2026 Behavioral Health Commercialization & Contracting Playbook (Adult + Pediatrics)

Why now

Behavioral health is no longer a sidecar: it’s a primary driver of system margin, network performance, and total-cost-of-care (TCOC). National health spend rose 7.5% in 2023 to ~$4.9T; Medicaid and private spend drove the increase, putting CFOs under pressure to bend cost curves without throttling access. Behavioral comorbidity multiplies medical spend (often 2–3×), especially in MSK and metabolic populations, making BH the keystone of 2026 contracting strategy. Centers for Medicare & Medicaid Services+2JAMA Network+2

What’s changing in 2025–2026 (and what it means for contracts)

• Medicare payment + codes: CY2025 PFS final rule lowers the base conversion factor but expands behavioral integration, digital mental health treatment coverage, crisis/suicide-risk planning codes, and keeps behavioral telehealth flexibilities (including audio-only) in place; further adjustments are proposed for 2026. Translation: lean into reimbursed integration and care-management codes to fund BH infrastructure. telehealth.hhs.gov+4Centers for Medicare & Medicaid Services+4Centers for Medicare & Medicaid Services+4

• Medicaid direction: States continue to scale CCBHC prospective payment systems with quality bonus payments, while 1115 waivers push whole-person care and SDOH—though some workforce/financing flexibilities are tightening. Translation: contract for clinic-level PPS stability plus quality upside; watch each state’s 1115 updates. KFF+4Pennsylvania Government+4Medicaid+4

• Commercial & MA: Value-based specialty risk is moving faster, with payers prioritizing cross-condition outcomes (post-discharge follow-up, ED de-escalation, depression remission, MSK functional improvement) and ECDS-friendly reporting. Translation: bring claims-level evidence, not anecdotes. McKinsey & Company+2NCQA+2

  
  

What’s working vs. what’s not

Working in 2025 → scaling in 2026

• Integrated behavioral models funded by CoCM/BHI monthly payments in primary care, paired with specialty BH access SLAs and rapid post-crisis follow-up. Centers for Medicare & Medicaid Services+1

• CCBHC PPS with QBP targets to stabilize clinic economics while rewarding access and continuity. Medicaid

• Tele-behavioral permanence (home originations, audio-only allowances for BH) that preserves capacity where clinician supply is tight. telehealth.hhs.gov+1

  
  

Underperforming / aging out

• FFS-only psychotherapy panels with no continuity, no ED/hospital follow-up accountability, and weak network adequacy signaling.

• Behavioral contracts siloed from MSK/Metabolic—they miss the bulk of savings, which shows up downstream in TCOC for pain, diabetes, and cardiometabolic risk. JAMA Network

  
  

Target economics: what “good” looks like (benchmarks & ranges)

(Use as talking points; local rates vary by MAC/state and payer contracts.)

• Medicare psychotherapy (non-facility national avgs): 90834 (45 min): ≈ $104; 90837 (60 min): ≈ $154. MediBillMD

• CoCM/BHI monthly: CMS materials and leading guides show ballpark $50–$170 PMPM depending on code/time (e.g., 99484 ≈ $53; 99492/99493 often in the $145–$200+ range non-facility; RHC/FQHC bundles track average CoCM rates). Use these to finance integrated care teams. Prevounce Blog+2AIMS Center -+2

• Medicaid CCBHC: Clinic-specific PPS rates rebased via MEI/cost reports + quality bonus; treat PPS as the floor and QBP as the upside pool. Medicaid

• Payer PMPM for integration (commercial/MA): Typical base $8–$20 PMPM for access/engagement add-ons; $20–$60 PMPM for full BH integration with outcome gates; shared-savings split 30–50% above threshold. (Use market discovery + directed-payment ceilings as guardrails in Medicaid MCOs.) MACPAC

Margin intent:

• Plans: ≥ 3–5% TCOC reduction in high-comorbidity cohorts within 12–18 months; hit HEDIS uplift on FUH/FUM/FUA and depression remission. NCQA+1

• Providers/Systems: Behavioral line should operate breakeven to +5% standalone, with system-level ROI coming from ED/hospital reduction, MSK escalation avoidance, and better metabolic control (largest savings). Recent meta-analyses show substantial TCOC impact when access improves. JAMA Network

  
  

KPIs payers and systems will actually pay for (2026 scorecard)

• Access velocity: days to first visit; post-ED/post-discharge follow-up at 7 & 30 days (HEDIS FUH/FUM). NCQA+1

• Clinical response: depression remission/response, anxiety reduction; adolescent SUD engagement.

• Utilization shifts: avoidable ED/hospital admits; length-of-stay; MSK procedures deferred; opioid risk mitigation. JAMA Network

• Continuity & adherence: med possession ratio, therapy completion, PCP/BH handoffs.

• Equity/SDOH: stratified outcomes; network adequacy by ZIP; ECDS-ready data. NCQA

  
  

How MSK & Metabolic tie in (and why CFOs care)

Behavioral stabilization improves adherence and pain self-management; metabolic control lowers cardiometabolic events; functional recovery reduces surgery and disability. Contract strategy is integrated even when contracts remain lane-specific. Use a shared TCOC model and negotiate aligned incentives across the three lanes. McKinsey & Company+1

Pharma & TCOC

Expect behavioral + cardiometabolic alignment in value models (e.g., GLP-1 adherence and depression management inside population health budgets). Pair outcomes-based drug arrangements with BH engagement metrics to protect TCOC. (CMS projects 2026 drug-pricing shifts that will ripple through payer budgets.) Health Affairs

Contracting playbook: lanes, levers, and numbers

1. Medicare (2026): Lock in CoCM/BHI PMPM for primary-care-anchored cohorts; leverage tele-BH permanence for home-based care and rural access; add digital mental health treatment where FDA-cleared. Tie to FUH/FUM and remission metrics. telehealth.hhs.gov+1

2. Medicaid: Where available, CCBHC PPS + QBP for clinics; otherwise Medicaid MCO directed payments and 1115 pilots. Bake network adequacy + post-crisis follow-up into the SOW; include pediatric-specific access SLAs. Medicaid+1

3. Commercial/MA: Start with integration PMPM + quality withholds; add shared-savings on TCOC for high-risk MSK and metabolic cohorts; require ECDS reporting and a 90-day data-sharing SLA. NCQA

Terms to insist on:

• Rate floors indexed to CMS updates (MEI) for multi-year stability. Medicaid

• Quality bonus ladders that map to FUH/FUM/remission and avoidable utilization. NCQA

• Data rights to monthly claims extracts for ROI proof and renewal leverage.

• Cross-condition attribution so BH benefit is credited when MSK/metabolic costs fall.

  
  

Execution calendar (Axis Annual Commercialization Cycle)

• Q1: Diagnose & design. Cost-of-care baseline; cohorting; payer list; contract hypotheses; pricing workbook (FFS + PMPM + upside).

• Q2: Validate & negotiate. Run 60–90-day pilots; lock CoCM/BHI billing ops; finalize payer exhibits and quality ladders.

• Q3: Scale & staff. Expand panels, stand up post-ED/post-discharge workflows, MSK & metabolic tie-ins; prepare renewal dossier.

• Q4: Renew & expand. Show TCOC savings; upgrade to multi-year deals; extend to peds/adjacent geos; set next-year QBP targets.

  
  

Team you need: Payer strategy lead, contract counsel, data/actuarial analyst, BH operations/program manager, clinician lead(s), revenue cycle lead. (Axis supplies the commercialization architecture, pricing models, payer negotiation, and the integration playbook.)

Materials that convert (and what to avoid)

Bring:

• Claims-based ROI model (12–18-month horizon) with MSK & metabolic spillover quantified;

• HEDIS uplift forecast; capacity plan (tele-BH, in-person mix, pediatric vs. adult);

• Billing & compliance pack (CoCM/BHI/psychotherapy codes; Medicaid PPS/QBP where relevant);

• SOW & pricing exhibits with PMPM + upside examples; monthly KPI dashboard mockups.Don’t bring: generic literature reviews, unsourced outcomes, or EHR screenshots with no denominators.

  
  

What leadership cares about

• CFO: predictable PMPM, credible downside protection, renewal leverage from documented TCOC impact.

• VP Payer Strategy/Growth: fast path to yes, clean measures, and references that mirror the payer’s book.

• CMO/Clinical Ops: workflows that clinicians can actually run; funded care-management time.

• CEO/Board: line-of-sight to contribution margin and a story investors understand.

  
  

Quick ranges you can say out loud (base case, adjust locally)

• Psychotherapy 90834 (Medicare non-facility): ≈ $104; 90837: ≈ $154. MediBillMD

• CoCM/BHI monthly (Medicare/RHC/FQHC analogs): $50–$170 PMPM depending on code/time/bundle. AIMS Center -+1

• Integration PMPM (Commercial/MA add-on): $8–$60 PMPM tiers with quality gates; 30–50% shared-savings above target. MACPAC

Why Systems and Plans Bring in Axis (Behavioral Health)

Behavioral Health is now the determinant of continuity across the entire care model — but no single leader inside the system owns the full Behavioral value chain.

• The CMO owns clinical quality, but not payer pricing or claims attribution.

• The CFO owns margin performance, but not stabilization timelines or care pathway friction.

• Behavioral Operations owns access and staffing, but not contracting economics.

• Payer Contracting owns rate exhibits, but not the clinical narrative that secures renewal leverage.

  
  

Everyone owns a piece.No one owns the system.

This is where Behavioral Health growth stalls — not because leaders lack strategy,but because Behavioral requires cross-functional commercialization, not clinical expansion alone.

Axis Fills the Missing Role

Axis serves as the Commercialization Architect for Behavioral Health:

We design and operationalize the alignment between:

• Stabilization → Continuity → Functional Recovery → Cost Curve Change

• Clinical improvement → Operational workflow → Financial result

• Evidence → Pricing → Renewal leverage

  
  

In other words:

What This Looks Like in Practice

We partner with systems and behavioral organizations to:

1. Define Behavioral cohorts that plans and systems will contract against

2. Build evidence the CFO and actuaries trust (not anecdotes or utilization snapshots)

3. Price Behavioral care models (FFS → PMPM → case rate → shared savings)

4. Negotiate payer and system contracting structures that reward continuity

5. Prepare renewal and expansion leverage long before negotiations begin

This is the work most organizations cannot do internally because it crosses clinical, operational, actuarial, and commercial boundaries.

The Positioning Statement

Behavioral Health is no longer a support service.It is the economic center of continuity in 2026.

Axis is the partner organizations bring in when they are ready to:

• Move from access to continuity

• Move from care delivery to value translation

• Move from contract participation to contract leadership

  
  

Let’s Architect What’s Next.

Tom

Founder & Commercialization Architect | Axis Growth Partners

tomriley@axisgrowthpartners.coaxisgrowthpartners.co

Sources (select)

CMS CY2025 PFS Final Rule; CMS MLN Behavioral Health Integration; CMS Telehealth FAQ (Oct 2025); HHS Telehealth Policy; NACHC FQHC Payment Guide (2025); Medicaid.gov CCBHC PPS & QBP Guidance; SAMHSA CCBHC Quality Measures; KFF Medicaid trends & 1115 tracker; NCQA HEDIS MY2025 updates & measure descriptions; Health Affairs/CMS NHE projections; Milliman Medical Index; McKinsey on value-based specialty risk; JAMA Network Open on BH ROI. JAMA Network+16Centers for Medicare & Medicaid Services+16Centers for Medicare & Medicaid Services+16