What services can a CMHC bill Medicare for?

A CMHC's Medicare provider agreement covers only partial hospitalization services and intensive outpatient services, under 42 CFR 489.2(c)(2). Clinicians' professional services are billed under their own enrollments.

Is a CMHC site visited before Medicare enrollment?

Yes. CMHCs are moderate-risk providers under 42 CFR 424.518, and moderate screening includes an on-site visit along with license and database checks.

Who certifies the CMHC 40 percent requirement?

An independent entity, at initial enrollment and every revalidation. A consultant working for the CMHC should not be that certifier; we organize the documents for the program's own independent certifier.

Medicare Enrollment for Community Mental Health Centers

Q: Which form does a CMHC use to enroll in Medicare?

The CMS-855A, which lists community mental health centers among the organizations that must complete it, or the equivalent PECOS application. CMHCs must report every alternative site where core services are provided.

In Medicare, a community mental health center (CMHC) is a specific kind of provider with a narrow job. It enters a provider agreement "only to furnish partial hospitalization services and intensive outpatient services" (42 CFR 489.2(c)(2)), and its Medicare billing covers those programs. Getting there means meeting a federal definition, a set of conditions of participation that surveyors apply, and an enrollment process with a requirement no other provider type has: an independent certification that at least 40 percent of the center's clients are not Medicare beneficiaries.

What makes an entity a CMHC?

The definition in 42 CFR 410.2 has six parts. A CMHC is an entity that:

Provides outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically mentally ill, and residents of its mental health service area discharged from inpatient treatment at a mental health facility.
Provides 24-hour-a-day emergency care services.
Provides day treatment or other partial hospitalization services, or intensive outpatient services, or psychosocial rehabilitation services.
Provides screening for patients being considered for admission to state mental health facilities to determine whether admission is appropriate.
Meets applicable state licensing or certification requirements for CMHCs in its state.
"Provides at least 40 percent of its services to individuals who are not eligible for benefits under title XVIII" of the Social Security Act, that is, Medicare.

The CMS-855A adds a geographic point: a CMHC "is required to provide mental health services principally to individuals who reside in a defined geographic area (service area)," so "CMHCs must service a distinct and definable community." CMHCs must also report on the 855A "all alternative sites where core services are provided." And the conditions of participation require the core services to be provided "to all clients served by the CMHC regardless of payer type" (42 CFR 485.918(b)(1)), so the program cannot be built around Medicare patients alone.

Which conditions of participation apply?

CMS established the CMHC conditions of participation effective October 29, 2014, at 42 CFR 485.904 through 485.920, and they "serve as the basis of survey activities" for deciding whether a CMHC qualifies for a provider agreement (42 CFR 485.900(b)). CMS's State Operations Manual Appendix F holds the surveyor guidance. In outline:

485.904, personnel qualifications. Everyone who furnishes services must be licensed, certified or registered as required and work within scope. The rule sets qualifications for administrators, physicians, psychiatrists, psychiatric registered nurses, advanced practice nurses, physician assistants, clinical social workers, social workers, occupational therapists, mental health counselors and marriage and family therapists, among others.
485.910, client rights. Informing clients of their rights and protecting their exercise, including rules on restraint and seclusion.
485.914, admission, assessment and discharge. For example, a licensed mental health professional employed by the CMHC completes the initial evaluation within 24 hours of admission.
485.916, treatment team and active treatment plan. An interdisciplinary team led by a physician, NP, PA, clinical nurse specialist, clinical social worker, MFT, mental health counselor or other listed professional.
485.917, quality assessment and performance improvement. A data-driven program with performance improvement projects and governing body responsibility.
485.918, organization, governance and services. A governing body of two or more people, one with mental health clinical knowledge and experience; an administrator who is a CMHC employee; the required services; the 40 percent rule; and standards for partial hospitalization and intensive outpatient services.
485.920, emergency preparedness. An all-hazards plan reviewed and updated at least every two years, with policies, communication plan and training.

The CY 2024 outpatient payment rule wove intensive outpatient services through these conditions, added a definition of marriage and family therapists and revised the definition of mental health counselors (88 FR 81540). See Medicare's intensive outpatient benefit.

Does the state license come first?

Yes. The definition requires the CMHC to meet state licensing or certification requirements for CMHCs, and 485.918(h) says "if State or local law provides for licensing of CMHCs, the CMHC must be licensed." Most states license the underlying outpatient and partial hospitalization services through their behavioral health agencies; our state pages show which agency licenses what. See also licensing outpatient, IOP and PHP programs.

What goes into the enrollment application?

The CMHC enrolls on the CMS-855A, which lists "Community Mental Health Center" among the organizations that must complete it, or the equivalent PECOS application. The pieces:

Application fee. Institutional providers pay CMS's application fee, adjusted each calendar year, with an initial application, a new practice location and revalidation, unless a hardship exception is approved (42 CFR 424.514).
Screening. CMHCs are designated moderate risk (42 CFR 424.518(b)(1)(ii)), which means the limited checks (federal and state requirements, license verification, database checks) plus an on-site visit (424.518(b)(2)).
The 40 percent certification. The CMHC must submit "a certification statement provided by an independent entity that certifies that the CMHC's client population meets the 40 percent requirement," at initial enrollment and at every revalidation, including off-cycle revalidation. Enrollment is denied or revoked without it, or if the requirement is not met (42 CFR 485.918(b)(1)(v)). See the CMHC 40 percent rule.
Signatures. An authorized official with authority to bind the organization and an ownership or control interest signs the initial application and revalidations; a delegated official may sign later changes (42 CFR 424.510(d)(3)).
Provider agreement. CMHCs sign a provider agreement under part 489 limited to partial hospitalization and intensive outpatient services (489.2(c)(2)).

Which patients may each program serve under Medicare?

Coverage rules shape the clinical program the CMHC builds. Partial hospitalization is intended for patients who "require a minimum of 20 hours per week of therapeutic services as evidenced in their plan of care" (42 CFR 410.43(c)(1)), and the physician certification must state that the individual needs at least 20 hours a week and "would require inpatient psychiatric care if the partial hospitalization services were not provided" (42 CFR 424.24(e)(1)). Intensive outpatient services are intended for patients who need at least 9 hours a week (410.44(c)(1)). Both programs must be a distinct and organized program offering less than 24-hour daily care, not in the patient's home or an inpatient or residential setting (410.2). The program descriptions, staffing plan and schedules in the enrollment file should reflect those definitions.

Who may serve as the 40 percent certifier?

The rule says "an independent entity," and that rules out anyone with a stake in the result. We organize the documentation the program's independent certifier needs, but we are never that certifier for a program we work for. Engage the certifier early; the statement is needed with the initial application.

Which requirements continue after enrollment?

Revalidation every five years (42 CFR 424.515), each time with a new independent 40 percent statement.
Change reporting: changes of ownership or control, including authorized or delegated officials, and practice location changes within 30 days; other changes within 90 days (42 CFR 424.516(e)).
Coverage rules for each program: partial hospitalization under 410.43 and 410.110, intensive outpatient under 410.44 and 410.111, with physician certification and plan of treatment requirements in 424.24.
Survey readiness against the conditions of participation at any time.

How is a CMHC different from a clinic billing under a practitioner's enrollment?

A group practice or clinic bills Medicare for professional services through its practitioners' enrollments. A CMHC enrolls as an institutional provider for partial hospitalization and intensive outpatient programs, with conditions of participation and surveys. Many organizations need both: the CMHC enrollment for the programs and individual enrollments for the clinicians. Our sister sites cover clinician Medicare enrollment for mental health counselors, MFTs and clinical social workers.

How do we help?

Our Medicare CMHC Enrollment service is $1,995 per CMHC. We prepare the 855A, check the program against the definition and the conditions of participation, organize the 40 percent documentation for your own independent certifier, and submit as your PECOS surrogate once your authorized official approves us. Your official signs; we never hold your I&A login. You pay CMS's application fee directly. A Mock Survey ($1,495) tests readiness against the conditions of participation. See pricing.