49–010 

Calendar No. 180 

114TH CONGRESS REPORT " ! SENATE 1st Session 114–101 

IMPROVING ACCESS TO EMERGENCY PSYCHIATRIC CARE 

ACT OF 2015 

JULY 30, 2015.—Ordered to be printed 

Mr. HATCH, from the Committee on Finance, 

submitted the following 

R E P O R T 

[To accompany S. 599] 

The Committee on Finance, to which was referred the bill (S. 

599) to extend and expand the Medicaid emergency psychiatric 

demonstration project, having considered the same, reports favorably thereon with an amendment and recommends that the bill, as 

amended, do pass. 

I. LEGISLATIVE BACKGROUND 

The Committee on Finance, to which was referred the bill (S. 

599) to extend and expand the Medicaid emergency psychiatric 

demonstration project, having considered the same, reports favorably thereon with an amendment and recommends that the bill, as 

amended, do pass. 

Background and need for legislative action 

A longstanding policy under Medicaid, called the institutions for 

mental disease (IMD) exclusion, prohibits the federal government 

from providing federal Medicaid matching funds to states for services rendered to Medicaid eligible individuals aged 21 through 64 

who are patients in IMDs. IMDs are inpatient facilities with more 

than 16 beds that primarily treat people with mental health and 

substance abuse disorders. While the original IMD exclusion is consistent with the goal of treating severe mental illness in the least 

restrictive setting feasible, there have been some unintended consequences. The IMD exclusion provided an incentive to shift the 

cost of care for mental illness to other care modalities and facilities 

where Medicaid matching funds were available. This contributed to 


emcdonald on DSK67QTVN1PROD with HEARING
2 

a decrease in the number of publicly funded inpatient psychiatric 

beds available for emergency services, and likely contributed to 

psychiatric boarding and recidivism in general hospital emergency 

departments. Psychiatric boarding occurs when an individual with 

a mental health condition is kept in a hospital emergency department for several hours or admitted to medical wards or skilled 

nursing facilities without psychiatric expertise because appropriate 

mental health services are unavailable. This leads to potential serious consequences for psychiatric patients and unnecessary hospital 

costs. The Patient Protection and Affordable Care Act (ACA) authorized a three-year demonstration to study the effects of allowing 

federal Medicaid payment for emergency psychiatric treatment otherwise prohibited by the Medicaid IMD exclusion. The demonstration was funded with $75 million in FY 2011, and these funds are 

available for obligation through December 31, 2015. The Secretary 

of Health and Human Services selected eleven states and the District of Columbia to participate in the demonstration in March 

2012, and the demonstration began July 1, 2012. The Committee 

recognizes the importance of extending the demonstration in a 

budget neutral manner so that the Secretary of Health and Human 

Services can finish its evaluation of the demonstration and make 

an informed recommendation regarding its continuation and expansion. 

II. EXPLANATION OF THE BILL 

PRESENT LAW

Section 2707 of the Patient Protection and Affordable Care Act 

(ACA, P.L. 111–148 as amended) authorized a three-year Medicaid 

demonstration project in which eligible states provide Medicaid 

payments to certain IMDs for services provided to Medicaid enrollees, aged 21 through 64, who require medical assistance to stabilize 

a psychiatric emergency medical condition. To participate in the 

demonstration, an IMD must be (a) not publicly owned or operated 

and (2) subject to the Emergency Medical Treatment and Active 

Labor Act (EMTALA, P.L. 99–272). 

EXPLANATION OF PROVISION

The bill would temporarily extend the Medicaid Emergency Psychiatric Demonstration for states already participating in the demonstration through September 30, 2016, provided that it meets the 

budget neutrality requirements as described below. Then, if the 

Secretary of Health and Human Services (HHS) recommends extending and expanding the demonstration, the legislation would extend the demonstration through December 31, 2019, subject to the 

budget neutrality requirements as described below. In April 2019, 

the Secretary of HHS would be required to make a recommendation to Congress regarding the permanent extension and expansion 

of the demonstration, but congressional approval would be required 

to permanently extend or expand the demonstration. 

The bill would allow the demonstration funding to be available 

until expended rather than expiring on December 31, 2015, and the 

bill would provide $100,000 to the Centers for Medicare & Medicaid 

Services (CMS) Program Management to carry out the demonstration. 


emcdonald on DSK67QTVN1PROD with HEARING
3 

1Pub. L. No 93–344. 

States would be able to continue (for states already participating) 

and begin (for new states) participation in the demonstration if the 

Secretary of HHS and the Chief Actuary of CMS project that participation of the state would not increase Medicaid expenditures. 

The Secretary of HHS will provide notice of projections to the 

states. Also the bill would require the Secretary of HHS to annually review each state’s demonstration expenditures to ensure the 

state’s participation in the demonstration has not increased net 

Medicaid expenditures. 

The bill would allow publicly owned IMDs to participate in the 

demonstration. 

EFFECTIVE DATE

The provision is effective on the date of enactment. 

III. BUDGET EFFECTS OF THE BILL 

A. COMMITTEE ESTIMATES

In compliance with paragraph 11(a) of rule XXVI of the Standing 

Rules of the Senate, the following statement is made concerning 

the estimated budget effects of the revenue provisions of the ‘‘Improving Access to Emergency Psychiatric Care Act of 2015’’ as reported. 

S. 599 would increase direct spending by $100,000 over the 

2015–2025 period. Because enacting the bill would affect direct 

spending pay-as-you-go procedures apply. Enacting the bill would 

not affect revenues. 

B. BUDGET AUTHORITY

Budget authority 

In compliance with section 308 (a)(1) of the Congressional Budget 

and Impoundment Control Act of 1974 (‘‘Budget Act’’) 1, the Committee states that the bill as reported involves increased budget authority (see Part A, above). 

Tax expenditures 

In compliance with section 308(a)(1) of the Budget Act, the Committee states that the bill does not involve increased tax expenditures. 

C. CONSULTATION WITH CONGRESSIONAL BUDGET OFFICE

In accordance with section 403 of the Budget Act, the Committee 

advises that the Congressional Budget Office has submitted a 

statement on the bill. 

S. 599—Improving Access to Emergency Psychiatric Care Act 

S. 599 would extend the period of time during which the Secretary of Health and Human Services could conduct the Medicaid 

Emergency Psychiatric Demonstration Project and would require 

the Secretary to recommend to the Congress whether to continue 

and expand the demonstration. CBO estimates that implementing 


emcdonald on DSK67QTVN1PROD with HEARING
4 

S. 599 would increase direct spending by $100,000 over the 2015– 

2025 period. Because enacting the bill would affect direct spending 

pay-as-you-go procedures apply. Enacting the bill would not affect 

revenues. 

With limited exception, under current law, Medicaid does not 

cover services provided in psychiatric institutions to enrollees aged 

21 to 64. Rather, Medicaid payment is available to other providers 

such as general hospitals that may provide emergency psychiatric 

services to such enrollees. The demonstration was established to 

assess the health outcomes and cost effectiveness of allowing private psychiatric hospitals to provide emergency psychiatric services 

to Medicaid enrollees aged 21 to 64. 

S. 599 would authorize the Secretary to extend a state’s participation in the demonstration from December 2015 through September 2016 if the Secretary determines and certifies that doing so 

would not increase net spending in the Medicaid program. The bill 

would require, not later than September 30, 2016, that the Secretary recommend to the Congress whether the demonstration 

should be continued beyond September 2016 or expanded to any 

additional states. The Secretary would be authorized to extend and 

expand the demonstration if the Secretary also determines and certifies that doing so would not increase net spending in the Medicaid program. After December 31, 2019, the Secretary’s authority 

to continue or expand the demonstration would expire. Finally, the 

bill would appropriate $100,000 for fiscal year 2015 for the Secretary to carry out the demonstration; thus increasing direct spending by that amount. 

S. 599 contains no intergovernmental or private-sector mandates 

as defined in the Unfunded Mandate Reform Act and would impose 

no costs on state, local, or tribal governments. 

The CBO staff contact for this estimate is Lisa Ramirez-Branum. 

The estimate was approved by Holly Harvey, Deputy Assistant Director for Budget Analysis. 

IV. VOTES OF THE COMMITTEE 

In compliance with paragraph 7(b) of rule XXVI of the Standing 

Rules of the Senate, the Committee states that, with a majority 

present, the ‘‘Improving Access to Emergency Psychiatric Care Act 

of 2015’’ as modified was ordered favorably reported on June 24, 

2015 as follows: 

Final Passage of the Improving Access to Emergency Psychiatric 

Care Act of 2015—approved, as modified, by voice vote. 

V. REGULATORY IMPACT AND OTHER MATTERNS 

A. REGULATORY IMPACT

Pursuant to paragraph 11(b) of rule XXVI of the Standing Rules 

of the Senate, the Committee makes the following statement concerning the regulatory impact that might be incurred in carrying 

out the provisions of the bill. 

Impact on individuals and businesses, personal privacy and paperwork 

The bill is not expected to impose additional administrative requirements or regulatory burdens on individuals. The bill is exVerDate Sep 11 2014 05:23 Aug 01, 2015 Jkt 049010 PO 00000 Frm 00004 Fmt 6659 Sfmt 6602 E:\HR\OC\SR101.XXX SR101

emcdonald on DSK67QTVN1PROD with HEARING
5 

pected to reduce administrative requirements and regulatory burdens on some businesses. 

The provisions of the bill do not impact personal privacy. 

B. UNFUNDED MANDATES STATEMENT

This information is provided in accordance with section 423 of 

the Unfunded Mandates Reform Act of 1995 (Pub. L. No. 104–4). 

The Committee has determined that the bill does not contain any 

private sector mandates. The Committee has determined that the 

bill contains no intergovernmental mandate. 

VI. CHANGES IN EXISTING LAW MADE BY THE BILL, AS 

REPORTED 

In the opinion of the Committee, it is necessary in order to expedite the business of the Senate, to dispense with the requirements 

of paragraph 12 of rule XXVI of the Standing Rules of the Senate 

(relating to the showing of changes in existing law made by the bill 

as reported by the Committee). 

Æ 


emcdonald on DSK67QTVN1PROD with HEARING