Demonstration project regarding medicaid reimbursements for stabilization of emergency medical conditions by non-publicly owned or operated institutions for mental diseases

(a)

Authority To conduct demonstration project

The Secretary of Health and Human Services (in this section referred to as the Secretary) shall establish a demonstration project under which an eligible State (as described in subsection (c)) shall provide reimbursement under the State Medicaid plan under title XIX of the Social Security Act to an institution for mental diseases that is not publicly owned or operated and that is subject to the requirements of section 1867 of the Social Security Act (42 U.S.C. 1395dd) for the provision of medical assistance available under such plan to an individual who— (1)has attained age 21, but has not attained age 65; (2)is eligible for medical assistance under such plan; and (3)requires such medical assistance to stabilize an emergency medical condition. (b)

In-stay review

The Secretary shall establish a mechanism for in-stay review to determine whether or not the patient has been stabilized (as defined in subsection (h)(5)). This mechanism shall commence before the third day of the inpatient stay. States participating in the demonstration project may manage the provision of these benefits under the project through utilization review, authorization, or management practices, or the application of medical necessity and appropriateness criteria applicable to behavioral health. (c)

Eligible state defined

(1)

Application

Upon approval of an application submitted by a State described in paragraph (2), the State shall be an eligible State for purposes of conducting a demonstration project under this section. (2)

State described

States shall be selected by the Secretary in a manner so as to provide geographic diversity on the basis of the application to conduct a demonstration project under this section submitted by such States. (d)

Length of demonstration project

The demonstration project established under this section shall be conducted for a period of 3 consecutive years. (e)

Limitations on federal funding

(1)

Appropriation

(A)

In general

Out of any funds in the Treasury not otherwise appropriated, there is appropriated to carry out this section, $75,000,000 for fiscal year 2010. (B)

Budget authority

Subparagraph (A) constitutes budget authority in advance of appropriations Act and represents the obligation of the Federal Government to provide for the payment of the amounts appropriated under that subparagraph. (2)

3-year availability

Funds appropriated under paragraph (1) shall remain available for obligation through December 31, 2012. (3)

Limitation on payments

In no case may— (A)the aggregate amount of payments made by the Secretary to eligible States under this section exceed $75,000,000; or (B)payments be provided by the Secretary under this section after December 31, 2012. (4)

Funds allocated to states

The Secretary shall allocate funds to eligible States based on their applications and the availability of funds. (5)

Payments to states

The Secretary shall pay to each eligible State, from its allocation under paragraph (4), an amount each quarter equal to the Federal medical assistance percentage of expenditures in the quarter for medical assistance described in subsection (a). (f)

Reports

(1)

Annual progress reports

The Secretary shall submit annual reports to Congress on the progress of the demonstration project conducted under this section. (2)

Final report and recommendation

An evaluation should be conducted of the demonstration project’s impact on the functioning of the health and mental health service system and on individuals enrolled in the Medicaid program. This evaluation should include collection of baseline data for one-year prior to the initiation of the demonstration project as well as collection of data from matched comparison states not participating in the demonstration. The evaluation measures shall include the following: (A)A determination, by State, as to whether the demonstration project resulted in increased access to inpatient mental health services under the Medicaid program and whether average length of stays were longer (or shorter) for individuals admitted under the demonstration project compared with individuals otherwise admitted in comparison sites. (B)An analysis by State, regarding whether the demonstration project produced a significant reduction in emergency room visits for individuals eligible for assistance under the Medicaid program or in the duration of emergency room lengths of stay. (C)An assessment of discharge planning by participating hospitals that ensures access to further (non-emergency) inpatient or residential care as well as continuity of care for those discharged to outpatient care. (D)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 plan as contrasted with the comparison areas. (E)Data on the percentage of consumers with Medicaid coverage who are admitted to inpatient facilities as a result of the demonstration project as compared to those admitted to these same facilities through other means. (F)A recommendation regarding whether the demonstration project should be continued after December 31, 2012, and expanded on a national basis. (g)

Waiver authority

(1)

In general

The Secretary shall waive the limitation of subdivision (B) following paragraph (28) 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 diseases) for purposes of carrying out the demonstration project under this section. (2)

Limited other waiver authority

The Secretary may waive other requirements of titles XI and XIX of the Social Security Act (including the requirements of sections 1902(a)(1) (relating to statewideness) and 1902(1)(10)(B) (relating to comparability)) only to extent necessary to carry out the demonstration project under this section. (h)

Definitions

In this section: (1)

Emergency medical condition

The term emergency medical condition means, with respect to an individual, an individual who expresses suicidal or homicidal thoughts or gestures, if determined dangerous to self or others. (2)

Federal medical assistance percentage

The term Federal medical assistance percentage has the meaning given that term with respect to a State under section 1905(b) of the Social Security Act (42 U.S.C. 1396d(b)). (3)

Institution for mental diseases

The term institution for mental diseases has the meaning given to that term in section 1905(i) of the Social Security Act (42 U.S.C. 1396d(i)). (4)

Medical assistance

The term medical assistance has the meaning given to that term in section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)). (5)

Stabilized

The term stabilized means, with respect to an individual, that the emergency medical condition no longer exists with respect to the individual and the individual is no longer dangerous to self or others. (6)

State

The term State has the meaning given that term for purposes of title XIX of the Social Security Act (42 U.S.C. 1396 et seq.).