II 

111TH CONGRESS 

1ST SESSION S. 1136 

To establish a chronic care improvement demonstration program for Medicaid 

beneficiaries with severe mental illnesses. 

IN THE SENATE OF THE UNITED STATES 

MAY 21, 2009 

Ms. STABENOW (for herself and Mr. LEVIN) introduced the following bill; 

which was read twice and referred to the Committee on Finance 

A BILL 

To establish a chronic care improvement demonstration program for Medicaid beneficiaries with severe mental illnesses. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Mental Illness Chronic 

5 Care Improvement Act of 2009’’. 

6 SEC. 2. CHRONIC CARE IMPROVEMENT DEMONSTRATION 

7 PROGRAM FOR MEDICAID BENEFICIARIES 

8 WITH SEVERE MENTAL ILLNESSES. 

9 (a) DEFINITIONS.—In this section: 

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1 (1) CHRONIC CARE IMPROVEMENT PROGRAM

2 OPERATOR.— 

3 (A) IN GENERAL.—Subject to subpara4 graph (B), the term ‘‘chronic care improvement 

5 program operator’’ means a qualified commu6 nity program under section 1913(b)(1) of the 

7 Public Health Service Act that has entered into 

8 a chronic care improvement program operator 

9 agreement that meets the requirements of sub10 section (e) with a participating State to carry 

11 out, directly or through contracts with sub12 contractors, a severe mental illness chronic care 

13 improvement demonstration program for tar14 geted beneficiaries in the State. 

15 (B) OTHER ENTITIES PERMITTED.—Sub16 ject to approval by the Secretary, such term 

17 may include any other entity that a partici18 pating State determines is appropriate to carry 

19 out a severe mental illness chronic care im20 provement demonstration program for targeted 

21 beneficiaries in the State. 

22 (2) MEDICAID.—The term ‘‘Medicaid’’ means 

23 the Federal-State medical assistance program estab24 lished under title XIX of the Social Security Act (42 

25 U.S.C. 1396 et seq.). 

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1 (3) PARTICIPATING STATE.—The term ‘‘partici2 pating State’’ means a State with an approved appli3 cation that has entered into a chronic care improve4 ment demonstration agreement with the Secretary to 

5 conduct a severe mental illness chronic care improve6 ment demonstration program under this section. 

7 (4) SECRETARY.—The term ‘‘Secretary’’ means 

8 the Secretary of Health and Human Services. 

9 (5) SEVERE MENTAL ILLNESS CHRONIC CARE

10 IMPROVEMENT DEMONSTRATION PROGRAM.—The 

11 term ‘‘severe mental illness chronic care improve12 ment demonstration program’’ means a program de13 scribed in subsection (d) that is conducted pursuant 

14 to a chronic care improvement demonstration agree15 ment between the Secretary and a participating 

16 State. 

17 (6) STATE.—The term ‘‘State’’ has the mean18 ing given that term for purposes of Medicaid. 

19 (7) THRESHOLD CONDITION.— 

20 (A) IN GENERAL.—The term ‘‘threshold 

21 condition’’ means a chronic mental illness such 

22 as schizophrenia, schizoaffective disorder, bipo23 lar disorder, major clinical depression, or such 

24 conditions with co-occurring substance abuse 

25 disorders. 

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1 (B) OTHER STATE-SPECIFIED CONDI2 TIONS.—Such term includes other conditions 

3 contained in the Diagnostic and Statistical 

4 Manual of Mental Disorders IV published by 

5 the American Psychiatric Association (or any 

6 successor publication by such Association) se7 lected by the participating State as appropriate 

8 criteria for selection of targeted beneficiaries 

9 for participation in a severe mental illness 

10 chronic care improvement demonstration pro11 gram. 

12 (8) TARGETED BENEFICIARY.— 

13 (A) IN GENERAL.—The term ‘‘targeted 

14 beneficiary’’ means an adult individual who— 

15 (i) is entitled to benefits under the 

16 State Medicaid plan (or a waiver of such 

17 plan); 

18 (ii) has 1 or more of the threshold 

19 conditions; and 

20 (iii) has been identified by the State 

21 as likely to benefit from participation in a 

22 severe mental illness chronic care improve23 ment demonstration program. 

24 (B) VOLUNTARY PARTICIPATION.—A tar25 geted beneficiary may participate in a severe 

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1 mental illness chronic care improvement dem2 onstration program on a voluntary basis and 

3 may terminate participation at any time. 

4 (b) AUTHORITY TO CONDUCT DEMONSTRATION PRO5 GRAM.— 

6 (1) CHRONIC CARE IMPROVEMENT DEMONSTRA7 TION AGREEMENTS.— 

8 (A) IN GENERAL.—The Secretary shall 

9 enter into chronic care improvement demonstra10 tion agreements with States that submit ap11 proved applications under this section to pro12 vide for the development, testing, evaluation, 

13 and implementation of severe mental illness 

14 chronic care improvement demonstration pro15 grams in accordance with this section. 

16 (B) PERIOD.—A chronic care improvement 

17 demonstration agreement entered into by the 

18 Secretary and a participating State shall be for 

19 a period of 4 years. 

20 (C) DEADLINE FOR INITIAL AGREE21 MENTS.—Not later than October 1, 2010, the 

22 Secretary shall enter into chronic care improve23 ment demonstration agreements with not more 

24 than 10 participating States to conduct a severe 

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1 mental illness chronic care improvement dem2 onstration program under this section. 

3 (2) CHRONIC CARE IMPROVEMENT PROGRAM

4 OPERATOR AGREEMENTS.—A chronic care improve5 ment demonstration agreement entered into between 

6 the Secretary and a participating State shall require 

7 the participating State to enter into chronic care im8 provement program operator agreements, consistent 

9 with subsection (e), with chronic care improvement 

10 program operators to carry out the severe mental ill11 ness chronic care improvement demonstration pro12 gram in the State. 

13 (3) POST-DEMONSTRATION PLAN FOR CON14 TINUITY OF SERVICES.—A State desiring to conduct 

15 a severe mental illness chronic care improvement 

16 demonstration program under this section shall in17 clude in its application to be selected as a partici18 pating State a plan for ensuring continuity of serv19 ices for targeted beneficiaries who are participating 

20 in the program on any date (expected or unexpected) 

21 that the demonstration program ceases to be con22 ducted in the State. 

23 (c) PAYMENTS; FUNDING.— 

24 (1) IN GENERAL.—Beginning October 1, 2010, 

25 the Secretary shall provide for payments for not 

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1 more than 10 participating States to conduct a se2 vere mental illness chronic care improvement dem3 onstration program in accordance with the require4 ments of this section. 

5 (2) MANNER OF PAYMENT.—Payment to a 

6 State under this section shall be made in the same 

7 manner as other payments are made to the State 

8 under section 1903(a) of the Social Security Act (42 

9 U.S.C. 1396b(a)). 

10 (3) NO STATE MATCH REQUIRED.—No State 

11 shall be required to provide State matching funds as 

12 a condition for receiving payments under this sec13 tion. 

14 (4) FUNDING.— 

15 (A) LIMITATION ON FUNDS.—The total 

16 amount of payments under this section shall 

17 not exceed $250,000,000 for the period of fiscal 

18 years 2011 through 2014. 

19 (B) BUDGET AUTHORITY.—This section 

20 constitutes budget authority in advance of ap21 propriations Acts and represents the obligation 

22 of the Secretary to provide for the payment of 

23 amounts provided under this section. 

24 (C) LIMITATION ON PAYMENTS.—In no 

25 case may— 

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1 (i) the aggregate amount of payments 

2 made by the Secretary to a participating 

3 State for administrative expenses relating 

4 to conducting a severe mental illness 

5 chronic care improvement demonstration 

6 program under this section exceed 10 per7 cent of the aggregate amount of payments 

8 made to the State under this section; and 

9 (ii) payments be provided by the Sec10 retary under this section for services pro11 vided under a severe mental illness chronic 

12 care improvement demonstration program 

13 conducted under this section for any fiscal 

14 year after fiscal year 2014. 

15 (d) SEVERE MENTAL ILLNESS CHRONIC CARE IM16 PROVEMENT DEMONSTRATION PROGRAM.— 

17 (1) IN GENERAL.—A severe mental chronic care 

18 improvement demonstration program shall be de19 signed to improve the health outcomes and satisfac20 tion of targeted beneficiaries participating in the 

21 program and shall— 

22 (A) provide such beneficiaries with regular 

23 screening, registry tracking, and outcome meas24 urement processes at the time of psychiatric 

25 visits for, among other purposes, developing an 

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1 individualized, goal-oriented care management 

2 plan that satisfies the requirements of para3 graph (2); 

4 (B) provide each such beneficiary with 

5 such a plan; and 

6 (C) carry out such plan and other chronic 

7 care improvement activities carried out by the 

8 State; 

9 (2) ELEMENTS OF CARE MANAGEMENT PLAN.— 

10 A care management plan for a targeted beneficiary 

11 shall be developed with the beneficiary using person12 centered planning principles and shall, to the extent 

13 appropriate, include the following: 

14 (A) Explicit general health care goals, 

15 measured on a regular basis, such as— 

16 (i) improved access to primary care 

17 services; 

18 (ii) improved prevention; 

19 (iii) early identification and interven20 tion to avoid serious health issues; and 

21 (iv) better management of chronic dis22 eases, including but not limited to hyper23 tension, diabetes, obesity, and cardio24 vascular disease. 

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1 (B) A designated point of contact respon2 sible for communications with the beneficiary 

3 and for facilitating communications with other 

4 health care and related community providers 

5 under the plan. 

6 (C) Coordination and communication with 

7 family members who are actively engaged in 

8 supporting the targeted beneficiary’s participa9 tion in the program. 

10 (D) Self-care education for the beneficiary 

11 in recognizing and managing symptoms of 

12 threshold conditions, educating parents and 

13 family members, and educating physicians and 

14 medical specialists as appropriate. 

15 (E) Education for physicians and other 

16 community providers on required collaboration 

17 to enhance communication of relevant clinical 

18 information. 

19 (F) Active coordination of supportive com20 munity services, including peer support, trans21 portation, day care, personal assistance, hous22 ing, primary care (including accompanying tar23 geted beneficiaries to medical appointments), 

24 mental health care, and other required services. 

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1 (G) The use of monitoring technologies 

2 that enable patient guidance through the ex3 change of pertinent clinical information. 

4 (e) TERMS AND CONDITIONS OF CHRONIC CARE IM5 PROVEMENT PROGRAM OPERATOR AGREEMENTS.— 

6 (1) REQUIREMENTS.—A chronic care improve7 ment program operator agreement entered into 

8 under this section between a participating State and 

9 a chronic care improvement program operator shall 

10 require the operator, with respect to targeted bene11 ficiaries enrolled in the program and covered by the 

12 agreement, to— 

13 (A) guide the beneficiaries in managing 

14 their health (including all co-occurring medical 

15 or surgical conditions, relevant health care serv16 ices, and pharmaceutical needs) and in per17 forming activities as specified under each such 

18 beneficiaries care management plan; 

19 (B) use decision-support tools, such as evi20 denced-based practice guidelines, medication al21 gorithms, or other criteria as determined by the 

22 Secretary; 

23 (C) arrange for core medical home team 

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1 tioners, primary care supervising physicians, 

2 and embedded nurse care managers; 

3 (D) initiate wellness activities, including 

4 smoking cessation and weight management and 

5 physical exercise programs; 

6 (E) participate with the State to develop a 

7 clinical information database to track and mon8 itor the beneficiaries across settings and to 

9 evaluate outcomes; 

10 (F) monitor and report to the participating 

11 State, in a manner specified by the Secretary, 

12 on health care quality, cost, outcomes, and clin13 ical milestones in achieving recovery from men14 tal illnesses and co-occurring addiction dis15 orders; 

16 (G) meet medical home quality standards, 

17 as promulgated by the National Committee on 

18 Quality Assurance (NCQA) or such other qual19 ity assurance organizations as the Secretary 

20 may specify; 

21 (H) meet such clinical, quality improve22 ment, financial, and other requirements as the 

23 participating State deems to be appropriate for 

24 the targeted beneficiaries to be served; and 

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1 (I) comply with such additional require2 ments as the participating State may specify. 

3 (2) OPTIONAL SERVICES.—The chronic care im4 provement program operator agreement may permit 

5 a chronic care improvement program operator to— 

6 (A) use intake assessment, health examina7 tion, medication management, vital signs moni8 toring, preventive healthcare, disease specific 

9 goals implementation, patient health education, 

10 or other primary care or general healthcare 

11 services as deemed appropriate by the operator 

12 to carry out the program; 

13 (B) be recognized as a patient-centered 

14 medical home in accordance with paragraph 

15 (4); and 

16 (C) where feasible, to collaborate with pri17 mary care providers, including federally quali18 fied health centers or other community health 

19 centers, to provide the services described in 

20 clause (i). 

21 (3) MANNER OF PAYMENT.—The chronic care 

22 improvement program operator agreement shall pro23 vide that the State shall pay the chronic care im24 provement program operator in accordance with a 

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1 methodology developed by the Secretary for deter2 mining payment. 

3 (4) PATIENT-CENTERED MEDICAL HOME REC4 OGNITION.—The Secretary shall enter into an agree5 ment with the National Committee for Quality As6 surance (NCQA), or other quality assurance organi7 zation with appropriate experience evaluating pa8 tient-centered medical homes as the Secretary may 

9 specify, for the purposes of granting patient-centered 

10 medical home status to qualified chronic care im11 provement operator sites. 

12 (f) INDEPENDENT EVALUATION.— 

13 (1) IN GENERAL.—The Secretary shall conduct 

14 an independent evaluation of the severe mental 

15 chronic care improvement demonstration programs 

16 conducted under this section. Such evaluation shall 

17 be done by grant, contract, or interagency agree18 ment with an entity with knowledge of severe mental 

19 illness chronic care improvement programs and dem20 onstrated experience in the evaluation of such pro21 grams. The evaluation shall include an assessment 

22 of whether the State demonstration programs con23 ducted under this section— 

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1 (A) enhance coordination and integration 

2 of primary care and community mental health 

3 and substance use disorder services; 

4 (B) improve prevention, early identifica5 tion, and intervention to avoid serious health 

6 issues, including chronic diseases; 

7 (C) improve the overall health status of 

8 targeted beneficiaries using a patient-centered 

9 approach; and 

10 (D) produce financial outcomes, including 

11 any cost savings to Medicaid. 

12 (2) INCLUSION OF FAMILY MEMBERS.—The 

13 Secretary shall ensure that the evaluation collects 

14 and assesses information from family members who 

15 are involved with supporting a targeted beneficiary’s 

16 participation in a severe mental illness chronic care 

17 improvement demonstration program conducted 

18 under this section with respect to the results of the 

19 beneficiary’s participation in the program. 

20 (3) REPORT TO CONGRESS.—The Secretary 

21 shall submit a report to Congress on the results of 

22 the evaluation conducted under this subsection. The 

23 report shall include such recommendations as the 

24 Secretary determines appropriate to— 

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1 (A) guide the development of future pro2 grams that provide comprehensive and inte3 grated behavioral and physical health care serv4 ices to the severely mentally ill; 

5 (B) assist pediatric populations (with ad6 justments made based on age-related clinical 

7 profiles); and 

8 (C) assist Medicare beneficiaries under 

9 title XVIII of the Social Security Act (42 

10 U.S.C. 1395 et seq.). 

11 (g) RULES OF CONSTRUCTION.—Nothing in this sec12 tion shall be construed as— 

13 (1) expanding the amount, duration, or scope of 

14 benefits under a State Medicaid plan (or waiver of 

15 such plan); 

16 (2) providing an individual entitlement to par17 ticipate in a severe mental illness chronic care im18 provement demonstration program; or 

19 (3) providing any hearing or appeal rights with 

20 respect to a severe mental illness chronic care im21 provement demonstration program established under 

22 this section. 

23 (h) CLARIFICATION OF MEDICAID REIMBURSEMENT

24 FOR INTEGRATED MENTAL HEALTH AND PRIMARY CARE

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1 retary shall provide, by regulation, for changes to require2 ments under Medicaid relating to reimbursement for pri3 mary care and behavioral health services to the same pa4 tient, on the same day, at the same service site, so as to 

5 permit payment for the provision of both types of services 

6 on the same day to the same patient. 

7 (i) SECRETARIAL OVERSIGHT AND COORDINATION.— 

8 The Secretary shall establish procedures to promote active 

9 and effective coordination, collaboration, and communica10 tion among the agencies, administrations, and centers of 

11 the Department of Health and Human Services that are 

12 responsible for any matter relating to the conduct or eval13 uation of the severe mental illness chronic care improve14 ment demonstration programs carried out under this sec15 tion. 

Æ 

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