As states continue to build out mental health crisis systems following the implementation of 988 and the opportunity to receive an enhanced Medicaid match under the American Rescue Plan Act (ARPA) for mobile crisis services, considerations for how to leverage limited behavioral health workforce are at the forefront. States are expanding opportunities for peers — non-licensed individuals with lived mental health or substance use disorder (SUD) experience — to support components of mental health crisis services. Leveraging this lived experience, peer services offer states a certified workforce that can provide navigation and other services across a complex system.
States are taking different approaches to incentivize the integration of Medicaid coverage for peer services in behavioral health. Specifically, states have expanded opportunities to leverage peers as part of a core continuum of crisis services that includes crisis call centers, mobile mental health teams, and facility-based care. As states take steps to enhance crisis services, including peer services along this continuum can be a workforce strategy to expand capacity.
Call center staff — which can include peers — answer calls or texts from individuals in mental health crisis and provide telephonic intervention. Peers can serve as staff on these lines but can also serve as connectors via peer-run warmlines. In New Mexico, the state’s peer-to-peer warmline works in conjunction with the New Mexico Crisis Access Line. Staff triages calls, offering an option to be connected to either a peer or a clinician, and connects them accordingly.
In order to be eligible for the enhanced Medicaid match for crisis services in ARPA, mobile teams must be composed of at least one licensed clinician and one other mental health worker, which can be a peer. The enhanced match provides an incentive for states to expand these services, and peers as a workforce bring not only lived experience but are able to be trained and certified quickly. Peers are, in fact, noted in the enabling statutory language as an option for inclusion on these teams, and many states are already taking this approach. Minnesota Medicaid, for example, covers peers as members of mobile teams, allowing them to bill for services that help to stabilize individuals in crisis in the community.
When an individual is assessed to need a higher level of care, crisis stabilization and receiving facilities are able to provide inpatient or 23-hour care. Michigan allows billing for peers serving Medicaid recipients as members of care teams within crisis stabilization units. Peers in these settings can provide supportive services, including necessary transition and recovery-oriented care. Virginia has also designed an additional community stabilization crisis benefit to ensure post-crisis follow up care, services that may include those delivered by peers.
This chart highlights the policy components of these four states’ approaches to including peers in providing services across the crisis continuum.
| State | Funding and Payment Authority | Service Design | Peer Certification & Supervision Requirements | Managed Care Billing Guidance |
| New Mexico: Call Centers | Community Mental Health Services Block Grant 24/7 Crisis Access Line services, including warm handoffs to peer-to-peer warmline are Medicaid reimbursable |
| Certified Peer Support Worker: Education: High school diploma or equivalent Exam: State exam Training and Experience:
Continuing Education: 40 CEUs every 2 years Supervision: Master’s level licensed professional | Contract requires that core services agencies have 24/7 crisis services available. The state’s Medicaid behavioral health provider manual also enumerates peer services, including safety planning as part of crisis response, and notes that crisis call encounters are billable. |
| Minnesota: Mobile Crisis Teams | State Plan Amendment (SPA) | Minnesota Medicaid covers peer services during all stages of crisis response:
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| Michigan: Crisis Stabilization Units | SPA | Crisis residential services/intensive crisis stabilization services: Peer support specialists may be part of multidisciplinary teams and can facilitate activities based on their scope of practice, including facilitating peer support groups, assisting in transitioning individuals to less intensive services, and mentoring towards recovery. | Education: High school diploma, GED, or provide college transcripts Exam: Pass a written exam with at least 71% Training and Experience:
Continuing Education: Attend professional advancement opportunities to maintain skills Supervision: Supervised by Qualified Mental Health Professional | Medicaid managed care organizations must include the choice of working with Certified PeerSupport Specialists (CPSS) as an option for individuals throughout the service array. |
| Virginia: Post-Crisis Follow-Up | SPA | Community stabilization:These services, many of which can be provided by Peer Recovery Specialist registered in the state, continue to provide stabilization to individuals within their communities and support the individual and/or support system during the period between either an initial mobile crisis response and entry into an established follow-up service at the appropriate level of care; or transitional step-down from a higher level of care if the next level of care service is identified but not immediately available for access. Community stabilization is an alternative to or diversion from inpatient hospitalization, residential crisis stabilization unit, or other, more intensive level of care. Community stabilization teams must be available to provide services to any individual in their home, workplace, or other convenient and appropriate setting and must be able to schedule appropriate services 24 hours per day, 7 days per week. Covered services components of Community stabilization include:
| Certified Peer Recovery Specialist:Education: High school diploma, GED, or equivalent Exam: IC&RC Exam Training and Experience:
Continuing Education: N/A Supervision: 25 hours specific to domains Other:
National Certified Peer Recovery Support Specialist (NCPRSS): Education: GED or high school diploma Exam: Passing score on the NCPRSS exam Training and Experience:
Continuing Education: N/A Supervision: 200 hours of direct practice (volunteer or paid) in a peer recovery support environment (supervisor-attested) Other: Candidate must submit a signed statement that they have read and adhere to the NAADAC/NCC AP Peer Recovery Support Specialist Code of Ethics. | Managed care contractors must include medically necessary peer services as a part of community mental health rehabilitation services. |
Acknowledgements: This blog and chart were supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award under the National Organizations of State and Local Officials (NOSLO) cooperative agreement totaling $836,859.00. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov. The authors would like to thank state leaders working with NASHP on enhancing mental health crisis services in rural areas for their thoughtful discussion on this topic.
