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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 participate in 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 participate in the Innovation in Behavioral Health (IBH) Model. CMS will select up to eight states to participate - 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 (referred to as “Practice Participants”). Specialty behavioral health practices within the state’s proposed geographic service area will be eligible Practice Participants if, at the time of their application, 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 Medicaid beneficiaries on average per month (age 18 or older) 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 dually eligible beneficiaries 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 NOFO for more information.Why are specialty behavioral health practices the focus of the IBH Model?
Research shows that many beneficiaries with moderate-to-severe behavioral health conditions often 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 Model (AHEAD) and the Making Care Primary Model (MCP) 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 for the IBH Model, specialty behavioral health practices must meet the criteria listed above. Examples of specialty behavioral health practices 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 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)
• 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 (such as 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 BH 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 and dually eligible beneficiaries through a Request for Application (RFA). - 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 (18 years of age and older) Medicaid and Medicare beneficiaries, and individuals who are dually eligible for both Medicaid and Medicare. 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. - Why does the IBH Model focus on adults?
The IBH Model is for adults aged 18 years and older. That is because research indicates that a 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 fee-for-service 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 fourth quarter of 2024, once state 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 participate. 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:
1) the care delivery framework;
2) development of health information technology (IT) infrastructure and capacity; and
3) Medicaid Payment Approach; and
• 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 recipients at CMS’ sole discretion. - Can states and/or practices currently participating in Section 223 Certified Community Behavioral Health Clinic (CCBHC) Medicaid Demonstration or CCBHC Planning, Development, and Implementation Grant participate in the IBH Model
Yes, states currently participating in the Section 223 CCBHC Medicaid Demonstration can participate in the 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. CMS worked closely with the Substance Abuse and Mental Health Services Administration (SAMHSA) in designing this model. CMS will work with participating states and CCBHC providers to ensure they meet all requirements of the IBH Model. Please refer to 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 Medicaid agency to inform a state’s application to participate in the IBH Model.
Care Delivery Framework
- What specific services will the IBH Model’s Payment Approach cover? Will the IBH Model require Practice participants to deliver specific behavioral and/or physical health services?
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, management, and 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. - How will the IBH Model address health equity?
States participating in the IBH Model must recruit rural, safety-net specialty BH 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 phase 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.
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 information technology (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, health-related social needs, IBH Model targeted health outcomes, patient-reported outcome measures (PROMs), and physical health screening.
- How will the IBH Model measure integrated care? Will it measure BH 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.
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 implementation 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 information technology infrastructure and capacity;
• Convening a diverse range of partners to collaborate on model development and implementation, including to develop 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 will the IBH Model support the health information technology (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, state Medicaid agencies, and other interested parties from across the country, as well as the Substance Abuse and Mental Health Services Administration (SAMHSA), the Center for Medicaid and CHIP Services (CMCS), the Indian Health Service (HIS), and the Office of the National Coordinator for Health Information Technology (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.
Can states currently participating in the Certified Community Behavioral Health Clinic Medicaid Demonstration (CCBHC) participate in the IBH Model?
Yes. States currently participating in the Certified Community Behavioral Health Clinic (CCBHC) Prospective Payment System (PPS) Demonstration, or CCBHC Planning Grants, programs administered by CMS and the Substance Abuse and Mental Health Services Administration (SAMHSA), can apply to participate in the Innovation in Behavioral Health Model (IBH Model). CCBHCs can bolster their existing efforts to integrate behavioral and physical health care while also receiving needed reimbursement for serving Medicare beneficiaries, including those dually eligible for Medicaid and Medicare.