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Mobile Crisis: Maximizing New Medicaid Opportunities

The new national crisis line for behavioral health — 988 — will go online this summer, and state crisis systems will need to be ready. Current crisis call centers will need to handle an increase in the volume of calls, and the mobile crisis systems to which they refer will need to provide remote and in-person crisis services to people with a range of behavioral health needs across the state.  To help build this capacity, the American Rescue Plan Act, among other resources to states, authorized a new Medicaid payment mechanism for Medicaid mobile crisis services, and awarded planning grants to twenty states to prepare for implementation. Through a state plan or within waiver authorities, states can draw down an enhanced 85% federal medical assistance percentage (FMAP) for mobile crisis services for 12 quarters, making this an attractive option for many states already facing overwhelmed mental health crisis systems.

CMS recently issued guidance to state health officials, outlining additional considerations on reimbursement for these new services. The guidance also calls out the Substance Abuse and Mental Health Services Administration’s National Guidelines for Behavioral Health Crisis Care, offering a good roadmap for states on clinical best practices for systems that incorporate:

  • Regional or statewide crisis call centers coordinating in real time
  • Centrally deployed, 24/7 mobile crisis
  • 23-hour crisis receiving and stabilization programs
  • Essential crisis care principles and practices

The following are some of the key factors and decision points states may want to consider as they build out services and systems that qualify for enhanced FMAP funding; engaging a cross-agency team and a broad range of external stakeholders can help ensure full consideration of diverse state crisis needs:

Describe the team structure for mobile crisis response: States can review their current crisis continuum and team structure to assess how/if it aligns with the newly authorized mobile crisis response service. Federal legislation and guidance emphasize that to qualify for Medicaid reimbursement, services must be delivered by a multi-disciplinary team that includes at least one licensed professional who can perform an assessment within the scope of their licensure. Other members of the team may be trained, non-licensed professionals and both CMS guidance and SAMHSA best practices underscore that peers can be an effective component of crisis teams. A number of states, such as Georgia, already embed peers throughout their crisis systems via warm lines, crisis intervention, and peer respite.

Review current training: Similarly, states may want to review the adequacy of current training for their state’s mobile crisis response teams. To qualify for Medicaid reimbursement, training must include trauma-informed care, de-escalation techniques, and harm reduction. In addition to ensuring that these core components are included in training crisis staff, states may want to look at how they can build or enhance key skills as part of the overall update to their crisis training.  For instance, CMS guidance notes that crisis teams could be equipped with naloxone, fentanyl strips, and suboxone. Building on harm reduction requirements and acknowledging the significant spike in overdose deaths over the past year, states may want to work with behavioral health providers and other stakeholders to ensure that mobile crisis teams can more fully assess and address substance use disorder as a component of crises. Follow up can include systematic linkages and warm hand offs to SUD treatment as well as mental health care.

Review current transportation policies: CMS guidance notes that mobile teams may provide transportation for people in crisis to other settings, such as crisis stabilization centers. States can decide to include this function as a billable medical service or they can pay crisis teams an administrative fee for transport. The guidance indicates these expenses would be paid as Non-Emergency Medical Transportation, and not as a service eligible for the Mobile Crisis enhanced FMAP. Notwithstanding, crisis teams that have the ability to provide and be reimbursed for transportation — particularly in rural areas — may be especially effective in reducing engagement of and burden to local law enforcement.

Build on telehealth: During the past two years of the COVID-19 pandemic, states have gained experience reimbursing for behavioral health services delivered via telehealth, and CMS guidance indicates that “screening, assessment and stabilization” offered via telehealth may be reimbursed as part of the new service.  Given workforce shortages and gaps — especially in rural/frontier areas — telehealth offers states additional flexibility to build virtual teams and models that use laptops or tablets to augment in-person crisis response.

Define the crisis episode: CMS guidance references that near term follow up to support individuals after the initial crisis — delivered either in person or via telehealth — is also eligible for enhanced FMAP. States can consider how broadly to define this post-crisis period: some states currently tailor this to a 24- or 48-hour period or cap the amount of crisis units that may delivered without prior authorization. New York, through its 1115 waiver, defines the crisis period as 14 days, during which crisis providers may continue to deliver medically necessary follow-up care including outpatient services, coordination with primary care, and engagement or reengagement with a health home or peer support provider.

Maximize Medicaid: In addition to billing at an enhanced FMAP rate for medically necessary services, CMS guidance offers a number of options for states to use Medicaid to fund the full crisis continuum:

  • Leading states such as Georgia have developed payment strategies that allocate some costs related to call centers, mobile crisis, and peer respite to administrative claiming.
  • States may consider building out new technology infrastructure through the Medicaid Information Technology Architecture. Guidance released in 2018 specifically provides opportunities for states to enhance behavioral health care by creating capacity to share data across providers and systems (e.g., hospitals, criminal justice, and specialty mental health providers). That guidance also allows MITA funding to be used to build out the infrastructure needed to connect mobile crisis services to people in need.
  • Enhanced FMAP available under ARPA for home and community-based services may be used to improve crisis infrastructure. NASHP review of initial state spending plans for ARPA identified investments for behavioral health crisis systems, including support for 988 capacity, workforce training and reimbursement, and improving the data interface between key state agencies, such as corrections and behavioral health.

Conclusion: States right now have an unprecedented opportunity to enhance and modernize their behavioral health crisis systems by leveraging new Medicaid funding options. The COVID-19 crisis, coupled with skyrocketing overdose deaths and suicide risk, has put state crisis systems in the spotlight as never before. The roll out of a national 988 call number for behavioral health crisis will bring further attention and traffic. Leveraging Medicaid funding can help states build out sustainable crisis systems that can respond to growing challenges.

Acknowledgements: This blog was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award under the National Organizations of State and Local Officials (NOSLO) cooperative agreement totaling $836,859.00. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov. The authors would like to thank HRSA project officer Diba Rab and her colleagues for their guidance and helpful feedback. 

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