In May of 2008, the U.S. House of Representatives announced July as “Bebe Moore Campbell National Minority Mental Health Awareness Month.”[1] The resolution was named after Bebe Moore Campbell, an author, advocate, co-founder of National Alliance on Mental Illness (NAMI) Urban Los Angeles and national spokesperson, who passed away in November 2006. The bipartisan resolution was intended to support to improve access to mental health treatment and services and promote public awareness of mental illness; and to enhance public awareness of mental illness and mental illness among minorities.

Despite the public attention that National Minority Mental Health Awareness Month generates, data continues to illustrate unfair, avoidable and remediable differences in health status between different populations. Most recently, the American Psychiatric Association concluded that “racial/ethnic, gender, and sexual minorities often suffer from poor mental health outcomes due to multiple factors including inaccessibility of high quality mental health care services, cultural stigma surrounding mental health care, discrimination, and overall lack of awareness about mental health.”[2] As states and programs wrestle with behavioral health system capacity, stigma, and issues related to parity, National Minority Mental Health Awareness Month provides an opportunity to examine the overall status of behavioral health in communities, as well as tools to support and improve systems serving individuals with serious mental illness (SMI). Specifically, these tools can help to bridge the health equity gap between the availability of behavioral health and social service supports available to minority populations.

For decades states have utilized §1915(c) HCBS Medicaid waivers to provide services and supports for seniors and persons with physical, intellectual, and developmental disabilities so that they may live in their communities. These waivers allow states to target customized health and social support services to certain populations, so long as the amount spent on such services is less than the cost of serving that person in an institutional setting.[3] Specifically, for waivers serving seniors and persons with physical disabilities, program costs are compared to costs of nursing facilities. For waivers serving persons with intellectual and developmental disabilities (IDD), program costs are compared to Intermediate Care Facilities (ICF). With respect to behavioral health, Medicaid does not provide coverage for Institutes of Mental Disease (IMD) (i.e., the classification for psychiatric hospitals). As such, there are no corresponding institutional costs to support an HCBS waiver for behavioral health services.[4]

However, in 2018, CMS issued guidance permitting states to apply for an §1115 demonstration waiver to provide coverage for services provided in an IMD for either mental health or substance use disorder (SUD) services.[5] As a result, states may now leverage IMD institutional costs to provide a full range of home and community based services that persons with SMI need in order to live and thrive in an integrated community setting. This approach not only provides sustainable revenue to support a historically underfunded system, it also creates a defined pathway toward an integrated system of care that stresses processes and settings that ensure a persons’ dignity, independence, and self-determination—values that can improve the lives of individuals with mental illness and strengthen the communities in which they live.

When States consider support options for persons living with SMI, a number of gaps are often identified in existing service systems that may be addressed via an HCBS waiver. For example, while housing inadequacy (i.e., attaining affordable housing and maintaining housing) often depends on timely payment of rental and utility bills, tenancy support services may help individuals manage behaviors and/or excessive noise, which can also be reasons why persons living with SMI lose housing. Similarly, while it’s widely acknowledged that food insecurity impacts overall health and wellbeing, medically managed home delivered meals may improve medication adherence, a significant factor in achieving quality outcomes for persons living with SMI. Finally, while stable employment may be attainable for persons living with SMI, supported employment services may assist with maintaining employment. 

Myers and Stauffer is available to assist States with opportunities to leverage HCBS waivers to strengthen behavioral health systems and to close the health equity gap. Specifically, our team of professionals are experts in developing HCBS strategies that achieve maximum program design flexibility. For example, we routinely meet with Medicaid and other agency leadership across the country to share and identify best practices; conduct data analyses and gather information from publicly available sources to support decision making; determine the need for waiver authority and recommend the appropriate approach to consultation with CMS; draft concept papers as needed to support internal communications and deliberations; consider how various waiver programs within a state should be aligned to meet overall state goals and objectives; conduct financial modeling; analyze enrollee, utilization and cost information to determine potential budget impact, assess alternative strategies, and conduct realistic sensitivity analyses. Moreover, our services also include working with internal and external stakeholders (e.g., consumers, providers, etc.) to communicate proposed changes and to obtain insight for program design and implementation.

If you would like more information about how Myers and Stauffer can support your state’s behavioral health system initiatives, please contact one of our contributors listed below.




[4] CMS State Medicaid Manual § 4309


Bobby Courtney, JD, MPH
Julia Kotchevar, MA
Senior Manager