PURPOSE: This rule establishes the requirements for Certified Community Behavioral Health Organizations (CCBHOs) to provide a comprehensive range of mental health and substance use disorder services to people with serious mental illness, serious emotional disturbances, long-term chronic addiction, mild or moderate mental illness and substance use disorders, and complex health conditions. CCBHOs provide services regardless of an individual’s ability to pay, including those who are underserved, have low incomes, are insured, uninsured, Medicaid-eligible, and active duty U.S. Armed Forces or veterans.

1. (1) Definitions. The following definitions apply to terms used in this rule:

   1. (A) Certified Community Behavioral Health Organization (CCBHO)—an entity certified by the department to provide CCBHO services within their designated service area(s);
   2. (B) Department—the Department of Mental Health; and
   3. (C) Designated Collaborating Organization (DCO)—an entity that is not under the direct supervision of a Certified Community Behavioral Health Organization (CCBHO) but is engaged in a contractual arrangement with a CCBHO to provide CCBHO services under the same requirements as the CCBHO.
2. (2) Regulations. All CCBHOs shall comply with all regulations, requirements, and standards specified in 9 CSR 10-7 and 9 CSR 30- 4.

3. (3) Designated Service Areas. Organizations must be certified by the department to provide CCBHO services in one (1) or more service areas as established by the department under 9 CSR 30-4.005. The required CCBHO services, as specified in this rule, must be provided in each designated service area.

   1. (A) Each CCBHO shall develop and maintain services and supports designed to meet the needs of the populations of focus. Populations of focus shall include:

      1. 1. Adults with serious mental illness as

defined in 9 CSR 30-4.005(6);

1. 2. Children and adolescents with serious

emotional disturbances as defined in 9 CSR 30-4.005(7);

1. 3. Children, adolescents, and adults

with moderate to severe substance use disorders;

1. 4. Children with behavioral health disor-

ders who are in state custody; and

1. 5. Individuals involved with law

enforcement, the courts, and hospital emergency rooms who have been identified as in need of community behavioral health services.

1. (B) Each CCBHO shall regularly assess the unique socio-demographic factors of their service area(s) and implement strategies to improve access, quality of care, and reduce health disparities experienced by relevant cultural and linguistic minorities.

1. (4) Availability and Accessibility of Services. Services shall not be denied or limited based on an individual’s ability to pay, place of residence, homelessness, or lack of a permanent address.

   1. (A) CCBHOs shall provide, at a minimum, crisis response, evaluation, and stabilization, as needed, for individuals who present for services but do not reside within the CCBHO’s designated service area(s). Policies and procedures shall specify the CCBHO’s process for managing the ongoing treatment needs of such individuals, such as linkage to a CCBHO in the service area where the individual currently lives.
   2. (B) CCBHOs shall provide outpatient services at times and locations that ensure accessibility and meet the needs of individuals in the service area, including some evening hours, and when appropriate and practicable, weekend hours.

   3. (C) CCBHOs shall ensure—

      1. 1. No individual in the populations of

focus is denied services including, but not limited to, crisis management because of an inability to pay for such services; and

1. 2. Any fees or payments required by the

CCBHO for such services shall be reduced as provided by the sliding fee schedule described in section (13) of this rule in order to enable the CCBHO to fulfill the assurance described in paragraph (4)(C)1. of this rule.

1. (D) CCBHOs shall ensure individuals determined to need specialized behavioral health services beyond the scope of its program are referred to a qualified provider(s) for necessary services.

1. (5) Certification and National Accreditation. CCBHOs shall maintain national accreditation and/or department certification as specified below:

   1. (A) Accreditation from the CARF Interna- 9 CSR 30-6

tional (CARF) to provide Outpatient Mental Health and Outpatient Alcohol and other Drugs/Addictions, or Outpatient Alcohol and Other Drugs/Mental Health to serve children, youth, and adults; or

1. (B) Accreditation from The Joint Commission (TJC) to provide Comprehensive Behavioral Health services to children, youth, and adults.

   1. 1. Provisional certification from the

department to provide outpatient mental health treatment and substance use disorder treatment for children, youth, and adults is acceptable until accreditation is obtained from CARF or TJC as specified;

1. (C) Accreditation from CARF or TJC as a Health Home for children, youth, and adults;
2. (D) Accreditation from CARF for Crisis and Information Call Center for the provision of a twenty-four (24) hour crisis line for children, youth, and adults with mental health and substance use disorders. If the CCBHO contracts with a DCO to provide this service, the DCO must be accredited by CARF as specified;

3. (E) Accreditation from CARF for Crisis Intervention Services for the provision of a twenty-four (24) hour mobile crisis team for children, youth, and adults with mental health and substance use disorders. If the CCBHO contracts with a DCO to provide this service, the DCO must be accredited by CARF as specified.

   1. 1. The twenty-four (24) hour crisis line

and twenty-four (24) hour mobile response team shall also comply with 9 CSR 30-4.195, Access Crisis Intervention (ACI) program; and

1. (F) Certification/deemed certification from the department in accordance with 9 CSR 30- 4 as a Community Psychiatric Rehabilitation

1. (CPR) program serving children, adolescents, and adults.

2. (6) Required Services. CCBHOs shall provide a comprehensive array of services to create and enhance access, stabilize people in crisis, and provide the necessary treatment for individuals with the most serious, complex mental illnesses and substance use disorders.

   1. (A) The following core CCBHO services must be directly provided by the CCBHO in each designated service area:

      1. 1. Crisis mental health services, includ-

ing a twenty-four (24) hour crisis line and twenty-four (24) hour mobile crisis response team. Crisis mental health services must be available at the CCBHO during regular business hours and be provided by a Qualified Mental Health Professional (QMHP). The crisis line and mobile crisis response team services may be directly provided by the CCBHO or by contract with a departmentapproved DCO;

1. 2. Screening, assessment, and diagno-

sis, including risk assessment;

1. 3. Patient-centered treatment, including

risk assessment and crisis prevention planning;

1. 4. Outpatient mental health and sub-

stance use disorder treatment services, including medication services for the treatment of addictions;

1. 5. Outpatient clinic primary care screen-

ing and monitoring of key health indicators and health risks;

1. 6. Targeted case management;
2. 7. Psychiatric rehabilitation services;
3. 8. Peer support, counseling, and family

support services, including peer and family support services for individuals receiving CPR and/or Comprehensive Substance Treatment and Rehabilitation (CSTAR) services, consistent with the array of services and supports specified in the job descriptions of Family Support Providers and Certified Peer Specialists; and

1. 9. Intensive, community-based mental

health services for active members of the U.S. Armed Forces and veterans.

1. (B) In addition to the core services, CCB- HOs shall directly provide, contract with a DCO, or have a referral agreement with an organization that is certified/deemed certified by the department to provide the following services:

   1. 1. General adult, adolescent, and

women and children’s CSTAR services;

1. 2. Recovery support services, if services

are available in the CCBHO’s designated service area(s);

1. 3. Outreach services to reduce unneces-

sary utilization of emergency rooms by the populations of focus, including case managers to respond to and engage individuals who present at collaborating emergency rooms, access necessary resources to meet the individual’s basic needs on an emergency basis, and assist individuals in accessing CCBHO services on an emergency, urgent, and/or routine basis, as needed.

1. (7) Required Staff. CCBHOs must maintain adequate staffing to meet the needs of the populations of focus. Staff may be fullor part-time employees of the CCBHO or contracted by the CCBHO to provide services.

   1. (A) Required staff shall include:

      1. 1. Medical Director who is a licensed

psychiatrist;

1. 2. Licensed mental health professionals

with expertise and specialized training in the treatment of trauma-related disorders;

1. 3. Community Mental Health Liaison (a

cooperative agreement with a CCBHO that employs a Community Mental Health Liaison is acceptable);

1. 4. Clinical staff to complete comprehen-

sive behavioral health assessments, annual assessments, and treatment plans;

1. 5. Licensed mental health professionals

who have completed training on evidencebased, best, and promising practices as required by the department;

1. 6. Physician(s) with a waiver in accor-

dance with the Drug Addiction Treatment Act of 2000 (DATA 2000) to treat opioid use disorders with narcotic medications approved by the Food and Drug Administration (FDA), including buprenorphine;

1. 7. Community Support Specialists who

have completed department-approved wellness training;

1. 8. Individuals who have completed

department-approved smoking cessation training;

1. 9. Family Support Providers who have

completed department-approved training; and

1. 10. Certified Peer Specialists who have

completed department-approved training.

1. (8) Screening, Assessment, and Treatment Planning. Unless a specific tool is required by the department, CCBHO staff shall use standardized and validated screening and assessment tools, including age-appropriate functional assessments and screening tools, and when appropriate, brief motivational interviewing techniques.

   1. (A) At first contact, individuals seeking CCBHO services shall receive a preliminary screening and risk assessment to determine acuity of need. Emergency, urgent, or routine service needs shall be identified and addressed as follows:

      1. 1. Individuals who present in crisis shall

receive services immediately, including arrangements for any necessary outpatient follow-up services;

1. 2. Individuals who present with an

urgent need shall receive clinical services and an eligibility determination within one (1) business day of the time the request was made; and

1. 3. Individuals who present with routine

needs shall receive clinical services and an eligibility determination within ten (10) days of first contact.

1. (B) Following the preliminary screening, qualified staff shall conduct an initial evaluation and further screening, and provide needed services as indicated by the initial evaluation. Additional screening shall include, but is not limited to:

   1. 1. Depression screening for all adoles-

cents age thirteen (13) to eighteen (18) years of age;

1. 2. Depression screening for all adults

age nineteen (19) and older;

1. 3. Suicide risk assessment for all adoles-

cents and adults diagnosed with major depression;

1. 4. Brief health screen, as specified by

the department;

1. 5. Alcohol use disorder screening; and
2. 6. Substance use disorder screening.

3. (C) The initial comprehensive assessment must be completed within specific treatment program timelines, not to exceed sixty (60) days.

   1. 1. A functional assessment shall be

completed utilizing an instrument approved by the department for all individuals enrolled in the CSTAR and/or CPR program, and must be updated at least every ninety (90) days.

1. 2. For individuals not enrolled in

CSTAR or CPR, a functional assessment shall be completed using a departmentapproved instrument, when an individual appears to be experiencing moderate or more serious impairment. If the functional assessment confirms an individual is experiencing moderate or more serious impairment, the functional assessment must be updated every ninety (90) days.

1. 3. The comprehensive assessment must

be updated in collaboration with the individual receiving services as warranted by changes in his or her health status, responses to treatment, and/or achievement of goals.

1. 4. The comprehensive assessment must

be updated at least every ninety (90) days for individuals with moderate or more serious impairment as determined by the functional assessment.

1. (D) Results of the comprehensive assessment shall be utilized to develop an initial treatment plan within sixty (60) days of the individual’s first contact with the CCBHO, unless a shorter timeframe is required by a specific treatment program. The treatment plan shall be developed collaboratively with the individual served and/or parents/guardian, family members, and other natural supports, as appropriate.

   1. 1. CCBHOs shall promote collaborative

treatment planning by providing the individual’s Primary Care Provider (PCP) with relevant assessment, evaluation, and treatment plan information, seeking all relevant treatment and test results from the PCP, and inviting the PCP to participate in treatment planning.

1. (E) The following information shall be collected and be available for reporting to the department or other entities, upon request:

   1. 1. The number and percentage of new

and established individuals served who were determined to need crisis, urgent, and routine care;

1. 2. The number and percentage of new

and established individuals with urgent needs who began receiving needed clinical services within one (1) business day;

1. 3. The number and percentage of new

and established individuals with routine needs who began receiving needed clinical services within ten (10) business days; and

1. 4. The mean number of days from first

contact to completion of the initial comprehensive assessment and initial treatment plan for individuals served.

1. (9) Services for Active Duty Members of the U.S. Armed Forces and Veterans. CCBHOs must determine whether all individuals seeking service are current or former members of the U.S Armed Forces.

   1. (A) CCBHOs shall refer Active Duty Members or activated Reserve Component Members to their Military Treatment Facility or TRICARE PRIME Remote Primary Care Manager for referral to services.
   2. (B) Members of the Selected Reserves, not on active duty, who are enrolled in TRICARE Reserve Select, shall be referred to a TRI- CARE Reserve Select provider.
   3. (C) If an individual is a veteran not currently enrolled in the Veterans Health Administration (VHA), CCBHO staff must offer to assist him/her in enrolling in the VHA.
2. (10) Crisis Response. CCBHOs must ensure individuals have access to crisis response services twenty-four (24) hours per day, seven

3. (7) days per week as follows:

   1. (A) Each CCBHO shall directly provide American Society of Addiction Medicine (ASAM) Level 1-Withdrawal Management

4. (WM) services;

   1. (B) Each CCBHO shall directly provide or contract with a DCO to provide:

      1. 1. ASAM Level 2-WM services;
      2. 2. ASAM Level-3.2 Clinically Managed

Residential Withdrawal Management, commonly referred to as social setting detoxification services; and

1. 3. ASAM Level 3.7-Medically Moni-

tored Inpatient Withdrawal Management, commonly referred to as modified medical detoxification services;

1. (C) If CCBHO staff determine that a faceto-face intervention is required based on the presentation of an individual, then that faceto-face intervention must occur within three

1. (3) hours; and

   1. (D) CCBHO staff shall monitor and have the capacity to report the length of time from each individual’s initial crisis contact to the face-to-face intervention and take steps to improve performance, as necessary.

2. (11) Care Coordination. CCBHOs shall actively pursue and promote collaborative working relationships with the broad array of community organizations and practitioners that provide services and supports for individuals receiving services from the CCBHO.

   1. (A) Consistent with requirements of privacy, confidentiality, and individual preference and need, CCBHO staff shall assist individuals and families of children and youth who are referred to external providers or resources in obtaining an appointment and confirming the appointment was kept.
   2. (B) Nothing about a CCBHO’s agreements for care coordination shall limit an individual’s freedom of choice of provider(s) with the CCBHO or its DCOs.

   3. (C) CCBHO policies and procedures shall promote and describe its care coordination roles and responsibilities, and whenever possible, the development of formal agreements with community organizations and practitioners that document mutual care coordination roles and responsibilities, with particular attention to emergency room, hospital, and residential treatment admissions and discharges. CCBHO policies and procedures shall ensure reasonable attempts are made and documented to—

      1. 1. Track admissions and discharges of

non-Medicaid eligible individuals to and from a variety of settings, and to provide transitions to safe community settings; and

1. 2. Follow up with individuals served

within twenty-four (24) hours following hospital discharge.

1. (D) For all individuals in the populations of focus, CCBHO staff shall inquire whether they have a PCP, assist individuals who do not have a PCP to acquire one, and establish policies and procedures that promote and describe the coordination of care with each individual’s PCP.
2. (E) For all individuals in the populations of focus, CCBHO staff shall document in the individual record the name of each individual’s PCP, indicate they are assisting him or her in acquiring a PCP, or the individual refuses to provide the name of their PCP or accept assistance in acquiring a PCP.

1. (12) Evidence-Based Practices. CCBHOs shall incorporate evidence-based, best, and promising practices into its service array.

   1. (A) CCBHOs shall have adopted, or be participating in a department-approved initiative, to promote trauma-informed care and 9 CSR 30-6

suicide prevention.

1. (B) CCBHOs shall have adopted with fidelity, a model for providing integrated treatment for co-occurring disorders approved by the department.

2. (C) CCBHOs shall demonstrate a continued commitment to adopting new evidencebased, best, and promising practices, such as—

   1. 1. Assertive Community Treatment

(ACT);

1. 2. Supported employment;
2. 3. Supported housing;
3. 4. Parent-Child Interaction Therapy;
4. 5. Dialectical Behavior Therapy;
5. 6. Multi-systemic Therapy; and
6. 7. First Episode Psychosis.

1. (13) Fee Schedule. CCBHOs shall publish a sliding fee discount schedule(s) that includes all available services. The fee schedule shall be included on the CCBHO website, posted in the waiting/reception area, and be readily accessible to individuals seeking services and their family members and other natural supports.

   1. (A) The sliding fee discount schedule shall be communicated in languages/formats appropriate for individuals seeking services who have Limited English Proficiency (LEP) or disabilities.
   2. (B) The fee schedule shall, to the extent relevant, conform to state statutory or administrative requirements or to federal statutory or administrative requirements that may be applicable to existing clinics. Absent applicable state or federal requirements, the schedule shall be based on locally prevailing rates or charges and include reasonable costs of operation.
   3. (C) CCBHOs shall have written policies and procedures describing eligibility for services in accordance with the sliding fee discount schedule. These policies and procedures shall be applied equally to all individuals seeking services from the CCBHO.
2. (14) Information Systems. CCBHOs shall maintain a health information technology

3. (HIT) system that includes, but is not limited to, electronic health records of all individuals served. Electronic health record systems must comply with state and federal regulations.

   1. (A) The HIT system must have the capability to capture structured information in individual records, including demographic information, diagnoses, and medication lists, provide clinical decision support, and electronically transmit prescriptions to the pharmacy.

4. (15) DCO Contracts. If the CCBHO enters into a contractual agreement(s) with a DCO, the contract shall include the following provisions:

   1. (A) DCO staff having contact with individuals served, and/or their families, are subject to the same training requirements as staff of the CCBHO;
   2. (B) The CCBHO coordinates care and services provided by the DCO in accordance with the individual’s current treatment plan;
   3. (C) The CCBHO is ultimately clinically responsible for all care provided;
   4. (D) The individual’s freedom to choose service providers is maintained;
   5. (E) All individuals have access to the CCBHO’s grievance procedures; and
   6. (F) Services provided by the DCO shall meet the same quality standards as those provided by the CCBHO.

5. (16) Governing Body Representation. CCB- HOs shall ensure individuals served and their parents/guardians, family members, and other natural supports have meaningful participation in the development and ongoing review of the organization’s policies and procedures, service delivery practices, and service array.

   1. (A) Meaningful participation shall be demonstrated by one (1) of the following:

      1. 1. At least fifty-one percent (51%) of the

governing body consists of individuals who are receiving or have received services for a serious mental illness, serious emotional disturbance, or substance use disorder, or the parents/guardian, family members/natural supports of individuals served;

1. 2. A substantial portion of the governing

body consists of individuals who are receiving services or have received services for a serious mental illness, serious emotional disturbance, or substance use disorder, or the parents/guardian, family members/natural supports of individuals served; or

1. 3. A transition plan is developed, with

timelines appropriate to the size of the governing body and target population, to establish a governing body with at least fifty-one percent (51%) or a substantial portion of the governing body consisting of individuals who are receiving services or have received services for a serious mental illness, serious emotional disturbance, or substance use disorder, or the parents/guardian, family members and other natural supports of individuals served.

1. (B) If the CCBHO is a subsidiary or part of a larger corporate organization and cannot meet the requirements identified in paragraphs (16)(A)1.-3. of this rule, the CCBHO shall have or develop an advisory structure or other specifically described process to ensure individuals who are receiving services or have received services for a serious mental illness, serious emotional disturbance, or substance use disorder, or the parents/guardian, family members and other natural supports of individuals served, have meaningful input to the governing body related to its policies and procedures, service delivery practices, and service array.
2. (C) CCBHOs may develop and implement an alternative process, which must be approved by the department, to ensure the governing body is responsive to the needs of individuals served and their parents/guardians, family members, natural supports, and the communities it serves.
3. (D) CCBHOs must be able to document input from individuals served and their parents/guardian, family members, natural supports, and communities served, including the impact on its policies, processes, and services.
4. (E) To the extent practicable, each CCBHO’s governing body and/or advisory board shall be representative of the populations served in terms of demographic factors such as, geographic area, race, ethnicity, sex, gender identity, disability, age, and sexual orientation.
5. (F) Each CCBHO’s governing body members or advisory board members shall be selected for their expertise in health services, community affairs, local government, finance and banking, legal affairs, trade unions, faith communities, commercial and industrial concerns, and social services within the communities served.
6. (G) No more than fifty percent (50%) of the governing body members may derive more than ten percent (10%) of their annual income from the health care industry.

AUTHORITY: sections 630.050 and 630.655, RSMo 2016.* Emergency rule filed March 20, 2019, effective July 1, 2019, expired Oct. 30, 2019. Original rule filed March 20, 2019, effective Oct. 30, 2019.

*Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.055, RSMo 1980.