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- State, Practice Participant, and Beneficiary Eligibility
- Application Timeline and Period of Performance
- Care Delivery Framework
- Measuring Quality of Care
- Model Funding and Other Participant Support
- IBH Model Design
State, Practice Participant, and Beneficiary Eligibility
- What entities are eligible to apply to the IBH Model?
State Medicaid agencies (SMAs or “states”) from all U.S. states, territories, and the District of Columbia are eligible to apply to the IBH Model. The Centers for Medicare & Medicaid Services (CMS) will select up to eight states to receive a cooperative agreement award.
- Can a state implement the IBH Model if they utilize Medicaid managed care, Medicaid fee-for-service (FFS), or a combination?
Yes, states can implement the IBH Model in Medicaid FFS, Medicaid managed care, and a combination, even if a managed care state separates Medicaid behavioral health services into or out of managed care. Where applicable, Medicaid managed care organizations (MCOs) will support states to implement program components including, but not limited to, recruiting Practice Participants, operationalizing the Medicaid Payment Approach, improving data sharing, collection, and analysis, and providing technical assistance.
What types of specialty behavioral health practices are eligible to participate in the IBH Model?
Selected states will be responsible for recruiting and selecting eligible specialty behavioral health practices to participate (i.e., “Practice Participants”). Specialty behavioral health practices within the state’s proposed geographic service area will be eligible Practice Participants if, at the time of recruitment, they meet all the following criteria:• Meet all state-specific requirements to deliver behavioral health services, if applicable;
• Have at least one behavioral health provider who is an employee, leased employee, or independent contractor of the practice licensed by the state to deliver behavioral health treatment services and who meets any state-specific Medicaid provider enrollment requirements and is eligible for Medicaid reimbursement;
• Serve at the outpatient level of care at least 25 adult (i.e., age 18 or older) Medicaid beneficiaries on average per month with moderate to severe behavioral health conditions; and
• Provide mental health and/or substance use disorder treatment services at the outpatient level of care.
All IBH Model Practice Participants must serve Medicaid beneficiaries and participate in their state’s Medicaid program. IBH Model Practice Participants also have the option of serving Medicare beneficiaries and people with Medicare and Medicaid (i.e., dually eligible individuals) through a CMS Request for Application (RFA), which will be released during the Pre-Implementation Period. Behavioral health practices serving only Medicare beneficiaries are not eligible to participate in the IBH Model. Please refer to Section A4.2.1 of the Notice of Funding Opportunity (NOFO) for more information.
Why are specialty behavioral health practices the focus of the IBH Model?
Research shows that many individuals with moderate-to-severe behavioral health conditions underuse primary care services and are more likely to use behavioral health services.To meet this population where they are currently receiving or most likely to access care, specialty behavioral health settings are a primary area of focus for the model. In the IBH Model, a specialty behavioral health organization (or setting) refers to a health care provider, practice, or facility, or other community-based organization, where behavioral health treatment services are the predominate health care service type delivered, and outpatient behavioral health services are available and delivered by a behavioral health provider. This arrangement involves a Practice Participant who agrees to be accountable for quality, utilization, patient experience, and care integration over a sustained period.
Other Innovation Center models, including the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model and the Making Care Primary (MCP) Model also include integration of behavioral health in primary care settings.
What are examples of specialty behavioral health practices that are eligible to participate?
To be eligible to participate in the IBH Model, specialty behavioral health practices must meet the criteria listed above. Examples of specialty behavioral health practices that are eligible to participate in the IBH Model (if they meet criteria above) include, but are not limited to:
• Certified Community Behavioral Health Clinics (CCBHCs), including those supported through the Section 223 CCBHC Medicaid Demonstration, through the Substance Abuse and Mental Health Services Administration (SAMHSA) administered CCBHC Expansion (CCBHC-E) Grants, or through independent state programs separate from the Section 223 CCBHC Medicaid Demonstration.
• Community mental health centers (CMHCs)
• Critical access hospital (CAH) outpatient behavioral health clinics
• Independent behavioral health providers with and without medical center affiliation
• Opioid Treatment Programs (OTPs)
• Specialty substance use disorder provider organizations
• Tribal health organizations and clinics
• Federally qualified health centers (FQHCs)
• Rural health clinics (RHCs), and
• Local health departments, or other entities that are part of a local government behavioral health authority where a locality, county, region, or state maintains authority to oversee behavioral health services at the local level and uses the entity to provide those services.A complete list of eligible practices is found in Section A4.2.1 of the NOFO, and separate guidance regarding FQHC and RHC eligibility will be forthcoming.
- What types of behavioral health practices or levels of care are not eligible to participate in the IBH Model?
The following behavioral health practices are not eligible to participate in IBH Model:
• Practices providing intensive outpatient (IOP) and partial hospitalization program (PHP) levels of care or services are ineligible as they are more acute and generally discharge beneficiaries to another level of care.
• Inpatient and post-acute care providers and settings (e.g., home health agencies and skilled nursing facilities) as well as ambulance and transportation providers are not eligible. Ineligible services also include those provided to individuals in institutional settings through an ambulatory license (e.g., licensed outpatient behavioral health providers serving nursing home residents).
• Short-term service providers, such as those using an outpatient license for services at an urgent care center or for crisis stabilization are ineligible.
• Behavioral health practices serving only Medicare beneficiaries are not eligible to participate in the IBH Model. At a minimum, all Practice Participants must serve Medicaid beneficiaries. However, they may also serve Medicare beneficiaries to participate in both the Medicaid and Medicare components of the model.
- How can state-selected IBH Model practices participate in the IBH Model Medicare Payment Approach?
To be eligible to participate, all IBH Model Practice Participants must serve Medicaid beneficiaries and participate in their state’s Medicaid program. These practices will also have the option to apply to participate in the IBH Model Medicare Payment Approach and provide IBH Model services to Medicare beneficiaries and people with Medicare and Medicaid (i.e., dually eligible individuals) through a CMS RFA, which will be released during the Pre-Implementation Period.
- How does the IBH Model interact with crisis providers?
As states are increasingly using mobile crisis intervention services to provide rapid, critical services to people experiencing mental health or substance use crises, the IBH Model was designed to dovetail with those services. The IBH Model provides whole-person, integrated care for beneficiaries with moderate to severe behavioral health conditions by supporting a long-term relationship between the beneficiary and a behavioral health provider. As the IBH Model’s care delivery and payment approach focus on care integration, care management, and care coordination, the model does not encompass payment for physical or behavioral health procedures, tests, or other services, including crisis services. States could implement the IBH Model in a way that would support longitudinal care for beneficiaries coming out of the crisis system. Additionally, IBH Model infrastructure funding will allow Practice Participants to enhance their systems, which could allow for real-time tracking of beneficiary involvement with the crisis system.
- What are the IBH Model’s beneficiary eligibility requirements?
The IBH Model will include adult (i.e., 18 years of age and older) Medicaid and Medicare beneficiaries, adults with Medicare and Medicaid (i.e., dually eligible individuals). The IBH Model is designed for those with moderate to severe behavioral health conditions receiving outpatient care for mental health conditions and/or substance use disorders from an eligible Practice Participant. A complete list of diagnoses that are considered moderate or severe for purposes of the IBH Model can be found in the NOFO, Appendix XIV: Moderate to Severe Behavioral Health Conditions, and includes a wide range of diagnoses, including but not limited to: bipolar disorder, generalized anxiety disorder, major depressive disorder, opioid use disorder and stimulant use disorder. These diagnoses represent a spectrum of disorders across mental health conditions and substance use disorders.
- What is the IBH Model's priority population?
The IBH Model is for adults (i.e., 18 years of age or older) with moderate to severe behavioral health conditions. Lack of integrated care and untreated and/or undertreated physical health conditions causes a disproportionate impact on the overall health of individuals with moderate to severe behavioral health conditions, including early death. These untreated and/or undertreated physical health conditions can also impact behavioral health outcomes, such as the worsening of depression. In response, the IBH Model includes a care delivery framework that integrates behavioral and physical health care, increases access for patients, and achieves greater equity in outcomes by focusing on identifying and making referrals related to health-related social needs (HRSNs).
- Could beneficiaries enrolled in Medicare Advantage and other commercial health plans receive IBH Model services?
The IBH Model is a Medicare FFS and Medicaid model. Beneficiaries enrolled in Medicare Advantage and other commercial health plans are not eligible to receive model services. During the Pre-Implementation Period (Model Years 1 – 3, from January 1, 2025 – December 31, 2027), CMS will offer guidance through the IBH Model learning system for Medicare Advantage and other commercial health plans interested in implementing the IBH Model in their networks. This approach will support directional alignment on a shared vision for the care delivery framework, quality measures, and payment.
Application Timeline and Period of Performance
- When will the IBH Model begin?
CMS anticipates the IBH Model will launch in the first quarter of 2025, once state cooperative agreement awardees are selected.
- How will states be selected to participate in the IBH Model?
States interested in participating in the IBH Model must apply to the NOFO by the specified deadline to be eligible to receive a cooperative agreement. This will be a competitive application process that will include a merit review of all applications using a detailed rubric. More information about the deadline for applications and the selection process can be found in the NOFO.
- What information will applicants be required to provide in their application?
States interested in applying to the IBH Model should be prepared to provide the following information in their application:
• Assessment of state readiness to operationalize key elements of the IBH Model including, but not limited to the care delivery framework, development of health information technology (IT) infrastructure and capacity, and the Medicaid Payment Approach;
• Description of the state’s behavioral health landscape including beneficiary needs, behavioral health care providers, and other key partners;
• Detailed budget, including a budget narrative; and
• Rationale for implementing the IBH Model in a sub-state region (if applicable).
The merit review and selection process are outlined in the NOFO. CMS will consider the geographic diversity and scale of all applications when making final award determinations. CMS will select up to eight state recipients at CMS’ sole discretion.
- Can states and/or practices currently participating in Section 223 CCBHC Medicaid Demonstration or CCBHC Planning, Development, and Implementation Grant participate in the IBH Model?
Yes, states participating in the CCBHC Prospective Payment System (PPS) Demonstration or CCBHC planning grants programs administered by CMS and SAMHSA can apply to participate in the IBH Model. The IBH Model was designed to complement the efforts of multiple, diverse states with different programs and initiatives focused on behavioral health, including pathways to build on and support the work of existing CCBHCs. CCBHCs can bolster their existing efforts to integrate behavioral health and physical health care while also receiving needed reimbursement for serving Medicare beneficiaries, including people with Medicare and Medicaid (i.e., dually eligible individuals). CMS will work with participating states and CCBHC providers to ensure they meet all requirements of the IBH Model. Please refer to the Appendix X: Medicaid Payment Scenarios for Health Homes and CCBHCs in the NOFO for details.
- Can states participate in other CMS Innovation Center state-based models and participate in the IBH Model?
Yes, states may participate in multiple CMS Innovation Center state-based models. States interested in participating in multiple Innovation Center models should reference the IBH Model Overlaps Policies Fact Sheet, and email IBHModel@cms.hhs.gov with any questions. Note that CMS’ model overlaps policies do not restrict beneficiary freedom to select the provider(s) of their choice.
- How can specialty behavioral health providers participate in the application process?
During the NOFO application period, specialty behavioral health providers can consult with their state to inform a state’s application to participate in the IBH Model.
Care Delivery Framework
Does the IBH Model require Practice Participants to implement specific behavioral health services, or make changes to existing services, to integrate behavioral health and physical health?
The IBH Model does not require specific behavioral health and physical health services. Rather, the care delivery framework serves as a guide for services provided, focusing on care integration, care management, and health equity, as detailed in Section A4.3.3 of the NOFO.Care integration includes screening, assessing, treating, and referring patients, as needed, for both behavioral and physical health conditions, within the provider’s scope of practice. Care management includes an interprofessional care team who will address the needs of the beneficiary, such as providing ongoing care management across the beneficiary’s behavioral and physical health needs. Health equity includes engaging in activities that foster equitable care, such as HRSN screenings and a health equity plan.
IBH Model Recipients and Practice Participants have the flexibility to determine which services are required or necessary to address the key elements of the care delivery framework, to improve priority health conditions and other behavioral health and physical health outcomes.
- What specific services will the IBH Model’s Payment Approach cover? Will the IBH Model require Practice Participants to deliver specific behavioral health, physical health services, or both?
The IBH Model is strategically focused on providing coordinated and integrated behavioral and physical health care through specialty behavioral health care settings. For this reason, the IBH Model Medicaid and Medicare Payment Approaches are focused on care integration, care management, and care coordination by behavioral and physical health providers. This is accomplished through a monthly payment for care management and care coordination activities and is paid to the specialty behavioral health practice responsible for facilitating the integrated care and leading the care team. The IBH Model does not independently reimburse for separate physical or behavioral health procedures, tests, or other services, and providers will continue to bill for these services as they normally do.
- What provider types can be part of the IBH Model interprofessional care team?
The interprofessional care team should reflect the needs of the priority population, based on a population needs assessment as detailed in the NOFO, Section A4.3.1, Care Delivery Framework Overview. In addition to including a state licensed specialty behavioral health provider who is eligible to bill for Medicaid services, the state, Practice Participant, or both, have flexibility to determine what provider types can participate in the interprofessional care team. This approach aims to assure that each beneficiary receives comprehensive and personalized care from a team of professionals best suited to address their specific behavioral health and physical health needs.
- How will the IBH Model address health equity?
States participating in the IBH Model must recruit rural, safety-net specialty behavioral health providers, under-resourced providers, tribal providers, and providers serving vulnerable populations to participate in the IBH Model. The IBH Model Practice Participants will engage in activities that foster equitable care through HRSN screenings, a population needs assessment, and a health equity plan (HEP). The HEP will detail steps to address the population needs and disparities identified in the population needs assessment, including how the Practice Participant will build care teams that reflect the needs of the population.
- How will individual beneficiary experiences be incorporated into the IBH Model?
The IBH Model’s care delivery framework is deliberate in its inclusion and engagement of beneficiaries and their caregivers as members of the care team. Beginning in the Pre-Implementation Period of the model, regional convenings will incorporate the voice of local communities, beneficiaries, beneficiary representatives, and advocacy groups. These groups will work alongside behavioral health and physical health care providers, payers, community-based organizations and regional associations and interests, to achieve a shared vision of behavioral health for the region. The IBH Model will also include a feedback loop to incorporate beneficiary perspectives over the model lifecycle by including a patient-reported outcome measure (PROM) that aims to assess outcomes that are most meaningful to beneficiaries.
Are the new Medicare behavioral health provider types included in the 2024 Medicare Physician Fee Schedule eligible to bill Medicare for IBH Model services?
Yes. On January 1, 2024, CMS released the 2024 Medicare Physician Fee Schedule (PFS) including marriage and family therapists (MFTs), mental health counselors (MHCs), and licensed alcohol and drug counselors (LADCs) who meet MHC requirements. If Practice Participants are also active in the Medicare Payment Approach, these newly included providers can serve as the billing practitioner for IBH Model services.
These providers must be in good standing with Medicare, comply with all applicable Medicare regulations, and hold valid state licensure for their services. The provider must also implement the care delivery framework outlined in the IBH Model NOFO, Section A4.3.1, Care Delivery Framework Overview.
Measuring Quality of Care
How will the IBH Model measure the quality of care provided through the model’s care delivery framework?
The IBH Model’s quality strategy seeks to evaluate the model’s ability to achieve IBH Model goals. These include improving quality of care, increasing access to care, achieving greater equity in outcomes, reducing avoidable emergency department and inpatient utilization, and strengthening health IT systems capacity.The model’s quality strategy strives to advance states and Practice Participants alike toward achieving the model’s desired outcomes, enabling quality improvement, reaching greater alignment among payers, as well as assisting in facilitation of model evaluation. The Innovation Center will use a set of quality measures to monitor state performance in the implementation and operation of the model, as well as patient care delivered by Practice Participants. The model’s quality strategy will measure several key areas, including beneficiary utilization of services, care coordination, HRSNs, IBH Model targeted health outcomes, PROMs, and physical health screening.
- How will the IBH Model measure integrated care? Will the IBH Model measure behavioral health conditions, physical health conditions, or both?
To measure outcomes and the integration of behavioral health and physical health, the IBH Model will track three priority health conditions: diabetes, hypertension, and tobacco use disorder. While Practice Participants are not required to treat these conditions in the behavioral health setting, they must make appropriate referrals and provide care management services related to these conditions, and track and monitor these outcomes. States may add additional behavioral health and/or physical health conditions to their state-specific requirements.
- Will this model qualify as a Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Model (APM)?
CMS does not anticipate that the IBH Model will qualify as an Advanced APM. However, we will explore whether the model would qualify as a MIPS APM for MIPS eligible clinicians.
- What are the quality metrics to show success and earn value-based payments?
The quality metrics are defined in Table A4.7.2, Practice-based Measures, of the NOFO, and include controlling high blood pressure, emergency department utilization, patient-reported outcomes and measurement-based care attestation, preventive care and screening, tobacco use screening and cessation intervention, and screening for social drivers of health.
How much Infrastructure Funding will be available to Practice Participants?
The level of Infrastructure Funding will be determined by a practice needs assessment and the population served.At a minimum, all Practice Participants must participate in the Medicaid Payment Approach. Practice Participants who participate in only the Medicaid Payment Approach will receive Infrastructure Funding through the state’s cooperative agreement funding. Section A4.5 of the NOFO details that Recipients (i.e., state Medicaid agencies) must reserve approximately $100,000 in cooperative agreement funding per Medicaid-only Practice Participant for budgeting purposes. Though the total amount of Infrastructure Funding per Medicaid-only Practice Participant is determined by the state through the practice needs assessment.
Practice Participants that opt to participate in both the Medicaid and Medicare Payment Approaches and have signed an agreement with CMS to participate in the IBH Model’s Medicare Payment Approach will not receive Infrastructure Funding through the state’s cooperative agreement funding. Rather, these Practice Participants will be eligible to receive up to $200,000 in Infrastructure Funding directly from CMS, as determined by the practice needs assessment.
- How will the performance-based payments work?
The pay-for-reporting and pay-for-performance incentives will be a percentage of the Medicare ISP, and this information is described in Appendix XI of the NOFO. The Medicaid Payment Approach will be set by participating states and must align with the Medicare Payment Approach.
Can states develop more than one Medicaid Payment Approach? Different Practice Participants may be best served by different payment approaches.
States may only develop one Medicaid Payment Approach for IBH Model services. However, if a state includes Practice Participants with different payment methodologies (e.g., PBPM vs. PPS), then the state would be permitted to develop more than one Medicaid Payment Approach, pending CMS review and approval. Refer to Section A4.4 of the NOFO for additional information on the Medicaid Payment Approach.
- Can states use a Prospective Payment System for the Medicaid Payment Approach?
Yes, states have the flexibility, pending CMS approval, to determine if their Medicaid Payment Approach is best served through a prospective payment (i.e., PBPM) or a traditional FFS payment. Each payment must meet the IBH Model Medicaid Payment Approach criteria listed in Section A.4.4 of the NOFO.
- How does the IBH Model avoid duplication of services?
CMS identified a list of codes that will be prohibited for a provider to bill when a Medicare beneficiary is participating in the IBH Model. This list of codes is available in Appendix XI of the NOFO. States will be responsible for identifying a state-specific approach to avoid duplication for Medicaid.
Model Funding and Other Participant Support
- How are states permitted to use cooperative agreement funding?
Participating states will receive up to $7.5 million in cooperative agreement funding over the IBH Model’s eight-year performance period. States will receive this funding to increase their capacity to implement the Medicaid Payment Approach and care delivery framework. States will also use these funds to support Practice Participants. Examples of allowable uses of funding include but are not limited to:
• Building and updating state and practice-level health IT infrastructure and capacity;
• Convening a diverse range of partners to collaborate on model development and implementation, including development of the Medicaid Payment Approach;
• Ensuring the flow and analysis of data needed for IBH Model monitoring, payment, and evaluation; and
• Identifying and recruiting Practice Participants.
How can Practice Participants bill Medicaid and Medicare for IBH Model care coordination and case management services?
The Integration Support Payment (ISP) will support the initial assessment of needs for screening and treatment for behavioral health and physical health conditions, the ongoing assessment of needs for screening and treatment for behavioral health and physical health conditions, care management, care integration, and health equity.For the Medicare Payment Approach, applicable for Medicare FFS beneficiaries, the IBH Model will establish a model-specific billing code, the Medicare ISP, that Practice Participants will use to submit Medicare claims for the model’s care coordination and case management services. The Medicare ISP is proportionate to the costs associated with managing care for Medicare beneficiaries and people with Medicare and Medicaid (i.e., dually eligible individuals) who are attributed to the IBH Model. The Medicare ISP is a prospective per-beneficiary-per-month (PBPM) payment that will begin at the start of Model Year 4 (i.e., 2028). While CMS will release more information (on the Medicare Payment Approach in 2025, we anticipate that the ISP will be approximately $200-220 per-beneficiary-per-month, and be risk adjusted.
For the Medicaid Payment Approach, applicable to attributed Medicaid beneficiaries, the state will design and develop an approach to support payment for care coordination and case management. CMS will provide technical assistance to states in the Pre-Implementation Period to develop a Medicaid Payment Approach that reaches directional alignment with the Medicare ISP and is responsive to the state’s unique context. This payment will represent the costs associated with care coordination and case management for Medicaid beneficiaries attributed to the IBH Model.
- How will the IBH Model support the health IT capacity of Practice Participants?
The IBH Model will support Practice Participants’ health IT capacity and interoperability by encouraging them to securely and efficiently transmit and exchange patient health information at the point of care. During the IBH Model’s Implementation Period, all Practice Participants will be required to adopt and use health IT standards set by the Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology (ONC) Health IT Certification Program. The requirements and guidelines for Practice Participants is detailed in the NOFO, Section F5. Health Information Technology (IT) Interoperability Language.
Examples of activities that will be supported by IBH Model infrastructure funding include but are not limited to health IT infrastructure (e.g., developing, modifying, or maintaining certified electronic health records), connections to enhance referral capabilities to physical health providers and/or social needs providers, and practice transformation activities.
- Will technical assistance be provided through the IBH Model?
Yes, CMS and its partners will provide robust technical assistance to IBH Model states and Practice Participants. The CMS Innovation Center designed the IBH Model with a three-year Pre-Implementation Period to ensure adequate time to provide technical assistance in crucial areas such as payment, care delivery, data, and quality. Technical assistance will be provided by CMS and its contractors, who will facilitate learning for the states and Practice Participants, and peer-to-peer learning.
IBH Model Design
- What type of external guidance did CMS solicit when developing this model?
The CMS Innovation Center sought input for the model from a range of behavioral health experts, including advocacy groups, provider and beneficiary groups, SMAs, and other interested parties from across the country, as well as SAMHSA, CMCS, the Indian Health Service (HIS), and ONC. Topics discussed during these conversations include payment innovation, funding use, health IT, workforce, and care integration. CMS plans to continue to consult with states, providers, beneficiaries, and other experts and interested groups during the life of the model to support effective implementation and proactively address any emerging hurdles. We appreciate their guidance on a successful model design.
How would the IBH Model align with the CCBHC Demonstration and Grant Program?
The CMS Innovation Center and CMCS worked with SAMHSA to design the IBH Model to compliment the CCBHC efforts and investments that states, and the Federal Government have already made.The Department of Health & Human Services (HHS) is currently supporting the CCBHC model through the Section 223 Medicaid CCBHC Demonstration, as well as SAMHSA CCBHC expansion grants, which include CCBHC Improvement and Advancement (CCBHC-IA) and CCBHC Community Behavioral Health Clinic Planning, Development, and Implementation (CCBHC-PDI). These programs have differing requirements and associated funding. In the NOFO, Appendix X outlines different IBH Model implementation scenarios for each type of CCBHC program. Those scenarios demonstrate how a state could envision and plan to include their CCBHC into the IBH Model in key domains, including payment and billing, infrastructure funding, and quality measurement.
CMS is committed to working with states on model alignment over the three-year Pre-Implementation Period, to include CCBHCs in the IBH Model. CMS and state engagement will be important as CCBHCs are at differing points when it comes to care integration. For CCBHCs that are already have strong integrated care programs, the IBH Model provides the opportunity to refine their care integration framework. Other CCBHCs may not have as robust integration efforts. Regardless of where a CCBHC is along this continuum, the IBH Model will provide CCBHCs with the opportunity to receive payment for IBH Model services in Medicare as well as increase attention to health-related social needs. Additionally, CCBHCs would be eligible for infrastructure funding to enhance health information technology, conduct practice transformation activities, or both, through the IBH Model.