Sec. 102. 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 2026, with respect to services furnished on or after January 1, 2026, and each succeeding fiscal year, a State that has elected in its State plan under this title to furnish the services described in section 1905(a)(31) shall provide under the plan for payment for services furnished by 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 subparagraphs
(B)and
(C)and the succeeding provisions of this subsection, and in accordance with paragraph (1), for services furnished by a clinic in the first fiscal year beginning after September 30, 2025, for which a State elects to provide for payment for services described in section 1905(a)(31), 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 which are reasonable and related to the furnishing such services during a base year corresponding to the fiscal year preceding such initial fiscal year. A State may elect in its State plan to carry out any of the following, consistent with the methodology described in guidance issued under the authority of section 223(b) of the Protecting Access to Medicare Act: Establishing separate prospective payment system rates for special populations. Using a system of outlier payments for a portion of costs of furnishing the covered benefit. With respect to the crisis services included within the benefit described in section 1905(a)(31)— requiring that clinics, in their cost reports, segregate costs relating to mobile crisis teams, emergency crisis intervention services, or crisis stabilization as components of the covered benefit described in section 1905(a)(31); and providing for a prospective payment system rate for any or all of such crisis services, distinct from the rate encompassing the remainder of the services described in section 1905(a)(31). If a State electing to furnish services described in section 1905(a)(31) under its State plan, as of the year prior to the initial fiscal year described above, operated a demonstration program under section 223 of the Protecting Access to Medicare Act, such State may elect under the State plan to establish as its initial rate under this paragraph, for any clinic that participated in such demonstration, the rate that would otherwise have applied under the demonstration. In the absence of complete actual cost data representing the provision of the full covered benefit in such base year, the State may provide in its State plan amendment to allow clinics to use estimated or projected data relating to specific services for which they lack cost experience. The per-unit rate derived from the cost data described in subparagraph
(A)shall be annually adjusted by the inflationary factor described in section 1834(aa)(2)(C), and 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 the succeeding provisions of this subsection, for services described in section 1905(a)(31) furnished by a clinic after the initial fiscal year 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 fiscal year— increased by the percentage increase in the inflationary factor described in section 1834(aa)(2)(C) for such fiscal year; 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 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), the State plan shall provide for payment for such services in the first fiscal year 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 reasonable projected costs per visit of the clinic. Not later than the second fiscal year in which a clinic described in subparagraph
(A)furnishes services described in section 1905(a)(31)— the State shall establish a unique payment rate for the clinic based on the methodology described in paragraph (2), using reasonable and related costs from the clinic’s first fiscal year of operation as the basis for establishing such rates; and in any year following the establishment of an initial rate under this subparagraph, the State plan shall provide for the payment amount to be adjusted in accordance with paragraph
(3)and (as applicable) reestablished in accordance with paragraph (5). Notwithstanding the preceding paragraphs, a State may elect in its State plan amendment to establish a new prospective payment system rate for clinics on a periodic basis. Under such an election, periodically (but not less frequently than every 3rd fiscal year) after the initial year, as described in paragraph (2), in which the State first furnishes the services described in section 1905(a)(31), the State shall set a new rebased rate for each clinic whose rate was initially set pursuant to paragraph (2), except that costs from the fiscal year preceding such rebasing year, rather than costs from the base year described in paragraph (2), shall be used in establishing a new cost-related rate for each clinic. States electing this option shall also follow this methodology and schedule in periodically establishing new rates for those clinics whose initial rates were set as described in paragraph (4). 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 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 as applicable, paragraph (7), 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 not less frequently than every 3 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 in accordance with paragraph (7), 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 as applicable, paragraph (7). In making a delegation under clause (i), a State shall ensure that it complies with the requirements described in paragraph
(7)and shall use reconciliation and 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, a State plan may provide for payment in any year to a certified community behavioral health clinic for services described in section 1905(a)(31) 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. 102
Establishing a Medicaid prospective payment system for certified community behavioral health clinics
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