II 117th CONGRESS 1st Session S. 1902 IN THE SENATE OF THE UNITED STATES May 27, 2021 Ms. Cortez Masto (for herself and Mr. Cornyn ) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions A BILL To empower communities to establish a continuum of care for individuals experiencing mental or behavioral health crisis, and for other purposes.

1. Short title This Act may be cited as the Behavioral Health Crisis Services Expansion Act . 2. Crisis response continuum of care (a) In general The Secretary of Health and Human Services (in this section referred to as the Secretary ) shall establish standards for a continuum of care for use by health care providers and communities in responding to individuals experiencing a mental or behavioral health crisis, including those individuals with co-occurring substance use disorders (referred to in this section as the crisis response continuum ). (b) Requirements (1) Scope of standards Such standards shall define— (A) minimum requirements of core crisis services, as determined by the Secretary, to include requirements that each entity that furnishes such services should— (i) not require prior authorization from an insurance provider nor referral from a health care provider prior to the delivery of services; (ii) serve all individuals regardless of age or ability to pay; (iii) operate 24 hours a day, 7 days a week, and provide care to all individuals; and (iv) provide care and support through resources described in paragraph (2)(A) until the individual has been stabilized or transfer the individual to the next level of crisis care; and (B) psychiatric stabilization, including the point at which a case may be closed for— (i) individuals screened over the phone; and (ii) individuals stabilized on the scene by mobile teams. (2) Identification of essential functions The Secretary shall identify the essential functions of each service in the crisis response continuum, which shall include at least the following: (A) Identification of resources for referral and enrollment in continuing behavioral health and other human services for the individual in crisis where necessary. (B) Delineation of access and entry points to services within the crisis response continuum. (C) Development of and adherence to protocols and agreements for the transfer and receipt of individuals to and from other segments of the crisis response continuum segments as needed, and from outside referrals including health care providers, law enforcement, EMS, fire, education institutions, and community-based organizations. (D) Description of the qualifications of crisis services staff, including roles for physicians, licensed clinicians, case managers, and peers (in accordance with State licensing requirements). (E) Requirements for the convention of collaborative meetings of crisis response service providers, first responders, and community partners operating in a common region for the discussion of case management, best practices, and general performance improvement. (3) Service capacity and quality standards Such standards shall include definitions of— (A) adequate volume of services to meet population need; (B) appropriate timely response; and (C) capacity to meet the needs of different patient populations, including all age groups, cultural and linguistic minorities, and individuals with co-occurring mental health and substance use disorder crisis, individuals with cognitive disabilities experiencing behavioral health crises, and individuals with chronic medical conditions and physical disabilities experiencing behavioral health crises. (4) Oversight and accreditation The Secretary shall designate entities charged with the oversight and accreditation of entities within the crisis response continuum. (5) Implementation timeframe Not later than 1 year after the date of enactment of this Act, the Secretary shall establish the standards under this section. (6) Data collection and evaluations (A) In general The Secretary, directly or through grants, contracts, or interagency agreements, shall collect data and conduct evaluations with respect to the provision of services and programs offered on the crisis response continuum for purposes of assessing the extent to which the provision of such services and programs meet certain objectives and outcomes measures as determined by the Secretary. Such objectives shall include— (i) a reduction in inappropriate arrests of individuals who are in mental health crisis; (ii) a reduction in inappropriate emergency room admissions and readmissions; and (iii) evidence of adequate access to crisis care centers and crisis bed services. (B) Rulemaking The Secretary shall carry out this subsection through notice and comment rulemaking, following a request for information from stakeholders. (C) Authorization of appropriations To carry out this subsection, there is authorized to be appropriated such sums as are necessary to remain available until expended. (c) Components of crisis response continuum The crisis response continuum consists of at least the following components: (1) Crisis call centers Regional clinically managed crisis call centers that provide telephonic crisis intervention capabilities. Such centers should meet National Suicide Prevention Lifeline operational guidelines regarding suicide risk assessment and engagement and offer air traffic control-quality coordination of crisis care in real-time. (2) Mobile crisis response team Teams of providers that are available to reach any individual in the service area in their home, workplace, or any other community-based location of the individual in crisis in a timely manner. (3) Crisis receiving and stabilization facilities Subacute inpatient facilities and other facilities specified by the Secretary that provide short-term observation and crisis stabilization services to all referrals, including the following services: (A) 23-hour crisis stabilization services A direct care service that provides individuals in severe distress with up to 23 consecutive hours of supervised care to assist with deescalating the severity of their crisis or need for urgent care in a sub-acute inpatient setting. (B) Short-term crisis residential services A direct care service that assists with deescalating the severity of an individual's level of distress or need for urgent care associated with a substance use or mental health disorder in a residential setting. (4) Behavioral health urgent care facilities Ambulatory services available 12-24 hours per day, 7 days a week, where individuals experiencing crisis can walk in without an appointment to receive crisis assessment, crisis intervention, medication, and connection to continuity of care. (5) Additional facilities and providers The Secretary shall specify additional facilities and health care providers as part of the crisis response continuum, as the Secretary determines appropriate. (d) Relationship to State law (1) In general Subject to paragraph (2), the standards established under this section are minimum standards and nothing in this section may be construed to preclude a State from establishing additional standards, so long as such standards are not inconsistent with the requirements of this section or other applicable law. (2) Waiver or modification The Secretary shall establish a process under which a State may request a waiver or modification of a standard established under this section. 3. Coverage of crisis response services (a) Coverage under the Medicare program (1) In general Section 1861(s)(2) of the Social Security Act ( 42 U.S.C. 1395x(s)(2) ) is amended— (A) in subparagraph (GG), by striking and at the end; (B) in subparagraph (HH), by striking the period at the end and inserting ; and ; and (C) by adding at the end the following new subparagraph: (II) crisis response services as defined in subsection (lll); . (2) Crisis response services defined Section 1861 of the Social Security Act ( 42 U.S.C. 1395x ) is amended by adding at the end the following new subsection: (lll) Crisis response services defined (1) In general The term crisis response services means mental or behavioral health services that are furnished by a mobile crisis response team, a crisis receiving and stabilization facility, behavioral health urgent care facility, or other appropriate provider, as determined by the Secretary, to an individual experiencing a mental or behavioral health crisis. Such term includes services identified by the Secretary as part of the crisis response continuum of care under section 2 of the Behavioral Health Crisis Services Expansion Act . (2) Definitions In this subsection, the terms mobile crisis response team , crisis receiving and stabilization facility , and behavioral health urgent care facility have the meaning given those terms for purposes of such section. . (3) Payment Section 1833(a)(1) of the Social Security Act ( 42 U.S.C. 1395l(a)(1) ) is amended— (A) by striking and (DD) and inserting (DD) ; and (B) by inserting before the semicolon at the end the following: and (EE) with respect to crisis response services described in section 1861(s)(2)(II), the amounts paid shall be 80 percent of the lesser of the actual charge for the service or the fee schedule amount provided under section 1848 . (4) Ambulance transport of individuals in crisis (A) In general Section 1834(l) of the Social Security Act ( 42 U.S.C. 1395m(l) ) is amended by adding at the end the following new paragraph: (18) Transportation of individuals in crisis With respect to ambulance services furnished on or after the date that is 3 years after the date of the enactment of the Behavioral Health Crisis Services Expansion Act , the regulations described in section 1861(s)(7) shall provide coverage under such section for ambulance services to transport an individual experiencing a mental or behavioral health crisis to an appropriate facility, such as a community mental health center (as defined in section 1861(ff)(3)(B)) or other facility or provider identified by the Secretary as part of the crisis response continuum of care under section 2 of the Behavioral Health Crisis Services Expansion Act , as appropriate, for crisis response services described in section 1861(s)(2)(II). . (B) Conforming amendment Section 1861(s)(7) of such Act ( 42 U.S.C. 1395x(s)(7) ) is amended by striking section 1834(l)(14) and inserting paragraphs (14) and (18) of section 1834(l) . (5) Effective date The amendments made by this subsection shall apply to services furnished on or after the date that is 3 years after the date of the enactment of this Act. (b) Mandatory coverage of crisis response services under the Medicaid program (1) In general Title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq.) is amended— (A) in section 1902(a)(10)(A), in the matter preceding clause (i), by striking and (30) and inserting (30), and (31) ; and (B) in section 1905— (i) in subsection (a)— (I) in paragraph (30), by striking ; and and inserting a semicolon; (II) by redesignating paragraph (31) as paragraph (32); and (III) by inserting the following paragraph after paragraph (30): (31) subject to subsection (jj), crisis response services (as defined in section 1861(lll)); and ; and (ii) by adding at the end the following new subsection: (jj) Exception to requirement To provide coverage for crisis response services The requirement to provide services described in paragraph (31) of subsection (a) shall not apply with respect to a State for a fiscal year, if before the beginning of such year the State certifies to the satisfaction of the Secretary that implementing such requirement statewide for all individuals eligible to enroll in the State plan (or waiver of the State plan) would not be feasible by reason of a shortage of qualified providers of crisis response services, or facilities providing such treatment, that will contract with the State or a managed care entity with which the State has a contract under section 1903(m) or under section 1905(t)(3). . (2) Presumptive eligibility determination by crisis response service providers Section 1902(a)(47)(B) of the Social Security Act ( 42 U.S.C. 1396a(a)(47)(B) ) is amended by inserting or provider of crisis response services (as defined in section 1861(lll)) after any hospital . (3) Effective date (A) In general Except as provided in subparagraph (B), the amendments made by this section shall take effect on the date that is 3 years after the date of the enactment of this Act. (B) Delay permitted if state legislation required In the case of a State plan under title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq.) which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirements imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of the failure of the plan to meet such additional requirements before the 1st day of the 1st calendar quarter beginning after the close of the 1st regular session of the State legislature that begins after the date of enactment of this Act. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature. (c) Essential health benefits Section 1302(b)(1)(E) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18022(b)(1)(E) ) is amended by inserting and crisis response services (as defined in section 1861(lll) of the Social Security Act) before the period. (d) Group health plans Section 2707 of the Public Health Service Act ( 42 U.S.C. 300gg–6 ) is amended by adding at the end the following: (e) Crisis response services A group health plan or a health insurance issuer that offers health insurance coverage in the large group market shall ensure that such coverage includes crisis response services (as defined in section 1861(lll) of the Social Security Act). . (e) TRICARE coverage (1) In general The Secretary of Defense shall provide coverage under the TRICARE program for crisis response services, as defined in section 1861(lll) of the Social Security Act ( 42 U.S.C. 1395x ) (as amended by section 3). (2) TRICARE program defined In this section, the term TRICARE program has the meaning given the term in section 1072 of title 10, United States Code. (f) Reimbursement for crisis response services for veterans Section 1725(f)(1) of title 38, United States Code, is amended, in the matter preceding subparagraph (A), by inserting , including crisis response services (as defined in subsection (lll) of section 1861 of the Social Security Act ( 42 U.S.C. 1395x )), after services . (g) Coverage under FEHB (1) In general Section 8902 of title 5, United States Code, is amended by adding at the end the following: (p) Each contract for a plan under this chapter shall require the carrier to provide coverage for crisis response services, as that term is defined in subsection (lll) of section 1861 of the Social Security Act ( 42 U.S.C. 1395x ). . (2) Effective date The amendment made by paragraph (1) shall apply beginning with respect to the third contract year for chapter 89 of title 5, United States Code, that begins on or after the date that is 3 years after the date of enactment of this Act. 4. Building the crisis continuum infrastructure (a) Additional amounts for Mental Health Block grant Section 1920 of the Public Health Service Act ( 42 U.S.C. 300x–9 ) is amended by adding at the end the following: (d) Support for crisis response services infrastructure (1) In general In addition to amounts made available under subsection (a), there are authorized to be appropriated such sums as are necessary for each of fiscal years 2022, 2023, and 2024, for purposes of supporting the infrastructure needed to provide crisis response services (as defined in section 1861(lll) of the Social Security Act) in the States, which may include training and continuing education, and administrative expenses with respect to the provision of such services. (2) Allotments Each fiscal year for which amounts are appropriated under paragraph (1), the Secretary shall allot to each State that receives a grant under section 1911 for the fiscal year an amount that bears the same relationship to the total amount appropriated under paragraph (1) for the fiscal year that the amount received by the State under section 1911(a) for the fiscal year bears to the total amount appropriated under subsection (a) for the fiscal year. . (b) Technical assistance The Secretary of Health and Human Services (referred to in this section as the Secretary ) shall provide to States technical assistance regarding the provision of crisis response services, as defined in section 1861(lll) of the Social Security Act ( 42 U.S.C. 1395x ) (as amended by section 3), including guidance on how States may blend Medicaid funds available to States under title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq.) and funds available to States under the community mental health services block grant program under subpart I of part B of title XIX of the Public Health Service Act ( 42 U.S.C. 300x et seq.) and the substance abuse prevention and treatment block grant program under subpart II of part B of title XIX of such Act ( 42 U.S.C. 300x–21 et seq.) to provide such services. (c) Clearinghouse of best practices The Secretary shall develop and maintain a publicly available clearinghouse of best practices for the successful operation of each segment of the system for providing crisis response services (as defined in section 1861(lll) of the Social Security Act ( 42 U.S.C. 1395x ) (as amended by section 3)) and the integration of such best practices into the provision of such services. The clearinghouse shall be updated annually. 5. Incident reporting (a) Establishment of protocol panel The Secretary of Health and Human Services (referred to in this section as the Secretary ), in consultation with the Attorney General, shall convene a panel for the purposes of making recommendations for training and protocol for 911 dispatchers to respond appropriately to individuals experiencing a psychiatric crisis based on the characteristics of the incident and the needs of the caller. (b) Panelists The Secretary shall appoint individuals to serve staggered 10-year terms on the panel established under subsection (a). Such individuals shall include— (1) firefighters; (2) emergency medical services personnel; (3) law enforcement officers; (4) 911 dispatchers; (5) representatives from each segment of the crisis response continuum, as described in section 2, including 988 dispatchers; (6) individuals who have received services under such crisis response continuum, including individuals under the age of 18 and members of underserved communities; and (7) other individuals, as the Secretary determines appropriate. (c) Recommendations (1) Topics In issuing recommendations under this section, the panel shall consider— (A) connecting 911 callers to crisis care services instead of responding with law enforcement officers; (B) integrating the 988 system into the 911 system, or transferring calls from the 911 system to the 988 system as appropriate; and (C) a process for identifying 911 callers who are in mental health distress and evaluating the level of need of such callers, as defined by standardized assessment tools such as the Level of Care Utilization System (LOCUS) and the Child and Adolescent Level of Care Utilization System (CALOCUS). (2) Updates The panel shall update recommendations issued under this section not less frequently than every 5 years.