II 116th CONGRESS 2d Session S. 4441 IN THE SENATE OF THE UNITED STATES August 5, 2020 Mr. Wyden (for himself and Ms. Cortez Masto ) introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To amend title XIX of the Social Security Act to encourage State Medicaid programs to provide community-based mobile crisis intervention services, and for other purposes.

1. Short title This Act may be cited as the Crisis Assistance Helping Out On The Streets Act or the CAHOOTS Act . 2. Enhanced Federal Medicaid support for community-based mobile crisis intervention services Section 1903 of the Social Security Act ( 42 U.S.C. 1396b ) is amended by adding at the end the following new subsection: (bb) Community-Based mobile crisis intervention services (1) In general Notwithstanding section 1902(a)(1) (relating to Statewideness), section 1902(a)(10)(B) (relating to comparability), section 1902(a)(23)(A) (relating to freedom of choice of providers), or section 1902(a)(27) (relating to provider agreements), a State may provide medical assistance for qualifying community-based mobile crisis intervention services under a State plan amendment or waiver approved under section 1115 or 1915(c). (2) Qualifying community-based mobile crisis intervention services defined For purposes of this subsection, the term qualifying community-based mobile crisis intervention services means, with respect to a State, items and services for which medical assistance is available under the State plan under this title or a waiver of such plan, that are— (A) furnished to an individual who is— (i) outside of a hospital or other facility setting; and (ii) experiencing a mental health or substance use disorder crisis; (B) furnished by a multidisciplinary mobile crisis team— (i) that includes at least 1 behavioral health care professional who is capable of conducting an assessment of the individual, in accordance with the professional's permitted scope of practice under State law, and other professionals or paraprofessionals with appropriate expertise in behavioral health or mental health crisis response, including nurses, social workers, peer support specialists, and others, as designated by the State and approved by the Secretary; (ii) whose members are trained in trauma-informed care, de-escalation strategies, and harm reduction; (iii) that is able to respond in a timely manner and, where appropriate, provide the following— (I) screening and assessment; (II) stabilization and de-escalation; (III) coordination with, and referrals to, health, social, and other services and supports as needed; and (IV) provision or coordination of transportation to the next step in care or treatment; (iv) that maintains relationships with relevant community partners, including medical and behavioral health providers, community health centers, crisis respite centers, managed care organizations (if applicable), entities able to provide assistance with application and enrollment in the State plan or a waiver of the plan, entitles able to provide assistance with applying for and enrolling in benefit programs, entities that provide assistance with housing (such as public housing authorities, Continuum of Care programs, or not-for-profit entities that provide housing assistance), and entities that provide assistance with other social services; (v) that coordinates with crisis intervention hotlines and emergency response systems; (vi) that maintains the privacy and confidentiality of patient information consistent with Federal and State requirements; and (vii) that operates independently from (but may coordinate with) State or local law enforcement agencies; (C) available 24 hours per day, every day of the year; and (D) voluntary to receive. (3) Payments (A) In general Notwithstanding section 1905(b), beginning October 1, 2020, during each of the first 12 fiscal quarters that a State meets the requirements described in paragraph (4), the Federal medical assistance percentage applicable to amounts expended by the State for medical assistance for qualifying community-based mobile crisis intervention services furnished during such quarter shall be equal to 95 percent. (B) Exclusion of enhanced payments from territorial caps To the extent that the amount of a payment to Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa for medical assistance for qualifying community-based mobile crisis intervention services that is based on the Federal medical assistance percentage specified in subparagraph (A) exceeds the amount that would have been paid to such territory for such services if the Federal medical assistance percentage for the territory had been determined without regard to such subparagraph— (i) the limitation on payments to territories under subsections (f) and (g) of section 1108 shall not apply to the amount of such excess; and (ii) the amount of such excess shall be disregarded in applying such subsections. (4) Requirements The requirements described in this paragraph are the following: (A) The State demonstrates, to the satisfaction of the Secretary— (i) that it will be able to support the provision of qualifying community-based mobile crisis intervention services that meet the conditions specified in paragraph (2); and (ii) how it will support coordination between mobile crisis teams and community partners, including health care providers, to enable the provision of services, needed referrals, and other activities identified by the Secretary. (B) The State provides assurances satisfactory to the Secretary that— (i) any additional Federal funds received by the State for qualifying community-based mobile crisis intervention services provided under this subsection that are attributable to the increased Federal medical assistance percentage under paragraph (3)(A) will be used to supplement, and not supplant, the level of State funds expended for such services for fiscal year 2019; (ii) if the State made qualifying community-based mobile crisis intervention services available in a region of the State in fiscal year 2019, the State will continue to make such services available in such region under this subsection at the same level that the State made such services available in such fiscal year; and (iii) the State will conduct the evaluation and assessment, and submit the report, required under paragraph (5). (5) State evaluation and report (A) State evaluation Not later than 4 fiscal quarters after a State begins providing qualifying community-based mobile crisis intervention services in accordance with this subsection, the State shall enter into a contract with an independent entity or organization to conduct an evaluation for the purposes of— (i) determining the effect of the provision of such services on— (I) emergency room visits; (II) use of ambulatory services; (III) hospitalizations; (IV) the involvement of law enforcement in mental health or substance use disorder crisis events; (V) the diversion of individuals from jails or similar settings; and (ii) assessing— (I) the types of services provided to individuals; (II) the types of events responded to; (III) cost savings or cost-effectiveness attributable to such services; (IV) the experiences of individuals who receive qualifying community-based mobile crisis intervention services; (V) the successful connection of individuals with follow-up services; and (VI) other relevant outcomes identified by the Secretary. (B) Comparison to historical measures The contract described in subparagraph (A) shall specify that the evaluation is based on a comparison of the historical measures of State performance with respect to the outcomes specified under such subparagraph to the State's performance with respect to such outcomes during the period beginning with the first quarter in which the State begins providing qualifying community-based mobile crisis intervention services in accordance with this subsection. (C) Report Not later than 2 years after a State begins to provide qualifying community-based mobile crisis intervention services in accordance with this subsection, the State shall submit a report to the Secretary on the following: (i) The results of the evaluation carried out under subparagraph (A). (ii) The number of individuals who received qualifying community-based mobile crisis intervention services. (iii) Demographic information regarding such individuals when available, including the race or ethnicity, age, sex, sexual orientation, gender identity, and geographic location of such individuals. (iv) The processes and models developed by the State to provide qualifying community-based mobile crisis intervention services under such the State plan or waiver, including the processes developed to provide referrals for, or coordination with, follow-up care and services. (v) Lessons learned regarding the provision of such services. (D) Public availability The State shall make the report required under subparagraph (C) publicly available, including on the website of the appropriate State agency, upon submission of such report to the Secretary. (6) Best practices report (A) In general Not later than 3 years after the first State begins to provide qualifying community-based mobile crisis intervention services in accordance with this subsection, the Secretary shall submit a report to Congress that— (i) identifies the States that elected to provide services in accordance with this subsection; (ii) summarizes the information reported by such States under paragraph (5)(C); and (iii) identifies best practices for the effective delivery of community-based mobile crisis intervention services. (B) Public availability The report required under subparagraph (A) shall be made publicly available, including on the website of the Department of Health and Human Services, upon submission to Congress. (7) State planning and evaluation grants (A) In general As soon as practicable after the date of enactment of this subsection, the Secretary may award planning and evaluation grants to States for purposes of developing a State plan amendment or section 1115 or 1915(c) waiver request (or an amendment to such a waiver) to provide qualifying community-based mobile crisis intervention services and conducting the evaluation required under paragraph (5)(A). A grant awarded to a State under this paragraph shall remain available until expended. (B) State contribution A State awarded a grant under this subsection shall contribute for each fiscal year for which the grant is awarded an amount equal to the State percentage determined under section 1905(b) (without regard to the temporary increase in the Federal medical assistance percentage of the State under section 6008(a) of the Families First Coronavirus Response Act ( Public Law 116–127 ) or any other temporary increase in the Federal medical assistance percentage of the State for fiscal year 2020 or any succeeding fiscal year) of the grant amount. (8) Funding (A) Implementation and administration There is appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, such sums as are necessary for purposes of implementing and administering this section. (B) Planning and evaluation grants There is appropriated, out of any funds in the Treasury not otherwise appropriated, $25,000,000 to the Secretary for fiscal year 2021 for purposes of making grants under paragraph (7), to remain available until expended. .