Establishing a Medicare demonstration program relating to crisis response services

Part E of title XVIII of the Social Security Act (42 U.S.C. 1395x et seq.) is amended by inserting after section 1866G the following new section:

1866H.

Crisis response services demonstration program

(a)

In general

Not later than January 1, 2026, the Secretary shall establish a crisis response services demonstration program (in this section referred to as the demonstration program) to determine whether payment for crisis response services furnished to applicable individuals by participating providers results in—(1)a reduction in emergency department visits;(2)increased access to crisis response services;(3)a reduction in expenditures under this title; or(4)improved behavioral health outcomes. (b)

Participating providers

(1)

In general

Subject to paragraph (3), the Secretary shall designate an eligible provider as a participating provider for purposes of the demonstration program if such eligible provider submits an application to the Secretary at such time and in such manner as specified by the Secretary and demonstrates that the provider meets the standards established by the Secretary under paragraph (2).(2)

Standards

The Secretary, in coordination with the Assistant Secretary for Mental Health and Substance Use, shall specify standards that an eligible provider must meet in order to be designated as a participating provider under paragraph (1). Such standards shall include the following:(A)Standards relating to the minimum set of crisis response services to be furnished by a participating provider under the demonstration program.(B)Standards relating to access to such services, including a requirement that such provider be available to furnish such services 24 hours per day, 7 days per week, and have a physician (which may include a psychiatrist), nurse practitioner, or physician assistant so available to furnish such services.(C)Standards relating to the provision of such services, including—(i)standards relating to the qualifications of individuals who may furnish such services, in accordance with applicable State licensure requirements;(ii)standards relating to collaboration of such individuals with other entities (such as community first responders and community-based organizations) to ensure appropriate case management and adherence to best practices;(iii)standards relating to the receipt of individuals from appropriate providers of services, suppliers, and other entities (such as law enforcement entities, educational institutions, and community-based organizations); and(iv)a requirement that such services may only be terminated once an individual is stabilized or transferred to receive care from another appropriate provider of services, supplier, or entity.(3)

Termination of designation

(A)

In general

The Secretary shall terminate a designation of a participating provider under paragraph (1) if—(i)the Secretary determines that such provider no longer meets the standards specified under paragraph (2); or(ii)such provider fails to meets such quality standards as the Secretary determines appropriate.(B)

Permissive termination

The Secretary may terminate a designation of a participating provider under paragraph (1) for such other reasons as determined appropriate by the Secretary.(c)

Payment

(1)

In general

Payment for crisis response services furnished by a participating provider under the demonstration program shall be equal to 100 percent of the lesser of the amount charged by such provider or an amount determined under the payment basis established by the Secretary under paragraph (2).(2)

Payment basis

The Secretary shall establish a single payment amount for crisis response services furnished to an applicable individual by a participating provider during a month. Such amount shall be equal to the average (as determined by the Secretary) costs incurred by eligible providers in furnishing such services to an individual during a month.(3)

Source of payment

Payment for crisis response services furnished by a participating provider under the demonstration program shall be made from the Federal Supplementary Medical Insurance Trust Fund established under section 1841.(d)

Evaluation and monitoring

The Secretary shall evaluate each participating provider under the demonstration program to assess whether the results described in subsection (a) have been achieved.(e)

Report

Not later than 3 years after the date of the enactment of this section, the Secretary shall conduct an independent evaluation of the demonstration program and submit to Congress a report on such program. Such report shall include an analysis of the following:(1)Whether such program has achieved results described in subsection (a).(2)The quality of crisis response services furnished under such program.(3)Any reduction in jail incarceration attributable to such program.(4)The number of individuals furnished services under such program who were not voluntarily so furnished such services.(f)

Definitions

In this section:(1)

Applicable individual

The term applicable individual means an individual who—(A)is entitled to benefits under part A and enrolled under part B;(B)is not enrolled in a Medicare Advantage plan under part C or a PACE program under section 1894; and(C)meets such other criteria as determined appropriate by the Secretary.(2)

Behavioral health urgent care facility

The term behavioral health urgent care facility means an ambulatory facility where individuals experiencing a mental or behavioral health crisis may walk in without an appointment to receive crisis assessment services, crisis intervention services, medication, and connection to other appropriate services.(3)

Crisis receiving and stabilization facility

The term crisis receiving and stabilization facility means a subacute inpatient facility or other facility specified by the Secretary that provides short-term observation and stabilization services to individuals experiencing a mental or behavioral health crisis.(4)

Crisis response services

The term crisis response services means mental or behavioral health services that are furnished to an individual experiencing a mental or behavioral health crisis to—(A)provide screening and assessment for the individual’s mental health or substance use disorder crisis;(B)support the de-escalation of the individual’s mental health or substance use disorder crisis;(C)facilitate or support subsequent referral to health, social, and other services, as determined appropriate by the Secretary; or(D)otherwise address the individual’s pressing behavioral health needs, as determined appropriate by the Secretary.(5)

Eligible provider

The term eligible provider means a provider of crisis response services that is a mobile crisis response team, a crisis receiving and stabilization facility, a behavioral health urgent care facility, or such other provider of services or supplier determined appropriate by the Secretary.(6)

Mobile crisis response team

The term mobile crisis response team means a team of physicians or practitioners (as described in section 1842(b)(18)(C)) that is available to furnish crisis response services to an individual experiencing a mental or behavioral health crisis in the individual’s home or at the individual’s workplace or another community-based location in a timely manner.(g)

Funding

For purposes of administering and carrying out the demonstration program, other than for payments for services furnished under the program, in addition to funds otherwise appropriated, the Secretary shall provide for the transfer to the Center for Medicare & Medicaid Services Program Management Account from the Federal Hospital Insurance Trust Fund under section 1817 and the Federal Supplementary Medical Insurance Trust Fund under section 1841 of this title (in proportions determined appropriate by the Secretary) of such sums as the Secretary determines are necessary for such purposes. Amounts transferred under this subsection shall remain available until expended.