CCBHC Criteria Frequently Asked Questions

These terms have a slightly different meaning. Furnishing services (e.g., clinical, peer support, vocational support, etc.) means the delivery of treatment, recovery support, or other interventions. The CCBHC must regularly assess the skills and competence of each individual furnishing services and, as necessary, provide in-service training and education programs. Direct contact is broader and includes non-service employees, such as office personnel who have contact with people being served. For this broader group, the CCBHC must maintain a record of in-service training provided for the duration of employment of each employee.

The CCBHC must have clinicians on staff who are licensed substance use counselors (Criteria 1.b.2), but there is not a requirement that all counselors providing SUD services be licensed SUD counselors. CCBHCs must follow state licensing requirements.

The purpose of a medical director is to provide guidance to foster the integration and coordination of behavioral health and primary care and to ensure the quality of broader clinical practice at the CCBHC. This is accomplished through a combination of consultation and protocol development as well as building and maintaining relationships with clinical and administrative staff. The medical director is expected to be a meaningful part of the behavioral health clinical service team at the CCBHC and this requires working with the CCBHC staff on site, with interspersed virtual attendance in administrative and clinical activities. Therefore, the Medical Director needs to be on-site at least some of the time to support these functions.

No, the CCBHC does not need to ensure all CCBHC services are provided during extended hours but should arrange for availability of services (including the services offered and the hours they are available) to meet the needs of the people being served, as informed by the Community Needs Assessment and based on input from people receiving services. Please note that people should be able to contact the CCBHC 24 hours a day and that a mobile crisis response should also be provided within 3 hours 24 hours a day.

A DCO is an entity that is not under the direct supervision of the CCBHC but is engaged in a formal relationship with the CCBHC to deliver one or more (or elements of) the required services as described in criteria 4. The DCO is rendering services on behalf of the CCBHC. The formal relationship between CCBHCs and DCOs creates the platform for seamlessly integrated services delivered across providers under the umbrella of a CCBHC.

DCOs are more than care coordination partners, and there is an expectation that relationships with DCOs will include more regular, intensive collaboration across organizations than would take place with other types of care coordination partners. From the perspective of the person receiving services, services received through a DCO should be part of a coordinated package with other CCBHC services and not simply accessing services through a separate provider organization.

CCBHCs are required to develop a range of care coordination partnerships to ensure that CCBHCs services are coordinated with other health and social services and supports. CCBHCs, as noted in criteria 3, must develop care coordination partnerships with a range of entities and are encouraged to develop these partnerships with other entities depending on their community’s needs.

Regardless of DCO relationships entered into, the CCBHC maintains responsibility for assuring that people receiving services from the CCBHC receive all nine services as needed in a manner that meets the requirements of the CCBHC certification criteria. In the 2015 version of the Certification Criteria (PDF | 760 KB) clinical responsibility for DCO provided services was included in the criteria, however this language was removed in the updated criteria – for a full definition of the DCO relationship see page 53 of the updated criteria (PDF | 1.3 MB).

Medicaid Conflict Free Case Management Application to CCHBCs: For a state that is approved as part of the official CCBHC demonstration project and wants to offer HCBS as part of the model, Medicaid Conflict of Interest (COI) provisions would not apply to those providers if the HCBS services are provided as a part of the 9 required CCBHC services reimbursed through the PPS. The demonstration authority is separate from Title XIX, and CCBHC demonstration expenditures are claimed on newly created “CCBHC” line items on the CMS-64. Other HCBS services authorized under traditional Medicaid waiver or state plan requirements outside of the CCBHC demonstration and separate from CCBHC services are still subject to the rules under the waiver or other formal Medicaid payment authorities.

CMS recognizes that the purpose of case management/care coordination under the CCBHC demonstration project is distinct from the purpose of providing case management functions under traditional Medicaid authorities separate from the CCBHC demonstration. For states that are not part of the CCBHC demonstration and want to implement CCBHCs under these traditional Medicaid authorities ( i.e., states not participating in the demonstration that implement the CCBHC model under traditional Medicaid state plan or wavier authority, states operating CCBHC programs through traditional authorities in parallel with CCBHC demonstration programs in their states, or demonstration states sustaining their demonstration programs through traditional Medicaid after the end of their CCBHC demonstration programs), COI provisions also would not apply to those providers for services included in the CCBHC bundled rate established under traditional Medicaid for payment.

The CCBHC should establish an agreement with the nearest FQHC if there are multiple clients who access services at the FQHC or could reasonably access services from the FQHC outside of the service area if there is not an FQHC in the service area.

No, this would not meet the CCBHC criteria. While there are cases where a telehealth response might be sufficient, the CCBHC needs to have the ability, either directly or through a DCO, to provide the mobile response in person within 3 hours.

If using a state-sanctioned crisis system to provide the required crisis services as a part of the CCBHCs delivery of these required CCBHC services identified in Section 4.C of the criteria, a Designated Collaborating Organization (DCO) relationship would be required, and a formal signed agreement is required as a result. A DCO is an entity that is not under the direct supervision of the CCBHC but is engaged in a formal relationship with the CCBHC to deliver one or more (or elements of) of the required services as described in criteria 4. For more information on DCOs, see the Terms and Definitions Appendix of the CCBHC Certification Criteria (PDF | 1.3 MB).

The CCBHC must have licensed addiction counselors and people who can prescribe medication for Opioid Use Disorder and Tobacco Use Disorder on their staff. They need to maintain an internal capacity to treat SUD but may provide SUD treatment services through a DCO agreement as well. Specifically, criteria 1.b.2 requires that CCBHC staff must include a medically trained behavioral healthcare provider, either employed or available through formal arrangement, who can prescribe and manage medications independently under state law, including buprenorphine and other FDA-approved medications used to treat opioid, alcohol, and tobacco use disorders. In addition, criteria 4.f.1 states that the CCBHC directly, or through a DCO, provides outpatient behavioral health care, including psychopharmacological treatment. This would not include methadone, unless the CCBHC is also an Opioid Treatment Program (OTP).

If a CCBHC would like to have a DCO relationship with a state-sanctioned crisis system that operates under less stringent standards, they must request approval from HHS to do so. No SAMHSA waiver or approval is needed if the state-sanctioned system operating as a DCO meets the standards for crisis services included in the criteria. Approval from HHS is required if the state-sanctioned crisis system being used as a DCO for crisis services operates under less stringent standards than identified in the criteria. As stated in 4.c.1: The CCBHC shall provide crisis services directly or through a DCO agreement with existing state-sanctioned, certified, or licensed system or network for the provision of crisis behavioral health services. HHS recognizes that state sanctioned crisis systems may operate under different standards than those identified in these criteria.

For CCBHC purposes, the statute (Social Security Act, § 1915(g)(2)) and regulations (42 CFR § 440.169) for Targeted Case Management do not apply to CCBHCs. For CCBHCs, the definition of targeted case management is outlined in the Certification Criteria (PDF | 1.3 MB). Please note that if a CCBHC expansion grant or other CCBHC is providing targeted case management that is being reimbursed through Medicaid state plan or waiver authority separate from the Demonstration, then they would have to follow the applicable rules and regulations for Targeted Case Management under Medicaid outside of the CCBHC demonstration.

The CCBHC must provide crisis services either directly or through a DCO agreement with existing state-sanctioned, certified, or licensed system or network for the provision of crisis behavioral health services. In the Medicaid Demonstration, the determination of what qualifies as a “state-sanctioned, certified, or licensed system,” should be made by the state. For Expansion grants, the crisis services provided under the DCO, should be identified by the state as state-sanctioned, or the specific crisis service being provided by the DCO should have state licensure or certification. If individual CCBHC Expansion grants have additional questions about what providers qualify, they should contact their government project officer. Whether provided directly by the CCBHC or by a state-sanctioned DCO, all three crisis services must be provided as part of the CCBHC: emergency crisis intervention services, 24-hour mobile crisis teams, and crisis receiving/stabilization. DCOs may also provide just a portion of the required services, such as one of the three crisis services mentioned here or a portion of one of the three services.

To fulfill the requirements under 4.g.1 and 4.g.2, the CCBHC should have the ability to collect biologic samples directly, through a DCO, or through protocols with an independent clinical lab organization. Laboratory analyses can be done directly or through another arrangement with an organization separate from the CCBHC. The CCBHC must also coordinate with the primary care provider to ensure that screenings occur for the identified conditions. If the person receiving services’ primary care provider conducts the necessary screening and monitoring, the CCBHC is not required to do so as long as it has a record of the screening and monitoring and the results of any tests that address the health conditions included in the CCBHCs screening and monitoring protocols developed under 4.g. Regardless of arrangements made with primary care providers or other organizations, the CCBHC has responsibility for assuring that the requirements under these criteria are fulfilled.

Yes. Criteria 4.f.1 states, "that SUD treatment and services shall be provided as described in the American Society for Addiction Medicine Levels 1 and 2.1 and include treatment of tobacco use disorders." In addition, 1.b.2 requires that CCBHCs have medically trained staff who can prescribe medications for the treatment of tobacco use disorders. CCBHCs are also required to screen from tobacco use disorders as a part of the comprehensive evaluation (4.d.4).

The primary care screening and monitoring requirements go beyond eliciting clients’ self-report of medical needs. Policies for primary care screenings must be based on agency policy, under the direction of the medical director, and in compliance with state recommendations. Specifically:

• "The Medical Director establishes protocols that conform to screening recommendations with scores of A and B, of the United States Preventive Services Task Force Recommendations (these recommendations specify for which populations screening is appropriate)" (4.G.1, page 34).
• "The Medical Director will develop organizational protocols to ensure that screening for people receiving services who are at risk for common physical health conditions experienced by CCBHC populations across the lifespan" (4.G.2, page 39).
• "In order to fulfill the requirements under 4.g.1 and 4.g.2 the CCBHC should have the ability to collect biologic samples directly, through a DCO, or through protocols with an independent clinical lab organization. Laboratory analyses can be done directly or through another arrangement with an organization separate from the CCBHC. The CCBHC must also coordinate with the primary care provider to ensure that screenings occur for the identified conditions. If the person receiving services’ primary care provider conducts the necessary screening and monitoring, the CCBHC is not required to do so if it has a record of the screening and monitoring and the results of any tests that address the health conditions included in the CCBHCs screening and monitoring protocols developed under 4.g" (4.G.2, page 39).

Criteria 4.g.3 (Page 35) also requires that they CCBHC engage in ongoing primary care monitoring of health conditions as identified in 4.g.1 and 4.g.2., and as clinically indicated for the individual. Monitoring includes the following: 1. ensuring individuals have access to primary care services; 2. ensuring ongoing periodic laboratory testing and physical measurement of health status indicators and changes in the status of chronic health conditions; 3. coordinating care with primary care and specialty health providers including tracking attendance at needed physical health care appointments; and 4. promoting a healthy behavior lifestyle.

Under 4.k.2, veterans who choose not to access VA services or are ineligible for VHA services will be served by the CCBHC consistent with minimum clinical mental health guidelines promulgated by the VHA. In addition, the CCBHC must serve all individuals regardless of their ability to pay or place of residence (2.d and 2.e).

The updated criteria require at least 51% of the 9 services be provided directly (4.A.1, Page 30) by the CCBHC. The CCBHC may use a DCO agreement to provide services to children and youth. However, the CCBHC must have some internal capacity to service children and youth and "must include staff with expertise in addressing trauma and promoting the recovery of children and adolescents with serious emotional disturbance (SED) and adults with serious mental illness (SMI) (1.b.2, Page 8)."

In the context of crises, “air traffic control” systems connect and coordinate across different aspects of the crisis system, such as bridging from an initial call to a mobile crisis response if needed. These systems should also track the individual in crisis across systems and services to ensure that their needs are met. In different communities, air traffic control systems are under varying levels of development and may involve different types of organizations. The criteria do not require development of a state, regional, or local air traffic control system, but the CCBHC should coordinate with any state, regional, or local systems that do exist. For more information see SAMHSA’s National Guidelines for Behavioral Health Crisis Care (PDF | 2.2 MB).

While there may not be a crisis intervention call center that meets this requirement in the CCBHC service area, CCBHCs may fulfill this requirement by coordinating with a 988 Suicide & Crisis Line center that is nearest to the CCBHC or generally takes calls from the service area served by the CCBHC. You can find the centers that are nearest to your CCBHC with 988 Suicide & Crisis Lifeline Crisis Centers. The CCBHC may also provide crisis intervention call center services directly, provided they meet the 988 Suicide & Crisis Lifeline standards for risk assessment and engagement of individuals at imminent risk of suicide.

Psychopharmacology services are a required part of the outpatient services under 4.f. Criteria 4.f.1 states that the CCBHC directly, or through a DCO, provides outpatient behavioral health care, including psychopharmacological treatment.

Under Criteria 2.b.1 CCBHCs must complete the comprehensive assessment within 60 calendar days of the first request for services.

A clinic must be a Demonstration CCBHC certified by a Demonstration state to receive the PPS. Only CCBHCs that are formal members of the Demonstration are eligible to receive the CCBHC PPS payment under the Demonstration. That means that your state must be a selected Demonstration participant and that you (the CCBHC) have been selected by your state and certified by your state to participate in the Demonstration as a CCBHC. For more information on the PPS, see the Centers for Medicare and Medicaid Services (CMS) CCBHC.