Sec. 102. Establishing a 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 2026 with respect to services furnished on or after January 1, 2026, and for each succeeding fiscal year, if a State elects to make medical assistance available for certified community behavioral health clinic services under section 1905(a)(31), the State plan shall provide for payment for such services furnished by (or under arrangement with) a certified community behavioral health clinic described in section 1905(jj)(2) (in this subsection referred to as a clinic ) in accordance with the provisions of this subsection.

Subject to paragraph (4), a State shall provide for payment for certified community behavioral health clinic services furnished by (or under arrangement with) a clinic in the first fiscal year (or portion of a fiscal year) described in paragraph

(1)for which a State elects to provide medical assistance for such services under section 1905(a)(31) under a prospective payment system developed by the State in accordance with this paragraph. In establishing the system under subparagraph (A), the State shall apply as the unit of service— daily visits; or monthly visits (excluding repeat visits from the same individual). Under the system under subparagraph (A), the State may, consistent with the methodology described in guidance issued under section 223(b) of the Protecting Access to Medicare Act of 2014— establish separate prospective payment system rates for special populations; use a system of outlier payments for a portion of costs of furnishing certified community behavioral health clinic services; or with respect to certified community behavioral health clinic services that are crisis services— require that each cost report of a clinic segregate costs relating to mobile crisis teams, emergency crisis intervention services, or crisis stabilization from other components of the services described in section 1905(a)(31); and provide for a prospective payment system rate for any or all of such crisis services that is distinct from the rate encompassing the remainder of the services described in section 1905(a)(31). Subject to subparagraph

(E), the State shall provide for computation of a prospective payment amount for an individual certified community behavioral health clinic under the system under subparagraph

(A)as follows: For the first fiscal year (or portion of a fiscal year) for which a State elects to provide medical assistance for such services under section 1905(a)(31), such amount— in the case of a State that did not operate a demonstration program under section 223 of the Protecting Access to Medicare Act of 2014 during a base year corresponding to the fiscal year immediately preceding such first fiscal year (or portion of a fiscal year), shall be equal to 100 percent of the costs of the clinic which are reasonable and related to the furnishing of such services during such base year; and in the case of a State that did operate a demonstration program under section 223 of the Protecting Access to Medicare Act of 2014 during such base year, shall be equal to, at the option of the State— the amount described in subclause

(I); or the amount that would have otherwise applied with respect to such services under such demonstration. For each subsequent fiscal year for which a State elects to provide medical assistance for such services under section 1905(a)(31), such amount shall be, subject to subparagraph

(F), the amount calculated under this subparagraph for the preceding fiscal year— increased by the percentage increase described in section 1834(aa)(3)(C) for the calendar year in which such preceding fiscal year began; 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. For purposes of subparagraph

(D)— in the case of a certified community behavioral health clinic that does not have available complete actual cost data representing the provision of all certified community behavioral health clinic services provided in the base year described in clause (i)(I) of such subparagraph, the State may use estimated or projected data relating to specific services for which the clinics lack cost experience; and in the case of an entity that first enrolls under this title as a certified community behavioral health clinic in a year after the first fiscal year in which the State first provides for payment for the services described in section 1905(a)(31) in accordance with paragraph

(1)— for the first fiscal year in which the clinic furnishes such services, the amount determined by the State for such clinic shall be— determined on the basis of the amounts established under this paragraph for other such clinics located in the same or adjacent area (as defined by the Secretary) with a similar case load; or in the absence of any such clinic, based on the reasonable projected costs per visit of the clinic; for the second fiscal year in which the clinic furnishes such services, the amount determined by the State for such clinic shall be determined under clause (i)(I) of such subparagraph on the basis of the reasonable and related costs and visits from the clinic’s first fiscal year of operation; and for the third and each subsequent fiscal year in which the clinic furnishes such services, the amount determined by the State for such clinic shall be determined under clause

(ii)of such subparagraph. A State may periodically (but no less frequently than every third fiscal year after the first fiscal year described in subparagraph

(D)) rebase the prospective payment amount determined under subparagraph

(D)such that costs from the fiscal year preceding the rebasing year, rather than costs from the base year described in clause (i)(I) of such subparagraph, shall be used in establishing a new cost-related rate for each clinic. Such rebasing shall include those clinics with initial rates determined under subparagraph

(E). 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)) or other specified entity (as defined in 1903(m)(9)(D)(iii)), the State shall provide for payment to the clinic by the State of a supplemental payment equal to the amount (if any) by which the amount determined under the preceding paragraphs of this subsection (or paragraph (4), as applicable) exceeds the amount of payments provided under the contract. Such supplemental payment shall be made pursuant to a payment schedule agreed to by the State and the clinic, but in no case less frequently than every 4 months. Notwithstanding subparagraph (A), nothing in this subsection shall be interpreted to preclude a State from amending its State plan to provide for an alternative payment methodology under paragraph (4), under which the State may delegate to a managed care entity, as defined in section 1932(a)(1)(B), the responsibility to pay the clinic at least the rate determined under the preceding subparagraphs (or paragraph (4), as applicable), provided that the State shall meet all requirements described in paragraph (4), and shall use oversight processes to ensure that each clinic is paid at least the amounts required under the preceding paragraphs of this subsection. Notwithstanding any other provision of this subsection, the State plan may provide for payment in any fiscal 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. . Section 1937(b)(4) of the Social Security Act ( 42 U.S.C. 1396u–7(b)(4) ) is amended— in the paragraph heading, by inserting after ; coverage of CCBHC services ; FQHC services by redesignating subparagraphs

(A)and

(B)as clauses

(i)and (ii), respectively, and adjusting the margins accordingly; by striking this section, a State and inserting: this section— a State ; and by adding at the end the following new subparagraph: in the case that a State provides for medical assistance for certified community behavioral health clinic services (as defined in section 1905(jj)(1)) through enrollment of an individual with benchmark coverage or benchmark equivalent coverage under this section, payment for such services shall be made in accordance with the requirements of section 1902(yy). .

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42 USC 1396a
42 USC 1396u–7(b)(4)

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Sec. 102

Establishing a prospective payment system for certified community behavioral health clinics

Cite42 USC 1396a

Cite42 USC 1396u–7(b)(4)

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