State Medicaid Program Reimburses for Physical Health and Wellness Services Provided by Mental Health Peers, Leading to Anecdotal Reports of Improved Outcomes | AHRQ Innovations Exchange
Policy Innovation Profile
State Medicaid Program Reimburses for Physical Health and Wellness Services Provided by Mental Health Peers, Leading to Anecdotal Reports of Improved Outcomes
SummaryThe Georgia Medicaid program expanded the definition of reimbursable services provided by mental health certified peer specialists to include physical health and wellness services (in addition to mental health services, which were already covered). The goal of this policy change is to improve the physical health and increase the life expectancy of Medicaid beneficiaries with mental illness, who face increased risk of medical illnesses and premature death. Under the revised policy, peer specialists delivering reimbursable physical health and wellness services must have professional supervision, be willing to self-disclose a personal wellness goal to the beneficiaries, and have certification from an approved health-related training program designated by the Georgia Department of Behavioral Health and Developmental Disabilities. The policy specifies a range of reimbursement based on where the services are provided and the experience and educational background of the peer specialist. Since implementation of the expanded service definition, approximately 175 peer specialists (out of more than 1,000) have been certified in the provision of physical health and wellness services through the designated training program, and community mental health centers employing these specialists report improved physical health outcomes among clients receiving such services.Suggestive: The evidence consists of post-implementation data on the number of peer support specialists receiving additional training and certification in physical health and wellness services, along with anecdotal reports from community health centers on the impact of such services on their clients' physical health outcomes.
Developing OrganizationsGeorgia Department of Behavioral Health and Developmental Disabilities
Use By Other OrganizationsProgram developers have been contacted by colleagues in North Carolina and Michigan regarding interest in adopting this reimbursement strategy.
Date First Implemented2013
Patient PopulationVulnerable Populations > Impoverished; Insurance Status > Medicaid; Vulnerable Populations > Mentally ill
Problem AddressedMental illness is common (particularly among low-income populations) and often leads to physical health problems and death. Certified peer specialist (CPS) services—support and education provided by peers who are also in recovery from mental and behavioral health conditions—have been shown to be effective, but payers often do not cover such services; when they do, coverage tends to be limited to mental and behavioral health services and does not extend to physical health and wellness services.
- A common condition, especially among low-income individuals: Roughly 20 percent of adults in the United States have a mental disorder, and approximately 5 percent have a serious mental illness.1Approximately one-fifth of individuals with mental illness also have a co-occurring substance dependence or abuse disorder,1and many also have low socioeconomic status.2
- Increased risk of physical health problems and death: Persons with mental illness are more likely than others to suffer from physical health problems, including chronic diseases such as diabetes, cardiovascular disease, diabetes, obesity, asthma, epilepsy, and cancer.3 As a result, the life expectancy of those with serious mental illness is roughly 25 years less than that of the average individual.3,4
- Unrealized potential of CPS services: Since 2000, a growing body of scientific research has found that CPS services improve mental and physical health outcomes.5 For example, the Health and Recovery Peer (HARP) program (a six-session intervention based on Stanford University’s Chronic Disease Model that helps individuals with serious mental illness manage their chronic illnesses) helped patients achieve greater improvements in patient activation, physical health-related quality of life, physical activity, and medication adherence than similar patients receiving usual care.6 In spite of this evidence, most payers do not cover CPS services, particularly those related to physical health and wellness.
Description of the Innovative ActivityThe Georgia Medicaid program expanded the definition of reimbursable services provided by mental health CPSs to include physical health and wellness services, in addition to mental health services, which were already covered. Under the revised policy, peer specialists delivering physical health and wellness services must have professional supervision, be willing to self-disclose a personal wellness goal to the beneficiaries, and have certification from an approved health-related training program. The policy specifies a range of reimbursement depending on where the services are provided and the experience and educational background of the CPS. Key elements of this new policy are detailed below:
- Expanded definition of reimbursable services to include physical health and wellness: In an effort to promote recovery, wellness, and healthy lifestyle-related behaviors among Medicaid beneficiaries with mental illness, the Georgia Medicaid program received approval from the Centers for Medicare & Medicaid Services (CMS) on June 6, 2012, to expand the definition of and provide reimbursement for physical health and wellness services provided by CPSs.
- Associated requirements to qualify for reimbursement: To qualify for reimbursement under the new service definition, the CPS providing the physical health and wellness services must be professionally supervised by a behavioral health professional; work with a nurse to provide medical technical assistance as needed; be willing to self-disclose a personal wellness goal to the beneficiaries; and have completed and received certification from a health-related training program approved by the Georgia Department of Behavioral Health and Developmental Disabilities, as described below.
- Training program and certification: CPSs providing physical health and wellness services under the new policy must complete and be certified by the Whole Health Action Management (WHAM) training program, a 2-day self-management training program and peer support group model developed by the National Council for Behavioral Health. The Department offers the program free of charge to CPSs several times a year. Session topics address the following:
- Whole health and resiliency factors: CPSs learn to address 10 health and wellness factors: stress management, healthy eating, physical activity, restful sleep, service to others, identification of support networks, optimism based on positive expectations, cognitive skills to avoid negative thinking, spiritual beliefs and practices, and a sense of meaning and purpose.
- Person-centered planning: CPSs learn to help clients develop individualized health goals and a weekly action plan focused on achieving those goals.
- Facilitation of support groups: CPSs learn to facilitate weekly peer support groups.
- Medicaid reimbursement based on location and CPS qualifications: The Georgia Medicaid program provides reimbursement to the organization employing the CPS through a Healthcare Common Procedure Coding System (HCPCS) billing code for health and wellness support (H0025) that was added to the State's Medicaid plan. This new code applies to health and wellness support services provided by CPSs. The payment rate for a 15-minute visit ranges from $15.13 to $24.36, depending on where the services are delivered and the level of education and experience of the CPS providing them.
Context of the InnovationThe Georgia Department of Behavioral Health and Developmental Disabilities provides treatment and support services to individuals with mental and behavioral health conditions, addictive diseases, and developmental disabilities. Since 1999, the Department has certified more than 1,000 CPSs to provide mental health and behavioral support to peers.
The impetus for this new policy goes back to 2006, when the National Association of State Mental Health Program Directors released a comprehensive study indicating that individuals with mental illness died 25 years earlier than their peers, largely as a result of comorbid medical illnesses and other factors such as low socioeconomic status.4 After seeing this study's findings, the Department chose to take action to extend the lives of individuals recovering from mental illness. The Department felt that by promoting recovery, wellness, and healthy lifestyles, CPSs could help to reduce identifiable physical health risks, thereby preventing the onset of disease and reducing the impact of existing chronic health conditions.
ResultsThe expanded service definition and associated reimbursement for physical health and wellness services has led to roughly 175 (out of just over 1,000) CPSs becoming trained and certified in the provision of such services and to anecdotal reports from community mental health centers of improved physical health outcomes among clients receiving them.
Suggestive: The evidence consists of post-implementation data on the number of peer support specialists receiving additional training and certification in physical health and wellness services, along with anecdotal reports from community health centers on the impact of such services on their clients' physical health outcomes.
- Many newly trained CPSs: Since implementation of the new service definition and reimbursement policy in January 2012, approximately 175 of the more than 1,000 peer specialists previously trained by the Department of Behavioral Health and Developmental Disabilities have completed the additional training and certification requirements of the WHAM program, meaning they have increased their knowledge base related to the provision of physical health and wellness services to clients.
- Anecdotal reports of improved physical health: Leaders of community health centers that employ the newly trained and certified CPSs report anecdotal instances of clients benefiting from the physical health and wellness services provided by these CPSs. Examples include obese and overweight individuals losing weight, hypertensive individuals achieving better blood pressure control, and those with diabetes achieving better glucose control. For their part, the newly trained and certified CPSs report that their clients seem to be more engaged in their own health.
- Ongoing evaluation: An ongoing study is comparing health outcomes for those in regular behavioral health groups with outcomes for those in whole health groups led by health-trained CPSs.
Planning and Development ProcessSelected steps included the following:
- Internal change to definition of "peer support": In 2007, the Georgia Department of Behavioral Health and Developmental Disabilities modified its definition of "peer support" to include the concepts of wellness and health management.
- Introduction of CPS-provided health and wellness support to medical professionals: The Department rolled out a training program for community mental health clinic physicians and nurses that described the physical health challenges facing people with mental and behavioral health issues and introduced the idea of having peer specialists provide health and wellness support to these individuals.
- Discussions with CMS: The Affordable Care Act introduced the concept of prevention into the Medicaid Rehabilitation Option, which is a funding mechanism provided by the Social Security Act that the State can opt to include in its plan for physical and mental health rehabilitation services. After passage of the Affordable Care Act, Department leaders saw an opportunity to formalize the ability of CPSs to support the physical health of clients. In collaboration with colleagues at the Georgia Department of Community Health (which administers the Georgia Medicaid program), Department staff engaged with CMS officials to request approval to expand the existing peer support service definition for CPSs to include health and wellness support and to receive reimbursement for such services.
- Release of study documenting CPS effectiveness: At around the same time, Emory University researchers conducted the HARP study6 (described previously), which demonstrated the effectiveness of CPS services in a six-session intervention.
- Approval from CMS: The State Medicaid agency submitted a formal request to change the CPS service definition in the Georgia Medicaid plan. In light of the HARP study findings and after a review by the regional Medicaid authority, CMS approved the request and created the associated reimbursement code.
- Training at community mental health centers: The Department sponsored training sessions for the chief executive officers and supervisors at community mental health centers to explain the health-related services that CPSs could provide. During these sessions, experts in health care delivery and billing provided details about service provision and operational issues, and CPSs shared their personal health stories.
Resources Used and Skills Needed
- Staffing: The program did not require additional staff.
- Costs: Details on program development and ongoing administrative costs are unavailable. The cost to provide the additional physical health and wellness training to one CPS through WHAM is approximately $1,000.
Funding SourcesCenters for Medicare and Medicaid Services; National Association of State Mental Health Program Directors; Georgia Department of Behavioral Health and Developmental Disabilities
The Department received a $210,881 grant from the National Association of State Mental Health Program Directors to develop the program and train the first 110 CPSs through WHAM. The Department has also provided additional financial support to train other CPSs. As noted, the Georgia Medicaid program and CMS provide reimbursement for CPS services provided to Georgia beneficiaries, including those related to physical health and wellness.
Tools and Other ResourcesFor more information about WHAM, consult the resources listed below:
Getting Started with This Innovation
- Arrange for nonprovider funding for CPS training: Community mental health center leaders may be reluctant to fund CPS training or may not have resources available to do so.
- Incorporate feedback from CPSs in developing policy: Innovators should involve CPSs and other individuals with mental illnesses in development of the new policy. Their feedback is invaluable in a number of areas, including defining physical health and wellness services and selecting the right training and certification program.
- Develop positive relationships with CMS: Successful implementation requires the development of transparent and trusting relationships with CMS staff based on a shared mission related to beneficiary well-being. To assist in building and maintaining such relationships, innovators should share evidence of the benefits achieved by other successful CPS programs.
Sustaining This Innovation
- Evaluate and share data on policy's impact: Innovators should evaluate the policy's impact on both a formal and an informal basis by collecting and analyzing data to gauge the impact on health outcomes and by collecting anecdotal reports from participating community mental health centers. Sharing this information on a regular basis helps to keep key stakeholders engaged in and supportive of the policy and the general concept of CPSs providing physical health and wellness services.
- Support continuing education for CPSs: Ongoing education helps CPSs refresh their knowledge and keep up with new disease treatments and educational techniques. In Georgia, continuing education is a required element for all CPSs; whole health has been a part of this continuing education for the past 5 years.
Use By Other OrganizationsProgram developers have been contacted by colleagues in North Carolina and Michigan regarding interest in adopting this reimbursement strategy.
Contact the InnovatorWendy White Tiegreen, MSW
Director, Office of Medical Coordination and Health System Innovation
Georgia Department of Behavioral Health and Developmental Disabilities
Two Peachtree Street, NW
Atlanta, GA 30303
Innovator DisclosuresMs. Tiegreen reported receiving a consulting fee from another State government that enlisted her expertise in writing a definition of certified peer specialist services for its Medicaid program.
References/Related ArticlesIn the news: Georgia’s peer support expansion into whole health coaches. SAMSHA–HRSA Center for Integrated Health Solutions. Available at: http://www.integration.samhsa.gov/health-wellness/NASMHPD-CIHS_GA_Peer_Whole_Health_Coaches.pdf.
Hudson CG. Socioeconomic status and mental Illness: tests of the social causation and selection hypotheses. Am J Orthopsychiatry. 2005;75(1):3–18. [PubMed]
Freeman EJ, Colpe LJ, Strine TW, et al. Public health surveillance for mental health. Prev Chronic Dis 2010;7(1):A17.[PubMed]
Druss BG, Zhao L, von Esenwein SA, et al. The Health and Recovery Peer (HARP) Program: a peer-led intervention to improve medical self-management for persons with serious mental illness. Schizophr Res. 2010;118(1-3):264-70.[PubMed]
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