A Statewide SUD Redesign: The Missouri CSTAR Program Case Study

April 11, 2025

This OPEN MINDS Executive Roundtable was delivered on April 10, 2025 by Natalie Cook, Vice President at CLIVE Solutions and Ryan Essex, Chief Operating Officer at Gibson Center for Behavioral Change. They discussed Missouri’s Comprehensive Substance Treatment and Rehabilitation (CSTAR) program, in which Missouri’s State Plan Amendment was revised to include the ASAM Criteria and a new payment model to support evidence-based treatment services.

The new payment model transitioned the state from a traditional fee-for-service (FFS) model of billing 15-minute increments to a team-based model billed by the ASAM level of care (LOC). ASAM level 1 is still traditional billing, with the rates adjusted based on current market cost. ASAM levels 2 and 3 have rates that are billed daily.

Ms. Cook and Mr. Essex also discussed how the Missouri Behavioral Health Council assembled state leaders and SUD treatment providers to rejuvenate an antiquated treatment system, as well as how the rates were set (e.g., training costs, indirect costs, staffing patterns, etc.).

Executive attendees of this session learned about:

The historical context and evolution of the CSTAR program in Missouri.
The impact of the ASAM Criteria and the new payment model on the delivery of SUD services.
The collaborative efforts of state leaders and treatment providers in the SUD redesign process.

Featured Speakers

Natalie Cook

Vice President, CLIVE Solutions

Natalie Cook (BA, MS) is the Vice President of CLIVE Solutions at the Missouri Behavioral Health Council in Jefferson City, Missouri. She earned her psychology degrees from Pittsburg State University in Pittsburg, KS. Natalie chose the behavioral health field after seeing her brother struggle with mental illness and substance use disorders as an adolescent. She used her education and training to provide direct care to youth, adults, and families before recognizing her strengths for “behind-the-scenes work.” She took an administrative job with the MO Department of Mental Health. She spent over 10 years in various positions with the state and was able to take policy and procedure and conceptualize it into practice guidance for community behavioral health agencies. Natalie joined the Missouri Behavioral Health Council in 2019. In her current role, she focuses on policy and quality improvement of Missouri’s Certified Community Behavioral Health Clinic (CCBHC) federal demonstration. She greatly enjoys hearing providers share their successes and the impact this has brought to the lives of many Missourians. With over a decade of experience consulting with states nationwide, Natalie continues this passion by offering consultation services through CLIVE Solutions on CCBHC planning and implementation and substance use disorder treatment program redesign.

Ryan Essex

Chief Operating Officer, Gibson Center for Behavioral Change

Mr. Essex has been in this role for 13 years and has served in many clinical and supervisory roles over the last 21 years. The responsibilities of his current role are to oversee and guide the day-to-day operations of a comprehensive substance abuse and mental health program that includes modified medical detoxification, and residential and outpatient services. Additionally, his responsibilities include new program development and contract compliance. Mr. Essex has been an administrative and program surveyor for the Commission on the Accreditation of Rehabilitation Facilities (CARF) for 16 years. This role allows him to evaluate and apply industry-approved standards to behavioral health facilities throughout the United States. Mr. Essex is the past President of the Missouri Credential Board. He served as the committee chair working on substance use treatment system transformation in Missouri. In addition to his clinical work, he serves as a local elected official in the state of Missouri and brings that experience to policy making.