SD CCBHC Provider Cohort 1 Application

CCBHC Provider Cohort 1 Application
Core CCBHC Program Requirements

The following questions center around your organization's alignment with several of the core required components of Certified Community Behavioral Health Clinics.

Eligible providers must meet each of the following criteria and all identified Statutory Organizational Requirements in order to consider becoming certified as a CCBHC:*

Rows	Yes/No	Have you held this accreditation for at least 2 years?
Accredited through the DSS Office of Licensing and Accreditation (OLA) as a Community Mental Health Center (CMHC) or accredited by a national accreditation body for relevant services such as National Committee for Quality Assurance (NCQA), The Joint Commission (TJC), and the Commission on Accreditation or Rehabilitation Facilities (CARF)
Accredited through OLA as a Substance Use Disorder Treatment Program for Early Intervention, Outpatient, and Intensive Outpatient Treatment
Accredited through OLA as a Substance Use Disorder Treatment Program for Prevention

Is a non-profit organization, exempt from tax under Section 501(c)(3) of the United States Internal Revenue CodeIs part of a local government behavioral health authorityIs operated under the authority of the Indian Health Service, an Indian tribe, or tribal organization pursuant to a contract, grant, cooperative agreement, or compact with the Indian Health Service pursuant to the Indian Self-Determination Act (25 U.S.C. 450 et seq.)Is an urban Indian organization pursuant to a grant or contract with the Indian Health Service under Title V of the Indian Health Care Improvement Act (25 U.S.C. 1601 et seq.)None of the above
Governance

CCBHC governance must be directly informed by individuals served. The CCBHC must incorporate meaningful participation from individuals with lived experience of mental and/or substance use disorders and their families, including youth.
Option 1: At least 51% of the CCBHC governing board is comprised of individuals with lived experience of mental and/or substance use disorders and their families.Option 2: Other means are established to demonstrate meaningful participation in board governance involving people with lived experience (such as creating an advisory committee that reports to the board). The CCBHC provides staff support to the individuals involved in any alternate approach that are equivalent to the support given to the governing board.If neither is accurate, please explain how your board design represents people with lived experience.
If Option 1 is chosen, describe how your organization meets this requirement, or provide a transition plan with a timeline that indicates how it will do so. *
If option 2 is chosen, describe how your organization meets this requirement, or provide a transition plan with a timeline that indicates how it will do so. *

CCBHC Provider Cohort 1 Application
Core Service Components

The following questions center around your organization's current service delivery and its alignment with required CCBHC services.
YesNo
No individual is denied services based on inability to payA sliding fee discount schedule is available and posted for patientsNo individual is denied behavioral health care services because of place of residence, homelessness, or lack of a permanent addressOther
Required CCBHC Services

The CCBHC Certification Criteria stipulates nine (9) required services that certified clinics must deliver or partner with a community-based agency to deliver on their behalf. The official Scope of Services can be reviewed in the Certification Criteria document available at the hyperlink below (beginning on page 25). Please reference this for any specific service definitions as you complete the matrix.

https://www.samhsa.gov/sites/default/files/ccbhc-criteria-2023.pdf
IMPORTANT NOTE: The application form and Program Narrative questions (required attachment) will be used collectively to capture information about your organization’s current readiness to implement required activities of being a CCBHC. The categories presented here are not exhaustive as several elements (e.g., development of required community-based services for veterans and members of the armed forces) will be collaboratively developed as part of the Cohort Learning Community.

Assessment of direct services required to be provided by the CCBHC*

Rows	Current Status	Will be active by	Current Status Update or Progress to Implementation
General Service: Access to Emergency / Crisis Care (immediate response)
General Service: Access to Urgent Needs Care (w/in 1 business day)
General Service: Access to routine needs care (w/in 10 business days)
2. Risk assessment / triage for behavioral health conditions
2. Initial evaluations that include diagnoses, immediate care needs, etc.
2. Comprehensive functional assessments (evaluations)
2. Brief intervention services in the event unsafe substance use is identified during screening
4. Outpatient mental health services including psychopharmacological treatment
4. Outpatient substance use disorder services in alignment with ASAM Levels 1 and 2.1

Assessment of direct services required to be provided by the CCBHC or a Designated Collaborating Organization (DCO)*

Rows	Current Status	How is it / will it be Provided	Will be active by	Current Status Update or Progress to Implementation
1. Able to provide same-day services to unscheduled clients
1. Emergency crisis intervention services
1. 24-hour mobile crisis care
1. Crisis receiving and stabilization services
1. Suicide prevention and intervention services
1. Overdose prevention including access to naloxone
5. Screening capable of identifing people receiving services that also have chronic diseases
5. Screening that ensures people receiving services are asked about physical health conditions
5. Care coordination with primary care and specialty health providers
5. Able to ensure ongoing periodic laboratory testing and physical measurement of health indicators
6. Targeted case management services beyond care coordination
7. Psychiatric rehabilitation services for both mental health and substance use disorders
7. Supported employment programs designed to help obtain or maintain employment
7. Support for clients finding and maintaining safe and stable housing
9. Community-based mental healthcare for members of the Armed Forces and Veterans

CCBHC Provider Cohort 1 Application
Partnership Requirements

CCBHCs are required by statute to develop partnerships with the below organizations that operate within the service area.

Please indicate your organization's current status of the following REQUIRED partnerships to facilitate care coordination within the CCBHC Certified Criteria or as defined in the SD CCBHC Provider Manual*

Rows	Current partnership?	Notes about the partnership
South Dakota's 988 Suicide and Crisis Lifeline call center
Federally Qualified Health Centers and Rural Health Clinics
Inpatient psychiatric treatment providers
Residential or inpatient facilities that serve children and youth (e.g, Psychiatric Residential Treatment Facilities)
Opioid Treatment Programs
Specialty providers including those who prescribe medications for the treatment of opioid and alcohol use disorders
Indian Health Service or other tribal programs
Medical withdrawal management facilities
Ambulatory medical withdrawal management providers for substance use disorders
Residential substance use disorder treatment programs, including tribally operated mental health, substance use, and crisis services
Emergency departments

Important Definitions for completeing the below section:

Formal Agreement: Signed MOU, MOA, data sharing agreement, or formal contract
Shared Protocol Only: Shared referral protocols or care pathways established, but no formal written agreement
Informal / Unwritten: Working relationship exists but not formally documented
None Currently: No partnership in place. Notes should include development plan.
Not Available: Partner type does not exist in the Designated Service Area

Please indicate your organization's current status of the following REQUIRED partnerships for community or regional services and supports within the CCBHC Certified Criteria*

Rows	Current partnership?	Notes about the partnership
Schools
Child welfare agencies
Juvenile and criminal justice agencies and facilities (including drug, mental health, veterans, and other speciality courts)
Indian Health Service youth regional treatment centers
State licensed and nationally accredited child placing agencies for therapeutic foster care service
Substance use prevention programs
Other social and human services

Please indicate your organization's current status of the following additional partnerships determined in response to needs of the population in your organizations proposed Designated Service Area*

Rows	Current partnership?	Notes about the partnership
Homeless shelters
Housing agencies
SUD recovery / transitional housing providers
Employment services systems
Peer-operated programs
Services for older adults, such as Area Agencies on Aging
Aging and Disability Resource Centers
State and local health departments and behavioral health and developmental disabilities agencies
Criminal and juvenile justice, including law enforcement, courts, jails, prisons, and detention centers
Legal aid
Programs and services for families with young children (e.g., WIC, Head Start)
Coordinated speciality care programs for first episode psychosis
Other social and human services

CCBHC Provider Cohort 1 Application
Care Coordination Requirements

CCBHCs are expected to coordinate care across settings and providers to ensure seamless transitions for patients across the full spectrum of health services, including acute, chronic, and behavioral health needs.

As an assessment of current care coordination capacity, respond with the current status or future interest in your organization's implementation of CCBHC care coordination requirements*

Rows	Current Status	How is it / will it be Provided	Will be active by	Current Status Update or Progress to Implementation
Coordinates access to physical health care
Coordinates access to supporting services (social services, housing, educational systems, etc)
Coordinates with the criminal and juvenile justice system
Facilitates appropriate consent for sharing information with community partners
Assists those referred to an external provider in obtaining an appointment and tracks participation in services
Develops crisis plans with each person receiving services
Makes reasonable attempt to determine any medications prescribed by other providers to its patients
Consults with the PDMP before prescribing medications
Assists people receiving services and families to access benefits, including Medicaid

CCBHC Provider Cohort 1 Application
Required Attachments
Three attachment files are required for applications to be considered complete:
- Attachment 1: Letter of Intent (.pdf signed by the authorized organization representative)
- Attachment 2: Program Narrative (.pdf)
- Attachment 3: CCBHC Implementation Timeline (.pdf)
Optional attachments include:
- Completed Community Health Needs Assessment (.pdf)
- Key Personnel documentation at the discretion of the applicant (.pdf)
Multiple files can be uploaded into the field below.
Attachments*

Please upload your completed Program Narrative, Letter of Intent, and CCBHC Implementation Timeline here. Multiple files accepted.
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Completed Independent CCBHC Cost Report*

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CCBHC Provider Cohort 1 Application
Cost Reporting Requirements

CCBHCs are required determine a PPS rate for providing services. This rate will be determined through the CCBHC Cost Report Template and must be approved by the Division of Behavioral Health.
A cost report covering current actual and anticipated costs for new services is required to be completed by all applicants prior to June 1, 2026. This report must include a review of a recent 12-month period for all providers associated costs for services currently provided that would qualify as allowable CCBHC billable services (found in the South Dakota CCBHC Provider Manual). Reports must include actual historical costs as well as anticipated costs for operating additional required CCBHC services not currently provided by the applicant. It is expected that anticipated costs will be estimated. All cost reports must be prepared using the CCBHC Cost Report template published by CMS, available at Medicaid.gov.

CCBHC Cost Report template, instructions, and federal cost principles are available HERE.
Completed in partnership with Myers & StaufferIn Progress, but will be completed by June 1, 2026 in partnership with Myers & StaufferWill be completing independently by June 1, 2026Completed independently and is available to upload
CCBHC Cost Report

Please upload your completed CCBHC Cost Report.
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CCBHC Provider Cohort 1 Application
Your application is ready to submit.

On behalf of the Division of Behavioral Health, SD Department of Social Services, thank you for completing this application. Click "Review Before Submit" to complete your final application review. On the review page you will need to click "Submit" to officially transmit your application. Once submitted, you will receive an email confirmation with a copy of your application to the contact information provided at the beginning of the application form. You will also have the option to print your application from the review page before final submission.
Additional comments (optional):
Thank you for your interest in the CCBHC program.

On behalf of the Division of Behavioral Health, SD Department of Social Services, thank you for your interest in the CCBHC model and its implementation across South Dakota. Your interest in becoming a DCO will be forwarded to leadership and relayed to entities that apply to be part of the 2026 cohort. Click "Submit" to close this form.
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Rural Behavioral Health Modernization (CCBHC) Cohort Application: Certified Community Behavioral Health Clinics

CCBHC Provider Cohort 1 Application

Designated Service Area

CCBHC Provider Cohort 1 Application

Core CCBHC Program Requirements

CCBHC Provider Cohort 1 Application

Core Service Components

CCBHC Provider Cohort 1 Application

Partnership Requirements

CCBHC Provider Cohort 1 Application

Care Coordination Requirements

CCBHC Provider Cohort 1 Application

Required Attachments

CCBHC Provider Cohort 1 Application

Cost Reporting Requirements

CCBHC Provider Cohort 1 Application

Your application is ready to submit.

Thank you for your interest in the CCBHC program.