```

[Senate Report 114-101]
[From the U.S. Government Publishing Office]

                                                      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 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.
    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).
---------------------------------------------------------------------------
    \1\Pub. L. No 93-344.
---------------------------------------------------------------------------

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 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 expected 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).

                                  [all]
```