective payment system (PPS) for the nine required services defined in the CCBHC criteria. When establishing a PPS rate for a CCBHC, understanding the key components is essential for financial sustainability and compliance. Cost is likely the key component when providers think of the cost report; however, visits can also be a significant factor that many sometimes overlook.
CCBHC PPS Rates
According to Section 223 CCBHC Demonstration PPS Guidance, under the CCBHC demonstration, participating states must select from among four PPS rate methodologies to reimburse CCBHC providers for the cost of delivering CCBHC services:
- Certified Clinic Prospective Payment System 1 (CC PPS-1) – Is a Federally Qualified Health Center (FQHC)-like PPS rate that provides reimbursement of the expected cost of providing CCBHC services on a daily basis. CCBHCs are limited to one PPS payment each day for a person receiving CCBHC services.
- CC PPS-2 – Provides reimbursement of the expected cost of providing CCBHC services on a monthly basis and allows states the option to develop separate Special Population (SP) rates to cover the high cost of individuals with certain clinical conditions. CCBHCs are limited to one PPS payment each month for a person receiving CCBHC services.
- CC PPS-3 – Provides reimbursement of the expected cost of providing CCBHC services on a daily basis. While CC PPS-3 mirrors CC PPS-1 with the requirement to set a clinic-specific daily PPS rate, it also includes the newly required daily Special Crisis Services (SCS) rates, which allow states to set separate PPS rates for crisis services provided by CCBHCs. SCS rates may be set for one or more of the following categories of crisis services: 1) mobile crisis services that meet the criteria for being qualifying community-based mobile crisis intervention services as authorized under §9813 of the American Rescue Plan Act of 2021 (P.L. 117-2, ARP), 2) mobile crisis services that do not meet the qualifying criteria of ARP §9813, and 3) on-site crisis stabilization services.
- CC PPS-4 – Similar to CC PPS-2 in that it also has a monthly unit of payment, and similar to CC PPS-3, it requires the new separate monthly SCS rates.
Costs
Costs normally should be categorized into three main groups:
- Direct CCBHC Costs – Includes labor and non-labor expenses directly tied to CCBHC services.
- Direct Non-CCBHC Costs – Expenses unrelated to CCBHC services, such as those for FQHC or Community Mental Health Center (CMHC) programs.
- Indirect Costs – Shared overhead expenses allocated proportionally between CCBHC and non-CCBHC services.
It is important for facilities to categorize all expenses into these groups correctly, especially if non-CCBHC services are provided as well, such as FQHC or CMHC programs, so duplicate costs are not claimed for each provider type.
Visits
According to CMS, any service that can be billed as a CCBHC service should be included in the reported visits, regardless of the payor or the program under which the services are billed. Depending on your PPS rate type, as described above, it is imperative to determine proper unduplicated visit counts to report on your CCBHC cost report. For PPS-1 and PPS-3, only one visit per day should be reported, regardless of whether multiple services were provided to the patient on that day. For PPS-2 and PPS-4, only one visit per month should be reported, regardless of whether multiple services were provided to the patient in that month. As an example, for PPS-2 and PPS-4, the number of unduplicated monthly visits per year equals the total number of months that a member received at least one service in a month from a clinic.
Once costs have been appropriately categorized and any non-allowable expenses removed (as instructed by CMS), the total allowable CCBHC costs, including the portion allocated via the indirect cost calculation, will be divided by total visits to calculate the PPS rate. Accurate visit counts are critical in setting a proper PPS rate. Overstating visits can dilute the PPS rate, underrepresenting the true cost per service. Conversely, understating visits may improperly inflate the PPS rate, potentially triggering compliance concerns during audits.
If you need assistance in categorizing costs or properly reporting visits, please reach out to a professional at Forvis Mazars.