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Making the Case: Medicaid Payment for the Collaborative Care Model

Below are resources for psychiatrists advocating for Medicaid payment for the Collaborative Care Model. This includes:

  • Overview of the Collaborative Care Model
  • Talking points to use when speaking with payers
  • Funding streams available for implementation, including states with 1115 waivers
  • Examples of states implementing the model through legislation and Medicaid waivers, and
  • Additional resources about the Collaborative Care Model

Understanding the Collaborative Care Model

Learn about the key components and evidence supporting the use of the Collaborative Care Model.

Talking Points

Review and use talking points on advocating for the Collaborative Care Model with payers.

Funding Opportunities

Learn about reimbursement and funding opportunities available.

State Action on Collaborative Care

Find the most recent action states are taking to implement Medicaid codes for the Collaborative Care.

Understanding the Collaborative Care Model

Over the past decade, the integration of behavioral health and general medical services has been shown to improve patient outcomes, save money, and reduce stigma related to mental health. Significant research spanning three decades has identified one model — the Collaborative Care Model — in particular, as being effective and efficient in delivering integrated care. Below are handouts to share with an overview of the model, as well as information about billing codes that have been developed to receiving payment for services provided through the model.

Overview

However, successfully expanding use of the model depends on appropriate reimbursement for services related to care management and psychiatric consultation, and infrastructure support for staffing changes and implementation of data tracking tools. New CPT codes are available to submit for reimbursement under those plans, such as Medicare, that provide coverage. FQHCs and RHCs can also receive reimbursement using specific HCPCS codes.

Adopting the Psychiatric Collaborative Care Management Codes

Primary care practices that are providing collaborative care services can now bill for those services using CPT® codes for Psychiatric collaborative care management services (99492, 99493, 99494). Medicare, and some commercial payers, and Medicaid plans are also providing coverage — check the local coverage policies in your area to determine coverage. Federally Qualified Health Centers and Rural Health Clinics can bill for these services using HCPCS code G0512 (for the initial 70 minute or subsequent 60 minute visits).

The Centers for Medicare and Medicaid Services (CMS) has provided a fact sheet and a short list of FAQs that describe CoCM services and their associated billing requirements as well as provides a information on a brief care management service, General behavioral health integration care management (99484). They have classified all of these as Behavioral Health Integration (BHI) services on their care management site: Care Management – Behavioral Health Integration.

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Talking Points: Advocating for the Collaborative Care Model with Payers

Problem

  • One in five Americans experienced mental illness in the past year. 1
  • Mental health and substance use disorders (MH/SUD) are often chronic conditions that people experience with other health conditions, such as heart disease and diabetes.
  • Yet, only 25 percent of patients receive effective mental health care, including in primary care settings, where the majority of patients with MH/SUD receive their usual care.2

Solution

  • Better care coordination via integration of mental health and primary care has been shown to improve patient access, outcomes, and reduce costs.
  • Three decades of research and over 80 randomized controlled trials (RCT) have identified one model in particular — the Collaborative Care Model — as being effective and efficient in delivering integrated care.3
  • In the Collaborative Care Model, a primary care physician treating patients’ behavioral health problems leads a team that consists of a behavioral health care manager and psychiatric consultant.
  • It is estimated that $26 – $48 billion could be saved annually through effective integration of mental health and other medical care.4

Ask

We urge you to support coverage and reimbursement for the Collaborative Care Model as approved in the 2018 Medicare Physician Fee Schedule.

References

  1. Department of Health and Human Services. “Mental Health Myths and Facts.” http://www.mentalhealth.gov/basics/myths-facts/
  2. Unützer J et al. “The Collaborative Care Model: An Approach for Integrating Physical and Mental Health Care in Medicaid Health Homes.” Health Home Information Resource Center Brief. Centers for Medicare and Medicaid Services. May 2013.
  3. Advancing Integrated Mental Health Solutions (AIMS) Center. “Evidence Base.” https://aims.uw.edu/collaborative-care/evidence-base
  4. Milliman, Inc. “Economic Impact of Integrated Medical-Behavioral Healthcare. Implications for Psychiatry.” April 2014.

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Funding Opportunities Available to Support Integrated Care

This section provides background information for speaking with your state officials about what funding opportunities may be available to incorporate the Collaborative Care Model into existing or future efforts.

Increasingly more states are reforming their Medicaid programs and working to integrate behavioral health services (including mental health and substance use disorder services) with general medical care through Medicaid waivers and funding streams available from the Substance Abuse and Mental Health Services Administration and Centers for Medicare and Medicaid Services Innovation Center.

Below is a list of funding streams available that may be used to integrate services, including by implementing the Collaborative Care Model. We’ve also included a chart of certain states approved for an 1115 waiver, which states may use to test new or existing ways to deliver and pay for health care services in Medicaid and the Children’s Health Insurance Program.

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State Action on Collaborative Care

New York

New York started implementing the Collaborative Care Model through a statewide grant in 2012. Following its success, the State turned on a Medicaid code to reimburse a limited number of practices in the model in 2015.

View Case Study

Maryland

The Maryland legislature has shown interest in the Collaborative Care Model by requesting the Department of Health and Mental Hygiene examine the model as a way to better integrate the delivery of physical and behavioral health services.

View Case Study

Washington State

Washington State has been implementing the Collaborative Care Model statewide since 2009.

View Case Study

Hawaii

During the 2016-2017 legislative session, House Bill 1272, Relating To Improving Access To Psychiatric Care for Medicaid Patients, was introduced in the Hawaii State Legislature to include Medicaid reimbursement for the Collaborative Care Model. The bill was approved by both the House and Senate but was stalled in the final days of the legislative session and not ultimately approved. Discussions are now underway with the State Medicaid office on the potential of implementing the model through the state’s 1115 waiver.

Introducing Legislation or Adopting Reimbursement Codes in Your State

Start a discussion with either members of your state legislature or Medicaid office on how to advance the use of the Collaborative Care Model. To begin discussions, draft legislation is available to use with your state legislature. Also available is draft waiver amendment language you may use to start a discussion with your Medicaid office to advocate for the Collaborative Care codes. Check our chart on 1115 waivers to see if your state has one.

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Additional Resources

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