III

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.

1 Resolved,

2 SECTION 1. SENSE OF THE SENATE.

3 It is the sense of the Senate that the model mental

4 health and substance abuse services provisions described

5 in this resolution should be considered in determining

6 those mental health and substance abuse services to be

7 included as part of any benefits package that is contained
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1 in any comprehensive health care or health insurance re2 form bill passed by the Congress.

3 SEC. 2. MODEL SERVICES AND COMMISSION.

4 (a) SERVICES.—The model services described in sec5 tion 1 should include:

6 (1) IN GENERAL.—Mental health and substance

7 abuse services described in this resolution, including

8 all medically or psychologically necessary services re9 lated to the prevention, diagnosis, treatment, and re10 habilitation of mental illnesses and substance abuse

11 disorders and the promotion of mental health.

12 (2) SERVICES.—To be included in coverage

13 under this section, services must be provided as part

14 of a continuum of care which includes—

15 (A) assessment, diagnosis, and referral

16 services;

17 (B) crisis intervention services including—

18 (i) intervention services designed to

19 facilitate entry into or continuation in

20 treatment; and

21 (ii) hospital, nonhospital, or ambula22 tory detoxification programs;

23 (C) outpatient services provided in a vari24 ety of State-licensed settings, including hos25 pitals, mental health or substance abuse clinics
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1 or centers, office practices or school-based

2 health services, including services ranging from

3 brief counseling to day and evening treatment

4 and family therapy, limited to the extent pro5 vided according to a utilization review that is

6 conducted at intervals determined appropriate

7 by the Secretary of Health and Human Services

8 (or the Federal entity responsible for the ad9 ministration of the comprehensive program), to

10 ensure that services are being appropriately

11 utilized;

12 (D) partial hospitalization (such as day

13 and evening treatment programs for seriously

14 emotionally disturbed children and adolescents

15 and seriously mentally ill adults, and other

16 types of day programs);

17 (E) psychosocial rehabilitation services;

18 (F) pharmacotherapeutic interventions;

19 (G) residentially based treatment, includ20 ing halfway house care and three quarter-way

21 house care;

22 (H) inpatient care that includes services

23 provided at hospitals, other inpatient facilities,

24 community-based facilities, and residential

25 treatment centers as clinically necessary, to the
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1 extent provided according to a utilization review

2 that is conducted at intervals determined appro3 priate by the Secretary of Health and Human

4 Services (or the Federal entity responsible for

5 the administration of the comprehensive pro6 gram), to ensure that adequate care is being

7 provided in the least restrictive and most clini8 cally appropriate setting for the needs of the

9 patient; and

10 (I) care coordination services, including—

11 (i) the coordination and monitoring of

12 mental health care and substance abuse

13 services; and

14 (ii) the provision of transition man15 agement from inpatient facilities to other

16 community based care services (or vice

17 versa) and assisting patients with identify18 ing and gaining access to appropriate an19 cillary services (such as housing assistance

20 programs, dental care, education, and job

21 placement and training).

22 (b) CARE COORDINATION.—

23 (1) OBJECTIVES OF CARE COORDINATION.—The

24 objectives of the care coordination services described

25 in subsection (a)(2)(I) shall be to ensure appropriate
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1 comprehensive, continuous, and coordinated care the

2 amount, duration, and scope of which shall be based

3 on the clinical needs of the patient.

4 (2) ELIGIBILITY.—

5 (A) IN GENERAL.—Patients with a serious

6 mental illness or a substance abuse disorder (as

7 defined by the Secretary or responsible Federal

8 entity) or who have encountered repeated treat9 ment failures (as defined by the Federal entity

10 responsible for the administration of the com11 prehensive program) shall be eligible for care

12 coordination services—

13 (i) on entry into a crisis intervention

14 setting or inpatient service setting as de15 scribed in subparagraphs (B) and (H) of

16 subsection (a)(2); or

17 (ii) on referral by a qualified mental

18 health or substance abuse treatment pro19 fessional.

20 (B) EXEMPTION.—Patients who enter

21 services described in subparagraph (B) or (H)

22 of subsection (a)(2) may be exempt from care

23 coordination services at the discretion of a

24 qualified professional if the qualified profes-
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1 sional determines that such services are not

2 clinically indicated.

3 (C) PREVIOUS CONDITIONS.—Individuals

4 whose previous condition entitled them to care

5 coordination services under this section will be

6 eligible for care coordination services after com7 pletion of treatment or discharge from a pro8 gram for a period of time to be determined by

9 the Secretary or responsible Federal entity.

10 (3) STANDARDS FOR CARE COORDINATION.—

11 (A) IN GENERAL.—To be covered under

12 the provisions of this subsection, care coordina13 tion services must be provided by a care coordi14 nator that—

15 (i) has successfully completed formal

16 training, or any other entry path deter17 mined appropriate by the State;

18 (ii) is supervised by a health profes19 sional with licensing and field experience

20 requirements as determined appropriate by

21 the State; and

22 (iii) for patients receiving services

23 from a Certified Employee Assistance Pro24 fessional (CEAP), has worked with a

25 CEAP in coordinating care.
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1 (B) REQUIREMENTS.—Care coordination

2 services shall be delivered pursuant to appro3 priate State requirements that—

4 (i) provide for services according to an

5 organizational plan developed by the State;

6 (ii) provide for the option of develop7 ing different levels of care coordination

8 services for subgroups;

9 (iii) provide for the establishment of

10 care coordination guidelines that detail the

11 levels of care coordination services pro12 vided, and that, at a minimum, will iden13 tify—

14 (I) the population targeted;

15 (II) the range of services offered;

16 and

17 (III) the maximum caseload size

18 for each care coordination service

19 level; and

20 (iv) establish safeguards to assure

21 that care coordinators receive no financial

22 benefits from treatment decisions or place23 ments.

24 (4) REQUEST FOR DIFFERENT COORDINA25 TOR.—Patients may ask for a different care coordi-
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1 nator or refuse care coordination after having been

2 offered such service.

3 (c) UTILIZATION REVIEW STANDARDS.—Utilization

4 review for services provided pursuant to this section shall

5 adhere to the following minimum standards:

6 (1) All utilization reviews shall be supervised by

7 a physician, or other professional licensed in that

8 State to provide the services under review.

9 (2) The utilization criteria to be applied shall

10 be provided to patients and providers upon request

11 and a written explanation of the basis for any denial

12 of payment based upon such a review shall be pro13 vided to the provider or patient upon request.

14 (3) Based on consultation with care coordina15 tors, care providers, and patients, utilization review16 ers shall make the final decision as to whether a pa17 tient’s benefits can be extended beyond its limits,

18 subject to the appeals process.

19 (4) Based on consultation with care coordina20 tors and patients, care providers shall make the final

21 decision as to the appropriate course of treatment

22 for a patient when treatment decisions are between

23 utilization review intervals, subject to the appeals

24 process.
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1 (5) Utilization review and appeals shall be con2 ducted promptly in order not to disrupt a course of

3 treatment and providers shall not deny necessary

4 care while a review or appeal is pending.

5 (6) During an appeal or alternative dispute res6 olution under this subparagraph, providers shall

7 have the right to be reviewed by an equivalent pro8 fessional.

9 (7) The utilization review system may not per10 mit any incentive or contingent fee arrangement

11 based on the reduction or denial of services through

12 utilization review.

13 (d) DUTIES OF SECRETARY.—The Secretary (or the

14 Federal entity responsible for the administration of the

15 comprehensive health care program) shall—

16 (1) authorize a mechanism for recognizing an

17 approved care coordination plan that shall include

18 timing intervals for utilization review and that is de19 vised by the care coordinator with input from the

20 utilization review professional, if there is one, the

21 mental health or substance abuse treatment provider

22 and the patient;

23 (2) devise a mechanism to review and monitor

24 care coordination and utilization review guidelines;
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1 (3) define an appeal and alternative dispute res2 olution process by which care coordinators, care pro3 viders and patients can appeal utilization review

4 treatment decisions; and

5 (4) determine intervals for utilization review,

6 and which services should be subject to review.

7 (e) COMMISSION ON MENTAL HEALTH AND SUB8 STANCE ABUSE.—

9 (1) ESTABLISHMENT.—With respect to model

10 services covered under this section the Secretary of

11 Health and Human Services shall establish a Com12 mission, under the auspices of the Substance Abuse

13 and Mental Health Services Administration, in col14 laboration with the National Institute of Mental

15 Health, the National Institute on Drug Abuse, the

16 National Institute on Alcohol Abuse and Alcoholism,

17 and other appropriate agencies, to study, prepare

18 and submit to the appropriate committees of Con19 gress and to the Secretary a report containing fur20 ther recommendations concerning the manner in

21 which the benefits for mental disorders and sub22 stance abuse treatment services should be modified

23 to best meet the objectives of this Resolution.

24 (2) DUTIES.—The duties of the Commission es25 tablished under paragraph (1) should include—
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1 (A) studying changes in utilization pat2 terns and costs which accompany the provision

3 of mental health and substance abuse treatment

4 benefits contained in this Resolution;

5 (B) making further recommendations on

6 ways to create a continuum of care and encour7 age the provision of care in the least restrictive,

8 most clinically appropriate setting;

9 (C) developing a standard set of practices

10 for care coordination services, including—

11 (i) the range of care coordination

12 services that should be offered for a spe13 cific target population;

14 (ii) the organizational structure in

15 which care coordination services should be

16 based;

17 (iii) the minimum training require18 ments for care coordinators; and

19 (iv) standards for the clinical neces20 sity of care coordination services; and

21 (D) studying peer care coordination and

22 making recommendations regarding the devel23 opment and implementation of peer care coordi24 nation services.
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1 (3) REPORT.—The Commission should make its

2 first report not later than 1 year after the date of

3 the enactment of any comprehensive health care bill

4 and at 2 year intervals thereafter.

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