With over 90 randomized controlled trials, the Collaborative Care Model is an evidence-based healthcare model for identifying and treating patients with depression and anxiety. By leveraging partnerships with behavioral health managers and mental health counselors, collaborative care gives primary care providers access to behavioral health care for their patients at a time when depression and anxiety are on the rise and many communities are struggling with access to behavioral health treatment. It has been increasingly adopted in recent years, as many prescriptions for depression and anxiety are written by primary care physicians, who are among the first people to interact with patients with behavioral health problems.
Adoption of collaborative care by Centers for Medicare and Medicaid Services
For many years, primary care providers had no direct or explicit reimbursement mechanism for services provided specifically to Medicare and Medicaid beneficiaries under the collaborative care model. That changed in 2017 when the Centers for Medicare and Medicaid Services (CMS) introduced specific CPT codes for collaborative care. These codes, 99492-99494, support and reimburse primary care cooperative care. The following year, in 2018, special dedicated codes G0511 and G0512 for Federally Qualified Health Centers (FQHC) and Rural Health Centers (RHC) were added. Unlike codes in traditional behavioral health services, these codes were specifically designed for use in primary care to support inclusion. Instead of using a fee model, collaborative nursing codes use a flat-rate monthly fee to make nursing more accessible and affordable.
CMS’s adoption of these codes has been paramount in promoting and supporting access to evidence-based behavioral health treatment and integrated care. Unfortunately, the agency has failed to provide explicit guidance on cooperative care and codes to state Medicaid programs. This has led to mixed messages and continued uncertainty about how these codes should be used and adopted.
Serving the country’s most underserved populations
Currently, 24 states have adopted cooperative nursing codes with different reimbursement rates, many of which are significantly lower than Medicare reimbursement rates. When reimbursement rates are low, as in Pennsylvania and New Hampshire, this effectively discourages providers from adopting collaborative care. Adoption of the Codes, however, vastly improves access for patients in need, especially those in underserved and underfunded communities.
Implementing collaborative care in federally qualified and rural health centers is especially important as they serve some of the most vulnerable and socially disadvantaged communities in the country. Although CMS intended to include specifically designated G-codes, no guidance was provided to states on including FQHCs and RHCs in the Medicaid fee schedules. As a result, there was significant confusion about how to include community health centers and how the federal prospective payment system rate should be included in FQHC’s and RHC’s fee schedules. Some states, like Montana, have completely banned FQHCs and RHCs from using the codes included in the state Medicaid fee schedule on the grounds that they are considered care management and are not applicable. Other states, such as California, have fee-for-service reimbursement methods instead of the monthly per-case rates specified for FQHCs and RHCs.
Precedent requires that decisions about Medicaid codes rest with states. However, this inevitably creates ambiguity as to whether states should use specialized FQHC and RHC G codes or extend their reimbursement to use the CPT codes. We believe that CMS should provide clear guidance on how to use CPT and G-codes. Such guidance is an essential first step toward broader recognition by state Medicaid agencies, nationwide adoption of the codes, and ultimately patient access to evidence-based behavioral therapy through their trusted healthcare provider in some of the nation’s most underserved communities.
Identify technical challenges and discrepancies in code implementation
In addition, technical challenges plague the consistent adoption of Medicare and Medicaid in various states. Medicare stated that staff need special training but are not required to be licensed to provide cooperative care services. However, some states have enacted restrictions that require employees to hold certain licenses before providing services. For example, North Carolina requires a licensed clinical social worker or registered nurse to provide cooperative care services. Another technical challenge arises from inconsistent guidelines on length of service. States like Michigan limit the length of care patients can receive under the Cooperative Code to just six months, while states like New York have no restrictions but require special authorization for all services over 12 months.
Some states, such as New York, have assisted providers in adopting the collaborative model by providing specialized technical assistance and a formal application process for participation and reimbursement through state Medicaid. Unfortunately, in New York’s case, this approach has completely detached collaborative care from the state’s managed care plans, thereby creating more fragmentation, not less.
In Illinois, the legislature was one of the first to enact collaborative care legislation that required commercial insurers to cover collaborative care codes. Despite these requirements, the state Medicaid agency has failed to include the codes in its fee schedule.
Additionally, many states that have adopted cooperative care codes only accept one code, 99494, which allows for 30-minute surcharges on the monthly case rate. The use of this code is further restricted as many payers and states limit the use of add-on codes to double. On the contrary, in Michigan, a large payer removed the restriction on additional codes and found that these codes were not abused, but rather adequately contributed to the amount of time spent assessing and engaging patients at the start of treatment.
On the other hand, states like Arizona have taken a broad view of adopting collaborative care, incorporating many codes into their fee schedules and including them in state integration initiatives. For example, Arizona uses the codes to meet post-hospital mental health care follow-up requirements, dramatically improving access to care for patients discharged from psychiatric hospitalizations.
This fragmented implementation has prevented additional states from activating the codes and confused state policymakers about best practices.
Resource requirements of collaborative care
Many practices and systems may also feel that they do not have the appropriate resources to implement the model. For example, the collaborative care model requires the addition of a behavioral care manager and a psychiatric consultant, roles that are not necessarily part of what is commonly considered care management services. As such, states often view these codes as management of care rather than primary care and consequently do not provide reimbursement rates to support the required components of collaborative care. Low reimbursement rates, in turn, perpetuate the lack of uptake of cooperative care codes at the state level.
When states like Connecticut view collaborative care as a primary care initiative, they allocate rates with a low percentage of Medicare consistent with primary care. However, these rates typically do not support the needs needed for cooperative care, such as: B. the additional team members.
At the same time, world leaders may have concerns that use and spending will increase as collaborative care improves access to evidence-based behavioral health care. In fact, this has not yet been confirmed. For example, New York State, while providing significant support at the institutional level, has engaged only a fraction of healthcare providers in the delivery of collaborative care services. Additionally, to the extent that collaborative care can replace more traditional care such as weekly visits and monthly meetings with mental health providers, the new model may actually reduce costs.
Better advise now
It’s not too late for CMS to develop a clear plan to increase access to collaborative care and encourage acceptance of the very codes it endorsed a full five years ago. And that plan needs to provide clearer and more explicit guidance for state Medicaid programs.
Some hope is on the horizon as there is currently a proposal for federal legislation to support the adoption of the collaborative care model. However, it is unclear whether this legislation will actually help states make some of the most impactful and critical decisions about including collaborative care in fee schedules.
At a time when the country is experiencing a mental health crisis and many communities have limited or no access to evidence-based behavioral therapy treatments, we must open the doors to equitable and effective practices. Collaborative care continues to hold immense potential to uphold this mission and meet the needs of the most underserved populations served by Medicaid.
Author’s note:
The authors are employees of Concert Health, which provides cooperative care services for the facilities discussed in this article.