Background

The American Rescue Plan Act (ARPA) establishes an enhanced 85 percent federal medical assistance percentage (FMAP) opportunity for mobile mental health crisis team services in Medicaid. This match supports states in ongoing efforts to build out mental health crisis systems that align to the core elements of a crisis continuum as outlined by the Substance Abuse and Mental Health Services Administration (SAMHSA): regional call centers, mobile response, and crisis stabilization facilities.

States may need to review and revise Medicaid state plans or other authorities in order to take full advantage of the enhanced FMAP opportunity. For states that deliver these services through managed care, Centers for Medicare and Medicaid Services (CMS) guidance indicates that qualifying crisis services must also be included in plan contracts, and the costs of those services integrated into corresponding capitation rates.

Prior to ARPA, several states expanded the delivery and payment of mobile crisis services under Medicaid care contracts. These innovations can continue as states seek the enhanced FMAP for mobile crisis services. Such innovations include:

Allowing Assessments to Be Performed via Telehealth

Section 9813 of ARPA requires that in order to qualify for the enhanced FMAP, mobile crisis teams must include at least one provider who can, under state requirements for scopes of practice, perform an assessment of an individual in crisis. Many states have or are considering allowing mobile crisis teams to conduct assessments via telehealth, as behavioral health workforce shortages and distance/transportation challenges can pose barriers, particularly in rural and underserved areas. For example:

• Virginia‘s Medicaid mobile crisis response services are included in the state’s Medallion 4.0 managed care contract, and the state’s mental health services manual outlines billing for “telemedicine assisted assessments” in which a non-licensed qualified mental health professional (QMHP) or certified substance abuse counselor (CSAC) can conduct an assessment with real-time remote support from a supervising licensed professional. This assessment is imperative to understanding the immediate factors contributing to a crisis, as well as the supports in place that can help to stabilize an individual; permitting the use of telehealth to provide an assessment can help to ensure that crises are de-escalated as quickly as possible and that mobile teams can make connections to follow up care as necessary.

Enabling Managed Care Data Transfer to Support Coordination and Billing

As the first component of the crisis continuum, call centers triage crisis situations, assessing the for the need for higher levels of intervention from mobile crisis teams. Getting insurance information from callers in crisis may not be possible and may interrupt or distract from the primary functions of triage and assessment. This information is, however, necessary to facilitate Medicaid billing for these services.

• Arizona takes a unique approach by contractually enabling information exchange among three entities: the state’s Regional Behavioral Health Authorities (RBHAs), their contracted call centers, and Medicaid managed care plans. Call centers receive minimal information from a caller — just first name, last name, and birth date — and use that to access an enrollment clearinghouse and data warehouse that contains both electronic health records and Medicaid managed care enrollment information submitted by the plans. Using these data, call centers can serve a further function, coordinating follow up services with community-based providers. This allows the centers to bill the managed care plans for both the call center services and care coordination after the call has been resolved.

Eliminating Service Authorization Requirements

Behavioral health services may be subject to prior authorization requirements to ensure medical necessity before a service for a Medicaid beneficiary is approved for delivery. The nature of mobile mental health crisis services, however, makes prior authorization challenging. Several Medicaid managed care contracts explicitly state that plans may not require prior authorization for these services.

• Virginia does not require prior authorization; instead, reimbursement for mobile crisis services is authorized using a registration process. This effectively notifies a Medicaid managed care plan of a provided service and indicates a need for ongoing coordination of care. This registration allows for eight hours (32 units) of services within a 72-hour period, and a service registration form must be submitted to the managed care plan within one business day. 

Extending Billable Service Windows Post-Crisis

Mobile crisis teams provide services for acute crisis events but also provide coordination of ongoing services or connections to higher levels of care upon resolution of the qualifying crisis.

• New York‘s billing guidance for mobile crisis intervention providers specifies that while services must be documented in clinical records within 24 hours of a crisis event, follow up services related to the event can be reimbursed within the 14-day period thereafter. During this time, providers can bill Medicaid managed care plans for follow up and coordination of services, including services to maintain stabilization and further engage community-based providers and other patient supports.

Aligning Systems and Innovation

The enhanced FMAP for team-based mobile crisis services offers an opportunity for states to develop innovations in mental health crisis systems, and Medicaid managed care contracts may be a helpful lever in maximizing state approaches. Issues such as workforce needs, systems coordination, and data infrastructure can be addressed in these contracts, connecting these services to broader state behavioral health systems. As states work across agencies to align existing resources and services in their Medicaid programs, leveraging managed care partners can help coordinate services and providers across the crisis continuum.