I 118th CONGRESS 1st Session H. R. 4331 IN THE HOUSE OF REPRESENTATIVES June 23, 2023 Mr. Goldman of New York introduced the following bill; which was referred to the Committee on Energy and Commerce A BILL To amend title XIX of the Social Security Act to increase Federal Medicaid funding for States that provide intensive community-based services for adults with serious mental illness, and for other purposes.

1. Short title This Act may be cited as the Strengthening Medicaid for Serious Mental Illness Act . 2. Purposes The purposes of this Act are the following: (1) To amend title XIX of the Social Security Act to increase Federal Medicaid funding for States that provide intensive community-based services for adults with serious mental illness. (2) To increase access to intensive community-based services in the most integrated setting appropriate. (3) To prevent unnecessary hospitalization or other institutionalization. (4) To promote continuity of care and coverage for young adults after they turn 21 and age out of the early and periodic screening, diagnostic, and treatment services benefit. 3. Increased FMAP for providing intensive community-based services under Medicaid (a) In general Section 1915 of the Social Security Act ( 42 U.S.C. 1396n ) is amended by adding at the end the following new subsection: (m) State plan amendment option To provide intensive community-Based services for elderly and disabled individuals (1) In general Subject to the succeeding provisions of this subsection, beginning January 1, 2025, a State may provide through a State plan amendment for the provision of medical assistance for intensive community-based services (not including room and board) for eligible individuals (as defined in paragraph (2)), without determining that but for the provision of such services the individuals would require the level of care provided in a hospital, nursing facility, or intermediate care facility described in section 1905(d), but only if the State meets the following requirements: (A) Application of HCBS State plan amendment requirements (i) In general Except as provided in clause (ii), the State satisfies the requirements described in subparagraphs (A) through (J) of subsection (i)(1) (except that, in applying such subparagraphs for purposes of this subsection, each reference to home and community-based services shall be deemed to be a reference to intensive community-based services ). (ii) Modification of assessment requirement In applying subparagraph (F)(i) of subsection (i)(1) for purposes of this subsection, or 1 or more activity of daily living and 1 or more instrumental activity of daily living (as defined in subsection (k)(6)(F)) shall be inserted after 2 or more activities of daily living (as defined in section 7702B(c)(2)(B) of the Internal Revenue Code of 1986) . (B) Application of regulations In providing intensive community-based services under this subsection, the State complies with the regulations applicable to home and community-based services provided under subsection (i) under subpart M of part 441 of title 42, Code of Federal Regulations, including sections 441.710 (commonly known as the HCBS settings rule ) and 441.725 of such title, except to the extent that such regulations are inconsistent with this subsection. (2) Definitions In this subsection: (A) Adult with a serious mental illness; serious mental illness (i) Adult with a serious mental illness The term adult with a serious mental illness has the meaning given that term by the Secretary pursuant to section 1912(c) of the Public Health Service Act. (ii) Serious mental illness The term serious mental illness means a diagnosable mental, behavioral or emotional disorder that meets the criteria for qualifying an individual as an adult with a serious mental illness. (B) Assertive community treatment The term assertive community treatment means services for the treatment of mental illness that are provided through an evidence-based practice that— (i) improves outcomes for individuals with severe mental illness who are at high risk of homelessness, psychiatric crisis, or hospitalization, or are involved in the criminal justice system; (ii) is comprised of a multidisciplinary staff, including peer specialists, who work as a team to provide the individualized psychiatric treatment, rehabilitation, and support services clients need for the maximum reduction of physical or mental disability and restoration to their best possible functional level; (iii) ensures that there is 1 direct care staff person for every 10 clients; and (iv) provides services 24 hours a day, 7 days a week, for as long as needed and wherever they are needed. (C) Eligible individual The term eligible individual means an individual— (i) who is eligible for medical assistance under the State plan or under a waiver of such plan; (ii) who is age 21 or older; (iii) whose income does not exceed 150 percent of the poverty line (as defined in section 2110(c)(5)); and (iv) who is an adult with a serious mental illness. (D) Intensive case management The term intensive case management means a type of case management service (as defined in section 440.169 of title 42, Code of Federal Regulations)— (i) that is reliable, systematic, flexible, and coordinated, designed to answer the unique combination of health and social care needs of individuals with serious mental illness; (ii) that is a long-term, intensive approach to supporting an individual in the community by providing a comprehensive range of treatment, rehabilitation, and support services; (iii) that helps individuals with serious mental illness acquire material resources (such as food, shelter, clothing, and medical care) and improve their psychosocial functioning; (iv) that provides sufficient support to individuals with serious mental illness to keep them involved in community life and encourage growth towards greater autonomy and develop coping skills to meet the demands of community life; (v) that ensures continuity of care among treatment agencies; (vi) in which a case manager, working alone or as part of a team, makes 4 or more face-to-face contact with a client each month; and (vii) in which the case manager-to-client ratio does not exceed 1:12. (E) Intensive community-based services The term intensive community-based services means a set of psychosocial rehabilitation services that includes all of the following: (i) Assertive community treatment. (ii) Supported employment. (iii) Peer support services. (iv) Qualifying community-based mobile crisis intervention services. (v) Intensive case management. (vi) Housing-related activities and services, including individual housing transition services, individual housing and tenancy sustaining services, and State-level housing-related collaborative activities, as those services are described in the informational bulletin published by the Center for Medicaid and CHIP Services on June 26, 2015, with the subject Coverage of Housing-Related Activities and Services for Individuals with Disabilities . (vii) Such other psychosocial rehabilitation services as a State may request and the Secretary may approve. (F) Peer support services The term peer support services means culturally competent individual and group services for individuals with serious mental illness that promote recovery, resiliency, engagement, socialization, self-sufficiency, self-advocacy, development of natural supports, and identification of strengths through structured activities such as group and individual coaching to set recovery goals and identify steps to reach the goals. Such services aim to prevent relapse, empower beneficiaries through strength-based coaching, support linkages to community resources, and to educate beneficiaries and their families about their conditions and the process of recovery. Such services include the following: (i) Participating in the treatment planning process. (ii) Mentoring and assisting the beneficiary with problem solving, goal setting, and skill building. (iii) Encouraging a beneficiary’s interest in pursuing and maintaining treatment services. (iv) Providing support and linkages to facilitate participation in recovery-based activities. (v) Sharing experiential knowledge, hope, and skills. (vi) Advocating for the beneficiary. (G) Qualifying community-based mobile crisis intervention services 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— (i) furnished to an individual otherwise eligible for medical assistance under the State plan (or waiver of such plan) who is— (I) outside of a hospital or other facility setting; and (II) experiencing a mental health or substance use disorder crisis; (ii) 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 in the State plan amendment under this subsection; (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— (aa) screening and assessment; (bb) stabilization and de-escalation; and (cc) coordination with, and referrals to, health, social, and other services and supports as needed, and health services as needed; (IV) that maintains relationships with relevant community partners, including medical and behavioral health providers, primary care providers, community health centers, crisis respite centers, and managed care organizations (if applicable); and (V) that maintains the privacy and confidentiality of patient information consistent with Federal and State requirements; and (iii) available 24 hours per day, every day of the year. (H) Supported employment The term supported employment means ongoing supports that are furnished to individuals who, because of their serious mental illness, need intensive support to obtain and maintain an individual job in competitive or customized employment, or self-employment, in an integrated work setting in the general workforce at or above their State's minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. The desired outcome of all supported employment services is sustained paid employment at or above the minimum wage in an integrated setting in the general workforce, in a job that meets personal and career goals. (3) Increase fmap for medical assistance for intensive community-based services (A) In general During each fiscal quarter that a State meets the requirements described in subparagraphs (B) through (D), the Federal medical assistance percentage applicable to the State for the quarter (as determined under section 1905(b) without regard to any adjustments applicable under such section or any other provision of law) shall be increased by the applicable number of percentage points (as determined under subparagraph (E) but not to exceed 100 percent) with respect to amounts expended by the State for medical assistance for intensive community-based services furnished to eligible individuals during such quarter under a State plan amendment under this subsection. (B) Service quality criteria (i) In general The State shall provide eligible individuals with intensive community-based services in accordance with such quality criteria as the Secretary shall by regulation establish. (ii) Criteria requirements The criteria established by the Secretary under clause (i) shall be designed to ensure that eligible individuals receive the intended benefits of receipt of the services, including avoiding preventable hospitalization or other institutionalization. The criteria will be adjusted as needed to account for future developments and best practice. The criteria shall include the following: (I) The standards for assertive community treatment in the Tool for Measurement of Assertive Community Treatment (TMACT), Dartmouth Assertive Community Treatment Scale (DACTS), or other generally accepted tool for evaluating assertive community treatment. (II) Individual Placement and Support (IPS) standards for supported employment services. (III) Securing and maintaining scattered-site housing with a Housing First approach as the goal for housing-related activities and services. (C) Integrated setting Eligible individuals shall receive intensive community-based services— (i) in the most integrated setting appropriate; and (ii) without limiting access to any such service on the basis of— (I) the individual’s need for assistance with activities of daily living or instrumental activities of daily living; (II) receipt of other disability support services; (III) the presence of additional disabilities such as a physical, communication, intellectual, developmental, or other disability or a record or history of having such a disability; or (IV) the existence of co-occurring substance use disorders or a record or history of having such substance use disorders. (D) Data collection and reporting Not less frequently than once every 2 years, the State shall collect and report data to the Secretary, including with respect to disparities in access to, or receipt of, intensive community-based services, according to criteria established by the Secretary and the Secretary shall analyze and report such findings to Congress. The criteria shall include the collection and reporting of data with respect to the following: (i) Demographic characteristics of eligible individuals who receive intensive community-based services, including but not limited to, race, ethnicity, disability status, disability category, age, sex, sex characteristics, sexual orientation, gender identity, primary language, rural or urban environment, and service setting. (ii) The utilization of intensive community-based services, including units of service and duration of receipt of service, per eligible individual receiving services. (iii) Consumer outcomes, as measured via a quality service review tool and methodology approved by the Secretary. (E) Applicable number of percentage points For purposes of subparagraph (A)— (i) if a State offers at least 1 but under 2 of the categories of intensive community-based services described in clauses (i) through (vii) of paragraph (2)(E) in a quarter, the applicable number of percentage points for the State and quarter is 3 percentage points; (ii) if a State offers at least 2 but under 3 of the categories of intensive community-based services described in clauses (i) through (vii) of paragraph (2)(E) in a quarter, the applicable number of percentage points for the State and quarter is 7 percentage points; (iii) if a State offers at least 3 but under 4 of the categories of intensive community-based services described in clauses (i) through (vii) of paragraph (2)(E) in a quarter, the applicable number of percentage points for the State and quarter is 12 percentage points; (iv) if a State offers at least 4 but under 5 of the categories of intensive community-based services described in clauses (i) through (vii) of paragraph (2)(E) in a quarter, the applicable number of percentage points for the State and quarter is 18 percentage points; and (v) if a State offers at least 5 of the categories of intensive community-based services described in clauses (i) through (vii) of paragraph (2)(E) in a quarter, the applicable number of percentage points for the State and quarter is 25 percentage points. (4) Application of HCBS State plan amendment provisions Paragraphs (3), (4), (5), (6), and (7) of subsection (i) shall apply to State plan amendments under this subsection and intensive community-based services in the same manner as such paragraphs apply to State plan amendments under such subsection (i) and home and community-based services. (5) Funding for state planning grants (A) In general There is appropriated, out of any funds in the Treasury not otherwise appropriated, $20,000,000 to the Secretary for purposes of implementing, administering, and making planning grants to States as soon as practicable for purposes of developing a State plan amendment request to provide intensive community-based services under this subsection, to remain available until expended. (B) Use of funds A State shall use funds received under a grant under this subsection to engage in planning activities for a State plan amendment under this subsection, including— (i) collaborative activities, at the State and Federal level, with providers of housing-related services; (ii) developing service quality criteria; and (iii) developing the infrastructure necessary to implement the State plan amendment, including data infrastructure and staffing. . (b) Rule of construction Nothing in this Act or the amendments made by this Act may be construed to limit the entitlement of children and youth who are eligible for medical assistance under a State Medicaid program to receive intensive community-based services through the early and periodic screening, diagnostic, and treatment services benefit.