I 115th CONGRESS 2d Session H. R. 6343 IN THE HOUSE OF REPRESENTATIVES July 12, 2018 Mr. Huizenga introduced the following bill; which was referred to the Committee on Energy and Commerce , and in addition to the Committee on Ways and Means , for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To provide for a demonstration program and pilot project to expand choice for inpatient psychiatric services under Medicaid and Medicare.

1. Short title This Act may be cited as the Increasing National Patient Access To Improved Effective Necessary Mental Health Treatment Act of 2018 or the INPATIENT Act of 2018 . 2. Demonstration project waiving IMD exclusion to expand access to inpatient psychiatric services under the Medicaid program (a) Authority To conduct demonstration project (1) In general The Secretary of Health and Human Services (in this Act referred to as the Secretary ) shall establish a demonstration project (in this Act referred to as the demonstration project ) to test the impact of waiving the limitation of subdivision (B) following paragraph (29) of section 1905(a) of the Social Security Act ( 42 U.S.C. 1396d(a) ) on average length of stay, readmissions, cost, and quality outcomes for inpatient psychiatric hospital services and substance abuse services. (2) Terms Under the demonstration project, an eligible State (as defined in subsection (b)) shall provide payment under its State Medicaid plan under title XIX of the Social Security Act to qualifying institutions (as defined in subsection (b)(3)(C)) for the provision of medical assistance available under such plan to individuals who— (A) have attained age 21, but have not attained age 65; (B) are eligible for medical assistance under such plan (or under a waiver of such plan); (C) require such medical assistance for inpatient psychiatric hospital services or residential substance abuse services; and (D) but for participation in the demonstration project, would otherwise receive medical assistance for such inpatient psychiatric hospital services if the services were provided in a general acute care hospital or other residential substance abuse facility. (b) Eligible state defined (1) In general In this section, the term eligible State means a State that has made an application under paragraph (2) and has had such application approved and has been selected under paragraph (3). (2) Application A State seeking to participate in the demonstration project shall submit to the Secretary, at such time and in such format as the Secretary requires, an application that includes such information, provisions, and assurances, as the Secretary may require. (3) Selection and limitation (A) State limitation The Secretary shall limit the number of States selected for participation in the demonstration project to no more than 3 States. (B) Conditions for application approval The Secretary shall not approve an application under paragraph (2) unless the State agrees to limit participation in the demonstration project to qualifying institutions (as defined in subparagraph (C)). (C) Qualifying institution defined In this Act, the term qualifying institution means an institution for mental diseases that is not publicly owned or operated, that is subject to the requirements of section 1867 of the Social Security Act ( 42 U.S.C. 1395dd ), and that meets all of the following criteria: (i) The institution furnishes inpatient psychiatric hospital services to individuals age 18 years of age or older under the Medicare and Medicaid programs. (ii) The institution has an average length of inpatient hospital stay of less than 15 days for individuals age 18 or older, but under 65 years of age. (iii) The institution has an average length of stay of less than 21 days for hospital inpatients age 65 or older. (iv) The institution has an approved medical residency training program and receive payment due under the Medicare and Medicaid programs for the reasonable costs of graduate medical education. (v) The institution uses psychiatric residents to provide inpatient psychiatric hospital services to individuals under the Medicare and Medicaid programs. (vi) The institution has documented experience in providing services to active duty military personnel and veterans. (vii) The institution has standards to care for the whole person, including referral agreements or other arrangements to address a patient’s medical, surgical, or diagnostic needs if such treatment services are not available within the institution. (viii) The institution agrees to report on quality measures (in such form, manner, and frequency as specified by the Secretary) and report to the Secretary (in a form, manner, and frequency as specified by the Secretary) such data as the Secretary determines appropriate to monitor and evaluate the demonstration project. (ix) The institution agrees to plan and implement an annual performance improvement project, aimed at improving the effectiveness of care provided to high utilizers of inpatient psychiatric hospital services (as defined in subsection (h)(1)), with identifiable measures in coordination with the Secretary and the State. (c) Deadline for implementation The Secretary shall implement the demonstration project by January 1, 2019. (d) Length of demonstration project The demonstration project shall be conducted for a period of 7 consecutive years. (e) Budget neutrality With respect to the operation of the demonstration project in a State for the period described in subsection (d), the State must demonstrate to the Secretary that project will not result in a net increase in the aggregate expenditures under the Medicaid program for such period for the State above the level of such expenditures if the demonstration project had not been implemented. (f) Evaluation and report to Congress (1) Evaluation The Secretary shall conduct an evaluation of the demonstration project in order to determine the impact of the project and to make recommendations on improvements to the performance of the health and mental health service system and on individuals enrolled in the Medicaid program, with particular emphasis on individuals who are high utilizers of inpatient psychiatric hospital services and substance abuse residential services. (2) Items included in evaluation Such evaluation shall include the following: (A) An assessment of the delivery of inpatient psychiatric hospital services, substance abuse residential services, and community-based services under the Medicaid program; average lengths of inpatient stays; emergency room visits; and readmissions. (B) An assessment of the impact of the demonstration project on the costs of the full range of mental health services (including inpatient, emergency and ambulatory care) under the Medicaid program. (C) An assessment of the impact of the demonstration project on psychiatric residency programs and the mental health workforce. (D) An assessment of the impact of the demonstration project on rates of recidivism. (E) Identification and assessment of best practices for caring for patients with serious mental illness, including high utilizers of inpatient psychiatric hospital services and substance abuse residential services. (F) A comparison of outcomes and costs for similarly situated patients receiving inpatient psychiatric hospital services at a general acute care hospital. (G) A recommendation regarding whether the demonstration project should be continued after December 31, 2024, and expanded on a national basis. (3) Report Not later than December 31, 2024, the Secretary shall submit to Congress (and make available to the public) a report on the findings of the evaluation conducted under this subsection. (g) IMD waiver; waiver authority (1) IMD waiver The limitation of subdivision (B) following paragraph (29) of section 1905(a) of the Social Security Act ( 42 U.S.C. 1396d(a) ), relating to limitations on payments for care or services for individuals under 65 years of age who are patients in an institution for mental disease, shall not apply to inpatient psychiatric hospital services or substance abuse residential services furnished under the demonstration project. (2) Waiver authority The Secretary may waive such requirements of titles XI and XIX of the Social Security Act (which may include the requirements of paragraph (1) (relating to statewideness) and paragraph (10)(B) (relating to comparability) of section 1902(a) of such Act ( 42 U.S.C. 1396b(a) ) only to extent the Secretary determines such a waiver to be necessary to carry out the demonstration project. (h) Definitions In this Act: (1) High utilizer of inpatient psychiatric hospital services The term high utilizer of inpatient psychiatric hospital services means an individual who, with respect to a point in time, meets the following conditions: (A) The individual had two or more inpatient admissions for psychiatric services in the previous 12 months. (B) The individual had 10 or more inpatient admissions for psychiatric services in the individual’s lifetime. (C) The individual had 100 or more days of inpatient psychiatric services in the individual’s lifetime. (D) The individual meets any of the following conditions: (i) The individual is receiving court-ordered psychiatric treatment. (ii) The individual has been receiving inpatient psychiatric services for a consecutive period of at least 12 days. (iii) The individual has a documented history of suicidal or self-harming behaviors due to mental illness. (iv) The individual has a documented history of threatened or actual physical harm to another individual due to mental illness. (2) Institution for mental disease The term institution for mental disease has the meaning given to that term in section 1905(i) of the Social Security Act ( 42 U.S.C. 1396d(i) ). (3) Medicaid program The term Medicaid program means the program under title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq.). (4) Medical assistance The term medical assistance has the meaning given that term in section 1905(a) of the Social Security Act ( 42 U.S.C. 1396d(a) ). (5) Medicare program The term Medicare program means the program under part A of title XVIII of the Social Security Act ( 42 U.S.C. 1395c et seq.) and includes the programs under parts B, C, and D of such title. (6) State The term State has the meaning given that term for purposes of the Medicaid program. 3. Pilot program waiving the Medicare 190-day lifetime limit on inpatient psychiatric hospital services to expand access to inpatient psychiatric services under the Medicare program (a) Demonstration program authorized The Secretary shall establish a pilot program (in this section referred to as the pilot program ) to test the impact of eliminating the Medicare 190-day lifetime limit on— (1) promoting value; (2) expanding choice; and (3) aligning inpatient mental health benefits with the inpatient physical health care benefits under the Medicare program. (b) Definitions In this section: (1) Applicable beneficiary The term applicable beneficiary means an individual who— (A) is entitled to, or enrolled for, benefits under part A, and enrolled for benefits under part B, of the Medicare program; (B) is admitted to a qualifying institution participating in the demonstration project; and (C) but for the pilot program established under this section, would otherwise receive benefits for inpatient psychiatric services under the Medicare program if the services were provided in a general acute care hospital. (2) Inpatient psychiatric hospital services The term inpatient psychiatric hospital services has the meaning given such term in section 1861(c) of the Social Security Act ( 42 U.S.C. 1395x(c) ). (3) Medicare 190-day lifetime limit The term Medicare 190-day lifetime limit means the 190-day lifetime limitation imposed on inpatient psychiatric hospital services under section 1812(b)(3) of the Social Security Act ( 42 U.S.C. 1395d(b)(3) ). (c) Program details (1) Duration and starting date (A) Starting date The pilot program shall begin no later than January 1, 2018. (B) Duration Subject to subparagraph (C), the pilot program shall be conducted for a period of 7 years. (C) Expansion The Secretary may, at any time after the pilot program has operated for a period of at least 3 years expand the duration and scope of the pilot program, to the extent determined appropriate by the Secretary, if— (i) the Secretary determines that such expansion is expected— (I) to reduce (or not to result in any increase in) net expenditures under the Medicare program without reducing the quality of care; or (II) to improve the quality of care without increasing such net expenditures; (ii) the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that such expansion would reduce spending under the Medicare program; and (iii) the Secretary determines that such expansion would not deny or limit the coverage or provision of benefits under the Medicare program for applicable beneficiaries. (2) Waiver of Medicare 190-day lifetime limit The Medicare 190-day lifetime limit shall not apply to applicable beneficiaries receiving inpatient psychiatric services at a participating institution under the pilot program. (3) Participating providers of services and suppliers (A) In general Only institutions participating in the demonstration project may submit an application to the Secretary to provide inpatient psychiatric services under the pilot program. (B) Requirements The Secretary may develop additional requirements for institutions to participate in the pilot program. Such requirements may include the collection and reporting of data related to the reasonable costs of graduate medical education. (4) Quality measures (A) In general The Secretary shall establish quality measures related to care provided by qualifying institutions participating in the pilot program, which measures shall include at least measures of the following: (i) Reducing rates of avoidable hospital readmissions. (ii) Rates of discharge to the community. (iii) Rates of admission to an emergency room after a hospitalization. (iv) Other measures, including measures of patient outcomes, determined appropriate by the Secretary. (B) Reporting on quality measures A qualifying institution shall submit (in a form and manner specified by the Secretary) data to the Secretary on quality measures established under subparagraph (A) during each year in which the institution is participating in the pilot program. (d) Waiver The Secretary shall waive such provisions of titles XI and XVIII of the Social Security Act as may be necessary to carry out the pilot program. (e) Independent evaluation and reports on pilot program (1) Independent evaluation The Secretary shall conduct an independent evaluation of the pilot program, including the extent to which the pilot program has— (A) improved quality measures established under subsection (c)(4)(A); (B) improved health outcomes; (C) improved patient satisfaction; and (D) reduced spending under the Medicare program. (2) Report Not later than December 31, 2024, the Secretary shall submit to Congress a report on the evaluation conducted under paragraph (1). (3) Coordination with expanding choice for medicaid inpatient psychiatric hospital services demonstration project The Secretary may combine the independent evaluation and reports required under this section and the reports required under the demonstration project under section 2(f). (f) Budget neutrality With respect to the period of the pilot program under subsection (c)(1) occurring before any expansion under subparagraph (C) of such subsection, the Secretary shall ensures that program does not result in a net increase in the aggregate expenditures under the Medicare program for such period above the level of such expenditures if the pilot program had not been implemented. The Secretary may make such adjustments to payments under the Medicare program as is necessary to carry out the previous sentence.