Medicaid and CHIP coverage of peer support services — coverage criteria
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Clarifies federal CMS guidance on establishing Medicaid/CHIP coverage of peer support services, supervision, training, and allowable program designs; intended for states, Medicaid agencies, and stakeholders implementing peer support benefits.
No material clinical or coverage changes in this revision.
Coverage Criteria for Peer Support Services
State-defined coverage criteria
Covered when states include peer support services under an appropriate Medicaid/CHIP authority and meet specified program elements:
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There is no federal requirement that peer support providers or recipients have any specific mental health or substance use disorder diagnosis. Federal guidance expects states to define training and certification requirements for peer support providers, including basic competencies and ongoing continuing education, but the specifics are set by each state. The guidance also notes that peers "should be self-identified consumers who are in recovery from mental illness or substance use disorders" and must "demonstrate the ability to support the recovery of others."
State Specification and Provider Responsibilities
State plan or waiver must define service scope and unit of service
States must specify the amount, duration, and scope of peer support services and identify the unit of service and provider in the Medicaid authority or waiver used; if added to CHIP, a state plan amendment describing these elements is required.
- Identify the Medicaid authority to be used for coverage and payment (e.g., rehabilitative services, preventive services, 1915(b), 1915(c) waivers).
- Specify the unit of service and the provider of the service in state plan or waiver documentation.
- If adding peer support to CHIP, submit a state plan amendment that describes amount, duration, scope, and any limitations of the benefit.
Document service, provider qualifications, and unit-based reimbursement
States must identify the Medicaid authority to be used, describe the service, the provider of the service, and their qualifications in full detail; reimbursement must be based on an identified unit of service provided by one peer support provider, based on an approved plan of care.
- Describe provider qualifications and the specific service definition in the state plan or waiver.
- Ensure reimbursement is tied to an identified unit of service provided by a single peer support provider and documented in an approved plan of care.
- Provide assurances of mechanisms to prevent over-billing (for example, utilization management methods).
Coordinate peer support within individualized plan of care and document benefit limits
Peer support services must be coordinated within an individualized, goal-oriented plan of care that reflects participant needs and preferences; states must describe amount, duration, and scope of the benefit (including limitations) in state plan amendments for CHIP when applicable.
- Ensure each peer support encounter is tied to an individualized, goal-oriented plan of care with measurable goals and results.
- Document amount, duration, and scope of services (and any limits) in the state plan or waiver; include these elements in CHIP state plan amendments if CHIP coverage is added.
Risk of denial if authority, service definition, or billing safeguards are missing
States must identify the Medicaid authority to be used, describe the service, provider qualifications, and ensure reimbursement is based on an identified unit of service provided by one peer support provider based on an approved plan of care; states must provide assurances of mechanisms to prevent over-billing.
- Failure to specify authority, service definition, provider qualifications, unit of service, or plan-of-care basis for reimbursement may result in noncompliance with federal guidance and risk denial of claims or program approval.
- Maintain utilization management or other mechanisms to prevent over-billing as required in the SMD letter.
Background on Peer Support Services
Peer support services are delivered by self-identified individuals with lived experience of mental health conditions and/or substance use disorders who demonstrate the ability to support others' recovery. Evidence summarized in federal guidance indicates peer support can increase engagement in treatment and reduce emergency department use, rehospitalization, and criminal justice involvement. States implementing peer support benefits must define the service model, provider qualifications, training and continuing education, supervision arrangements, and the amount, duration, and scope of the benefit within the applicable Medicaid or CHIP authority.
Key Definitions
Settings and Level of Care
Peer Support Specializations and Modalities
Peer support specialization
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Amount, Duration, and Scope
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