OCA proposes a behavioral‑health‑in‑primary‑care module to avoid double counting and better capture integrated care

The Office of Health Care Affordability proposed a behavioral health and primary care module to capture services provided in primary care settings that qualify as behavioral health while avoiding double counting in total medical spending calculations.

The module would identify services that fall within OCA’s primary care definition (by provider taxonomy and place of service) and also qualify as behavioral health when accompanied by a behavioral health primary diagnosis. Debbie Lindes, manager in OCA’s Healthcare Delivery System Group, said the module "allows OCHA to calculate combined behavioral health and primary care spend without double counting" and "separately identify spending for behavioral health care that's provided in a primary care setting, which can support further integration."

What OCA proposes - Expand the primary care provider taxonomy to include certain behavioral health professionals (for example, psychologists, social workers and marriage and family therapists) so that integrated behavioral health services billed with primary care codes will appear in both categories and be placed in the module (the shared green intersection in OCA slides). - Count primary‑diagnosis behavioral health services delivered in primary care (e.g., screening, brief integrated interventions, medication monitoring) as part of both primary care and behavioral health; therapy codes (longer psychotherapy codes) would continue to be counted as behavioral health only. - Use the same capitation apportionment formula (FFS equivalent ratio) with encounters that use behavioral‑health‑in‑primary‑care codes to apportion capitation for the module.

Stakeholder feedback and tradeoffs - Several participants welcomed the module as a way to avoid double counting and to expose integrated care spending, but asked for a concrete CPT/code list. Kevin (surname not given) requested OCA provide the specific CPT codes that would be included and excluded so payers and providers can assess accuracy. - Concerns were raised about falsely attributing freestanding behavioral health clinicians as integrated primary care when place-of-service or organizational affiliation is indistinguishable in claims. OCA staff acknowledged that it cannot reliably tell whether a clinician billed from an office belongs to an integrated team versus a freestanding practice and therefore plans to limit the primary care code set to a narrow list tied to integration (screening, brief intervention, collaborative care codes). - On diagnosis coding, OCA would use the primary diagnosis on the claim; staff noted this will undercount integrated behavioral health when behavioral health appears as a secondary diagnosis. - Collaborative care and medication‑management visits billed under collaborative care CPT codes would fall into the module and therefore be counted as both behavioral health and primary care in modular reporting.

Why this matters: integrated behavioral health is often delivered in primary care settings. Without a module, counting such services only as primary care would undercount behavioral health investment and distort where services are delivered; counting them only as behavioral health would understate primary care’s role in integration.

Next steps: OCA committed to circulate the proposed CPT/code set and taxonomy changes for review and said it may present the revised list before the March or April meetings. The office also asked stakeholders to review how peer supports, school‑based clinics and emerging workforce models should be reflected in the taxonomy.

Ending: OCA staff said expanding the taxonomy is intended to "reduce the undercount" of integrated behavioral health but recognized remaining limits because many therapy codes and organizational affiliations are not reliably identified in claims.