Key Takeaways
- A rapidly expanding evidence-based model. Commercial-market CoCM penetration grew roughly 27-fold (from 2.2 to 58.8 patients per 100,000 eligible commercially insured individuals) between 2018 and 2023, according to a May 2025 Milliman analysis commissioned by Path Forward and conducted in partnership with the American Psychiatric Association. A separate February 2026 progress report from Shatterproof and the Bowman Family Foundation, using a different denominator (per 100,000 individuals with a diagnosed mental health or substance use condition), reported a 26-fold increase from 12 to 317 patients between 2018 and 2024.
- Strong evidence base. CoCM has been validated in more than 90 randomized controlled trials, with documented improvements in depression and anxiety outcomes, reduced symptom severity, and improved cost-effectiveness through reductions in unnecessary hospitalization and higher-intensity care.
- Uneven Medicaid adoption. As of mid-2025, 36 state Medicaid programs covered the four CoCM billing codes, after Colorado and Tennessee added coverage on July 1, 2025, with substantial state-by-state variation in reimbursement rates and provider requirements.
- Workforce and reimbursement remain the binding constraints. Trilliant Health’s 2026 Behavioral Health Report found that fewer than 10 percent of behavioral health providers are MD or DO psychiatrists, and Medicaid reimbursement for CoCM codes still trails Medicare in many states, slowing adoption among the primary care practices the model is designed to support.
For most of the past two decades, the search for a way to integrate behavioral health into primary care has been a story of small pilots, federal demonstrations, and well-intentioned partnerships that have struggled to scale. The Collaborative Care Model is the closest thing the field has to a counterexample. Developed at the University of Washington in the 1990s, formally recognized by CMS as a reimbursable service in 2017, and now adopted by Medicare, most large commercial payors, and a growing majority of state Medicaid programs, CoCM has gone from research curiosity to the integration model the rest of behavioral health is increasingly being measured against. The question is no longer whether it works. The question is who can deliver it, who can afford it, and whether the financing structures that have brought it this far will hold under the Medicaid environment that took shape in 2025 and 2026.
The growth curve is unambiguous. A May 2025 Milliman analysis, commissioned by the Meadows Mental Health Policy Institute on behalf of Path Forward and in partnership with the American Psychiatric Association, reviewed CoCM utilization among 219 million Americans (roughly two-thirds of the U.S. population) using a denominator of total eligible insured individuals. Among commercially insured Americans, CoCM penetration grew from 2.2 patients per 100,000 in 2018 to 58.8 per 100,000 in 2023, a 27-fold increase. Growth was meaningful but more modest in other payor segments: 10.0 to 56.1 patients per 100,000 in Original Medicare (a 5.6-fold increase, 2018 to 2022), 11.5 to 64.8 per 100,000 in Medicare Advantage (5.6-fold), and 4.2 to 32.1 per 100,000 in Medicaid and CHIP (7.7-fold). A separate February 4, 2026 progress report from Shatterproof and the Bowman Family Foundation, using a narrower denominator (per 100,000 individuals diagnosed with a mental health or substance use condition), reported that CoCM use among commercially insured patients grew 26-fold, from 12 to 317 patients per 100,000, between 2018 and 2024. Both analyses confirm the same structural conclusion: states with high Medicaid CoCM use also had high use across Medicare and commercial insurance, while states with low Medicaid adoption consistently lagged across all payor types. State Medicaid policy is the variable that most reliably predicts whether CoCM is being delivered, regardless of who is paying.
What the Collaborative Care Model is, and why the evidence base is strong
CoCM is a team-based, measurement-driven approach to managing common behavioral health conditions, principally depression and anxiety, within the primary care setting. The core team has three members: a primary care provider, a behavioral health care manager (typically a licensed clinician trained in social work, psychology, or nursing), and a psychiatric consultant. The care manager conducts initial screenings using validated instruments, supports the primary care provider in developing and adjusting treatment plans, and maintains contact with the patient between visits. The psychiatric consultant reviews the practice’s caseload through a registry, often without seeing patients directly, and recommends medication or therapy adjustments for patients who are not improving. The model leverages psychiatrists’ time across multiple primary care practices, a structural feature that has been credited with allowing a single consulting psychiatrist to reach substantially more patients than a traditional referral arrangement: Path Forward estimates a roughly 8-fold extension; the Meadows Mental Health Policy Institute’s Healthy Minds analysis estimates approximately 13 times more patients reached over a psychiatrist’s lifetime (226,800 patients in CoCM versus 17,500 in traditional psychiatry); and the AMA has quoted Harvard Medical School’s Dr. Rebecca Weintraub Brendel describing the extension as “twentyfold.”
The model’s five core principles, as defined by the AIMS Center, are patient-centered team care, population-based care (tracked through a registry), measurement-based treatment to target (with validated rating scales such as the PHQ-9 for depression and GAD-7 for anxiety), evidence-based care, and accountable care (in which reimbursement is linked to quality of care delivered). The combination of these elements distinguishes CoCM from earlier “co-located” behavioral health integration efforts, which often placed a therapist in a primary care practice without the registry, the psychiatric consultant, or the structured treatment-to-target framework.
The empirical literature is unusually deep for a behavioral health delivery model. Path Forward and MMHPI estimate that more than 90 randomized controlled trials have evaluated CoCM, with consistent findings of improved mental health outcomes, reduced symptoms, and improved recovery rates, particularly for depression and anxiety. Specific findings cited in the literature include a 7x reduction in remission time for depression and significant cost savings tied to reductions in unnecessary hospitalization and higher-intensity care, both reported by Path Forward citing peer-reviewed work. Path Forward also estimates the model could prevent approximately 14,000 suicide deaths annually if implemented nationwide, an estimate attributed to Andy Keller, president and CEO of the Meadows Mental Health Policy Institute. Sheppard Pratt, a major behavioral health system that has implemented CoCM through its Greater Baltimore Medical Center partnership, has cited 80-plus RCTs in its policy advocacy for Maryland Medicaid coverage expansion. The model’s evidentiary depth is a meaningful contrast to the broader behavioral health reimbursement environment Acuity has documented, where payors often fund interventions for which the evidence base is weaker than CoCM’s simply because billing codes exist for them.
How Medicare reimbursement for CoCM codes changed the trajectory
CoCM existed as a clinical model for nearly 25 years before it became a reimbursable service. In 2017, CMS established three CPT codes specific to CoCM (99492, 99493, and 99494) for monthly billing of initial and subsequent CoCM services, with reimbursement beginning January 1, 2018. CMS subsequently added HCPCS code G2214 for shorter monthly service periods. The codes can be billed only by primary care providers or non-physician practitioners working in primary care, not by the psychiatric consultant or behavioral health care manager directly. The structure was designed to make the financial sustainability of integration the primary care practice’s responsibility, while preserving the consulting model that allows specialty behavioral health to scale.
The Medicare reimbursement structure is meaningful because the codes pay for the non-face-to-face work that earlier integration efforts could not bill. Care manager outreach, registry review, curbside psychiatric consultation, and treatment-plan adjustment between visits all fall within what the CoCM codes are designed to cover. Prior to 2017, the literature consistently identified the inability to bill for this indirect care as one of the principal barriers to CoCM adoption. A 2017 review in Focus, the American Psychiatric Association’s journal, identified the absence of reimbursement for non-face-to-face contact, curbside consultation, and caseload-focused registry reviews as the central economic obstacle to widespread adoption. The 2017 CMS coverage decision directly addressed that obstacle, though it did not eliminate it.
The uptake has been substantial but uneven. According to studies analyzing Medicare data, fewer than 0.1 percent of eligible beneficiaries received CoCM services billed under the new codes in the first years of coverage. Adoption has accelerated as commercial payors followed Medicare’s lead and as state Medicaid programs added the codes, but a 2025 study published in Administration and Policy in Mental Health and Mental Health Services Research noted that provider hesitance to use the CoCM codes has persisted, particularly in states that have been late to adopt them for Medicaid. The complexity of the billing requirements, the registry and measurement-based-care infrastructure required for compliance, and the workforce challenge of recruiting and retaining behavioral health care managers all factor into the uneven adoption pattern.
State Medicaid coverage of CoCM is expanding but heterogeneous
The state Medicaid landscape is where most of the action has taken place in the past two years. As of July 1, 2025, Colorado and Tennessee added CoCM billing codes to their Medicaid coverage, joining 34 other states for a total of 36 state Medicaid programs covering Collaborative Care, according to Path Forward’s Collaborative Care Coalition tracking. A separate count cited in a 2025 Administration and Policy in Mental Health study put the figure at 38 state Medicaid programs as of June 2025, a discrepancy that reflects the granularity of how “coverage” gets defined: some states have activated the codes only for limited populations (dually eligible Medicare-Medicaid beneficiaries, for instance) or with restrictions that other states have not imposed.
The state-by-state variation is consequential. North Carolina Medicaid, an early adopter, increased its CoCM reimbursement rate to 120 percent of the Medicare fee-for-service rate in December 2022 (up from 70 percent of Medicare), removed copays for CoCM services, and earmarked $5 million in state funds for capacity building among primary care practices implementing the model. North Carolina contracted with Community Care of North Carolina and the North Carolina Area Health Education Centers to provide implementation support. Massachusetts, by contrast, has been identified in a May 2025 Massachusetts Health Policy Forum issue brief as a state where MassHealth reimburses CoCM codes at rates below Medicare, even though it matches Medicare on psychotherapy and psychiatric consultation. The same Massachusetts Health Policy Forum brief recommended that the state raise CoCM rates at least to Medicare levels and permit FQHCs and Rural Health Clinics to use the standard CoCM CPT codes and G2214 in lieu of the bundled G0512 currently required.
The pattern is one Acuity has tracked elsewhere in behavioral health: federal action establishes a framework, state-level implementation determines who actually benefits, and the rate-setting decisions that follow are made under fiscal pressure that does not always reflect clinical evidence. The KFF 50-state Medicaid budget survey for fiscal year 2026 noted that the number of states planning behavioral health rate increases dropped from 23 in FY 2025 to 14 in FY 2026, a contraction that complicates the operational case for primary care practices considering whether to invest in CoCM infrastructure. Acuity has reported on the same fiscal contraction in connection with Medicaid managed care behavioral health spending, where the rates and contracts that govern most public-payor behavioral health are tightening at the same time CoCM is asking primary care to take on more responsibility for managing mental health conditions.
Why primary care practices implement CoCM, and where it falls apart
Beyond the reimbursement question, implementation is technically demanding. CoCM requires a primary care practice to establish workflows for systematic screening (typically PHQ-9 and GAD-7 at intake and on follow-up), to maintain a population-based registry of patients in active CoCM treatment, to hire or contract a behavioral health care manager, to engage a consulting psychiatrist, and to document the time-based service delivery that the CPT codes require. For a small or mid-sized primary care group, the up-front investment can be material, and the reimbursement cycle does not begin until the patients have been engaged in care for the requisite minimum monthly time (70 minutes for the initial 99492 code, 60 minutes for the subsequent 99493 code).
Case studies suggest the model can reach financial sustainability quickly when the operational support is in place. Primary Care IPA, the first organization in Western New York to implement CoCM across adult and pediatric populations, reported in a May 2025 case study that a review of more than 12 successful practices demonstrated financial viability within months of implementation. The Meadows Mental Health Policy Institute has documented implementation case studies at Family Medicine Centers in the Texas Panhandle (rural), Baylor Scott & White Health (more than 7,000 patients served), and Texas A&M University Health Services (more than 77,000 students), each with technical assistance from MMHPI. The recurring pattern in successful implementations is leadership commitment, technical assistance for billing and registry workflows, and a clinical champion within the primary care practice.
The workforce constraint is harder to engineer around. Trilliant Health’s 2026 Behavioral Health Report found that fewer than 10 percent of behavioral health providers are MD or DO psychiatrists, with the majority of the workforce comprised of master’s-level clinicians whose scope of practice limits their ability to prescribe medication or manage the full range of behavioral health conditions. The same report found that allied health providers, principally nurse practitioners and physician assistants, became the most common prescribing provider type for SSRIs, SNRIs, mood stabilizers, and stimulants between 2018 and 2024, growing from 20.7 percent to 34.3 percent of total prescription volume. The arithmetic creates pressure on the CoCM model: psychiatric consultants are the scarcest input, primary care providers are increasingly burdened, and the behavioral health care manager role is being filled by clinicians who often have other employment options at higher pay. Acuity has documented similar tradeoffs in how the behavioral health workforce is responding to reimbursement and administrative pressure and in related coverage of the dual-diagnosis billing silos that complicate integrated care.
What the federal and state policy environment is doing to CoCM
The policy outlook is mixed. On the federal side, CMS launched the Innovation in Behavioral Health Model in January 2025 with three Cohort I state Medicaid agencies (Michigan, New York, and South Carolina), each receiving up to $7.5 million in cooperative agreement funding to design integrated, value-based payment models that complement CoCM and broader behavioral health integration. The IBH Model’s Cohort II Notice of Funding Opportunity, released in October 2025, will add up to five additional states starting January 2027. CCBHC-state demonstrations remain active in multiple states, and SAMHSA’s Promoting the Integration of Primary and Behavioral Health Care (PIPBHC) program has continued to provide CoCM-specific grant support for safety-net providers.
The One Big Beautiful Bill Act, signed July 4, 2025, complicates the picture. The law’s approximately $1 trillion in federal Medicaid cuts over a decade, combined with work requirements taking effect January 1, 2027 and six-month redeterminations beginning December 30, 2026, will reduce the Medicaid population eligible for any behavioral health services, CoCM included. The law’s narrow behavioral health exemptions (cost-sharing carve-outs for mental health and SUD services beginning October 2028) preserve some access for those who remain enrolled, but the overall trajectory of Medicaid coverage contraction is not favorable for a model that depends on stable enrollment and consistent reimbursement to function. Parallel pressures are reshaping the SUD side of integration, as Acuity has documented in coverage of the in-network migration in the substance use disorder industry.
At the state level, the parallel structural pressure is real. Six states implemented Medicaid provider rate restrictions in FY 2025 and another six are planning them for FY 2026, per the KFF Medicaid budget survey. The KFF data on planned behavioral health rate increases (23 states in FY 2025, dropping to 14 in FY 2026) describes the fiscal environment in which primary care practices are being asked to absorb the operational complexity of CoCM. The implications track the broader pattern Acuity has documented in coverage of the addiction-treatment ROI gap, where evidence-based interventions exist alongside reimbursement structures that have not adjusted to recognize their cost-effectiveness.
What CoCM’s expansion still depends on
Three issues will determine whether CoCM continues its expansion trajectory or stalls in the next two years. The first is whether the states currently lagging in Medicaid coverage close the gap. The Path Forward heat map identifies a set of states (concentrated in the South and Mountain West) where Medicaid has not yet activated the CoCM codes or where reimbursement rates are below Medicare. The clinical and policy case for expanding coverage is strong, but the fiscal environment is the constraint that has consistently slowed adoption. The H.R.1 environment makes the fiscal constraint more acute.
The second is whether the workforce pipeline for behavioral health care managers and psychiatric consultants can keep pace with demand. The Path Forward case for CoCM emphasizes that the model leverages psychiatrist time efficiently, but the model still requires psychiatrists, and the country is short of them. Acuity’s prior reporting on the behavioral health workforce shortage, including HRSA’s December 2025 projection of a 36,780-psychiatrist deficit by 2038, underscores that the pipeline question is not separable from the integration question. If the consulting workforce does not grow, the integration model that depends on it cannot scale beyond a certain point.
The third is whether the broader policy environment can deliver on payment reform without simultaneously contracting coverage. The federal parity rollback announced May 15, 2025 (through pending litigation plus 18 months) has weakened the leverage payors face on behavioral health network adequacy and rate equity. The H.R.1 cuts will reduce the Medicaid population. The state-level rate contractions in FY 2026 reduce the funding behavioral health providers receive even for the patients who remain covered. Against that backdrop, an evidence-based, federally reimbursable, state-supported integration model with documented cost savings is one of the few unambiguously positive trends in behavioral health policy. Whether it continues to scale depends less on the model itself than on the financing environment around it. Acuity’s ongoing coverage of behavioral health regulation and reimbursement tracks the decisions that will determine the answer.
Frequently Asked Questions
What is the Collaborative Care Model?
The Collaborative Care Model (CoCM) is an evidence-based, team-based approach to integrating behavioral health treatment into primary care. The core team consists of a primary care provider, a behavioral health care manager (typically a licensed clinician), and a psychiatric consultant. The model uses validated screening tools (such as the PHQ-9 and GAD-7), a population-based registry, measurement-based treatment to target, and structured psychiatric consultation to manage common conditions like depression and anxiety within the primary care setting. It was developed at the University of Washington in the 1990s and is recognized as one of the most evidence-supported behavioral health integration models, with more than 90 randomized controlled trials.
How is CoCM reimbursed?
CMS established three CPT codes specific to CoCM (99492, 99493, and 99494) for monthly billing of initial and subsequent CoCM services, with reimbursement beginning January 1, 2018. CMS subsequently added HCPCS code G2214 for shorter monthly service periods. The codes can be billed only by primary care providers or non-physician practitioners in primary care settings, not by the psychiatric consultant or behavioral health care manager directly. The codes pay for non-face-to-face work, including registry review, care manager outreach, curbside psychiatric consultation, and treatment-plan adjustment, that previous integration models could not bill.
How many state Medicaid programs cover CoCM?
Coverage varies by source and definition. As of July 1, 2025, Colorado and Tennessee added CoCM codes to their Medicaid coverage, joining 34 other states for a total of 36 state Medicaid programs covering CoCM, per Path Forward. A separate count in the academic literature cited 38 state Medicaid programs as of June 2025, a difference that reflects how “coverage” is defined (some states activate the codes only for limited populations or with specific restrictions). Reimbursement rates, provider eligibility, and billing requirements vary substantially across covering states.
What does the evidence say about CoCM outcomes?
The evidence base is unusually strong for a behavioral health delivery model. More than 90 randomized controlled trials have evaluated CoCM, with consistent findings of improved mental health outcomes, reduced symptoms, and improved recovery rates, particularly for depression and anxiety. The model has been shown to reduce remission time for depression (a 7x reduction per Path Forward, citing PMID 26769872) and to extend psychiatric reach across substantially larger patient populations than a traditional referral arrangement, with published estimates ranging from approximately 8 times (Path Forward) to 13 times over a psychiatrist’s lifetime (Meadows Mental Health Policy Institute / Healthy Minds). Cost savings are typically attributed to reductions in unnecessary hospitalization and higher-intensity care.
What is the difference between CoCM and general Behavioral Health Integration (BHI)?
General Behavioral Health Integration is a less prescriptive Medicare service, billed monthly under CPT code 99484, that does not require a psychiatric consultant or a designated behavioral health care manager. General BHI is more accessible to primary care practices that lack the staffing or psychiatric partnership to implement CoCM, but the evidence base for outcomes is less developed than for CoCM specifically. Many practices begin with general BHI and migrate to CoCM as capacity grows.
Will H.R.1 affect CoCM?
Indirectly, but materially. The One Big Beautiful Bill Act, signed July 4, 2025, cuts approximately $1 trillion in federal Medicaid funding over a decade and is projected to reduce Medicaid coverage by 10 to 12 million people, according to CBO estimates. Because CoCM is delivered primarily to publicly and commercially insured populations, the contraction of Medicaid enrollment and the tightening of state Medicaid budgets in fiscal year 2026 will pressure the primary care practices that have been investing in CoCM infrastructure. Cost-sharing carve-outs for mental health and substance use services in the law preserve some access, but the overall trajectory is not favorable. Acuity’s coverage of the broader regulatory environment tracks the implications for behavioral health integration models.
