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[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[S. Res. 107 Introduced in Senate (IS)]

103d CONGRESS
  1st Session
S. RES. 107

  To express the sense of the Senate that comprehensive and equitable 
 mental health and substance abuse benefits should be included in any 
         comprehensive health care bill passed by the Congress.

_______________________________________________________________________

                   IN THE SENATE OF THE UNITED STATES

                May 12 (legislative day, April 19), 1993

 Mr. Wellstone (for himself, Mr. Simon, and Mr. Inouye) submitted the 
following resolution; which was referred to the Committee on Labor and 
                            Human Resources

_______________________________________________________________________

                               RESOLUTION

 
  To express the sense of the Senate that comprehensive and equitable 
 mental health and substance abuse benefits should be included in any 
         comprehensive health care bill passed by the Congress.

    Resolved,

SECTION 1. SENSE OF THE SENATE.

    It is the sense of the Senate that the model mental health and 
substance abuse services provisions described in this resolution should 
be considered in determining those mental health and substance abuse 
services to be included as part of any benefits package that is 
contained in any comprehensive health care or health insurance reform 
bill passed by the Congress.

SEC. 2. MODEL SERVICES AND COMMISSION.

    (a) Services.--The model services described in section 1 should 
include:
            (1) In general.--Mental health and substance abuse services 
        described in this resolution, including all medically or 
        psychologically necessary services related to the prevention, 
        diagnosis, treatment, and rehabilitation of mental illnesses 
        and substance abuse disorders and the promotion of mental 
        health.
            (2) Services.--To be included in coverage under this 
        section, services must be provided as part of a continuum of 
        care which includes--
                    (A) assessment, diagnosis, and referral services;
                    (B) crisis intervention services including--
                            (i) intervention services designed to 
                        facilitate entry into or continuation in 
                        treatment; and
                            (ii) hospital, nonhospital, or ambulatory 
                        detoxification programs;
                    (C) outpatient services provided in a variety of 
                State-licensed settings, including hospitals, mental 
                health or substance abuse clinics or centers, office 
                practices or school-based health services, including 
                services ranging from brief counseling to day and 
                evening treatment and family therapy, limited to the 
                extent provided according to a utilization review that 
                is conducted at intervals determined appropriate by the 
                Secretary of Health and Human Services (or the Federal 
                entity responsible for the administration of the 
                comprehensive program), to ensure that services are 
                being appropriately utilized;
                    (D) partial hospitalization (such as day and 
                evening treatment programs for seriously emotionally 
                disturbed children and adolescents and seriously 
                mentally ill adults, and other types of day programs);
                    (E) psychosocial rehabilitation services;
                    (F) pharmacotherapeutic interventions;
                    (G) residentially based treatment, including 
                halfway house care and three quarter-way house care;
                    (H) inpatient care that includes services provided 
                at hospitals, other inpatient facilities, community-
                based facilities, and residential treatment centers as 
                clinically necessary, to the extent provided according 
                to a utilization review that is conducted at intervals 
                determined appropriate by the Secretary of Health and 
                Human Services (or the Federal entity responsible for 
                the administration of the comprehensive program), to 
                ensure that adequate care is being provided in the 
                least restrictive and most clinically appropriate 
                setting for the needs of the patient; and
                    (I) care coordination services, including--
                            (i) the coordination and monitoring of 
                        mental health care and substance abuse 
                        services; and
                            (ii) the provision of transition management 
                        from inpatient facilities to other community 
                        based care services (or vice versa) and 
                        assisting patients with identifying and gaining 
                        access to appropriate ancillary services (such 
                        as housing assistance programs, dental care, 
                        education, and job placement and training).
    (b) Care Coordination.--
            (1) Objectives of care coordination.--The objectives of the 
        care coordination services described in subsection (a)(2)(I) 
        shall be to ensure appropriate comprehensive, continuous, and 
        coordinated care the amount, duration, and scope of which shall 
        be based on the clinical needs of the patient.
            (2) Eligibility.--
                    (A) In general.--Patients with a serious mental 
                illness or a substance abuse disorder (as defined by 
                the Secretary or responsible Federal entity) or who 
                have encountered repeated treatment failures (as 
                defined by the Federal entity responsible for the 
                administration of the comprehensive program) shall be 
                eligible for care coordination services--
                            (i) on entry into a crisis intervention 
                        setting or inpatient service setting as 
                        described in subparagraphs (B) and (H) of 
                        subsection (a)(2); or
                            (ii) on referral by a qualified mental 
                        health or substance abuse treatment 
                        professional.
                    (B) Exemption.--Patients who enter services 
                described in subparagraph (B) or (H) of subsection 
                (a)(2) may be exempt from care coordination services at 
                the discretion of a qualified professional if the 
                qualified professional determines that such services 
                are not clinically indicated.
                    (C) Previous conditions.--Individuals whose 
                previous condition entitled them to care coordination 
                services under this section will be eligible for care 
                coordination services after completion of treatment or 
                discharge from a program for a period of time to be 
                determined by the Secretary or responsible Federal 
                entity.
            (3) Standards for care coordination.--
                    (A) In General.--To be covered under the provisions 
                of this subsection, care coordination services must be 
                provided by a care coordinator that--
                            (i) has successfully completed formal 
                        training, or any other entry path determined 
                        appropriate by the State;
                            (ii) is supervised by a health professional 
                        with licensing and field experience 
                        requirements as determined appropriate by the 
                        State; and
                            (iii) for patients receiving services from 
                        a Certified Employee Assistance Professional 
                        (CEAP), has worked with a CEAP in coordinating 
                        care.
                    (B) Requirements.--Care coordination services shall 
                be delivered pursuant to appropriate State requirements 
                that--
                            (i) provide for services according to an 
                        organizational plan developed by the State;
                            (ii) provide for the option of developing 
                        different levels of care coordination services 
                        for subgroups;
                            (iii) provide for the establishment of care 
                        coordination guidelines that detail the levels 
                        of care coordination services provided, and 
                        that, at a minimum, will identify--
                                    (I) the population targeted;
                                    (II) the range of services offered; 
                                and
                                    (III) the maximum caseload size for 
                                each care coordination service level; 
                                and
                            (iv) establish safeguards to assure that 
                        care coordinators receive no financial benefits 
                        from treatment decisions or placements.
            (4) Request for different coordinator.--Patients may ask 
        for a different care coordinator or refuse care coordination 
        after having been offered such service.
    (c) Utilization Review Standards.--Utilization review for services 
provided pursuant to this section shall adhere to the following minimum 
standards:
            (1) All utilization reviews shall be supervised by a 
        physician, or other professional licensed in that State to 
        provide the services under review.
            (2) The utilization criteria to be applied shall be 
        provided to patients and providers upon request and a written 
        explanation of the basis for any denial of payment based upon 
        such a review shall be provided to the provider or patient upon 
        request.
            (3) Based on consultation with care coordinators, care 
        providers, and patients, utilization reviewers shall make the 
        final decision as to whether a patient's benefits can be 
        extended beyond its limits, subject to the appeals process.
            (4) Based on consultation with care coordinators and 
        patients, care providers shall make the final decision as to 
        the appropriate course of treatment for a patient when 
        treatment decisions are between utilization review intervals, 
        subject to the appeals process.
            (5) Utilization review and appeals shall be conducted 
        promptly in order not to disrupt a course of treatment and 
        providers shall not deny necessary care while a review or 
        appeal is pending.
            (6) During an appeal or alternative dispute resolution 
        under this subparagraph, providers shall have the right to be 
        reviewed by an equivalent professional.
            (7) The utilization review system may not permit any 
        incentive or contingent fee arrangement based on the reduction 
        or denial of services through utilization review.
    (d) Duties of Secretary.--The Secretary (or the Federal entity 
responsible for the administration of the comprehensive health care 
program) shall--
            (1) authorize a mechanism for recognizing an approved care 
        coordination plan that shall include timing intervals for 
        utilization review and that is devised by the care coordinator 
        with input from the utilization review professional, if there 
        is one, the mental health or substance abuse treatment provider 
        and the patient;
            (2) devise a mechanism to review and monitor care 
        coordination and utilization review guidelines;
            (3) define an appeal and alternative dispute resolution 
        process by which care coordinators, care providers and patients 
        can appeal utilization review treatment decisions; and
            (4) determine intervals for utilization review, and which 
        services should be subject to review.
    (e) Commission on Mental Health and Substance Abuse.--
            (1) Establishment.--With respect to model services covered 
        under this section the Secretary of Health and Human Services 
        shall establish a Commission, under the auspices of the 
        Substance Abuse and Mental Health Services Administration, in 
        collaboration with the National Institute of Mental Health, the 
        National Institute on Drug Abuse, the National Institute on 
        Alcohol Abuse and Alcoholism, and other appropriate agencies, 
        to study, prepare and submit to the appropriate committees of 
        Congress and to the Secretary a report containing further 
        recommendations concerning the manner in which the benefits for 
        mental disorders and substance abuse treatment services should 
        be modified to best meet the objectives of this Resolution.
            (2) Duties.--The duties of the Commission established under 
        paragraph (1) should include--
                    (A) studying changes in utilization patterns and 
                costs which accompany the provision of mental health 
                and substance abuse treatment benefits contained in 
                this Resolution;
                    (B) making further recommendations on ways to 
                create a continuum of care and encourage the provision 
                of care in the least restrictive, most clinically 
                appropriate setting;
                    (C) developing a standard set of practices for care 
                coordination services, including--
                            (i) the range of care coordination services 
                        that should be offered for a specific target 
                        population;
                            (ii) the organizational structure in which 
                        care coordination services should be based;
                            (iii) the minimum training requirements for 
                        care coordinators; and
                            (iv) standards for the clinical necessity 
                        of care coordination services; and
                    (D) studying peer care coordination and making 
                recommendations regarding the development and 
                implementation of peer care coordination services.
            (3) Report.--The Commission should make its first report 
        not later than 1 year after the date of the enactment of any 
        comprehensive health care bill and at 2 year intervals 
        thereafter.

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