Differences in Services Offered by Certified Community Behavioral Health Clinics and Community Mental Health Centers

Established by the Protecting Access to Medicare Act of 2014, the demonstration requires state Medicaid programs to reimburse CCBHCs through an enhanced prospective payment rate designed to cover the total cost of all CCBHC services. Eight states (Minnesota, Missouri, Nevada, New Jersey, New York, Oklahoma, Oregon, and Pennsylvania) originally participated in the demonstration and, after an initial planning phase, began delivering CCBHC services and started using the new payment system in mid-2017. States certified that clinics met the CCBHC criteria and provided technical assistance to maintain CCBHC services throughout the demonstration. States could exercise some discretion in applying the criteria and designing specific service packages to align with Medicaid state plans and community needs. The demonstration is ongoing, it has expanded to two new states (Kentucky and Michigan), and other states have taken steps to expand or implement CCBHCs through Medicaid 1115 waivers or state plan amendments (6).

Authorized by Congress in 2018 and administered by the Substance Abuse and Mental Health Services Administration, the CCBHC-E grant program has awarded clinics 2 years of grant funding to provide CCBHC services (7). Clinics in both demonstration and nondemonstration states have received grants. CCBHC-E grantees attest to meeting the same criteria as CCBHCs participating in the demonstration, but the grant does not alter Medicaid reimbursement or require states to certify clinics or support implementation or oversight. CCBHC-E grantees must begin providing CCBHC services within 4 months of the grant award.

Interim findings from an evaluation of the demonstration found that CCBHCs added services and took other steps to increase access to meet the certification criteria (8). However, data were not available at the time of that evaluation to directly compare the services provided by CCBHCs and CMHCs and understand how they differ on other characteristics. As the CCBHC model expands, such information would help policy makers understand the extent to which CCBHCs offer more comprehensive services and may otherwise affect the availability of care in communities relative to CMHCs. This information would be useful to have for both demonstration and nondemonstration states, given that the demonstration began before the CCBHC-E grant program and the expansion of CCBHCs through other mechanisms, possibly giving demonstration CCBHCs more time to establish services compared with CCBHCs in nondemonstration states. There could also be differences between demonstration and nondemonstration states that are due to the different funding streams used to support the CCBHC model. In this study, we used national survey data to examine the types of services available at CCBHCs and CMHCs in the eight original demonstration states and in nondemonstration states. We also examined whether CCBHCs and CMHCs serve special populations or differ on other characteristics.

We used the 2020 National Mental Health Services Survey (N-MHSS) public use files (1). N-MHSS is an annual survey of all known specialty mental health treatment facilities across all states and territories. N-MHSS collects information on the services available from facilities (including several of the services included in the CCBHC certification criteria), their organizational characteristics, populations served, and whether they have programs targeted at specific populations. In 2020, N-MHSS added a response option that allowed facilities to self-identify as either a CCBHC or a CMHC. We used descriptive statistics to compare the percentage of CCBHCs and CMHCs that reported offering services that align with the CCBHC certification criteria and compared these two groups of facilities on other characteristics related to the criteria. Statistical testing was unnecessary because N-MHSS is not a sample survey but rather includes the full universe of facilities.

In 2020, there were 336 CCBHCs (156 in the original eight demonstration states and 180 in 24 nondemonstration states) and 1,953 CMHCs (267 in demonstration states and 1,686 in nondemonstration states).

In both demonstration and nondemonstration states, a higher proportion of CCBHCs than CMHCs offered some mental health and substance use disorder services, including substance use disorder treatment, integrated mental health and substance use disorder treatment, treatment for co-occurring disorders, assertive community treatment, antipsychotic medications, and chronic disease management (see an online supplement to this report). Some differences were greater for demonstration states versus nondemonstration states. For example, in demonstration states, 83% (N=129 of 156) of CCBHCs offered substance use disorder treatment compared with only 49% (N=131 of 267) of CMHCs, whereas in nondemonstration states, 84% (N=152 of 180) of CCBHCs offered substance use disorder treatment compared with 72% (N=1,209 of 1,686) of CMHCs. CCBHCs and CMHCs had fewer differences in many other mental health services. Compared with CMHCs, a higher proportion of CCBHCs also provided crisis services in demonstration and nondemonstration states.

A higher proportion of CCBHCs than CMHCs offered certain general medical health screenings in demonstration and nondemonstration states. For example, 91% (N=142 of 156) of CCBHCs and 75% (N=199 of 267) of CMHCs offered tobacco use screening in demonstration states, compared with 76% (N=137 of 180) of CCBHCs and 66% (N=1,114 of 1,686) of CMHCs in nondemonstration states. In both demonstration and nondemonstration states, a higher proportion of CCBHCs than CMHCs also offered counseling for smoking, vaping, and tobacco cessation; nicotine replacement therapy; and integrated primary care services.

In demonstration and nondemonstration states, a higher proportion of CCBHCs than CMHCs offered most psychiatric rehabilitation services. For example, 42% (N=66 of 156) of CCBHCs and 23% (N=61 of 267) of CMHCs offered supported employment in demonstration states, compared with 47% (N=84 of 180) of CCBHCs and 34% (N=578 of 1,686) of CMHCs in nondemonstration states. However, some psychiatric rehabilitation services were more common among CCBHCs, and other services were more common among CMHCs; this varied by demonstration and nondemonstration states (see the online supplement). In addition, 75% (N=117 of 156) of CCBHCs and 43% (N=116 of 267) of CMHCs offered peer support services in demonstration states, whereas 59% (N=107 of 180) of CCBHCs and 49% (N=828 of 1,686) of CMHCs offered this service in nondemonstration states.

A higher proportion of CCBHCs than CMHCs offered services to veterans in both demonstration and nondemonstration states. However, the difference in the proportion of CCBHCs versus CMHCs offering services to veterans was greater in nondemonstration states (41% [N=73 of 180] vs. 20% [N=329 of 1,686]) than in demonstration states (31% [N=48 of 156] vs. 19% [N=51 of 267]). A higher proportion of CCBHCs than CMHCs offered services to all the populations included in the N-MHSS (e.g., children with serious emotional disturbance, individuals with co-occurring mental health and substance use disorders, and those experiencing first-episode psychosis) in both demonstration and nondemonstration states. For some populations, the magnitude of these differences was greater for demonstration than for nondemonstration states. In both demonstration states and nondemonstration states, a higher proportion of CCBHCs than CMHCs offered treatment at no charge or minimal payment or offered a sliding fee scale.

With few exceptions, a higher proportion of CCBHCs than CMHCs offered services described in the CCBHC certification criteria. CCBHCs and CMHCs differed in services that have not historically been universally available from CMHCs, such as general medical health screening, substance use disorder treatment, and psychiatric rehabilitation services. For most services, the differences between CCBHCs and CMHCs were more striking in demonstration states than in nondemonstration states. However, for a few services, a higher proportion of CMHCs than CCBHCs offered the services.

These results are consistent with those of previous studies that found that nearly all the CCBHCs in demonstration states provided the services required in the certification criteria and offered services to a range of populations regardless of insurance coverage or ability to pay (8–10). Our study goes beyond previous research by using newly available data to compare CCBHCs and CMHCs. Several factors could explain why there were greater differences between CCBHCs and CMHCs in demonstration states versus nondemonstration states in some of the services offered. One reason for these differences could be that the demonstration began before the CCBHC-E grant program or the expansion of CCBHCs through other financing mechanisms started; therefore, CCBHCs in demonstration states had more time to implement services included in the criteria than those in nondemonstration states. Demonstration states were also required to certify that clinics met criteria, and states provided ongoing monitoring, whereas state involvement and oversight varied more extensively across clinics that have become CCBHCs through other financing mechanisms. However, we could not definitively draw these distinctions among CCBHCs that participated in different financing models because N-MHSS does not identify which funding mechanism a clinic used to become a CCBHC. Some explanations may be specific to certain services. For example, although all CCBHCs must provide primary care screening and monitoring of key health indicators, CCBHC criteria give demonstration states flexibility to define the indicators used. Furthermore, some demonstration states layered additional primary care service requirements onto the certification criteria, such as requiring clinics to provide onsite primary care services (8).

Policy makers should consider how the financing model and state support for CCBHCs could influence CCBHCs’ ability to provide all services required in the certification criteria. More rigorous research that goes beyond cross-sectional survey data could provide insights into the effectiveness of alternative financing and implementation strategies for the CCBHC model to inform future policy decisions. Although these findings provide, to our knowledge, the first comprehensive comparison of CCBHCs and CMHCs, the cross-sectional data did not allow us to attribute differences between CCBHCs and CMHCs to the introduction of the CCBHC model. It is possible that some differences existed before the clinics implemented the model. Additionally, although the service categories and types of services included in N-MHSS are similar to those required by the certification criteria, the N-MHSS service categories may not fully capture or align completely with all nine types of services described in the CCBHC criteria. It is also possible that not all CCBHCs reported the services listed in the criteria, for example, in cases where CCBHCs were working toward full implementation of the model or struggled to retain staff at the time of the survey (8).

Our analysis of data from the 2020 N-MHSS indicated that CCBHCs differed from CMHCs in the services they provided and populations they served, and differences between CCBHCs and CMHCs were more pronounced in demonstration states than in nondemonstration states for some service categories. The extent to which these differences existed before the introduction of the CCBHC model, however, remains unknown.

The authors thank Jacqueline Agufa, B.S., and Natalie Hazelwood, B.A., for providing programming support and Luke Horner, M.P.P., for research support.