Sec. 101. Establishing a Medicaid Prospective Payment System for Certified Community Behavioral Health Clinics
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Section 1902 of the Social Security Act ( 42 U.S.C. 1396a ) is amended by adding at the end the following new subsection: Beginning with fiscal year 2024, with respect to services furnished on or after January 1, 2024, and each succeeding fiscal year, a State may provide under the State plan under this title (or under a waiver of such plan) for payment for services described in section 1905(a)(31) furnished by a certified community behavioral health clinic (in this subsection referred to as a clinic ) in accordance with the provisions of this subsection.
Subject to paragraphs (4), (5), and (6), for services furnished by a clinic in the first fiscal year for which a State elects to provide for payment for services described in section 1905(a)(31) in accordance with the payment option under paragraph (1), and every third fiscal year thereafter in which the State makes such an election, the State shall provide for payment for such services in an amount (calculated on the basis of daily visits or unduplicated monthly visits, at the State’s election) that is equal to 100 percent of the average costs of the clinic of furnishing any of the services described in paragraph
(31)of section 1905(a) during the 2 fiscal years preceding the fiscal year involved which are reasonable and related to the costs of furnishing such services; provided that, in the absence of complete actual cost data representing the provision of the full covered benefit in such preceding fiscal years, certified community behavioral health clinics may, at the State’s discretion, use estimated or projected data relating to specific services for which they lack cost experience. The per-unit rate derived from such cost data shall be adjusted to take into account any increase or decrease in the scope of such services furnished by the clinic in the fiscal year involved. Subject to paragraphs (4), (5), and (6), for services described in section 1905(a)(31) furnished by a clinic for which a State elects to provide for payment for such services in accordance with the payment option under paragraph
(1)and that are furnished in a fiscal year that is not described in paragraph (2), the State plan shall provide for payment for such services in an amount (calculated on the basis of daily visits or unduplicated monthly visits, at the State’s election) that is equal to the amount calculated under this subsection for such services and clinic for the preceding year— increased by the percentage increase in the inflationary factor described in section 1834(aa)(2)(C); and adjusted to take into account any increase or decrease in the scope of such services furnished by the clinic during the fiscal year involved. In any case in which an entity first qualifies as a certified community behavioral health clinic after the first fiscal year in which a State elects to provide for payment for services described in section 1905(a)(31) in accordance with the payment option under paragraph (1), the State plan shall provide for payment for such services in the first 2 years in which the clinic so qualifies in an amount (calculated on the basis of daily visits or unduplicated monthly visits, at the State’s election) that is equal to the rates established under this subsection for other such clinics located in the same or adjacent area with a similar case load, or in the absence of any such clinic, based on the average per-unit rate for other certified community behavioral health clinics in the State; provided, however, that effective, at latest, as of the 3rd year in which the clinic furnishes such services, the State establishes a unique payment rate for the clinic based on the methodology described in paragraph (2), using allowable costs from the clinic’s first 2 fiscal years of operation as the basis for establishing such rates; and provided, additionally, that in any year following the establishment of an initial rate under this paragraph, the State plan or waiver provides for the payment amount to be calculated in accordance with paragraph
(2)or
(3)(as applicable). In the case of services furnished by a certified community behavioral health clinic pursuant to a contract between the clinic and a managed care entity (as defined in section 1932(a)(1)(B)), the State plan or a waiver of such plan shall provide for 1 of the following: Payment to the clinic by the State of a supplemental payment equal to the amount (if any) by which the amount determined under paragraph (2), (3), or
(4)(as applicable) exceeds the amount of payments under the contract, with such supplemental payment being made pursuant to a payment schedule agreed to by the State and the certified community behavioral health clinic, but in no case less frequently than every 3 months. Delegation by the State to the managed care entity of the obligation to pay the clinic at least the rate determined under paragraph (2), (3), or
(4)(as applicable); provided, however, that the State shall use reconciliation and oversight processes to ensure that each clinic is paid at least the amounts required under such paragraphs. Notwithstanding any other provision of this subsection, the State plan or a waiver of such plan may provide for payment in any year to a certified community behavioral health clinic for services described in paragraph
(31)of section 1905(a) in an amount which is determined under an alternative payment methodology that— is agreed to by the State and the clinic; and results in payment to the clinic of an amount which is not less than the amount otherwise required to be paid to the clinic under this subsection. .
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Sec. 101
Establishing a Medicaid Prospective Payment System for Certified Community Behavioral Health Clinics
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