New CMS Guidance on Community-Based Mobile Crisis Services
Ashley Traube and Jocelyn Guyer, Manatt Health
On December 28, 2021, the Centers for Medicare & Medicaid Services (CMS) released a State Health Official letter (SHO) providing guidance on the scope of and enhanced payments for qualifying community-based mobile crisis intervention services for Medicaid enrollees experiencing a mental health or substance use disorder (SUD) crisis as established by Section 9813 of the American Rescue Plan Act of 2021 (ARP). As an incentive to state adoption, the law provides an 85 percent enhanced federal matching assistance percentage (FMAP) for qualifying services for the first three years of the five-year period of state coverage. Earlier in 2021, CMS also issued 20 planning grants totaling $15 million to states to implement the qualifying community-based mobile crisis intervention service in their Medicaid programs. The CMS guidance comes as the United States is grappling with staggering need for mental health and SUD services that has grown as a result of the COVID-19 pandemic.
Overview of New Guidance on Community-Based Mobile Crisis Services
The new SHO details a straightforward process for states that do not already cover community-based mobile crisis intervention services to use standard federal requirements to add coverage for this service. The SHO lists the steps that states will need to take: pursuing the relevant federal Medicaid authority, modifying managed care contracts or updating fee-for-service (FFS) delivery systems, developing reimbursement rates, complying with maintenance of effort (MOE) requirements, and making system modifications to take advantage of the 85 percent matching rate. Notably, the guidance highlights the opportunity for states to secure Medicaid administrative funding, including enhanced 90/10 match, for implementing 988 as the National Suicide Prevention Lifeline. The SHO retains state flexibility granted under ARP regarding the design of community-based mobile crisis services. Earlier this year, State Health and Value Strategies (SHVS) published two resources to assist states as they design or evolve their existing Medicaid community-based mobile crisis intervention services to align with the ARP provision, as well as move toward universal community-based mobile crisis intervention services.
Requirements for Community Mobile Crisis Services
The SHO expands on the statutory requirements and clarifies where states have flexibility across several key areas, including:
- Service Requirements. States must establish and ensure training and timeliness standards for mobile crisis teams. States can leverage telehealth to connect the responding mobile crisis team to psychiatrists or other specialized practitioners, as well as a part of the assessment, screening, and stabilization processes. In addition, states may reimburse teams for transporting enrollees who require additional care.
- Medicaid Authority. States have flexibility to cover community mobile crisis services using Medicaid state plan authority—via 1905(a) benefit category, 1915(i) state plan amendment (SPA), 1932(a) SPA, 1915(c) waiver, 1915(b) waiver application, and/or an 1115 demonstration. Standard timelines and requirements for each authority apply. States can also waive the federal requirement to offer the service statewide and can restrict provider networks for this service. States that currently cover mobile crisis services do not need to modify their existing authorities if they already meet ARP’s statutory provisions for qualifying mobile crisis intervention services.
- Provider Payment and Delivery Systems. States have flexibility to cover qualifying community mobile crisis services in FFS and/or managed care delivery systems. States will need to detail their rate-setting methodology depending on the Medicaid authority and delivery system used for these services. For example, states that authorize such services via their Medicaid state plan will need to detail their approach in their SPA reimbursement pages (e.g., Attachment 4-19B). States covering these services via Medicaid managed care will need to add these services to Medicaid managed care contracts and incorporate the cost of these services in capitation rates.
- Claiming Increased FMAP. For FFS payments, CMS will advance payments at the increased 85 percent FMAP based on budget estimates submitted on quarterly CMS-37 forms, and reconcile payments based on actual expenditures submitted on quarterly CMS-64 For managed care payments, states are instructed to estimate the portion of the capitation rate associated with the service. The SHO clarifies the 85 percent FMAP does not displace higher applicable matching rates, like the 90 percent matching rate that applies to the adult expansion population.
- MOE Requirements. In order to claim federal financial participation (FFP) at the enhanced 85 percent FMAP, states must demonstrate that the increased FMAP for community-based mobile crisis intervention services has not supplanted state funds for mobile crisis services expended in the federal fiscal year ending on September 30, 2021, by:
- Refraining from imposing stricter eligibility standards for community-based mobile crisis intervention services;
- Maintaining or exceeding the amount, scope, and duration of community-based mobile crisis intervention services; and
- Maintaining the reimbursement rate for community-based mobile crisis intervention providers in place on September 30, 2021.
States must also provide community-based mobile crisis intervention services in the same regions of the state that they covered at any point during fiscal year 2021.
Other Medicaid Claiming Opportunities for Community-Based Mobile Crisis Services
In addition to claiming federal match for service costs associated with providing community-based mobile crisis services, states may seek federal matching funds for:
- Administrative Costs: States can seek 50 percent federal match for costs associated with establishing and supporting the delivery of community-based mobile crisis services, including operating state crisis access lines and dispatching mobile crisis teams.
- Information Technology (IT) System Costs: States can seek enhanced 90/10 federal match for qualifying IT costs by submitting an advanced planning document. Qualifying costs may include efforts to establish or improve a crisis call center, system integration activities to support 988 implementation, and providing iPads, or cell phones to connect the mobile crisis team to a clinician via telehealth.
The SHO emphasizes that administrative and enhanced IT claiming is only available to support activities on behalf of Medicaid enrollees, and states must isolate and allocate the portion of their costs associated with the Medicaid program to receive reimbursement for general public health activities.
The CMS guidance on community-based mobile crisis intervention services methodically walks states through the implementation process for claiming enhanced FMAP for this service, which follows standard Medicaid requirements for adding coverage of a Medicaid benefit. The community-based mobile crisis option provides an opportunity for states seeking to improve their behavioral health crisis response, as well as complements their efforts to prepare for the establishment of 988 as the national suicide prevention and mental health crisis hotline in July 2022. For additional resources on the design of community-based mobile crisis intervention services, see the following SHVS briefs: American Rescue Plan Provides a New Opportunity for States to Invest in Equitable, Comprehensive and Integrated Crisis Services, and A Hybrid Funding and Coverage Model to Ensure Universal Access to Mobile Crisis Services.
 ARP defines qualifying community-based mobile crisis services as those provided: to Medicaid enrollees outside of a hospital or facility that are available 24/7; and on a timely basis by a multidisciplinary team that includes at least one behavioral health professional and other professionals or paraprofessionals with appropriate expertise and training in trauma-informed care, de-escalation strategies, and harm reduction. Components of qualifying mobile crisis services include screening and assessment, stabilization and de-escalation, and coordination with health, social and other supports, as needed. Mobile crisis teams are also required to maintain relationships with community partners (e.g., medical, behavioral, and other crisis providers) and comply with privacy provisions.