The Emerging Field of Behavioral Health Paraprofessionals

State Regulatory Approaches for Peer Specialists, Community Health Workers and Behavioral Health Technicians/Aides

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Historically, the workforce supporting behavioral health has generally included health professionals with a master's degree or higher in education and training. These workers have included counselor-level licensed professionals (such as mental health counselors, clinical social workers, marriage and family therapists, psychiatric advanced practice nurses, etc.) and doctorally trained professionals (such as psychologists and physicians). More recently, states have adopted various approaches toward training and regulating the workforce dedicated to substance use, such as addiction counselors. For these dedicated professionals, states have adopted multiple levels of professional certifications, from peer professionals (people with lived experience with mental health or substance use issues) requiring a high school diploma, to master's level counselors providing clinical counseling services. In fact, 49 states had a formal credential for peer professionals as of 2023. However, fewer states have formalized training including certifications and licensing for the behavioral health workforce providing support services in a non-peer role or outside of substance use disorder treatment settings.

As such, an emerging topic of interest among states is moving from filling the behavioral health workforce mainly with professionals who have a significant amount of post-secondary education to create opportunities for behavioral health support among professionals with more accessible levels of schooling. This interest is dually inspired by states seeking strategies to address behavioral health workforce shortages and an acknowledgement that current state-credentialed behavioral health roles may be too reliant on those with a master's degree or other higher trained professionals.

Without additional pathways for employment in behavioral health fields, states may be left with perpetual shortages, prospective workers with training or experience with no current path for meaningful contribution to the behavioral health system, and a long lead time needed to fill roles requiring at minimum many years of post-secondary education and training (four years for bachelor's degree, two years for master's degree and two years of experience for full licensure). However, it should be noted that state credentialing approaches for this new subset of the workforce would not be a silver bullet to address behavioral health workforce shortages; there will still be a need for higher level services that can only be provided by certain professionals. States are exploring these credentialing strategies in concert with other strategies to enhance access to behavioral health services, including participation in licensure compacts, education or clinical training expansion, telehealth and other strategies.

As it relates to this "untapped pool" of potential behavioral health workers, little research has been formalized nationally to develop a common terminology for and definition of these workers. However, a recent study by the Bipartisan Policy Center refers to this category of behavioral health workers as "Behavioral Health Support Specialists."

For the purposes of this brief, the term "behavioral health paraprofessionals" is an umbrella term which will be used to include (but may not be exclusive to) the following roles:

• Peer Specialists (peer support workers)
• Community Health Workers
• Behavioral Health Technicians/Aides

Among these roles, states have implemented different approaches toward regulating and credentialing them. The remainder of this brief provides an overview of state approaches and highlights key examples.

Peer Specialists (Peer Support Workers)

State regulation for peer support specialists has been a well-developed area of study and assessment. Although the peer specialist role has been around for many decades, the first state regulation for these roles was established in 2001. Since that time, the majority of states have followed suit, with 49 states offering a certification for peer specialists as of 2023.

Peer specialist roles exist in states through two common worker types: substance use and/or mental health recovery. According to an analysis completed by the Peer Recovery Center of Excellence (funded by the Substance Abuse and Mental Health Services Administration (SAMHSA)), state regulation for these roles falls into the following categories:

State Approaches to Peer Specialist Licensing/Certification

State Role in Regulation

As it relates to state approaches for regulation of these certifications, the state's role varies widely. The most common approach is for states to provide the certification to qualified individuals directly, but some states defer to (or contract with) third party entities to provide the certification on behalf of the state. For states that provide the certification directly, this function is done most commonly through the state's executive branch agency dedicated to behavioral health (such as in Arkansas where the Department of Human Services administers the certification), but some states may provide certification through an executive branch entity dedicated to licensing (such as the New Hampshire Office of Professional Licensing and Certification, Board of Licensing for Alcohol and Other Drug Use Professionals).

State Regulatory Standards

Certification requirements also vary substantially across states. Lived experience is the most common requirement among states for both substance use and mental health peer specialists. Education requirements are generally around 40 hours, with an associated written exam. About half of states specify supervised work experience requirements; of those, requirements are generally less than or equal to around 500 hours of experience. Most states do not require a criminal background check. However, of those that do, some states outline which criminal offenses would disqualify an individual from being certified. Additional information about state requirements for peer support certifications can be found in the previously referenced report, Comparative Analysis of State Requirements for Peer Support Specialist Training and Certification in the United States. Additional information about peer support certification models and standards can be found in the SAMHSA report National Model Standards for Peer Support Certification.

Community Health Workers

Community Health Workers (CHWs) are another category of behavioral health support specialists. CHWs are defined as "frontline public health workers that are trusted members of the community they serve." These individuals engage with communities and community members to facilitate connections with the health care system and address social drivers of health.

Connection between Community Health Workers and Behavioral Health

Over the last decade and a half, the role of CHWs in mental health interventions has been the topic of research as well as exploration by states. Findings suggest that, with the appropriate training, CHWs may be able to support the delivery of mental health interventions, expanding access to care for underserved populations. No standardized or widely accepted mental health training currently exists for CHWs. Given this, states have the opportunity to develop their own approach to train and deploy CHWs to provide behavioral health support. The extent to which CHWs specialize in or serve in behavioral health settings or roles varies by state and by individual CHW. For example, the Michigan Medicaid reimbursement model reimburses CHW services for members under the Behavioral Health Home and Opioid Health Home programs for specialty behavioral health populations.

State Role in Regulation

Several states have developed certification and training standards for CHWs through a variety of approaches. As of 2024, 25 states have a CHW Certification program. Certification is typically voluntary to provide CHW service-in other words, CHW services can be legally provided without the certification. However, in many states, certification is required in order to access Medicaid funding.

A recent state tracker from the National Academy for State Health Policy found that 24 states have supported Medicaid reimbursement for CHW-provided services by amending their state plan through the section 1115 waiver process, through encouraging or requiring managed care organizations to support CHW services, or some combination. As it relates to states' specific role in the certification of CHWs, states with certification programs usually administer their own credentialling, and this is generally through their health or human services department.

As an example, Arizona defines the CHW role in statute (A.R.S. 36-765(2)) and administrative code (R9-16-802(C)(D)) and defines an optional credentialing pathway through their Medicaid agency (Arizona Health Care Cost Containment System). Other state certification approaches include the use of independent credentialing boards or working with a local CHW professional association to manage credentialing.

State Regulatory Standards

In order to qualify for certification as a CHW, states generally require state-approved or administered training, which generally align with CHW competencies outlined in the CHW Core Consensus Project. However, some states also require demonstration of hours of experience or provide experience as an alternate pathway to certification.

Behavioral Health Technicians/Aides

The final category of behavioral health support specialists is behavioral health technicians/aides. This role of paraprofessionals in the behavioral health space is an emerging area of interest for states. These roles are commonly seen as extenders of behavioral health services for activities that do not require professionals trained with a master's degree or higher.

Behavioral health technicians/aides are distinct from peer specialists and community health workers in that they generally do not require lived experience, but instead focus on state-approved or state-provided training. However, in some cases, experience (lived or other) does serve as a qualifying pathway. Additionally, behavioral health aide/technician functions and duties vary widely across state implementation models.

Before discussing state implementation approaches for these roles, it is important to note that this is an emerging field, and no single term has been designated to refer to these roles. For the purposes of this brief, the term "behavioral health technician/aide (technician/aide)" will be used. Other terms that have been put forth by states and in the research include "behavioral health support specialists," "behavioral health aide," "behavioral health paraprofessional" or "psychiatric technician."

State Role in Regulation and State Standards

State approaches to regulation for technician/aide roles vary widely. For states with formalized roles, guidelines are developed through statute, rules, Medicaid modules, or other state programming to define these roles and associated entry criteria. Below are categories of state approaches offered for consideration, with examples of states that have implemented that strategy:

Defined technician/aide role in state code or rules

One approach states have taken is to define the technician/aide role within state statute or rules. To achieve this, the definition must have gone through either the legislative or executive branch rule-making process. For states that have followed this approach, the extent to which the role is defined varies; some states define the role and associated services/scope of practice without having formal training requirements, while others may define the role and outline training and/or certification requirements. Below are examples of states that have defined the role within statute or rules:

Statutorily defined role with state-outlined training requirements, both with and without formal certification.

• Minnesota Mental Health Behavioral Aides: Minnesota has developed a Mental Health Behavioral Aide (MBHA) occupation modeled after Alaska's Behavioral Health Aide model, see below. MBHAs are outlined within Minnesota statute (45I.04.16). This MBHA role requires approximately 30 hours of pre-service state training. MBHAs support children with mental illness by helping them develop skills under their individual behavioral plan. A Level I MBHA requires a high school diploma and two years of experience (no formal certification), whereas a Level II MBHA requires at least an associate degree and formal certification (administered after receiving state training provided through a university partnership).
• Minnesota Mental Health Practitioners: Minnesota has "Mental Health Practitioner" (MHP) roles that are eligible to provide certain treatment services to adult clients (education, rehabilitative services, functional assessments, level of care assessments, treatment planning, and crisis assessments/interventions) and child clients (skill-building, treatment plans). This role is statutorily defined (245I.04.4) to include a variety of education/experience qualification paths (including pathways for individuals with lived experience, current college students, those not fluent in English, those with at least 30 hours of college experience and masters-trained professionals). MHPs work under the supervision of a mental health professional. There is no formal state certification associated with this role.
• Minnesota Mental Health Rehabilitation Workers: Minnesota also has an adult population-focused role, called "mental health rehabilitation workers," which provides basic living and social skills under rehabilitative mental health services. Like the MHP role, there are various pathways to qualify to serve in this role, including formal academic training (associate degree), qualifying experience (>2,000 hours) or lived experience. There is no formal state certification associated with this role.
• Utah Behavioral Health Technicians and Behavioral Health Coaches: Utah recently developed two state-certified behavioral health aide/technician-type roles through statute: "behavioral health technician" and "behavioral health coach." The behavioral health technician role requires completion of a one-year certificate program or an associate degree in a qualifying field. The behavioral health coach role provides two pathways to certification: 1) a higher education pathway through completion of a bachelor's degree in a qualifying field and a letter of recommendation to verify competency; or 2) a "stackable" credential and experience pathway which can be achieved through completion of an associate's degree or higher in a relevant field, two years of experience as a technician or other relevant role (such as peer support specialist, case manager, etc.), and a letter of recommendation to verify competency.
• Wyoming Certified Mental Health Workers: Wyoming utilizes a "certified mental health worker" (CMHW) role, which is defined through statute with entry requirements defined in rules and regulations. CMHWs are individuals with a bachelor's degree or higher in a human behavioral discipline who have met relevant coursework requirements, have experience under direct and indirect supervision (500 hours total) and who have successfully passed a state-defined examination. CMHWs receive certification through the Mental Health Professions Licensing Board and can provide assessment, treatment, and prevention-related services under the supervision of a designated qualified clinical supervisor (fully licensed behavioral health professional or advanced practitioner).

Role defined through regulation, with associated training requirements but no certification.

• Arizona Behavioral Health Paraprofessionals: Arizona has implemented a title for the role of "Behavioral Health Paraprofessionals" which are non-Behavioral Health Counselor staff providing behavioral health services in a facility-based setting, under the supervision of a behavioral health professional. The role is defined in Arizona regulations (A.A.C. R9-10-101(34)) as "an individual who is not a behavioral health professional who provides behavioral health services at or for a health care institution according to the health care institution's policies and procedures that: (a) If the behavioral health services were provided in a setting other than a licensed health care institution, the individual would be required to be licensed as a behavioral professional under A.R.S. Title 32, Chapter 33; and (b) Are provided under supervision by a behavioral health professional." The Arizona Department of Health Services (ADHS) has also provided guidance for employers related to the Behavioral Health Paraprofessional role. The Arizona Health Care Cost Containment System rearticulates the ADHS definition of the paraprofessional role and specifies education requirements in guidance for employers/providers. Professional requirements for this role include at least a high school diploma and having the knowledge necessary to provide the service (as verified by a clinical director).
• Arizona Behavioral Health Technicians: In addition to Arizona's Behavioral Health Paraprofessionals role, the role of Behavioral Health Technician is also defined within Arizona regulations (A.A.C. R9-10-101(39)). The Technician role has associated clinical oversight requirements. Compared to the Paraprofessional role, the Technicians play a more substantial role in behavioral health service delivery, including conducting assessments, counseling, and implementing treatment plans (with specified clinical oversight requirements met). The Arizona State Plan specifies the level of education/degree required to serve as a Technician; this includes a wide range of experience/education, from an individual with a high school diploma and at least four years of related experience, to an individual with an associate, bachelor's or master's degree in a related field. While not defined in statute, the Behavioral Health Technician and Behavioral Health Paraprofessional roles are exempted from licensure per statute.
• Oregon Qualified Mental Health Associates: Oregon has various pathways to become a paraprofessional through rule-defined Qualified Mental Health Associate (QMHA) roles (OAR 309-019-0125(9)(a)(b)). Additional guidance is provided by the Mental Health and Addiction Certification Board of Oregon. There are both degree and non-degree (experience) pathways to certification. Certification is required to serve in these roles within state-certified mental health programs. QMHAs are eligible to provide a number of behavioral health services in the state fee schedule under mental health outpatient services, including case management, screenings, activity therapy and patient education.

Defined technician/aide role in state guidance or Medicaid modules

As an alternative to outlining this role in state code or rules, many states have defined a role within an executive branch agency or division's guidance. For example, some states have included information on their website which specifies the role, or the role has been defined within Medicaid provider modules or service delivery guidelines. State approaches to training and certification for these roles also vary. Below are examples of roles outlined in non-statute or rule mechanisms:

• Executive branch agency-defined role with state training without formal certification. Georgia uses "paraprofessionals" (individuals with or without a bachelor's degree) to provide a variety of services under their Community Behavioral Health Providers module. Paraprofessionals are individuals with (Level 4 staff) or without (considered Level 5 staff) a bachelor's degree who have completed a state-required training module.
• Executive branch agency-defined state training and associated formal certification.Alaska developed a "Behavioral Health Aide/Practitioner" (BHA/P) role to provide behavioral health services to community members and clients of a Tribal Health Organization within the Alaska Tribal Health System. There are various levels of BHA/P roles, each with varying expectations for training/education and experience. Each level results in a state certification which must be renewed every two years. BHA/Ps are generally members of the community they serve, meaning this role could be categorized as either a community health worker or behavioral health technician/aide. BHA/Ps serve under masters-level behavioral health clinicians. BHA/Ps can provide a number of services under the Indian Health Service, but also serve as Qualified Addiction Professionals under Alaska's Medicaid substance use disorder plan. Of note, Alaska has developed a number of hiring and onboarding resources to support recruitment of prospective BHAs, including recent high school graduates.
• Executive branch agency-defined state training and associated formal certification. Maine has a state training and certification for a "Mental Health and Rehabilitation Technician (MHRT)" through the Department of Health and Human Services. MHRTs work with adults with serious mental illness and are specialized into one of three categories: Community (MHRT/C), Residential (MHRT/I) and Crisis Service Provider (MHRT/CSP). MHRTs are categorized in state Medicaid programming as "other qualified mental health professionals." There are various pathways to qualify for state MHRT Certification, including traditional academic training (bachelor's degree), completing a qualifying program at state-approved program, or completing free training online with at least 12 months of experience.

State Approaches to Behavioral Health Technician/Aide Licensing/Certification (A Sample)

Considerations

As states seek to address behavioral health workforce challenges, the development of formal roles is a strategy to create a meaningful pathway for mental health workers who do not qualify as therapists, social workers, counselors, psychologists or other traditional roles. For states that may be interested in exploring the establishment of these roles through regulation, below are key considerations:

• Financial Sustainability. As described above, the establishment of many of these formal state credentialing initiatives is done by or in concert with state Medicaid programming. Coordination with a payer source supports the financial viability of these roles and the contributions these workers make to behavioral health service delivery.
• Stackable Credentials. Among the states with paraprofessional roles, many have developed tiers which align with education or experience requirements and additional levels of services that can be provided by higher tier roles. This framework provides a pathway for growth and development among paraprofessionals and could be built out to create a cohesive ladder to master's level and other higher-level roles.
• Reciprocity. State approaches to formalization of these roles, particularly with the paraprofessional roles, vary widely. Given the lack of standardization among states, states may consider how to support interstate mobility of these professionals. Pathways for reciprocity can be acknowledged and formalized alongside in-state qualification pathways. Specifically for peer specialist roles and in acknowledgement of a greater likelihood that these individuals may have criminal histories, it may be important to consider enhanced transparency of disqualifying crimes and pathways for remediation, both for reciprocity and career pathway buildouts for these roles.
• Coordination with Other Strategies. In many state models, the services provided by behavioral health support specialists (especially paraprofessionals) require supervision by other behavioral health roles, typically licensed professionals. Specific supervision provisions vary, but generally some amount of a licensed professionals' time is required. Given the ubiquitous nature of workforce shortages in behavioral health, it is important for states to consider the broader impact of these strategies on the overall workforce and ensure coordination across approaches to support the behavioral health workforce broadly.

This publication was developed by Courtney Medlock and Dr. Hannah Maxey of Veritas Health Solutions on behalf of the National Governors Association Center for Best Practices (the NGA Center). The NGA Center would like to thank the Health Resources and Services Administration in the U.S. Department of Health and Human Services for their generous support in the development of this publication under National Forum Cooperative Agreement No. U98OA09028. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of HRSA or the U.S. Department of Health and Human Services.

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