On September 8, staff to the Behavioral Health Commission presented the findings of a review of two initiatives to enhance Medicaid-funded behavioral health services. These initiatives are intended to fill gaps in the continuum of services available for behavioral health needs to ensure that each Medicaid member can receive necessary care in the most appropriate setting.
Project BRAVO, which began in 2019, discontinued several legacy services, added new services, and enhanced other services for individuals who need more support than routine outpatient therapy, but do not require hospitalization. The initiative focused on intensive outpatient and community-based services delivering treatment in a person’s home or in the community in order to prevent hospitalization; intensive clinic or facility-based services providing structured treatment in a program setting for several hours a day or several days a week; and comprehensive crisis services designed to respond when an individual needs immediate attention to avoid an emergency department visit or psychiatric hospitalization.
The second major initiative, behavioral health redesign, is in progress; it was directed in the 2024 Appropriation Act and focuses on services that help individuals remain in the community. When fully implemented, redesign will replace four legacy services (mental health skill building, intensive in-home, therapeutic day treatment, and psychosocial rehabilitation) with new services (community psychiatric treatment and support, mental health clubhouse, and coordinated specialty care for individuals experiencing a first episode of psychosis). Community psychiatric treatment and support serves youth and adults and provides skills training, care coordination, crisis management, and support, and is offered in the home, school, or community. Clubhouse is a center-based program for adults with serious mental illness that supports members in pursuing employment, education, and independent living. Coordinated specialty care for individuals experiencing a first episode of psychosis offers therapy, medication management, family education, and support in returning to school or work. As originally planned, the new services would have begun July 1, 2026, with the legacy services phased out at the same time, but the 2026 Appropriation Act delayed the start date until July 1, 2027, due to concerns about provider readiness to offer the new services – an action VACo supported. Commission staff recommended that the legislature consider further delays to the rollout of redesign, as well as other modifications to the initiative, to ensure that providers can be appropriately trained and licensed to offer the new services.
Key findings from the study:
- Project BRAVO enhanced access to intensive outpatient services, but fewer Medicaid members participated in certain services than projected, notably multi-systemic therapy and functional family therapy, which are services for youth who are at risk of removal from their homes.
- Project BRAVO expanded access to crisis services, and spending on these services far exceeded projections. Improper use of these services accounts for some of this growth, in part due to the structure of the program, in which high rates attracted providers and typical safeguards (such as prior authorization requirements and licensing standards) were not applicable or insufficient. Staff from the Department of Behavioral Health and Developmental Services (DBHDS) and the Department of Medical Assistance Services (DMAS) addressed the Commission later in the meeting and reported on agency efforts to curtail overuse of these services and to combat fraud by certain providers.
- There are a number of concerns about the rollout of behavioral health redesign, even with the one-year delay to July 2027. Since the budget language authorizing the redesign of services requires the new services to be delivered in a cost-neutral way, rates and limitations on hours of service delivery were established to achieve budget neutrality, and there are questions about whether these rates and hours of service are adequate to sustain providers’ ability to offer the new services. Staff suggested that the General Assembly direct DMAS to assess and report on the sufficiency of hours after the redesign is implemented, and consider increasing reimbursement rates. Staff also suggested that the legislature could delay implementation to 2028 and allow for phased implementation of the new services, since key manuals for providers are not ready, DBHDS may need additional staff to process license applications for the new services, and providers have not been trained on the new services.
- For both Project BRAVO and behavioral health redesign, staff stressed the importance of investing in an accountability system that would ensure that the service enhancements achieve their goals of improving access to care, quality of care, and cost-effectiveness.
Staff’s presentation to the Commission is available at this link and the full report is available at this link.
VACo Contact: Katie Boyle