Behavioral Health Qualified Directed Payments

A uniform percent increase in reimbursement rates to qualified behavioral health participating/contracted providers. This increase is in addition to CCO contracted rates already in place effective in January 2022 and limited to the following covered services: Assertive Community Treatment (ACT), Supported Employment Services (SE), Outpatient Mental Health Treatment and Services (OP MH), and Outpatient and Non-inpatient withdrawal management Substance Use Disorder Treatment and Services (OP SUD). All rate increases received in 2022 will count towards the total 15% or 30% tiered increase effective January 1, 2023. This increase is in addition to any other ICD and/or CLSS QDP rate increases.

The increased percentage has two tiers based on the details of a provider’s total patient service revenue:

• 30% increase for “Primarily Medicaid” – defined as having at least 50% of its total patient service revenue derived from providing Medicaid services in the prior calendar year.
• 15% increase for “Primarily Non-Medicaid” – defined as having less than 50% of its total patient service revenue from providing Medicaid services in the prior calendar year.

Which Providers Qualify?

Qualified participating providers of:

• Assertive Community Treatment (ACT)
• Supported Employment Services (SE)
• Outpatient Mental Health Treatment and Services (OP MH)
• Outpatient Substance Use Disorder Treatment and Services (OP SUD)
  • This includes non-inpatient withdrawal management

How Do Providers Get Paid the Increased Rate?

• All qualified participating providers who held a contract on or after January 1, 2022, will automatically receive the “Primarily Non-Medicaid” rate increase of 15% (over the 1/1/22 rates) effective January 1, 2023. This will be applied retroactively once implemented. This means that providers who did not hold a contract on 1/1/22 will not be penalized and will have comparable rates as the rest of the network.
• If a qualified participating provider meets criteria for the “Primarily Medicaid” rate increase of 30%, the provider must provide documentation demonstrating criteria is met based on the BH revenue from Medicaid services provided in calendar year 2022.
• Fill out the OHA’s Primarily Medicaid Provider Attestation form, available on the Oregon.gov website. Completed forms are to be submitted through a secure email to Jackson Care Connect at BH_attest@careoregon.org.
  • DOCUMENTATION:
    • If documentation is received by March 31, 2023, the 30% rate increase (over 1/1/22 rates) will be retro-effective January 1, 2023.
    • If documentation is received after March 31, 2023, the 30% rate increase (over 1/1/22 rates) will be retroactively implemented to the first day of the calendar quarter of which the documentation was submitted.  For example, if the documentation is received May 31, 2023, then the rate will be retro-effective April 1, 2023.

All qualified non-contracted BH providers will be reimbursed at rates that are no less than OHA’s Medicaid Fee-for-Service (FFS) Behavioral Health Fee Schedule in effect on the date of service.

A uniform payment increase for qualified behavioral health providers certified by OHA for integrated treatment of Integrated Co-Occurring Disorders (ICD) rendered by qualified staff per OAR 309-019-0145. This increase is in addition to CCO contracted rates already in place effective January 2022 and any other tiered payment and/or CLSS QDP rate increases.

The following payment increases are available to qualified participating providers of:

• BH participating/contracted providers of Non-residential ICD services per OAR 309-019-0105:
  • Add on payment that is 10% of OHA’s Medicaid FFS Behavioral Health Fee Schedule in effect on the date of service for:
    • Qualified Mental Health Associate (QMHA)
    • Peer
    • Substance Use Disorders (SUD) Treatment Staff
  • Add on payment that is 20% of OHA’s Medicaid FFS Behavioral Health Fee Schedule in effect on the date of service for:
    • Qualified Mental Health Professional (QMHP)
    • Licensed Health Care Professional (LHCP)
    • Mental Health Intern
• BH participating/contracted providers of SUD Residential ICD services per OAR Chapter 309, Division18:
  • Add on payment that is 15% of OHA’s Medicaid FFS Behavioral Health Fee Schedule in effect on the date of service.

Which Providers Qualify?

• To qualify for the ICD rate increase, a provider must be approved by the OHA to provide ICD services. Please refer to the OHA’s ICD webpage for details, including a list of approved ICD programs.

How Do Providers Get Paid the Increased Rate?

• Providers do not need to notify us of your ICD designation.
• All ICD claims must contain at least 2 OHA ICD approved diagnoses. Please refer to the OHA’s ICD Billing Guide for these details.
• ICD claims must include ICD modifiers as appropriate, but do not add a second detail line for these modifiers when billing CareOregon.
  • All non-residential ICD claims beginning June 1, 2023, must include OHA approved modifier(s). Please refer to the OHA’s ICD Billing Guide for these details.
  • All residential ICD claims beginning June 1, 2023, must include a U2 modifier. See CareOregon’s Behavioral Health Fee Schedule for details.
• Reimbursement for ICD claims submitted for dates of service January 1, 2023 – September 30, 2023, will be made through a lump sum payment outside of claims based on provider self-report as outlined in your contract amendment. 

A uniform payment increase to qualified behavioral health participating/contracted providers who deliver culturally and/or linguistically specific services (CLSS) as defined by the Oregon Administrative Rules (OARs). This increase is in addition to CCO contracted rates already in place effective January 2022 and any tiered payment and/or ICD QDP rate increases.

The following payment increases are available based on “Rural” and “Non-Rural” classifications:

• Add on payment for “Rural” CLSS Providers: add on payment of 27% of OHA’s Medicaid FFS Behavioral Health Fee Schedule in effect on the date of service.
• Add on payment for “Non-Rural” CLSS Providers: add on payment of 22% of OHA’s Medicaid FFS Behavioral Health Fee Schedule in effect on the date of service.

Which Providers Qualify?

• CLSS organizations and programs, individuals, and bilingual service and sign language providers enrolled as a Medicaid provider and meet criteria defined in OAR Chapter 309, Division 65 and provide the following services:
  • Assertive Community Treatment (ACT)
  • Supported Employment Services (SE)
  • Applied Behavior Analysis (ABA)
  • Wraparound
  • Outpatient Mental Health Treatment and Services (OP MH)
  • Outpatient Substance Use Disorder Treatment and Services (OP SUD) and non-Inpatient withdrawal management

How Do Providers Get Paid the Increased Rate?

For providers designated as follows by the OHA (per their online approved-provider list):

• CLSS Programs (459)
• CLSS Organizations (460)
• CLSS Individual Providers (461)
  • You do not need to notify us of your CLSS designation.
  • Effective for January 1 through December 31, 2023, dates of service, participating/contracted CLSS providers with these 459, 460, and 461 CLSS designations are no longer required to submit quarterly reports of the total revenue received for CLSS services.
  • Due to updated guidance from the OHA, CareOregon will pay providers the CLSS add-on amount, if applicable, based on the CLSS fee schedule.
  • CareOregon will pay eligible providers within 45 days of the end of each quarter.

For providers designated as follows by the OHA (per their online approved-provider list):

• individual Bilingual Providers (462)
• Individual Sign Language Provider (463)
  • You do not need to notify us of your CLSS designation, however, effective for January 1, 2023 through September 30, 2023 dates of service, participating/contracted CLSS providers must submit quarterly reports of the total revenue received for CLSS services based on the below reporting schedule. 
  • These quarterly reports must include the following information: member name, member ID#, date of service, rendering provider and total claim payment received.
    • For dates of services from January 1, 2023 through March 31, 2023, providers should submit the report to CareOregon no later than July 15, 2023.
    • For dates of services from April 1, 2023 through June 30, 2023, providers should submit the report to CareOregon no later than August 15, 2023.
    • For dates of services from July 1, 2023 through September 30, 2023 and claims payment not captured in the prior quarterly report, providers should submit the report to CareOregon no later than November 15, 2023.
  • CareOregon will pay providers the CLSS add-on amount, if applicable, based on the CLSS fee schedule. If approved, CareOregon will pay eligible providers within 45 days of receipt of the quarterly reports.
  • Please submit reports as outlined above to CareOregon’s Contracting team using secure email at contractmanager@careoregon.org.

Regardless of a provider’s contract status with a CCO, effective January 1, 2023, the Oregon Health Authority requires CCOs to reimburse qualified providers of Substance Use Disorders (SUD) Residential services, Applied Behavior Analysis (ABA), and Mental Health Children’s Wraparound services at rates that are no less than OHA’s Medicaid FFS Behavioral Health Fee Schedule in effect on the date of service.

Which Providers Qualify?

• The directed payment is limited to Medicaid covered SUD Residential, Applied Behavior Analysis, and MH Children’s Wraparound services.

How Do Providers Get Paid?

• All qualified providers will receive payment no less than OHA’s Medicaid FFS Behavioral Health Fee Schedule in effect on the date of service.