[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 2128 Introduced in Senate (IS)]

<DOC>






118th CONGRESS
  1st Session
                                S. 2128

   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.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             June 22, 2023

Mrs. Gillibrand 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 increase Federal 
  Medicaid funding for States that provide intensive community-based 
    services for adults with serious mental illness, and for other 
                               purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Strengthening Medicaid for Serious 
Mental Illness Act''.

SEC. 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.

SEC. 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.
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