Integration of Primary Care and Behavioral Health Services

Models and Approaches

  • Presentation is also available in Portable Document Format (PDF)
January 2016

Integration Models and Approaches
(Single Provider)

  • Licensure Thresholds
  • DSRIP Project 3.a.i Licensure Threshold
  • Collaborative Care Model
  • Integrated Outpatient Services (IOS) Regulations
  • Multiple Licenses

Licensure Thresholds

  • Licensure Thresholds:
    • A clinic site licensed by DOH (PHL Article 28) must be licensed by OMH if more than 10,000 or 30 percent of its annual visits are for mental health services
    • A clinic site licensed by OMH (MHL Article 31) or certified by OASAS (MHL Article 32) must be licensed by DOH if more than 5 percent of its visits are for medical services or any visits are for dental services
    • Licensure Thresholds are not applicable for OASAS services
  • No application is required

DSRIP Project 3.a.i Licensure Threshold

  • The objective of DSRIP Project 3.a.i is to promote the integration of mental health and substance use disorder services with primary care for the purpose of ensuring coordination of care, through one of three models – Model 1 (PCMH), Model 2 (BH) or Model 3 (IMPACT)
  • The DSRIP Project 3.a.i Licensure Threshold is available to a provider participating in a PPS that has been identified by the PPS Lead as being part of DSRIP Project 3.a.i, as identified in the PPS Implementation Plan, and pursuing Model 1 or Model 2
  • The DSRIP Project 3.a.i Licensure Threshold allows the provider to integrate primary care and behavioral health services under a single license or certification, as long as the service to be added is not more than 49 percent of the provider’s total annual visits
  • A provider must follow the programmatic requirements of its licensing agency and the prescribed requirements of the IOS Regulations as outlined in the DSRIP Project 3.a.i Licensure Threshold Guidance
  • Guidance:
  • Application and instructions:

To provide services under the DSRIP Project 3.a.i Licensure Threshold, a provider must submit an application to the agency that licensed the site

  • A provider licensed by DOH to provide primary care services that wishes to add mental health and/or substance use disorder services must submit a CON application or an LRA through NYSE–CON – one separate application must be submitted for each site
  • A provider licensed by OMH or OASAS that wishes to add primary care or the other behavioral health service must submit the DSRIP Project 3.a.i Integrated Services Application – multiples sites may be included on one application

Integrated Outpatient Services Regulations

The IOS Regulations (10 NYCRR Part 404 and 14 NYCRR Parts 598 and 825) allow a provider licensed or certified by more than one agency to add services at one of its sites (the "host" site) without additional license or certification, as long as it is licensed or certified to provide such services at another site:

  • Primary Care Host Model (DOH licensed providers adding mental health and/or substance use disorder services)
  • Mental Health Behavioral Care Host Model (OMH licensed providers adding primary care and/or substance use disorder services)
  • Substance Use Disorder Behavioral Care Host Model (OASAS certified providers adding primary care and/or substance use disorder services)

In addition to the requirements of the state agency that licensed or certified the proposed host site, IOS providers must meet operating and physical plant standards set forth in the IOS Regulations such as:

Effective July 1, 2015, all clinics authorized under the IOS Regulations will be eligible for enhanced payment pursuant to Medicaid policy for multiple service type visits in which primary care and behavioral care or two types of behavioral care (i.e., mental health and substance use disorder) services are rendered:

  • Full payment for multiple behavioral health services (10 percent discount usually applies for second and subsequent services) – applies to all IOS rate codes (1122, 1124, 1130, 1132, 1134, 1480, 1483 or 1486)
  • Additional payment for multiple Evaluation and Management (multiple E&M consolidation usually applies) if two E&Ms are billed (one for physical health and the second for behavioral health) on the same date of service. However, this does not apply to DOH licensed host clinics
  • The second E&M will pay $75 if modifier 27 is appended and at least one behavioral and one non–behavioral health diagnosis is included on the claim

Collaborative Care Model

  • The Collaborative Care Model is an evidence–based model of behavioral health integration for detecting and treating common mental health conditions such as depression and anxiety in primary care settings
  • The DSRIP Project 3.a.i. Model 3 Collaborative Care Model is an integration project which does not physically integrate behavioral health provides into the primary care site, but relies upon collaborative care/care management
  • The model is based on the IMPACT model, more information on which is available at–care
  • Provides a monthly case rate for each Medicaid patient being treated with Collaborative Care for depression
    • Each practice given a cap of patients they can bill for to maintain budget & ensure they do not exceed their capacity, and focus on value over volume
    • Carve out; all Medicaid, regardless of Managed Care
    • Case rate covers elements that would not be billable in traditional environment: Depression Care Manager time, use of a registry, Consulting Psychiatrist time, time spent on phone contacts
  • 25% of each payment is withheld to ensure quality outcome standards are met
    • After 6 months, if the practice can attest that the patient has demonstrated clinically significant improvement or their treatment plan has been revised, they can submit to receive the 25% withholding back

Multiple Licenses

A provider may integrate primary care and behavioral health services by applying for a license or certificate from the agency (DOH, OMH or OASAS) that licenses or certifies the additional services:

Social Worker Billing Provisions

  • DOH (Article 28) licensed clinics may only bill Medicaid for Licensed Clinical Social Worker (LCSW) or Licensed Master Social Worker (LMSW) counseling for recipients who are under age 21 or pregnant (including up to 60 days postpartum)
  • Clinics that bill Medicaid FFS billers are required to use the following rate codes: 4257 Individual Brief Counseling, 4258 Individual Comprehensive Counseling, or 4259 Family Counseling
  • Applies to all DOH licensed clinics including those that integrate services under:
    • Existing Licensure Thresholds – single licensed clinic
    • DSRIP 3.a.i. Licensure Thresholds – single licensed clinic, or
    • IOS Regulation – dual licensed/certified facility
  • The following clinics may bill Medicaid for social worker counseling rendered to all recipients:
    • Federally Designated Health Clinics
      • Federally Qualified Health Center (FQHC)
      • FQHC "look–alike" (not in receipt of a grant under Section 330 of Public Health Service Act), or
      • Rural Health Clinic (RHC)

Thank You!

For further questions on Integrated Services, please send with Subject Line – "Integrated Services Webinar" to the DSRIP e–mail: