Innovation in Behavioral Health (IBH)

Innovation in Behavioral Health (IBH) Cohort 2 NOFO

U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
Center for Medicare and Medicaid Innovation
Innovation in Behavioral Health (IBH)
Notice of Funding Opportunity Type: New
Funding Opportunity Award Type: Cooperative Agreement
Notice of Funding Opportunity Number: CMS-2Q2-26-001
Federal Assistance Listings Number (CFDA): 93.610
Notice of Funding Opportunity Posting Date: October 16, 2025
Applicable Dates:
(Optional) Letter of Intent to Apply Due Date: April 1, 2026
Electronic Application Due Date: June 3, 2026
Anticipated Issuance Notice(s) of Award: September 15, 2026
Anticipated Period of Performance: January 1, 2027 - December 31, 2033
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Table of Contents
Executive Summary ...................................................................................................................................... 5
A. Program Description ................................................................................................................................ 6
A1. Purpose ............................................................................................................................................... 6
A2. Authority ............................................................................................................................................ 7
A3. Background ........................................................................................................................................ 7
A3.1 How the IBH Model Addresses These Challenges Through Integrated Care and VBP ............. 10
A3.2 Alignment with Federal Priorities and State Medicaid Program Trends and Themes................ 11
A4. Program Requirements ..................................................................................................................... 12
A4.1 Model Structure Overview ......................................................................................................... 12
A4.2 Recruitment of Practice Participants .......................................................................................... 18
A4.3 IBH Care Delivery Framework .................................................................................................. 21
A4.4 IBH Payment Strategy................................................................................................................ 29
A4.5 Infrastructure Development and Funding .................................................................................. 35
A4.6 Convening Structure .................................................................................................................. 37
A4.7 Data, Quality, and Evaluation .................................................................................................... 39
A5. Technical Assistance and Information for Prospective Applicants .................................................. 47
B. Federal Award Information ..................................................................................................................... 48
C .Eligibility Information ............................................................................................................................ 50
C1. Eligible Applicants ........................................................................................................................... 50
C2. Cost Sharing or Matching................................................................................................................. 50
C3. Letter of Intent .................................................................................................................................. 50
C4. Ineligibility Criteria .......................................................................................................................... 50
C5. Single Application Requirement ...................................................................................................... 50
C6. Continued Eligibility ........................................................................................................................ 50
C7. EIN, UEI, Login.gov and SAM Registrations .................................................................................. 51
C8. Faith-Based Organizations ............................................................................................................... 51
C9. Other Eligibility Requirements ........................................................................................................ 51
D. Application and Submission Information ............................................................................................... 52
D1. Address to Request Application Package ......................................................................................... 52
D2. Content and Form of Application Submission ................................................................................. 52
D2.1 Application format ..................................................................................................................... 52
D2.2 Standard forms ........................................................................................................................... 53
D2.3 Application cover letter or cover page (optional) ....................................................................... 54
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D2.4 Program Requirements and Expectations .................................................................................. 55
D3. Submission Dates and Times ........................................................................................................... 63
D4. Intergovernmental Review ............................................................................................................... 63
D5. Cost Restrictions .............................................................................................................................. 63
D5.1 Direct Costs ................................................................................................................................ 64
D5.2 Indirect Costs ............................................................................................................................. 64
D5.3 Prohibited Uses of Award Funds ................................................................................................ 64
D5.4 Program Income ......................................................................................................................... 65
D6. Mandatory Disclosures..................................................................................................................... 66
E. Application Review Information ............................................................................................................ 67
E1. Criteria .............................................................................................................................................. 67
E2. Merit Review and Selection Process ................................................................................................ 72
E3. Review of Risk Posed by Applicants ............................................................................................... 72
F .Federal Award Administration Information ............................................................................................ 73
F1. Federal Award Notices ...................................................................................................................... 73
F2. Administrative and National Policy Requirements ........................................................................... 73
F3. Terms and Conditions ....................................................................................................................... 75
F4. Cooperative Agreement Terms and Conditions of Award. ................................................................ 76
Centers for Medicare & Medicaid Services ........................................................................................ 76
F5. Health Information Technology (IT) Interoperability Language ...................................................... 78
F6. Reporting .......................................................................................................................................... 78
F6.1 Monitoring .................................................................................................................................. 78
F6.2 Progress Reports ......................................................................................................................... 79
F6.3 Performance Milestones ............................................................................................................. 79
F6.4 Evaluation ................................................................................................................................... 85
F6.5 Learning System Participation .................................................................................................... 86
F6.6 Financial Reports ........................................................................................................................ 87
F6.7 Federal Funding Accountability and Transparency Act (FFATA) Reporting Requirements ....... 87
F6.8 Responsibility and Qualification Reporting................................................................................ 87
F6.9 Audit Requirements .................................................................................................................... 87
F6.10 Payment Management System Reporting Requirements .......................................................... 88
F6.11 Government-wide Suspension and Debarment Reporting Requirements ................................. 88
G .CMS Contacts ........................................................................................................................................ 89
G1. Programmatic Questions .................................................................................................................. 89
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G2. Administrative and Budget Questions .............................................................................................. 89
H. Other Information .................................................................................................................................. 89
Appendix I. Application Check-off List ..................................................................................................... 90
Appendix II: Health IT Capabilities and Support for Practice Participants ................................................ 91
Appendix III: State-Based Quality Measure Data Reporting Burden ......................................................... 94
Appendix IV: Model context data templates. .............................................................................................. 96
Appendix V: Medicaid Payment Scenarios for Health Homes and CCBHCs ............................................ 99
Appendix VI: Medicare Payment Approach Details ................................................................................. 105
Infrastructure Funding .......................................................................................................................... 105
Integration Support Payment (ISP) ....................................................................................................... 106
Appendix VII: CMS Attribution Methodology for Medicare and Dually Eligible Beneficiaries ............. 116
Appendix VIII: Glossary of Acronyms ..................................................................................................... 119
Appendix IX: Moderate to Severe Behavioral Health Conditions ............................................................ 122
Appendix X: References ........................................................................................................................... 137
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Executive Summary
The Innovation in Behavioral Health (IBH) Model (the “Model”) for Cohort II Recipients1 is a
seven-year, voluntary service delivery and payment model promoting integrated care in behavioral
health (BH) settings. The IBH Model will test the impact of a value-based payment (VBP) model
aligned across Medicaid and Medicare that supports an integrated care delivery framework in
specialty BH organizations and settings for adult Medicaid, Medicare, and dually eligible
beneficiaries with moderate to severe mental health conditions and/or substance use disorders
(SUDs).
The Centers for Medicare & Medicaid Services (CMS), through its Center for Medicare &
Medicaid Innovation (Innovation Center), will select up to five state Medicaid agencies (SMAs)
to participate in the Model. The Model will have a seven-year performance period, which will be
comprised of a two-year Pre-Implementation Period (beginning January 2027 and ending
December 2028) along with a five-year Implementation Period (beginning January 2029 and
ending December 2033). Up to $7.5 million dollars in cooperative agreement award funding will
be available to each selected Recipient over the course of the seven years.
Item Description
HHS Awarding Agency Centers for Medicare & Medicaid Services (CMS)
CMS Awarding Center Center for Medicare and Medicaid Innovation (The Innovation Center)
Innovation in Behavioral Health
Notice of Funding
Opportunity Title
Section 1115A of the Social Security Act (the Act)
Authorization
93.610
Federal Assistance Listings
Number (CFDA)
New
Funding Opportunity Type
CMS-2Q2-26-001
Funding Opportunity
Number
Cooperative Agreement
Type of Award
Type of Competition Competitive
1 CMS previously released an earlier version of this NOFO for Cohort 1 Recipients and issued those awards in 2024.
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Item Description
CMS recommends a letter of intent to apply for this funding
Letter of Intent
opportunity. These are optional. See Section C.3 Letter of Intent for
more information.
Application Due Date and June 3, 2026, by 11:59 pm EST
Time
September 15, 2026
Anticipated Issuance
Notice(s) of Award
January 1, 2027
Period of Performance
Start Date
December 31, 2033
Period of Performance End
Date
$37.5 million (subject to availability of funds)
Anticipated Total
Available Funding
$7.5 million per Recipient
Estimated Maximum
Award Amount
Estimated Maximum 5
Number of Recipients
A. Program Description
A1. Purpose
This Notice of Funding Opportunity (NOFO) provides details and instructions on how to apply to
the Innovation in Behavioral Health (IBH) Model.
The IBH Model will test the impact of a value-based payment (VBP) model aligned across
Medicaid and Medicare that supports an integrated care delivery framework in specialty BH
organizations for adult Medicaid, Medicare, and dually eligible beneficiaries with moderate to
severe mental health conditions and/or substance use disorders (SUDs). The IBH Model
framework for integrated care in BH settings will:
• Build and strengthen connections to physical health (PH) care for beneficiaries;
• Promote screening and referral for needs that impact health;
• Identify beneficiary issues that interfere with diagnosis, management, and treatment of
health conditions, such as food, housing, and transportation needs;
• Leverage care management and care coordination to increase access to and engagement
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with primary care and community services; and
• Encourage investments in certified health information technology (health IT) products and
infrastructure improvement for their practice and patient population.
CMS will evaluate the Model's ability to:
• Improve quality of care;
• Increase access to care;
• Achieve greater balance in outcomes;
• Reduce avoidable emergency department and inpatient utilization, and thereby reduce
federal program spending under Medicare and Medicaid; and
• Strengthen health IT systems capacity.
CMS will award up to five Cohort II cooperative agreement awards to state Medicaid agencies
(SMAs). The Model for Cohort II Recipients will consist of a two-year Pre-Implementation Period
along with a five-year Implementation Period as follows:
• Pre-Implementation Period: Two-year Pre-Implementation Period begins January 1,
2027, and ends on December 31, 2028.
• Implementation Period: Five-year Implementation Period begins on January 1, 2029, and
ends on December 31, 2033.
This NOFO provides detailed information regarding the level of funding, flexibilities, and
requirements for Recipients.
A2. Authority
Section 1115A of the Social Security Act (the Act) authorizes the Secretary of the Department of
Health and Human Services to test innovative payment and service delivery models expected to
reduce Medicare, Medicaid, or Children's Health Insurance Program (CHIP) expenditures while
preserving or enhancing the quality of care.
The Medicaid elements of the IBH Model shall operate according to existing Medicaid law,
regulation, and sub-regulatory guidance, including, but not limited to, all requirements of any
Medicaid demonstration projects under Section 1115 of the Act.
A3. Background
The United States is currently facing an unprecedented BH crisis, which was further exacerbated
by the COVID-19 public health emergency that began in 2020.(1) A quarter of Medicaid
beneficiaries have BH diagnoses, yet they account for nearly half of total Medicaid expenditures.(2)
An increasing number of Americans have mental health conditions and substance use disorders
(collectively referred to in this document as “behavioral health” or “BH”). As of 2022, 23.1 percent
of adults age 18 or older (or 59.3 million people) had a mental illness in the past year.(3) Among
people age 12 and older, 17.3 percent (or 48.7 million people) had a SUD in the past year.
Additionally, during the COVID-19 public health emergency, racial and ethnic minority
communities experienced disproportionately higher rates of psychosocial stressors. The BH
system has long been uncoordinated and under-resourced, resulting in the following long-standing
challenges:
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1. Poor Clinical Outcomes & Premature Mortality: People with BH conditions more frequently
report co-occurring health conditions, such as diabetes, cardiovascular disease, and metabolic
conditions, and higher rates of tobacco use.(4) Moreover, people with BH conditions are more likely
to live with untreated or unmanaged HIV/AIDS and hepatitis C.(5, 6) Without adequate attention to
PH needs, adults with mental health conditions and/or SUDs often have more emergency
department (ED) visits and potentially preventable medical hospitalizations resulting from
uncontrolled chronic conditions.(7) Adverse issues related to food, housing, or transportation,
further contribute to the medical comorbidity of people with BH conditions. Research has found
that, “persons with mental illness have increased rates of poverty…lack of access to healthy food
choices, unsafe living conditions, exposure to early trauma, chronic psychological stress, and poor
social networks.”(8)
Due in part to these factors, people with BH conditions experience worse health outcomes and
significantly increased risk of premature mortality.(9-11) Premature mortality among people with
mental illness is further magnified by substance use.(12) Preventable PH conditions contribute to
premature mortality among people with severe mental illness and SUDs, reducing their lifespan
by an average of 10 - 20 years.(13, 14) Compared to the general population, people living with serious
mental illness (SMI) and/or moderate to severe SUDs have worse health outcomes and premature
mortality due to: access to care obstacles, stigma related to receiving care, and untreated health
conditions.(15, 16) A substance use disorder increases risk for overdose, accidental injury, attempted
suicide, associated medical conditions, infectious diseases, and mental health conditions.
2. Increased Expenditures: Mismanaged (or unmanaged) BH conditions can lead to difficulty
managing people's other chronic conditions as well as overutilization of certain types of costly
care across the continuum, particularly in emergency department settings that are expensive and
not aimed at prevention.(17) Total spending on BH increased approximately 62 percent between
2006 and 2015.(18) CMS spends substantially more on beneficiaries with BH conditions compared
to spending for beneficiaries without.(19) People with co-occurring BH and PH conditions have
higher overall health care needs and expenditures, and there is an opportunity for an intervention
targeted at these people that aims to improve outcomes and reduce unnecessary spending. These
higher costs are not just attributable to the costs of needed BH treatment, but to the mismanagement
of BH conditions and lack of coordinated, accessible care for both BH and PH conditions. Because
people with co-occurring BH and PH conditions have higher overall health care needs and
expenditures, there is an opportunity for an intervention that aims to increase access to appropriate
levels of prevention and treatment, coordinate care, improve outcomes, and reduce unnecessary
spending.
3. Uncoordinated System with Significant Disparities in Care and Outcomes: Negative
outcomes and disparities of care for patients with BH conditions are driven by systemic issues,
including historical underinvestment in BH care, siloing of BH and PH services, and the stigma of
BH treatment.(20) Individuals with mental health disorders often have poor access to and continuity
of quality medical care, and exhibit patterns of underusing primary care and overusing emergency
and medical inpatient care.(8) Individuals with SUDs often experience difficulties navigating the
complex SUD treatment system due in part to structural barriers within the system itself like
limited access to providers and treatment, insufficient team training, and policy and legal
constraints.(21) The BH care delivery system is often fragmented from PH care and lacks the
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integrated structures of care that promote long-term recovery.2 While care in acute clinical settings
remains important, there is also a need for clinically appropriate, community-based integrated
services to meet people in the settings in which they are already actively engaged.
4. Health Information Technology (health IT) Barriers: BH system challenges are further
exacerbated by slow adoption of certified health IT products and infrastructure improvements for
their practice and patient population, including certified electronic health record (EHR)
technology, and lower participation in health information exchanges (HIEs) among specialty BH
providers compared to PH providers, as current reimbursement rates and increasing costs leave
specialty BH providers unable to invest in the necessary hardware, software, staff, and training to
support integrated care.(22) Many specialty BH providers were not eligible for financial incentives
for EHR adoption that were provided to other categories of providers as part of the Health
Information Technology for Economic and Clinical Health Act (HITECH Act), of 9, further
exacerbating low uptake rates.(23) Interoperability across different providers and settings of care is
critical to facilitate the collaboration and communication necessary for integrated, preventative
care and health promotion.
The HHS Substance Abuse and Mental Health Services Administration (SAMHSA) and the HHS
Office for Civil Rights has made modifications under the authority of 42 U.S Code § 290dd–2
regarding the confidentiality of substance use disorder patient records, which are codified at 42
C.F.R. Part 2 and generally prohibits certain types of treatment programs from disclosing a
patient's SUD information treatment records without patient consent except under specific
circumstances such as reporting alleged child abuse, valid court orders, medical emergencies, and
health care operations. The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Privacy and Security Rules also include protections for protected health information. Additionally,
SAMHSA supports the Center of Excellence for Protected Health Information to help educate
health professionals, family members, patients and others on HIPAA, Part 2, and other BH privacy
requirements.(24) SAMHSA and the Office of the National Coordinator for Health Information
Technology (ONC) also are working on efforts to promote use of EHRs by specialty BH
providers.(25)
5. Lack of Payment Innovation in the BH Space: Payment innovation has not focused on BH
services, which are historically underfunded and rely on a patchwork of state, federal, and grant
sources. Specialty BH providers often lack a clearly defined role in VBP models designed for PH
providers, leaving specialty BH providers with limited opportunities to meaningfully participate
in alternative payment models (APMs). There is a lack of BH process measures that evidence has
shown are appropriate for use in clinical quality improvement programs. This absence of BH
process measures has made it difficult for specialty BH providers to meaningfully engage in
accountable care.(27) VBP arrangements have the potential to transform the way providers deliver
care, by encouraging more time spent on collaboration and services that may not be traditionally
covered under Medicare and Medicaid fee-for-service (FFS).
2 SAMHSA defines recovery as “a process of change through which individuals improve their health and wellness, live a self-
directed life, and strive to reach their full potential.” https://store.samhsa.gov/sites/default/files/d7/priv/pep12-recdef.pdf
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A3.1 How the IBH Model Addresses These Challenges Through Integrated
Care and VBP
The challenges described above demonstrate that there is a need for a broader, federally
coordinated effort to advance BH and PH care integration, improve the quality of care, and test
innovative payment models within Medicare and Medicaid to achieve better, improved outcomes
for beneficiaries with BH needs and reduce program expenditures.
Value-based care, where providers are paid based on patient outcomes, has the potential to reduce
health care spending and improve overall health. However, specialty BH providers have had
limited opportunities to participate in VBP models. The IBH Model will address these challenges
by providing a VBP model for specialty BH organizations and settings to deliver preventive care.
Integrated care improves access to general health care by fostering better communication,
alignment, and collaboration among providers caring for individuals with complex BH and co-
occurring priority health conditions. Members of a care team collaborate to establish a
comprehensive treatment plan addressing the person's biological, psychological, and other needs
that impact health. For many individuals with moderate to severe BH (MSBH) needs and co-
occurring PH conditions, the BH setting may be the setting in which they are most actively engaged
to receive needed care.
Significant progress has been made in developing various frameworks to build upon and advance
integrated care(30-33), but the barriers described in Section A3 Background persist. The IBH Model
will help minimize the barriers to high quality integrated care as exhibited in Table A.1.
Table A.1: IBH Model care delivery solutions for barriers to integrated care
Barriers to Care IBH Care Delivery Solutions
1. Poor Clinical Outcomes: People often face The care delivery framework will prioritize
barriers to having their PH needs identified in specialty BH practices as the entry points for
BH settings. This is due in part to a lack of: integrated, value-based care. Interprofessional
provider knowledge, support, and training care teams will provide screening, assessment,
related to PH screening needs; patient treatment, and referral for PH and BH needs
knowledge regarding PH screening needs; with ongoing care management and individual-
clarity regarding provider responsibility and level interventions to address beneficiary issues
accountability for screening for PH conditions; that interfere with diagnosis, management, and
as well as insufficient resources and time during treatment of health conditions, such as food,
visits to facilitate screening and associated housing, and transportation needs.
referrals.(34, 35)
2. Increased Expenditures: BH and PH services Interprofessional care teams will collaborate to
and providers are often siloed, and people are establish a comprehensive treatment plan
not connected with the range of health services addressing the person's biological,
they need. This fragmentation can be especially psychological, and other needs that impact
difficult for people with BH diagnoses and health, improving access to PH care by fostering
results in underutilization of primary care, lack better communication, alignment, and
of access to specialty PH care, and the overuse collaboration among providers caring for
of emergency department and inpatient medical individuals with complex BH and co-occurring
care. chronic conditions. The Model will also support
the development of care pathways and protocols
to ensure that people are connected with needed
PH care when a need is identified.
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Barriers to Care IBH Care Delivery Solutions
3. System Challenges: Broader health system The IBH Model will require needs that impact
lacks capacity to address needs that impact health are screened and referred using a
health. Individuals with BH conditions have validated screening tool, such as the
increased rates of poverty, limited access to Accountable Health Communities (AHC)
healthy food choices, and unsafe living screening tool and ensure that providers
conditions, which have been shown to consider other needs that impact health within
exacerbate PH comorbidities.(8) their treatment plans.
4. Health IT Barriers: Limited investment The IBH Model will provide specialty BH
opportunities for specialty BH providers. Many practices and SMAs infrastructure and
specialty BH providers were not eligible for the cooperative agreement funding and technical
EHR adoption financial incentives that were assistance necessary for them to effectively
provided to other categories of providers as part adopt and implement health IT tools and to
of the Health Information Technology for participate in local, regional, or state
Economic and Clinical Health Act (HITECH) information sharing systems.
Act enacted in 2009, further exacerbating low
uptake rates.(23)
5. Lack of Payment Innovation: Payment The IBH Model will provide an on-ramp to
innovation has not focused on specialty BH value-based payment by providing support for
practices. Specialty BH practices often lack a necessary infrastructure and health IT funding,
clearly defined role in VBP models, leaving preparing these providers to participate in VBP
them with limited opportunities to meaningfully models. The IBH VBP model will align
participate in APMs. Medicare and Medicaid to enhance multi-payer
alignment.
6. Preventive Care and Health Promotion in Practice Participants will engage in activities
BH: Differences in access to and quality of that improve health for all beneficiaries,
care, use of care, and comprehensiveness of including conducting a population health needs
insurance coverage are persistent in BH care. assessment and identifying beneficiary issues
Limited access can be rooted in historical that interfere with diagnosis, management, and
exclusion from social and economic treatment of health conditions, such as food,
opportunities that result in barriers to care and housing, and transportation needs. Practice
unequal treatment over time. Participants will develop plans to address needs
identified in the population health needs
assessment through enhanced care coordination
or closed-loop referrals to community-based
organizations.
A3.2 Alignment with Federal Priorities and State Medicaid Program Trends
and Themes
The IBH Model is aligned with the BH priorities set by CMS and the Department of Health and
Human Services (HHS) in the September 2022 HHS Roadmap for Behavioral Health Integration.
The IBH Model will support these priorities by:
• Reducing silos across programs and settings; and
• Ensuring that “the full spectrum of BH care will be integrated into health care, social
service, and early childhood systems to ensure all people have equitable access to evidence-
based culturally appropriate, person-centered care.”(36)
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In addition, the IBH Model is designed to harness state interest and capacity-building in BH and
build directly on this architecture, where appropriate. Specific examples that may support the IBH
Model include:
• States have been the early innovators in designing and operationalizing VBP efforts among
specialty BH practices through various Medicaid innovation initiatives including but not
limited to waivers, demonstration programs, and grants.(37)
• Approximately eight states are utilizing flexibilities under Section 1115 of the Social
Security Act to cover services for needs that impact health that would otherwise not be
available for federal match, including services such as housing and housing supports,
transportation assistance, and nutritional services.
• Over twenty states noted initiatives in their American Rescue Plan Act of 2021 Section
9817 State Spending Plans related to mental health, substance use disorder treatment, and
initiatives focused on needs that impact health.
• States have also undertaken the Certified Community Behavioral Health Clinic (CCBHC)
demonstration, the Promoting Integration of Primary and Behavioral Health Care
(PIPBHC) program, and the Medicaid State Plan option to provide coordinated care
through the establishment of Health Homes3 for individuals with chronic conditions (see
Section 1945 of the Social Security Act) to improve access to BH care, improve statewide
BH crisis systems and develop comprehensive approaches to PH and other needs that
impact health.(38-40) As of December 2023, 20 states support 35 health home models to
support care coordination for patients with complex needs, including those with BH
conditions.
A4. Program Requirements
Below are the core functions Recipients are required to complete in the Pre-Implementation and
Implementation Periods of the IBH Model, with associated examples of cooperative agreement
funding use.4 Recipients may fulfill these requirements themselves and may also work with
managed care entities or other state entities like agencies with regulatory authority over mental
health and/or substance use disorder providers to ensure these tasks are completed. Of note, the
funding provided pursuant to the Cooperative Agreement may not be claimed for Federal financial
participation (FFP) purposes.
Recipients also have reporting and evaluation requirements throughout the period of performance
as detailed in Section F6. Reporting.
Recipients must detail their potential plans to operationalize the core functions as part of their
application as further described in Section D2.4.1 Project Narrative.
A4.1 Model Structure Overview
The IBH Model will focus on state-based innovation, led by the state Medicaid agency (SMA) as
the Recipient, to test a care delivery framework where the BH setting is the facilitator of integrated
care. Specialty BH practices and settings (see Section A4.1.1 Definitions) within the selected states
3 https://www.medicaid.gov/resources-for-states/medicaid-state-technical-assistance/health-home-information-resource-
center/index.html
4 This is not an exhaustive list of requirements or cooperative agreement funding use.
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will be the Practice Participants and entry points for adult Medicaid, Medicare, and dually eligible
beneficiaries to receive integrated care.
Recipients of this award will develop a Medicaid Payment Approach that includes a Medicaid
performance-based payment (PBP). The Medicaid Payment Approach shall align with the
Integration Support Payment (ISP) and Medicare PBP developed by CMS (further details available
in Appendix VI Medicare Payment Approach Details). The Medicaid Payment Approach will be
implemented in parallel to the Medicare Payment Approach for eligible Practice Participants
within the selected states. Recipients can operate the IBH Model across their state or in a specified
sub-state area.
CMS will award, through a competitive process, cooperative agreements to up to five successful
Cohort II Recipients. During the two-year Pre-Implementation Period, Recipients will be required
to undertake several readiness and technical assistance activities to support Practice Participants
and develop their Medicaid Payment Approach in partnership with CMS. The Pre-Implementation
Period is designed to help Recipients:
• identify and recruit Practice Participants alongside relevant partners (Such as MCOs or
state mental health authorities and/or single state agencies for SUDs;
• support their Practice Participants in developing the needed infrastructure and technical
expertise to implement the care delivery framework;
• meet data reporting requirements; and
• establish a Medicaid Payment Approach, in partnership with CMS, to support the care
delivery framework.
Figure 4.1.3: IBH Model Structure
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A4.1.1 Model Definitions and Components
IBH Model Definitions
Infrastructure Funding Payments made by Recipients to Practice Participants to
support and fund investments in certified health IT products
and infrastructure improvements for their practice and patient
population, including (1) improving data infrastructure; (2)
establishing quality goals; (3) supporting data collection efforts
to advance toward accountable care and the development of a
plan to address needs specified in the population health needs
assessment; and (4) support practice transformation activities.
Integration The coordination (and as appropriate, provision) of PH care5 by
the BH care team and in the BH setting, along with attention to
needs that impact health and appropriately matched BH
interventions. Integration in the IBH Model is a person-
centered approach to identify and address (as appropriate
within scope of practice) PH in the BH setting in which the
person with moderate to severe BH conditions may be already
or more frequently engaged to supporting preventive care and
health promotion. This care may be co-located or virtual.
Moderate to Severe Mental Health The specific BH diagnoses defined by CMS, in consultation
Conditions and/or Substance Use with clinical subject matter experts from SAMHSA, as
Disorders (SUD) “moderate to severe” are listed in Appendix IX.
Physical Health (PH) Consultant A PH provider who specializes in the diagnosis, evaluation, and
therapeutic management of PH conditions and is qualified to
prescribe medication (physician, nurse practitioner, etc.). The
PH Consultant participates in regular review of the clinical
status of beneficiaries receiving IBH services and advises the
billing practitioner and care management team about screening
and follow-up for positive screens, PH diagnosis, treatment
initiation, care options, monitoring for complications of PH
conditions, and options for resolving issues with beneficiary
adherence and tolerance of PH treatment with a culturally
informed and person-centered approach. The PH Consultant
also advises on managing any negative interactions between
beneficiaries' PH and BH treatments and other needs that
impact health and offers a referral for direct provision of
primary care when clinically indicated and suggests specialty
care options as needed. The PH Consultant could be an in-
house provider working at a specialty BH practice or could be
an outside provider who contracts with a specialty BH practice.
5 Physical health care includes care and services for non-behavioral health conditions (i.e., mental health and SUDs) and is
inclusive of oral health.
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IBH Model Definitions
Physical Health (PH) Providers Physicians and non-physician practitioners whose primary area
of practice involves the diagnosis, evaluation, and therapeutic
management of non-BH conditions.
Primary Care Primary care is the provision of preventive and integrated
health care by interprofessional teams that are accountable for
addressing the majority of an individual's health and wellness
needs across settings and through sustained relationships with
patients, families, and communities.
Specialty BH Organizations and A health care provider, practice, facility, or other community-
Settings based organization delivering BH treatment services outside of
an inpatient, emergent, or urgent care level of care where BH
services are available to beneficiaries and are the predominate
health care service type delivered, or where longitudinal BH
services are available and delivered by a specialty BH provider.
This includes local health departments, or another entity that is
part of a local government behavioral health authority where a
locality, county, region, or state maintains authority to oversee
behavioral health services at the local level and uses the entity
to provide those services. This longitudinal accountable BH
care arrangement involves a Practice Participant who agrees to
be accountable for quality, utilization, patient experience, and
care integration over a sustained period.
Specialty Behavioral Health (“BH”) Specialty BH providers refers to physicians, non-physician
Providers practitioners, and other eligible professionals whose primary
area of practice involves the diagnosis, evaluation, and
therapeutic management of mental health and SUD conditions,
as permitted under federal and state law. Specialty BH
providers must be eligible to bill for services (i.e., be billing
practitioners) and may include physicians (medical doctors or
doctors of osteopathy), clinical psychologists, clinical social
workers, clinical nurse specialists, nurse practitioners,
physician assistants, independently practicing psychologists,
marriage and family therapists, and mental health counselors as
specified in the CY2024 Physician Fee Schedule final rule.
IBH Model Components
Care Delivery Framework An Integration framework for adult Medicaid and Medicare
beneficiaries with MSBH implemented for Practice Participants
statewide or within a sub-state region.
Commercial payer participation Recipients are encouraged to use existing relationships with
commercial payers to further strengthen payer alignment efforts
in their states.
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IBH Model Components
Medicaid participation Practice Participants that currently serve (or will serve)
Medicaid beneficiaries and/or are currently billing Medicaid in
participating states by the start of model year MY1 (BP1).
Practice Participants must at minimum participate in their
state's Medicaid Payment Approach to participate in the IBH
Model. Practices that participate in the Medicaid Payment
Approach may be eligible to participate in the Medicare
Payment Approach. State agreements with Practice Participants
will follow existing state protocols for Medicaid participation.
Recipients will lead the design of the Medicaid Payment
Approach and care delivery framework and provide technical
assistance and programmatic support to Practice Participants.
Medicare participation Practice Participants that participate in their state's Medicaid
Payment Approach and are accepted to participate in the
Medicare Payment Approach. Practice Participants will enter
into separate participation agreements with CMS that govern the
Medicare Payment Approach. Providers that do not participate
in the Medicaid Payment Approach cannot participate in the
Medicare Payment Approach.
Multi-Payer Approach The IBH Model is focused on multi-payer alignment. Multi-
payer alignment is critical to achieving model success because it
streamlines care delivery efforts and payment for IBH Practice
Participants across their patients and lines of business. The IBH
multi-payer approach consists of the following principles:
• Directional alignment: CMS will work with Recipients
to closely align on areas of the Model that directly reduce
provider burden and are important to model aims and
evaluation of outcomes, such as quality measurement,
the type and format of data provided, and learning
priorities. CMS will not require Recipients to build
identical payment arrangements to other Recipients
and/or to what is proposed in the Medicare ISP and PBP.
Directional alignment is detailed further in Section
A4.4.4: Multi-Payer Alignment.
• Medicaid Flexibility: Recipients may customize certain
model elements, such as Medicaid payment systems and
care delivery, while remaining directionally aligned with
IBH's Medicare Payment Approach. Specifically, CMS
will require Recipients to move Practice Participants
away from traditional Medicaid FFS payment, but
Recipients will have flexibility to choose what type of
non-FFS Medicaid payment to implement. (See Sections
A4.4 IBH Payment Strategy and A4.3 IBH Care Delivery
Framework for specific areas of flexibility.)
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IBH Model Components
Practice Participation Eligible specialty BH organizations and settings (“Practice
Participants”) may elect to participate by delivering the IBH
care delivery framework (A.4.3 IBH Care Delivery Framework)
and, in exchange, receive payment for their eligible
beneficiaries (defined further in Section A4.2.1 Eligible Practice
Participants). Practice Participants may also be eligible to
receive specific funding to procure necessary health IT upgrades
such as adopting EHRs.
SMA Participation Recipients (SMAs) receive cooperative agreement funding in
both the Pre-Implementation and Implementation Periods to
support the development of key model activities, including, but
not limited to, the Medicaid Payment Approach, care delivery
framework, and key data sharing and infrastructure activities.
This section displays the Recipient cooperative agreement requirements for the pre-
implementation and implementation periods. Table A.4.1.2 exhibits a summary of each
requirement and where further details can be found.
Table A.4.1.2: Cooperative agreement requirements – at a glance:
Requirement Description Relevant Section
Recruit IBH Practice The Recipient will be required A4.2 Recruit Practice
Participants to work with relevant parties to Participants
recruit eligible BH Practice
Participants to the IBH Model
Design and implement the IBH The Recipient will collaborate A4.3 IBH Care Delivery
care delivery framework with CMS, Practice Framework
Participants, and relevant
parties to design and implement
the IBH care delivery
framework
Design and implement the IBH The Recipient will design, A4.4 IBH Payment Strategy
Medicaid payment arrangement establish, and implement the
IBH Medicaid Payment
Approach in partnership with
CMS
Distribute cooperative The Recipient will distribute A4.5 Infrastructure
agreement funding, including cooperative agreement funding Development and Funding
Infrastructure Funding (including Infrastructure Distribution
Funding) to help achieve model
goals
Participate in the convening The Recipient will aid in A4.6 Convening Structure
structure identifying and implementing a
convening of relevant IBH
parties
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Requirement Description Relevant Section
Participate in model data, The Recipient will enable the A4.7 Data, Quality, and
quality, and evaluation efforts continuous flow of IBH Model Evaluation
data, including through
quarterly measure submission
and technical assistance to
Practice Participants
A4.2 Recruitment of Practice Participants
A4.2 Recruitment Requirements:
Pre-implementation period requirements Implementation period requirements
During the pre-implementation period, Recipients During the implementation period, Recipients
must: must:
• Implement the BH practice recruitment • Enroll and retain BH Practice Participants.
strategy. • Continue to recruit Practice Participants
Identify, recruit, and enroll eligible BH through the end of MY3 (BP3).
○
Practice Participants.
• Secure a letter of intent from at least one
managed care organization (MCO),
prepaid inpatient health plans (PIHPs), or
prepaid ambulatory health plans (PAHPs)
(where applicable) to participate in the
IBH Model.
• Secure a letter of intent from the State
Mental Health authorities and/or Single
state agencies for SUDs.
Recipients are required to solicit interest and recruit Practice Participants into the IBH Model who
meet the eligibility criteria detailed below in Section A4.2.1 Eligible Practice Participants and must
submit a practice recruitment strategy with their application. CMS encourages Recipients to
include State Mental Health Authorities and/or Single State Agencies for SUDs, and managed care
organizations, risk-based prepaid inpatient health plans (PIHPs), risk-based prepaid ambulatory
health plans (PAHPs)6 , or other intermediaries in developing the practice recruitment strategy
given their knowledge of existing practice networks. The practice recruitment strategy shall
include:
a. A plan for recruiting Practice Participants into the IBH Model, including key partners
and how they may support recruitment activities.
b. Plans to include outreach with rural, safety-net specialty BH providers, under-
resourced providers, tribal providers, and providers serving vulnerable populations in
the recruitment strategy.
c. An estimated number of Practice Participants enrolled in the IBH Model by the end of
MY3 (BP3).
d. An estimated number of total Medicaid enrollees with MSBH conditions to be
attributed to the IBH Model for the entire duration of the Implementation Period.
6 All references to PIHPs and PAHPs refer to risk based PIHPs and PAHPs
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Recipients may begin enrolling practices starting in MY1 (BP1). Recipients (or their fiscal
intermediaries) are required to have Practice Participants recruited into the IBH Model by the start
of MY2 (BP2) and may continue recruiting Practice Participants through the end of MY3 (BP3).
In addition to recruiting Practice Participants, the Recipient must secure a letter of intent (LOI)
from at least one MCO, PIHP, or PAHP, if the Recipient's BH network is managed through an
MCO, PIHP, or PAHP, at the time of submitting this application. The Recipient must also secure
a letter of intent from their State Mental Health Authorities and/or Single State Agency for SUDs.
CMS will work with participating state Medicaid agencies to determine the pathway for
implementing the Medicaid payment arrangement, including any state plan amendments, waivers
(including but not limited to Medicaid section 1115(a) authority, 1915 authority), or Medicaid
managed care contract modifications that may need to be approved.
A4.2.1 Eligible Practice Participants
Within the Recipient's proposed geographical service area, specialty BH organizations and
settings will be eligible Practice Participants who, at the time of application, meet all the following
criteria:
• Have at least one BH provider that is an employee, leased employee, or independent
contractor of the practice and:
1) Is licensed by the state to deliver BH treatment services; an
2) Meet any state-specific Medicaid provider enrollment requirements and is eligible for
Medicaid reimbursement.
• Meet all state-specific requirements to deliver BH services, if applicable;
• Serve adult Medicaid beneficiaries (age 18 or older) with moderate to severe BH
conditions; and
• Provide MH and/or SUD treatment services at the outpatient (OP) level of care. This does
not include the intensive outpatient (IOP) level of care.
Practices that provide only case management7 or only recovery services or do not provide direct
delivery of diagnostic or treatment of BH services are not eligible to be Practice Participants.
Inpatient and post-acute care settings are not eligible to participate in the IBH Model. Post-acute
care includes, but may not be limited to, home health agencies, skilled nursing facilities, inpatient
rehabilitation facilities, and long-term care hospitals. The IBH Model has adopted this policy to
assure program integrity and avoid duplicate services and payments with inpatient and post-acute
care prospective payment systems and value-based purchasing programs.
Examples of eligible Practice Participants may include but are not limited to:
• Community Mental Health Centers (CMHCs);
• Rural Health Clinics (RHCs) that provide specialty BH care services;8
• Federally Qualified Health Centers (FQHCs) that are dually-certified as a BH provider
• Critical Access Hospital (CAH) outpatient BH clinics;
• Independent health care providers with and without clinic affiliations;
7 The Social Security Act, § 1915(g)(2), defines case management services as those assisting individuals eligible under the State
plan in gaining access to needed medical, social, educational, and other services. Case management services do not include the
direct delivery of an underlying medical, educational, social, or other service for which an eligible individual has been referred.
8 Additional information regarding RHC eligibility requirements will be released in future guidance materials.
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• Certified Community Behavioral Health Clinics (CCBHCs);
• Opioid Treatment Programs (OTP);
• Private specialty clinics with and without medical center affiliations.
• Specialty substance use disorder provider organizations;
• Tribal health organizations and clinics; and
• Local and territorial health departments and governments or other entity that is part of a
local government BH authority where a locality, county, region, or state maintains
authority to oversee BH services at the local level and uses the entity to provide those
services.
Practice Participants will be identified using a combination of their tax identification number (TIN)
and national provider identifier (NPI), cross-referenced through the required provision of Medicaid
provider identification numbers.
To be eligible to participate in the model, when the state recruits a practice to participate, that
practice must serve, at the outpatient level of care, at least 25 Medicaid MSBH beneficiaries on
average per month. As outlined in Section A4.2.2 Eligible Beneficiaries all adults served by the
eligible Practice Participant are eligible to receive model services where medically necessary and
appropriate regardless of diagnostic status. CMS anticipates each state will include approximately
10,000 Medicaid beneficiaries with MSBH conditions throughout the course of the Model. To
reduce practice burden and ensure an equitable continuity of services, states are encouraged to
require Practice Participants to treat all Medicaid beneficiaries with BH needs through the IBH
care delivery framework, where the services are deemed reasonable and medically necessary.
The specific BH diagnoses defined by CMS, in consultation with clinical subject matter experts
from SAMHSA, as “moderate to severe” are listed in Appendix IX. 9 CMS reserves the right to
consider changes should diagnoses need to be added or removed from the list of MSBH diagnoses.
CMS will communicate any changes to Recipients with advance notice. Recipients will work with
their Practice Participants, State Mental Health authorities and Single state agencies for SUDs and
partnering MCO (or other fiscal intermediary) to develop a process to verify that practices serve
the minimum number of Medicaid MSBH beneficiaries, no less than annually. Additionally,
Recipients will make their Practice Participant Lists available to CMS as part of their model
reporting requirements detailed in Section F6.3 Performance Milestones.
The Practice Participant eligibility criteria will be the basic framework that Recipients will be
required to use to identify eligible Medicaid Practice Participants. Recipients and their applicable
subrecipients (such as MCOs, PIHPs, or PAHPs) may not apply further limiting eligibility criteria
in addition to the criteria laid out by CMS, except for limiting eligibility by sub-state region as
allowable and identified in its application.
Medicaid Practice Participants will also be eligible to participate in the Medicare Payment
approach of the Model, assuming they are enrolled as fee-for-service Medicare providers and are
in good standing,10 and meet the IBH Practice Participant criteria. Practice Participants will not be
allowed to participate in the Model as Medicare-only providers, but Practice Participants may
choose to participate only in the Medicaid payment arrangement. Ideally, all IBH Model Practice
9 The IBH Model's “moderate to severe” behavioral health conditions are not to be confused with SUD mild, moderate, or severe
classifications that are based on the number of diagnostic criteria that are fulfilled. Thus, in this NOFO, "moderate to severe"
does not refer to those specific SUD classifications.
10 Good standing means able to bill Medicare, Medicare Provider Enrollment, Chain, and Ownership System (PECOS) is up to
date, and provider does not have any outstanding fraud and abuse litigation.
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Participants will participate in both Medicaid and Medicare to bolster multi-payer alignment. Any
IBH Medicaid Practice participant unable to have payments withheld will be required to also
participate in the Medicare Payment Approach, where applicable. CMS will review this on a case-
by-case basis. Please see Appendix VI for more details on this requirement.
A4.2.2 Eligible Beneficiaries
All adult Medicare and/or Medicaid beneficiaries receiving care from eligible Practice Participants
will be eligible for the Model, regardless of their specific BH diagnoses, if the services are deemed
reasonable and medically necessary. If services are not reasonable and medically necessary (i.e.,
the level of care required by the IBH care delivery framework is not needed), the beneficiary will
not be enrolled in the IBH Model. Recipients shall encourage Practice Participants to educate
beneficiaries regarding IBH services and develop standardized practices to assess a beneficiary's
need for the IBH care delivery framework services.
A4.3 IBH Care Delivery Framework
A4.3 Section Requirements:
Pre-implementation period requirements Implementation period requirements
During the pre-implementation period, Recipients During the implementation period, Recipients
must: must:
• Design and prepare implementation of the IBH • Implement the IBH Medicaid care delivery
Medicaid care delivery framework as framework as described in this section.
described in this section. Provide implementation updates,
○
Provide updates on the design of the successes, challenges, and lessons
○
care delivery framework in quarterly learned in quarterly progress reports.
progress reports.
The Recipient must design and prepare for implementation of the IBH care delivery framework
that enables Practice Participants and their partners to deliver care integration, care management,
preventive care and health promotion services as detailed below in Section A4.3.1 Care Delivery
Framework Overview.
The Recipient must provide updates on the development of the care delivery framework in
Quarterly Progress Reports during the pre-implementation period. The IBH care delivery
framework must be ready for implementation by Practice Participants at the start of MY3 (BP3).
Recipients must adhere to all applicable Federal, state, and local laws and ordinances, and shall
work with their Convening Structure to determine what patient authorizations and reauthorizations
may be required to implement the IBH Model as designed, for example, to engage in data sharing
activities.
The Recipient must implement the IBH care delivery framework including maintaining the
infrastructure, processes, and programs established during the model Pre-Implementation Period
throughout the duration of the Model. As detailed below and throughout this NOFO, these include,
but are not limited to, maintaining and supporting required staff to implement the Model, and
ensuring all required services are being furnished by Practice Participants and their partners.
Additionally, Recipients must maintain relationships with Practice Participants and MCOs, PIHPs,
PAHPs, or other fiscal intermediaries.
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Examples of funded activities:
• Practice transformation activities for Practice Participants to carry out the IBH care delivery
framework.
• Clinical subject matter support to implement the IBH care delivery framework.
• Benefit design activities to support the implementation of the IBH care delivery framework.
A4.3.1 Care Delivery Framework Overview
The Recipient is responsible for developing the IBH Medicaid care delivery framework in
partnership with CMS according to the requirements set forth in this document. Recipients will
leverage convenings with commercial payers, potential Practice Participants, and other
stakeholders to design and operationalize the IBH Model's Medicaid component of the care
delivery framework. The Recipient will use a shared vision for population health, preventive care,
and health promotion outcomes, considering state-specific nuances and context, to build the
Medicaid care delivery framework, capitalizing on existing infrastructure and capacity within the
state. CMS will publish further care delivery framework guidance in model pre-implementation.
Required Elements: The IBH Model's care delivery framework includes three required core
elements necessary to test a standard of integrated, person-centered care in specialty BH
organizations and settings. Recipients will aid Practice Participants in delivering the following
services:
1) Care integration: Practice Participants will screen, assess, treat, and refer patients as
needed for both BH and PH conditions, within the scope of practice of the Practice
Participants' providers.
2) Care management: an interprofessional care team will address the needs of the beneficiary
and provide ongoing care management across the beneficiary's BH and PH needs.
3) Preventive Care and Health Promotion: Practice Participants will engage in activities
that improve health for all beneficiaries, including conducting a population health needs
assessment and identifying beneficiary issues that interfere with diagnosis, management,
and treatment of health conditions, such as food, housing, and transportation needs.
Practice Participants will develop plans to address needs identified in the population health
needs assessment.
Optional and Complementary Components: As previously noted, the IBH Model encourages
Recipients to build on existing initiatives, and as such, Recipients may include additional care
delivery services, particularly those that are relevant to their state or sub-state context. The care
delivery framework requirements listed in Section A4.3.3 Care Delivery Framework Requirements
are necessary to reach model directional alignment for integration and shall not deter additional
innovation at the state level.
• The IBH Model encourages Recipients to provide additional services, as relevant to their
populations and context.
• Recipients are encouraged to build on existing policy infrastructure and integrate the IBH
Model into existing Medicaid BH models focused on the priority population (beneficiaries
with moderate to severe BH conditions) including but not limited to CCBHCs, Medicaid
Health Homes, OTPs, and the PIPBHC program.
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A4.3.2 Priority Health Condition Requirements: Diabetes, Hypertension, Tobacco
Use
The IBH Model will use diabetes, hypertension, and tobacco use as measures of care integration.
Therefore, Practice Participants must screen eligible beneficiaries for diabetes, hypertension, and
tobacco use. These priority health conditions were based on:
• evidence on their prevalence in the BH beneficiary population;
• the level of spending on each condition by CMS;
• clinical expertise on the ability to treat these conditions in the BH setting; and
• the increased risk of morbidity, disability, and mortality for beneficiaries associated with
these conditions.
Assessment and treatment of these conditions in BH settings can be carried out by an in-person
PH consultant. Alternatively, a telehealth appointment may also be used for assessment and
treatment where the use of telehealth appointments is otherwise allowed.
Mandatory Components: Recipients will develop a Medicaid Payment Approach that enables
their Practice Participants to screen and assess the beneficiary's PH needs, followed with
appropriate treatment and/or referral. Screening must be evidence-based and must include, at a
minimum, diabetes, hypertension, and tobacco use. Screening may include, but is not limited to:
• Reviewing the beneficiary's medical history and medications to assess for a current
diagnosis;
• Assessing risk factors or symptoms; and
• Performing screening labs or tests in accordance with evidence-based guidelines.
Optional Components: Recipients may require additional priority health conditions to be included
in each beneficiary's screening. Recipients are encouraged to include:
• conditions that are a priority within the Recipient's state or regional context;
• conditions where health disparities are prevalent; and
• conditions that can enhance the case for post-model sustainability. For example, high-cost
conditions that have savings potential within the proposed geographic region.
For example, a Recipient may choose to include hepatitis C as a priority health condition.
If a Recipient chooses to add additional priority health conditions, the Recipient shall propose an
accompanying quality measure to assess outcomes.
A4.3.3 Care Delivery Framework Requirements
The requirements for the IBH Model care delivery framework are listed in the table below. The
first two columns of the table include requirements for Recipients and Practice Participants. The
third column lists examples of enhanced innovation opportunities for Recipients and Practice
Participants to drive further innovation. The fourth column shows existing initiatives and policies
as examples of activities or requirements that are occurring in states. The latter two columns are
not exhaustive and are intended for illustrative purposes only.
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Enhanced Existing
Recipient Practice Participant Innovation Initiatives and
Core Element Requirements Requirements Opportunities Policies
Care • Provide evidence- • Use evidence-based • Recipients may • CCBHC
Integration based guidelines guidelines to screen and establish demonstrations
for BH and PH assess BH and PH guidelines and grants
screenings to conditions, and other around the • Medicaid
Practice Participants needs that impact health provision of PH Health Homes
as needed. as part of the IBH treatment in the • PIPBHC
• Evaluate and map Welcome Visit.11 BH setting, program
Current Procedural • Use evidence-based including but not
Terminology (CPT) guidelines to screen and limited to:
and Healthcare assess BH and PH Telehealth
○
Common Procedure conditions and other
consultation by
Coding System needs that impact health
a PH provider,
(HCPCS) codes to as part of ongoing patient
Co-location of
ensure all IBH care. ○
a PH pr ovider,
requirements can be
delivered.
• Screen to determine if a
○ Treatment by a
beneficiary is engaged
• Work with dual-trained or
with a provider to receive
intermediaries to certified BH/
primary care services.
evaluate primary PH provider,
care provider
• Build a comprehensive
and/or
care plan with input from
networks and Protocol-
a PH consultant12 . ○
access standards to guided
ensure IBH • Consult with a PH
treatment
beneficiaries can provider on PH treatment
initiation with
access PH care in a initiation, care options
PH provider
timely manner. and monitoring for
referral and
• Work with the complications of PH
follow-up
convening structure conditions, and negative
and or interactions of PH with
BH treatment and other
intermediaries to
needs that impact health.
facilitate learnings
and TA around care
integration.
11 The IBH Welcome Visit also involves the receipt of informed consent from the beneficiary for IBH Model services and
participation in the model.
12 Practice Participants who cannot provide identified E&M services within their scope of practice will be encouraged to develop
an annual care agreement or other relationship with PH providers outlining roles and shared accountability and will be required to
submit a roster of their partnering PH providers; the roster would make the listed PH providers eligible to use a new or modified
consult and/or care management code. If no roster is in place, the PH provider will use existing professional consult codes for
payment. Referral to a specific PH care provider shall align with the beneficiary's preferences; if the beneficiary's physical health
provider is not included on the roster under this model with the Practice Participant, the physical health provider shall use existing
professional consult codes for payment.
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Enhanced Existing
Recipient Practice Participant Innovation Initiatives and
Core Element Requirements Requirements Opportunities Policies
Care • Work with CMS to • Re-evaluate the care plan
Integration
ensure compliance based on patient
(continued)
with Medicaid outcomes, with input
rules and secure from a PH consultant if
any necessary needed.
modifications to • Treat identified BH and
existing program
PH conditions based on
structures.
the specialty BH
provider's scope of
practice or refer to a PH
provider as needed.
• Refer beneficiaries to
social services to address
identified needs that
impact health, with
support from a
community health
worker, peer support
specialist, or other
navigator as needed.
• Track beneficiary goals,
treatment progress,
and/or outcomes using a
standardized patient-
reported outcome
measure.
• The implementation and
use of certified Health IT
products and
infrastructure
improvements for their
practice and patient
population
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Enhanced Existing
Recipient Practice Participant Innovation Initiatives and
Core Element Requirements Requirements Opportunities Policies
Care • Recipients will • Provide care • Recipients may • MCO may
Management provide state- management that add additional support
specific guidance includes person-centered care providers with
planning, care
to Practice management data analytics,
coordination, utilization
Participants on requirements for care
management, transitional
utilization of any Practice management
care services, and health
state-based data Participants, workflows,
care navigation for each
warehouse or care with associated provide
beneficiary's BH and PH
management tools quality metrics encounter
conditions and other
for health care and as appropriate information and
needs that impact health.
social service • Provide beneficiary self- claim line feed,
navigation management support, provide data on
and outreach and engage member
beneficiaries in BH and preferences,
PH care, with support of educate
peer support workers or providers on
other clinical staff. existing
• Establish care pathways programs or
to ensure that identified
opportunities
conditions are tracked
for members to
over time, beneficiaries
connect them
are receiving care
appropriately,
included in the care plan,
enrollment
and that updates to the
support, connect
care plan occur when
there are relevant with social
changes in a support
beneficiary's status. agencies and
• Establish procedures for organizations
and manage instances of etc.
hospitalization,
emergency department
use, and other care
transitions (admission,
discharge, and transfer)
• Track and monitor
beneficiaries' BH and
PH conditions, other
needs that impact health,
and treatment needs to
coordinate across
disciplines
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Enhanced Existing
Recipient Practice Participant Innovation Initiatives and
Core Element Requirements Requirements Opportunities Policies
Preventive • Facilitate • Screen each beneficiary • Recipients may • Existing
Care and relationships for other needs that develop and population
Health between social impact health on a implement health/needs
Promotion service agencies minimum of an annual statewide assessments
and Practice basis and use this protocols for • State-led whole
Participants information to inform the screening, person health
through beneficiary's care plan. referral, and coalitions
introductions, • Participants will (1) follow up of • State
shared meetings, choose a state-required food, housing, departments of
and appropriate other needs that impact transportation, social and/or
connections to health screening and other needs. human services
facilitate warm instrument or (2) select • Recipients may
hand-offs (e.g., questions for each be able to use
through the required domain from the new or existing
Model's convening Gravity Project's list of waiver
structure). validated, health IT- authorities or
• Provide Practice encoded screening demonstrations
Participants with a instruments, located in to fund the
population needs the National Library of provision of
assessment Medicine Value Set social services
detailing the health Authority Center, or (3) for identified
disparities from a list of screening needs that
experienced by the instruments provided by impact health.
Practice CMS.
Participant's
service population.
This population
needs assessment:
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Enhanced Existing
Recipient Practice Participant Innovation Initiatives and
Core Element Requirements Requirements Opportunities Policies
Preventive • Will include • Develop and implement • Recipients may • Section 1115
Care and cultural, linguistic, protocols for screening, add additional demonstration
Health geographic, and referrals, and follow-up state • Other needs
Promotion technological of needs that impact requirements for that impact
(continued) needs, the impacts health. health-related health
of large-scale • Build a plan that details needs data opportunities
public health steps Practice collection in • Managed care
emergencies (e.g., Participants will take to addition to the contracts
COVID-19), and address the needs CMS-approved • SAMHSA
BH and PH identified in the screening tools. block grants
treatment needs as population needs • Recipients may
well as other needs assessment, including facilitate closed-
that impact health. how the Practice loop referrals
• Identify existing Participant will build with social
disparities in care teams that reflect service agencies
outcomes stratified the needs of the by providing
by certain population based on the appropriate data
characteristics. population needs warehousing and
• Will include a assessment. The plan management.
statewide plan that shall stipulate how the • Recipients are
identifies the Practice Participant will encouraged to
strengths and address needs that use an existing
challenges in how disproportionately population needs
the Recipient is impact their service assessment that
addressing these populations. is completed for
disparities at the another state or
state level. federal program
• Provide suggested
opportunities for
how Practice
Participants can
address disparities
within their
practice and align
their efforts with
state activities.
• Be no less than 5
years old and be
updated at least
every 5 years
during this model.
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A4.4 IBH Payment Strategy
A4.4 Section Requirements:
Pre-implementation period requirements Implementation period requirements
During the pre-implementation period, Recipients During the implementation period, Recipients
must: must:
• Develop the IBH Medicaid Payment Approach • Implement the IBH Medicaid Payment
by the end of MY2 (BP2) for implementation Approach.
at the start of MY3 (BP3). Provide Medicaid Payment Approach
○
Provide updates on the design of the updates, successes, challenges, and
○
Medicaid Payment Approach in lessons learned in quarterly progress
quarterly progress reports. reports.
The Medicaid Payment Approach Provide CMS with a list of Medicaid
○ ○
shall include an attribution approach. attributed beneficiaries on a quarterly
basis.
The Recipient must develop an IBH Medicaid Payment Approach that includes all of the required
services detailed in Sections A4.3 IBH Care Delivery Framework, A4.4.1 Medicaid Payment
Approach Overview, and D2.4.1 Project Narrative. The IBH Medicaid Payment Approach must
have a performance-based payment component which includes all practice-based measures
detailed in Section A4.7.2.1 State-based and Practice-based Measures. Recipients are encouraged
to engage members of their Convening Structure (further described below) in the design of their
Medicaid payment arrangement. The Medicaid Payment Approach must be established by the end
of MY2 (BP2) for Practice Participants to utilize at the start of MY3 (BP3). The Recipient must
communicate successes and difficulties in developing their Medicaid Payment Approach with their
federal Project Officer so they can help in providing technical assistance. Examples of relevant
updates in the design phase of the Medicaid Payment Approach include but are not limited to:
• Identifying the applicable federal or state authorities to establish the IBH Model Medicaid
Payment Approach;
• Developing the IBH Model payment rates; and
• Designing and implementing any necessary billing procedures.
The Recipient must implement the approved Medicaid Payment Approach starting at the beginning
of MY3 (BP3). The Recipient shall clearly report progress and impediments in implementing the
Medicaid Payment Approach in quarterly progress reports. Such updates shall include information
about the performance-based payments that the Practice Participants are receiving, including but
not limited to:
• Collection of cost data to support monitoring and overall evaluation of the IBH payment
approach;
• Performance of practice participants in the Medicaid Payment Approach and PBP;
• Successes and challenges of implementing the Medicaid Payment Approach.
Please note that payments for the Medicaid Payment Approach are required to come from existing
state Medicaid funds. The federal funds provided as part of this NOFO cannot be used to cover
any clinical services or administrative expenses for which the state is claiming FFP for Medicaid
administrative services.
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A4.4.1 Medicaid Payment Approach Overview
The Medicaid Payment Approach shall support practice participants in achieving person-centered
care and include value-based incentives that reach the care teams who deliver care and incentivize
practice participants to invest in and adopt new approaches to care delivery and integration of care,
while striking a balance of financial and clinical risk that is appropriate and manageable. The
Medicaid Payment Approach includes the Medicaid Payment Approach and the PBP.
The Medicaid Payment Approach and PBP shall move Recipients away from traditional Medicaid
FFS payments to value-based payments. More specifically, Recipients must at a minimum initially
meet the LAN Category 2A payment model with ties to infrastructure (such as those provided for
health IT investments). No later than MY3 (BP3), the payment shall progress to at least a LAN
Category 2B and transition to a Category 2C or above for select measures in MY4 (BP4), where
payments are based on FFS architecture with ties to reporting and performance on specific quality
measures. By MY6 (BP6), each Recipient will be required to include both a withhold and an upside
bonus payment in the Medicaid payment approach, where appropriate. The Medicaid Payment
Approach is designed to be flexible to meet the unique needs of individual states and comply with
existing state Medicaid program rules and regulations. CMS recognizes that many states have
undergone comprehensive innovation in BH benefit design and payment. In addition, many states
have implemented, or are considering implementing, existing Medicaid state-based initiatives,
such as Behavioral Health Homes and CCBHCs. CMS will work with states to implement IBH in
a way compatible with those programs' requirements.
The IBH Model's approach to Medicaid payments aims to:
• Leverage the strengths and innovation of Recipients;
• Harness the policy momentum in states;
• Bring Medicare to the table; and
• Develop aligned Medicare and Medicaid alternative payment models that provide
stability and support providers during their transition to value-based care. Recipients have
flexibility in designing their approach to the Medicaid IBH payment model to allow the
state to align IBH with their state's current BH delivery systems design and priorities.
As described in Section A4.1 Model Structure Overview, the IBH Model will include aligned
Medicaid and Medicare Payment Approaches. Each payment approach includes the same core
elements, described below. Recipients who are currently participating in the federal CCBHC
Demonstration and want to include their CCBHC Demonstration providers in the IBH Model shall
reference Appendix V: Medicaid Payment Scenarios for Health Homes and CCBHCs for
information about Infrastructure Funding, payment, and performance-based payments.
The IBH Model's approach to multi-payer alignment is designed to provide flexibility across three
core features in a way that enables payer alignment and offers Practice Participants a glidepath to
VBP. The Model's multi-payer alignment approach is built with key elements that are required
across payers, but with considerable room for customization. If desired, Recipients are permitted
to use the Medicare Payment Approach (Appendix VI Medicare Payment Approach Details) to
build their Medicaid Payment Approach, increasing alignment between payers while also
promoting state innovation.
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A4.4.2 Medicaid Payment Approach Requirements
The IBH Model allows states to build their own Medicaid Payment Approach in partnership with,
and subject to approval by, CMS, use existing state or federal authorities (i.e., State Plan
Amendments, 1915 waivers, Section 1115(a), managed care contracts) or use the Medicare
Payment Approach as a basis for their payment design. Recipients may also be able to adapt an
existing Medicaid payment authority to meet IBH Model requirements. The Cooperative
Agreement funding can be used in part for developing the Recipient's Medicaid Payment
Approach, and CMS will also offer technical assistance to Recipients in this development process.
The Medicaid Payment Approach must be established by the end of MY2 (BP2) for Practice
Participants to utilize at the start of MY3 (BP3) and must shift that payment away from traditional
Medicaid FFS. The payment principles and guidelines outlined further in Section D2.4.1 Project
Narrative are flexibly designed to align with a variety of state Medicaid BH programs or payment
arrangements (e.g., BH MCOs, PIHPs, PAHPs, and Medicaid FFS).
The IBH Model recognizes that many Medicaid programs have invested significant time and
resources into developing BH programs and payment authorities. Therefore, the Model will not
ask Recipients to revert to less sophisticated payment strategies if they have already developed (or
are on track to implement) their Medicaid Payment Approach that can be leveraged for the
purposes of the IBH Model.
Recipients have flexibility, subject to CMS approval, in reaching directional alignment in the
design of the following components of their Medicaid Payment Approach:
• Payment type: Whether the payment uses a per-beneficiary per-month (PBPM),
prospective payment system (PPS), or fee-for-service14.
• Financial risk level: The payment must have a combination of both upside and downside
risk.
• Performance-based payment strategy: How the Recipient plans to reward improvements
in quality and potential reductions in cost at the Practice Participant level. Please note that
the Recipients' performance-based payment strategy must at least align with the Medicare
Payment Approach's performance-based payment strategy.
• Attribution strategy: Recipients are required to attribute Medicaid beneficiaries using an
attribution methodology outlined as part of their Medicaid Payment Approach. Recipients
are not required to replicate the Medicare attribution methodology outlined in Appendix
VII: CMS Attribution Methodology for Medicare and Dually Eligible Beneficiaries.
However, the Recipient must align their approach with the Medicare attribution
methodology and send CMS a list of Medicaid attributed beneficiaries on at least a
quarterly basis.
Core Required Elements of the Medicaid Payment Approach
• Payments for implementing the care delivery framework: Recipients will make
payments to Medicaid Practice Participants to support the package of services and activities
under the care delivery framework, as described in Section A4.3 IBH Care Delivery
Framework, beginning at the start of MY3 (BP3). Recipients may rely on existing Medicaid
programs to implement this care delivery framework, where existing programs can provide
14 The Medicaid payment Approach must have a performance-based payment that aligns with the Medicare payment
arrangement, at a minimum.
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the required level of alignment as described in Section A4.3 IBH Care Delivery
Framework. Under the aligned Medicare model, Practice Participants that participate in
Medicare will also receive an Integration Support Payment (ISP), as described in Appendix
VI: Medicare Payment Approach Details, that will be paid to Practice Participants
beginning at the start of MY3 (BP3). Medicaid Payment Approach payments must come
from existing state Medicaid funds, and the federal funds provided pursuant to this NOFO
may not be used to cover any clinical services or administrative expenses for which the
state is claiming FFP for Medicaid administrative services.
• Performance based payments (PBP) to Practice Participants that participate in
Medicaid: Recipients must also make Performance Based Payments to Practice
Participants, in addition to payments for clinical services during MYs 3 – 7 (BPs 3-7). The
PBP must have a combination of upside and a withhold that shall be designed to encourage
and reward behaviors such as data reporting, the advancement of care quality and
accountability across multiple dimensions including care integration, care coordination,
care efficiency, and patient-centered outcomes as demonstrated through performance on
certain model quality measures. If Recipients are unable to include a withhold in the PBP
of certain provider types, CMS will work with Recipients on a case-by-case basis to
determine other performance-based accountability features. These practices will also be
required to participate as a Medicare Practice Participant. The PBP to Medicaid providers
will be paid for out of existing state Medicaid funds. The Medicare Payment Approach will
also include an aligned PBP, as described in Appendix VI: Medicare Payment Approach
Details.
A4.4.3 Practice Participant Infrastructure Funding:
The IBH Model includes Infrastructure Funding during MY2–5 (BP2-5) for Practice Participants
to develop infrastructure and capacity that will be necessary to address challenges to implement
the care delivery framework for their patient population. Infrastructure Funding is available to
Practice Participants through two mechanisms:
• Infrastructure Funding to Practice Participants who participate in both the Medicaid
and Medicare Payment Approaches:
• Practice Participants who participate in the IBH Medicare Payment Approach may
receive Infrastructure Funding directly from CMS.
• Infrastructure Funding to Practice Participants who participate in the Medicaid
Payment Approach but not the Medicare Payment Approach:
• Recipients must implement a standardized practice needs assessment process to determine
the final amount of Infrastructure Funding to pass through to each Medicaid-only practice.
• Funding allocated towards infrastructure costs on behalf of the Practice Participant(s) will
remain restricted until the Recipient submits a detailed budget for these costs and
subsequently receives CMS approval.
• More details on this requirement are available in Section A4.5 Infrastructure Development
and Funding.
Please note that federal funding provided to Recipients pursuant to their Cooperative Agreement
for infrastructure-related activities may not also be claimed for Medicaid FFP purposes. Regardless
of whether Infrastructure Funding is facilitated by CMS or Recipients, Practice Participants can
use the Infrastructure Funding for the uses identified below in Table A4.4.3. Recipients can also
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propose additional categories of permitted uses that are not currently listed, subject to review and
approval by CMS.
Practice Participants with existing EHRs may be allowed to use Infrastructure Funding to further
the goals of the Model, such as updating their EHR to allow for referral for needs that impact health.
Recipients may also use their Cooperative Agreement funding to support similar, aligned activities,
and will be encouraged to offer centralized resources and TA to their Practice Participants. Examples
of activities that Infrastructure Funding may be used for are listed in Table A4.4.3.
Table A4.4.3: Examples of ways Practice Participants are allowed to use Infrastructure Funding
from Recipients.
Category of Example activities
activity
Health IT and • Adoption and upgrading of EHRs
data sharing
• Adoption, use and maintenance of interoperability solutions, including legal and
capacity
technical costs associated with engaging in data exchange activities
building
• Use of standards, including support for piloting of priority emerging data standards for
BH15 . Training on relevant privacy and confidentiality regulations such as 42 CFR Part
2 to promote secure and appropriate data sharing practices, population management
and quality reporting
Telehealth • Telehealth needs assessment, tools, and in-practice support and necessary capabilities to
tools connect the patient to a primary care or specialty provider, including use of audio-only
telehealth as appropriate
• Training and technical assistance to enhance knowledge around telehealth rules,
regulations, and best practices.
Practice • Developing new clinical and payment infrastructure, policies, procedures, and
transformation workflows for systematic screening and tracking of PH conditions and other needs that
activities impact health, referrals, and /or social service agency referrals as well as ongoing
clinical coordination.
• Implementing organization change management activities to facilitate provider behavior
change, mastery, and self-efficacy in providing integrated care.
• Hiring and training of care coordination staff such as peer support workers, community
health workers, or other applicable staff.
• Training staff on integration, goals, and new clinical workflows.
• Collaborating with PH consultants to establish care protocols.
• Establishing formal or informal agreements with primary care providers and formal or
informal agreements with social service organizations for enhanced referral.
• Developing communication strategies to notify patients and caregivers regarding
screening opportunities and clinical changes they may expect to see, such as added
screenings for needs that impact health or peer support worker assistance.
• Arranging for phlebotomy or increased availability of CLIA-waived laboratory testing,
on site, including quality assurance and quality control standards.
15 For example, Practice Participants could explore piloting activities for USCDI+ Behavioral Health, an initiative developed by
SAMHSA and ONC to address core data and interoperability for behavioral health needs beyond the scope of USCDI (United
States Core Data for Interoperability). For more information, see:
https://uscdiplus.healthit.gov/uscdi?id=uscdi_record&table=x_g_sshh_uscdi_domain&sys_id=8deaa2658778465098e5edb90cbb
3597&view=sp
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A4.4.4: Multi-Payer Alignment
Due to the likelihood that many Recipients may already have BH innovations underway, the IBH
Model is intentionally designed to ensure Recipients can continue to build on these efforts. Some
Recipients may have developed well-established relationships with MCOs and commercial payers,
and CMS expects Recipients to use these relationships to advance multi-payer alignment in their
state. In addition, Recipients will build their care delivery framework and Medicaid Payment
Approach in alignment with the requirements outlined in this NOFO.
Below, Table A4.4.4 shows key areas of directional alignment among Recipients, Medicare, (and,
where applicable, commercial payers to the core model design elements. This approach provides
a way for Recipients, MCOs, PIHPs, PAHPs, intermediaries, and other commercial payers taking
part in, or aiming to align with, the IBH Model to move forward with a shared model framework
while limiting provider burden in the process.
Table A4.4.4: IBH Medicare, Medicaid, and Multi-Payer Alignment Principles
Design Design Directional Alignment
Element Feature Required Elements for Recipients
• Recipients must develop a Medicaid Payment Approach that is new, adapted
from, or complements existing payment approaches in their state.
• At a minimum, the Recipient's Medicaid Payment Approach must begin with
pay for reporting by MY3 (BP3), (LAN Category 2B) and shift into pay for
Payment performance on certain measures by MY4 (BP4) (LAN Category 2C). The
alignment Payment Approach should also include a performance-based payment
withhold by MY6.
• Recipients will ensure alignment and eliminate payment duplication of any
state waiver or demonstration that provides payment for services listed in this
NOFO.
IBH
Risk • Recipients are encouraged to implement a Medicaid Payment Approach that
Payment
adjustment uses a risk adjustment methodology for both clinical and social risk factors16
S trategy
• Beneficiary attribution is a method to associate beneficiaries with Practice
Participants for the purposes of payment. Recipients will attribute Medicaid
beneficiaries to the IBH Model using the Recipient's own attribution
methodology (or using an existing attribution model, such as health homes)
that generally aligns with the Model's Medicare alignment parameters. For
Attribution
example, Recipients will send each Medicaid Practice Participant a list of its
attributed Medicaid beneficiaries on a quarterly basis during the Model
Implementation Period.
• Recipients will provide CMS, on a quarterly basis, a list of all dually eligible
and Medicaid-attributed beneficiaries.
16 Though the Medicare risk adjustment methodology is currently under development, initial plans include leveraging non-
clinical (social) and clinical risk factors. See Appendix VI: Medicare Payment Approach Details for additional detail.
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Design Design Directional Alignment
Element Feature Required Elements for Recipients
• Recipients and MCOs, PIHPs, or PAHPs must agree to report on the state-
Quality based quality measures listed in Table A4.7.1.
Data, measures • Recipients, MCOs, PIHPs, or PAHPs, will help Practice Participants to
Quality, submit practice-based measures.
and
• Recipients must develop a performance-based Medicaid Payment Approach
Evaluation
Quality using the quality measures listed in Table A4.7.2 under practice-based
incentives measures. Recipients shall add measures for any additional PH conditions
they plan to add into the care delivery framework.
• Alongside CMS, identify a third-party convener to host the IBH Model-
related efforts six months after the start of the pre-implementation period.
Convening
Frequency
Structure
• By the start June MY1 (BP1), it is strongly recommended that the
convening structure meet no less than quarterly.
*Recipients shall refer to Section A4.3.3 Care Delivery Framework Requirements to reach directional alignment for
the care delivery framework.
A4.5 Infrastructure Development and Funding
A4.5 Section Requirements:
Pre-implementation period requirements Implementation period requirements
During the pre-implementation period, Recipients During the implementation period, Recipients must:
must:
• Develop yearly funding requests for Cooperative
• Develop yearly funding requests for Agreement Funding
Cooperative Agreement Funding
• Distribute funding to eligible parties, where
• Distribute funding to eligible parties, where applicable
applicable
• Develop and implement the Health IT
implementation plan
• Provide cooperative agreement funding to
Medicaid only Practice Participants between
MYs 1-4 (BPs 1-4) using a standardized
practice needs assessment process
Recipients are required to develop detailed annual plans for Cooperative Agreement funding use,
in a form and manner specified by CMS, as part of their non-competing continuation (NCC)
application. The annual plans must address the following factors:
• Practice participants that participate in the IBH Medicare Payment Approach will receive
Infrastructure Funding directly from CMS. Medicaid-only Practice Participants cannot
receive Infrastructure Funding from CMS and, instead, must receive Infrastructure Funding
from the Recipient as available under this cooperative agreement.
• Recipients will be required to allocate a portion of cooperative agreement funding for each
Medicaid-only Practice Participant between MYs 1-4 (BPs 1-4) using a standardized
practice needs assessment process. This funding must be passed through for practice-level
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Infrastructure Funding.
• Recipients shall plan to set aside approximately $100,000 in cooperative agreement
funding per Medicaid-only Practice Participant for budgeting purposes.
• Recipients must implement a standardized practice needs assessment process to determine
the final amount of Infrastructure Funding to pass through to each Medicaid-only Practice
Participant.17
If this needs assessment discovers a Medicaid-only practice has part of the necessary
○
infrastructure needed for implementing the IBH Model, the Recipient is permitted to
distribute only partial Infrastructure Funding to support practice transformation.
• Each Medicaid-only practice shall receive at least a portion of infrastructure funding for
practice transformation activities.
Recipients can distribute Infrastructure Funding to Medicaid-only Practice Participants
○
during MYs 1-4 (BPs 1-4), as a one-time payment, or in more frequent installments.
The practice needs assessment process for Medicaid-only practices is required to align
○
to the process set forth by CMS for practices participating in the Medicare Payment
Approach (Appendix VI). The needs assessment must assess for relevant infrastructure
such as adoption of certified health IT, HIE integration, other population health
management tools, as well as the need for practice transformation activities.
Recipients may cap Infrastructure Funding for Medicaid-only Practice Participants at
○
30 percent of the Recipients' total cooperative agreement funds. If the Recipient
chooses to cap infrastructure funding for Medicaid-only Practice Participants at 30
percent of the Recipient's total cooperative agreement funds, the Recipient must work
with CMS on a plan for how to appropriately target the funding. Recipients can provide
more than 30 percent of their total cooperative agreement funds if they choose.
Funding allocated towards infrastructure costs on behalf of the Practice Participant(s)
○
will remain restricted until the Recipient submits a detailed budget for these costs and
subsequently receives CMS approval.
• Recipients and Practice Participants may seek other sources of funding to supplement
Infrastructure Funding activities. Recipients shall communicate other sources of funding
used to CMS via programmatic reporting, including assurances that such other sources do
not duplicate or supplant cooperative agreement funding.
• The requirements listed in Appendix II: Health IT Capabilities and Support for Practice
Participants apply regardless of the funding source for the Infrastructure Funding.
Recipients will be required to develop a Health IT Implementation Plan. The Health IT
Implementation Plan shall be submitted as part of the NOFO application. The Health IT
Implementation Plan shall detail how Cooperative Agreement funding, specifically Infrastructure
Funding to Practice Participants, would aid in achieving the anticipated future state of health IT
and data infrastructure and capacity. Furthermore, the Health IT Implementation Plan shall detail:
• Existing goals for health IT and how the IBH Model can help the applicant reach these
goals;
• Existing data infrastructure;
• Approaches to ensuring privacy and confidentiality consistent with applicable laws,
including HIPAA, 42 CFR Part 2 and state requirements;
17 CMS will provide further information on the Medicare needs assessment in the pre-implementation period.
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• Existing and projected (if awarded) staff capacity;
• Existing and projected (if awarded) data analytic capabilities;
• Experience supporting value-based payment and quality reporting;
• Anticipated technical assistance needs in meeting model requirements related to data and
health IT;
• Facilitate data sharing agreements between Practice Participants and payers;
• Provide data and health IT technical assistance to Practice Participants;
• Enable Practice Participants to use quarterly data in support of continuous quality
improvement.
• Submit relevant claims and encounter data;
• Facilitate data alignment between payers, MCOs, PIHPs, PAHPs, intermediaries and
Practice Participants; and
• Support health information exchange to identify admissions, discharges, transfers, and
other events important to care coordination.
Example of health IT uses for infrastructure funds:
• Health IT and practice transformation funding for Practice Participants.
• Statewide infrastructure necessary to implement the IBH Model.
A4.6 Convening Structure
A4.6 Section Requirements:
Pre-implementation period requirements Implementation period requirements
During the pre-implementation period, Recipients During the implementation period, Recipients
must: must:
• Alongside CMS, identify a third-party • Implement the convening structure:
convener to host the IBH Model-related efforts Provide necessary technical assistance
○
six months after the start of the pre- for Practice Participants.
implementation period. Develop strategies to improve
○
• The convening structure must begin meeting no performance on the state and Practice-
later than the end of Q2 of MY1 (BP1). based measures.
• It is strongly recommended to meet with the ○ Develop performance improvement
convening structure on no less than a quarterly projects at the state or sub-state level.
basis. ○ Troubleshoot issues with data sharing
among model partners.
○
Use the convening structure to develop the
Share best practices among payers,
○
Medicaid Payment Approach among the
Practice Participants, and other
relevant parties.
interested parties.
Use the convening structure to develop the
○
Medicaid care delivery framework among
the relevant parties.
Provide updates on convenings in
○
quarterly progress reports.
In cooperation with CMS, Recipients will identify a third-party convener within three months after
the start of MY1 (BP1). The third-party convener is intended to serve as a neutral forum to bring
together IBH Model stakeholders including the State, CMS, Practice Participants, community
organizations, and others to drive consensus on model design elements and shared priorities. If a
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third-party convener is not readily identifiable, Recipients may act as conveners for up to the first
1.5 years of the model. During this time, CMS will work with states/territories to identify a third-
party convener to support this effort – thus reducing state burden and allowing states to come to
the table with stakeholders on prioritizing outcomes, measures, and model design. As a party to
the convenings, Recipients will sustain or build upon or support the development of convening
initiatives. Examples of neutral conveners envisioned in this work include but are not limited to
Quality Improvement Organizations, academic or philanthropic organizations, or other
organizations focused on aligned care transformation and improvement efforts.
Section A4.6.1 Members of the Convening Structure exhibits essential and recommended
interested parties for the convening structure. Recipients will aid in garnering alignment from the
essential and recommended members listed below.
The convening structure will align interested parties on efforts to improve key BH outcomes
through priority setting, operational support, and learning activities. The convening structure must
begin meeting no later than June of MY1 (BP1) Q2, and it is strongly recommended that the
convening structure must meet no less than quarterly, thereafter. In the Pre-Implementation Period,
the interested parties in the convening structure will collaborate to design model components and
ensure specific components reach directional alignment, where applicable (Section A4.4.4 Multi-
Payer Alignment).
At a minimum, Recipients are expected to use the convening structure along with support from
CMS to:
• Improve data collection and sharing efforts among payers, Practice Participants, and
community-based organizations (where applicable).
• Provide a channel for CMS, SMAs, and MCOs, State Mental Health authorities and Single
state agencies for SUDs, (or other intermediaries) to communicate technical assistance to
Practice Participants.
• Accelerate the development and implementation of the Medicaid Payment Approach.
• Identify additional model priority health conditions in addition to diabetes, hypertension, and
tobacco use, such as the human immunodeficiency virus (HIV)/acquired immunodeficiency
syndrome (AIDS), sexually transmitted infections, intellectual/developmental disabilities,
asthma, heart disease, obesity/overweight, and hepatitis.
• Identify additional practice-based and state-based quality measures (where applicable).
• Design the Recipient's Population Needs Assessment as specified in Section A4.3.3 Care
Delivery Framework Requirements
• Collaborate with CMS to make corrections and improve data in a timely manner.
Example funded activities:
• Support implementation and operational activities of the convening structure.
• Support to share best practices among the convening structure.
A.4.6.1 Members of the Convening Structure
The convening structure will optimally use a collective impact approach to drive alignment among
the Recipient, Practice Participants, and other interested parties regarding their shared visions and
measurements and mutually reinforcing activities. The convening structure will also optimally
incorporate continuous communication among members as a core backbone group that will
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provide ongoing support, drive momentum, and advance model development by guiding vision
and strategy.
Table 4.6.1: Members of convening structure.
Essential members Recommended members
• State/territorial Medicaid agencies • Patient advocacy organizations
• State, local, tribal, and/or territorial and public • Commercial payers
health agencies • Criminal justice
• State Mental Health Authorities and Single • Faith-based entities
State Agencies for SUDs • Major employers
• Licensing agency • Crisis system service providers
• Managed care organizations (or other • Community based organizations and social
intermediaries) services providers which address food,
• Specialty behavioral health provider transportation, etc.
organizations • Data service organization (e.g., relevant health
• Physical health providers information networks)
• Social service agencies • State/territorial primary care association
• Beneficiaries from the geographic focus area • Other tribes and tribal governments (where
(states are encouraged to consider a variety of applicable)
participating beneficiaries, and compensation • Other government agencies such as those
for participation). working on education and employment
• Family members and caregivers • State or community substance use prevention
• Federally recognized tribes and tribal coalitions.
governments (where applicable).
A4.7 Data, Quality, and Evaluation
Section Requirements:
Pre-implementation period requirements Implementation period requirements
During the pre-implementation period, Recipients During the implementation period, Recipients
must: must:
• Facilitate data sharing agreements • Report on required state and practice-
between providers and payers based quality measures
• Provide data-related technical assistance • Continue to facilitate alignment in data
to Practice Participants sharing, reporting, and decision making.
• Submit relevant claims and encounter data • Provide technical assistance to Practice
• Facilitate data alignment across interested Participants
parties in the model. • Work with Practice Participants to use
quarterly data to make necessary course
corrections within the model.
• Submit relevant claims and encounter data
• Participate in the state-wide quality
improvement program
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CMS, through the Innovation Center, with its federal partners and external stakeholders, has
started building the foundation toward a health system that achieves equitable outcomes through
high-quality, affordable, person-centered care. To make this lasting change, the Innovation Center
is incorporating patient and caregiver perspectives across the lifecycle of its models, implementing
more patient-reported outcome measures (PROMs) to quantify and qualify what matters to
beneficiaries, and to evaluate patient and caregiver experience in models.
Recipients are required to submit the quality measures listed in Table A4.7.1 State Based Measures
(see Section A4.7.2.1 State-based and Practice-based measures) to CMS on a quarterly and annual
basis for their Medicaid population.
Example funded activities:
• Hire an IBH Model Data Analyst, or other relevant data staff
• Practice transformation activities to improve the flow and usage of data for decision
making.
• Activities to support data sharing among payers and providers needed to support model
operations.
• Data warehousing and management.
• Support for the development of admission, discharge, and transfer (ADT) systems.
A4.7.1 Data Collection, Reporting, and Analysis
Recipients play a pivotal role in arranging efforts related to model data collection, sharing, and
analysis. Recipients must ensure that monitoring and evaluation data is collected, analyzed, and
shared in a timely fashion to support IBH Model goals in collaboration with MCOs, PIHPs,
PAHPs, intermediaries, and State Mental Health authorities and Single state agencies for SUDs,
CMS, and CMS contractors for monitoring and evaluation.
Recipients must hire or leverage data expertise to assist in data coordination and analysis. CMS
encourages states to consider the scope of their implementation, such as the potential number of
Practice Participants, and statewide versus sub-state implementation, to decide the full level of
effort needed for model data activities. Recipients are also responsible for taking any steps required
under applicable laws to engage in data sharing under the model, including obtaining required
authorizations. As previously noted, Recipients are allowed to use cooperative agreement funding
to support model data efforts. Recipients are also required to:
• Facilitate data sharing agreements between providers and payers: In the Pre-
Implementation Period, Recipients must prepare to share quality measure and process data
(e.g., by connecting to an HIE or health information network) with Practice Participants
that enables them to improve care delivery and achieve model-specified performance
outcomes such as care coordination. Partnering MCOs, PIHPs, and PAHPs, (or
intermediaries) are required to contribute to data sharing efforts. Where applicable, the
Recipient shall coordinate data sharing strategies with State Mental Health authorities and
Single state agencies for SUDs.
• Provide technical assistance to Practice Participants: The Recipient will use the Pre-
Implementation Period to provide technical assistance to Practice Participants to capture
model data. Also, applicable MCOs, PIHPs, PAHPs, or other intermediaries may provide
this technical assistance to Practice Participants. CMS will provide technical assistance to
Recipients on capturing and reporting data as well as improving key outcomes.
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• Submit relevant claims and encounter data: Recipients or partnering MCOs, PIHPs,
PAHPs, or intermediaries are required to submit timely and accurate Medicaid claims
and/or encounter data through the Transformed Medicaid Statistical Information System
(T-MSIS). If necessary, an alternative mechanism will be approved by CMS, to ensure
compliance with the requirements for data submission for model monitoring and evaluation
under 42 C.F.R. § 403.1110. Recipients must work with Practice Participants and CMS to
address any issues or questions on sharing such data.
• Facilitate data alignment: The Recipient is required to streamline the data reporting
requirements at the state and federal level. For example, the Recipient shall align IBH
Model quality reporting with other state or federal initiatives, to the extent possible, to limit
practice burden. This includes alignment with MCOs, PIHPs, or PAHPs (or intermediaries)
and state agencies for mental health and/or substance abuse.
A4.7.2 Quality Strategy
Measures are core to the IBH Model's quality strategy, which seeks to evaluate the Model's ability
to achieve the goals of improving quality of care, increasing access to care, achieving improved
health outcomes for all beneficiaries, reducing avoidable emergency department and inpatient
utilization (thereby reducing Medicare and Medicaid program expenditures), and strengthening
health information technology (health IT) systems capacity. The Model's quality strategy strives
to advance Recipients and Practice Participants alike toward achieving the Model's desired
outcomes, enabling quality improvement, reaching greater alignment among payers, as well as
assisting in facilitation of model evaluation. CMS will use several measures, including at least one
PROM, to monitor Recipient performance in the implementation and operation of the Model, as
well as patient care delivered by Practice Participants.
CMS will keep Recipients abreast of any new measures that are developed or prioritized through
the annual Measures Under Consideration18 list and may explore changing the measure set as the
Model evaluation policy develops (adding, modifying, and/or removing measures). CMS reserves
the right to consider changes should a measure need to be suspended, suppressed, or removed due
to changes in standards of care or data evaluation considerations, and CMS will communicate any
changes in the measures to Recipients with advance notice and will work with Recipients to modify
reporting requirements.
The Model's quality strategy will measure several key areas, including:
• Health outcomes targeted by the Model
• Care coordination
• Beneficiary utilization of services
• Other needs that impact health
• Patient-reported outcome measures
• Physical health screening
These measures areas will be addressed through a combination of state-based and practice-based
measures. Table A4.7.1 below shows state-based measures to be included in the Model. Table
A4.7.2 shows practice-based measures to be included in the Model.
18 As part of the CMS Pre-Rulemaking process for programs under Section 3014 of the Affordable Care Act, the Department of
Health and Human Services (DHHS) must annually issue a Measures under Consideration List (MUC List)
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Recipients must report state-based measures data and practice-based measures data, for Medicaid
beneficiaries, directly to CMS in a process to be outlined in the Cooperative Agreement Program
Terms and Conditions. The anticipated level of burden for reporting on quality measures, including
the number of hours and cost, is available in Appendix III: State-Based Quality Measure Data
Reporting Burden. Applicants shall consider model reporting requirements in their decision to
implement the model across their entire state or in a sub-state region. For example, applicants shall
consider the capacity and infrastructure available in the area they intend to operate the model in.
Data submission requirements will include the following:
• Data submitted must be beneficiary level-data, unless noted otherwise. Reporting data in
the aggregate will not be sufficient to effectively evaluate model outcomes.
• Please see details on performance-based payments in the Medicare payment appendix for
more information on what practice-based measures must be included in the Medicaid
Payment Approach.
Practice Participants participating in the Medicare side of the IBH Model will submit Practice-
based measures for Medicare beneficiaries directly to CMS.
A4.7.2.1 State-based and Practice-based measures
For National Committee for Quality Assurance (NCQA) Measures: CMS will provide measure
materials to model Participants for all IBH Model required NCQA quality
measures. NCQA measures and specifications are owned by NCQA. NCQA holds a copyright on
these materials and may rescind or alter these materials at any time. Users of the NCQA measures
and specifications shall not have the right to alter, enhance or otherwise modify
the NCQA measures and specifications, and shall not disassemble, recompile, or reverse engineer
the NCQA measures and specifications. Participants may not provide NCQA materials to any
other person, entity, organization, or association. Except for employees of the Participant, each
person, entity, organization, or association, including agents, vendors, and consultants of the
Participant, is required to separately purchase a license to obtain, access, and use
the NCQA materials, including but not limited to using the measures and specifications to
calculate measure results.
Table A4.7.1: State-based measures
CBE19 CMIT20
endorsement measure
Measure Description Steward number family ID
Total Cost of CMS will develop a total cost of care CMS N/A N/A
Care measure specific for Medicaid.
Emergency Reports the observed and expected NCQA N/A 1755
Department ED utilization rates for the
Utilization+ population.
19 CMS-contracted consensus-based entity (CBE) refers to the entity with a contract under section 1890(a) of the Act responsible
for quality measure endorsement, measure maintenance, synthesizing evidence, and convening key interested parties to make
recommendations regarding performance measurement.
20 The CMS Measure Inventory Tool (CMIT) is the repository of record for information about the measures which CMS uses to
promote healthcare quality and quality improvement.
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CBE19 CMIT20
endorsement measure
Measure Description Steward number family ID
Acute The risk-adjusted ratio of observed- NCQA N/A 14
Hospital to-expected acute inpatient and
Utilization observation stay discharges during
(AHU): Age the measurement year.
18 and Older
Follow-Up Percentage of ED visits for NCQA 3488 264
After beneficiaries aged 18 and older with
Emergency a
Department principal diagnosis of a SUD, or any
Visit for diagnosis of drug overdose, for
Substance which there was follow-up. Two
Use: Age 18 rates are reported: * Percentage of
and Older ED visits for which the beneficiary
(FUA-AD) received follow-up within 30 days of
the ED visit (31 total days) *
Percentage of ED visits for which the
beneficiary received follow-up
within 7 days of the ED visit (8 total
days)
Follow-Up Percentage of emergency department NCQA 3489 265
After (ED) visits for beneficiaries aged 18
Emergency and older with a principal diagnosis
Department of mental illness or intentional self-
Visit for harm and who had a follow-up visit
Mental for mental illness. Two rates are
Illness: Age 18 reported: * Percentage of ED visits
and Older for mental illness for which the
(FUM-AD) beneficiary received follow-up
within 30 days of the ED visit (31
total days) * Percentage of ED visits
for mental illness for which the
beneficiary received follow-up
within 7 days of the ED visit (8 total
days)
Plan All- For beneficiaries ages 18 to 64, the NCQA N/A 561
Cause number of acute inpatient and
Readmissions observation stays during the
(PCR-AD) measurement year that were
followed by an unplanned acute
readmission for any diagnosis within
30 days and the predicted probability
of an acute readmission. Data are
reported in the following categories:
• Count of Index Hospital Stays
(IHS) • Count of Observed 30-Day
Readmissions • Count of Expected
30-Day Readmissions
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CBE19 CMIT20
endorsement measure
Measure Description Steward number family ID
Follow up Percentage of discharges for adults NCQA 0576 268
after ages 18 and older who were
Hospitalizatio hospitalized for treatment of selected
n for Mental mental illness diagnoses and who
Illness: Age 18 had a follow-up visit with a mental
or older health practitioner. Two rates are
(FUH-AD) reported. Percentage of discharges
for which beneficiary received
follow-up within 30 days of
discharge Percentage of discharges
for which the beneficiary received
follow-up within 7 days of discharge
Hemoglobin The percentage of members 18-75 NCQA 0059 and 204/148
A1c Control years of age with diabetes (type 1 or 0575
for Patients type 2) who had a HbA1c at the
with Diabetes following levels: HbA1c Control
(HBD-AD)21 (<8.0%) and HbA1c Poor Control
(>9.0%)
Diabetes Percentage of Medicaid beneficiaries NCQA 1932 202
Screening for ages 18 to 64 with schizophrenia,
People with schizoaffective disorder, or bipolar
Schizophrenia disorder who were dispensed an
or Bipolar antipsychotic medication and had a
Disorder diabetes screening test during the
Who Are measurement year.
Using
Antipsychotic
Medications
(SSD-AD)
States will pick one of the following two measures to include in their model to better capture the importance of
screenings for PH conditions in the IBH Model.
Colorectal Percentage of beneficiaries ages 45 NCQA 0034 139
Cancer to 75 who had recommended
Screening screening for colorectal cancer.
(COL-AD)
Breast Cancer Percentage of women 50 to 74 years NCQA 2372 093
Screening of age who had a mammogram to
(BCS-AD) screen for breast cancer.
21 The Diabetes Control measure is now known as Glycemic Status Assessment for Patients with Diabetes.
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Table A4.7.2: Practice-based measures
CBE CMIT
endorsement measure
Measure Description Steward number family ID
Acute Hospital Reports the observed acute NCQA N/A 14
Utilization hospitalization utilization rates for
(Observed Rates) the population
Preventive Care Percentage of patients aged 18 years NCQA 0028/0028e 596
and Screening: and older who were screened for
Tobacco Use: tobacco use one or more times
Screening and within the measurement period AND
Cessation who received tobacco cessation
Intervention intervention during the measurement
period or in
the six months prior to the
measurement period if identified as a
tobacco user.
Controlling high Percentage of patients 18 - 85 years NCQA N/A 236
blood pressure of age who had a diagnosis of
hypertension and whose blood
pressure was adequately controlled
(< 140/90 mmHg) during the
measurement period
Emergency Reports the observed and expected NCQA N/A 1755
Department ED utilization rates for the
Utilization+ population.
Glycemic Status The percentage of members 18-75 NCQA 0059 and 204 and 148
Assessment for years of age with diabetes (type 1 or 0575
Patients with type 2) who had a HbA1c at the
Diabetes following levels: HbA1c Control
(<8.0%) and HbA1c Poor Control
(>9.0%)
Patient-reported Measure under development by
outcomes and CMS.
Measurement-
based care
attestation
Note: Practice Participants will be required to screen for upstream drivers of health and report
aggregate data in a form and manner and by the date(s) specified by CMS.
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A4.7.2.2 State Quality Improvement Program
Recipients will participate in a quality improvement program (tied to state-based measures)
separate from the performance-based payment component of the Medicaid Payment Approach for
Practice Participants (tied to practice-based measures).
• During the Implementation Period, ten percent of the annual cooperative agreement
funding will be restricted, not guaranteed, and subject to achievement on reporting and
performance improvement on the IBH Model state-based measures (detailed in Section
A4.7.2.1 State-based and Practice-based Measures). In MY6 (BP6), CMS will increase this
restriction to twenty percent. In MY7 (BP7), CMS will increase this restriction to thirty
percent.
• Throughout MY6 (BP6) and MY7 (BP7), the cooperative agreement funding withhold will
maintain at 10 percent if there is satisfactory performance on model performance measures
in the first years of model implementation.22
• The performance benchmarks for the state-based measures will include partial and full
achievement categories that correspond to earning a certain proportion of the cooperative
agreement funding available for each measure.
• CMS, along with its contractors, will provide support to both Recipients and their Practice
Participants on the state-wide quality improvement program.
A4.7.3 Evaluation
The independent evaluation of the IBH Model will consider the model pre-implementation and
implementation periods, along with key outcomes related to model goals. This will be
accomplished through using a mixed-methods approach that incorporates both qualitative and
quantitative data. In support of gathering the necessary data for these analyses, Recipients are
required to ensure compliance and participation with the IBH model evaluation by all model
participants and partners in model evaluation, including:
• the Recipient;
• any MCOs or intermediaries with whom the Recipient forms memorandum of
understandings (MOUs); and
• clinical delivery site providers and staff, patients, and any other individuals or entities in
the Model's evaluation conducted by CMS.
Specifically, the Recipient shall attest to its capacity to participate and help facilitate individual
patient- and program-level data provision and qualitative evaluation tasks, which may include:
• arranging site visits, observations, interviews and focus groups with providers and patients
as well as program staff;
• tracking data from screening patients for other health related needs;
• submitting patient medical information through a system that complies with all applicable
privacy requirements, including HIPAA and 42 C.F.R. Part 2 and applicable state
requirements;
22 Guidance on the precise benchmarks will be issued by CMS at a later date. Recipients will be expected to show
a reasonable decrease in total cost of care, acute hospital utilization, and emergency department utilization among Medicaid
beneficiaries enrolled in the IBH Model when compared to Medicaid beneficiaries with moderate-to-severe behavioral health
diagnoses who are not enrolled in the IBH Model. CMS will incorporate relevant and timely research, literature, and data
available from similar ongoing models when determining the benchmarks.
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• gathering required patient consent/authorization;
• and other activities as needed.
All Recipients must be able to provide personal identifiers that will allow all Practice Participants
to be identified in Medicaid claims. Recipients are solely responsible for any necessary procedures
and approvals needed by Institutional Review Boards (IRBs). Recipients are also solely
responsible for obtaining any other permissions from beneficiaries, their organizations, or state
entities that may be needed to share or analyze internal data. These procedures and approvals shall
not hinder cooperation with evaluation activities, data collection, or data sharing and submission
to CMS or its contractors related to this award. Recipients may use award funds to pay for a full-
time equivalent staff member with data and evaluation experience to help in accomplishing such
tasks and ensuring full cooperation.
A5. Technical Assistance and Information for Prospective Applicants
Prior to the application deadline, CMS hosts a series of webinars to provide details about the IBH
Model to answer questions from potential applicants regarding this funding opportunity.
Information about the webinars will be posted on the IBH Model website at
https://www.cms.gov/priorities/innovation/innovation-models/innovation-behavioral-health-ibh-
model.
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B. Federal Award Information
Federal Award Information:
B1. Total $37.5 million
Funding
B2. Award Up to $7.5 million to each Recipient
Amount Pre-implementation period:
$1,500,000 in MY1 (BP1), $1,250,000 in MY2 (BP2).
Implementation period: $1,000,000 in MYs 3-6 (BPs 3-6). $750,000 in MY7
(BP7).
B3. Anticipated January 1, 2027
Award Dates
B4. Period of Overall: January 1, 2027, through December 31, 2033
Performance
After the initial award, continued funding is distributed via Non-Competing
Continuation Awards
Seven total budget periods:
Budget Period 1: January 1, 2027 – December 31, 2027
Budget Period 2: January 1, 2028 – December 31, 2028
Budget Period 3: January 1, 2029 – December 31, 2029
Budget Period 4: January 1, 2030 – December 31, 2030
Budget Period 5: January 1, 2031 – December 31, 2031
Budget Period 6: January 1, 2032 – December 31, 2032
Budget Period 7: January 1, 2033 – December 31, 2033
**Each budget period corresponds to a MY (BP) as detailed in the chart below. For
example, budget period 1 reflects the same dates as MY1.
B5. Number of Up to 5 awards
Awards
B6. Type of Cooperative Agreement
Award Statutes, regulations, policies, that apply to grants also apply to cooperative
agreements, unless the award itself provides otherwise. References throughout this
NOFO to grants also apply to cooperative agreements unless this NOFO states
otherwise. Please refer to section F4. Cooperative Agreement Terms and
Conditions of Award.
B7. Type of
Competition Open to All Eligible Applicants
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Cohort II
Model Year Calendar Year Maximum Cooperative Agreement
(MY)/Budget Funding
Period (BP)
Pre-Implementation Period
MY1 (BP1) January 1, 2027 – December 31, 2027 $1,500,000
MY2 (BP2) January 1, 2028 – December 31, 2028 $1,250,000
Implementation Period
MY3 (BP 3) January 1, 2029 – December 31, 2029 $1,000,000
MY4 (BP 4) January 1, 2030 – December 31, 2030 $1,000,000
MY5 (BP 5) January 1, 2031 – December 31, 2031 $1,000,000
MY6 (BP 6) January 1, 2032 – December 31, 2032 $1,000,000
MY7 (BP 7) January 1, 2033 – December 31, 2033 $750,000
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C. Eligibility Information
C1. Eligible Applicants
Eligible applicants are state Medicaid agencies (SMAs) with the authority and capacity to accept
the Cooperative Agreement award funding. Eligible applicants are all 50 states, Washington DC,
and U.S. territories. Eligible U.S. territories include American Samoa, Guam, the Northern
Mariana Islands, Puerto Rico, and the United States Virgin Islands. Applicants may select to
participate at the state level or designate a sub-state region, subject to CMS approval during the
application review.
(Select all that apply)
Government Organizations
✓
State governments
C2. Cost Sharing or Matching
This program has no cost-sharing requirement. If you choose to include cost-sharing funds, we
will not consider it during review. However, we will hold you accountable for any funds you
add, including the requirements for grant reporting.
C3. Letter of Intent
CMS requests that interested applicants submit Letters of Intent (LOIs); this is optional and will
not impact application scoring. Applicants may email LOIs to the following address:
IBHModel@cms.hhs.gov. LOIs must include:
1. An expression of interest, including the proposed regions of participation.
2. A brief description of the interested organization.
3. Contact information, including the organization's street address and a contact person's
name, position, email, and phone number.
LOIs are due April 1, 2026.
C4. Ineligibility Criteria
Non-applicable
C5. Single Application Requirement
Applicants may submit only one application.
C6. Continued Eligibility
Recipients must demonstrate satisfactory progress during the previous budget period to be issued
additional year funding through a non-competing continuation award. Non-competing
continuation funding is a Recipient's request for additional funding for the next subsequent Budget
Period within an approved competitive segment (i.e., period of performance). Such funding is
requested either through an application or a performance report, as explained in the terms and
conditions of the award. A non-competing continuation application does not compete with other
applications for support.
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