H.R 2646 Summary and S. 1945 Comparison TITLE I ASSISTANT SECRETARY FOR MENTAL HEALTH AND SUBSTANCE USE DISORDERS It establishes an Office of the Assistant Secretary for Mental Health and Substance Use Disorders, Asst. Sec. can also be Ph.D. in Social Work which must be led by a psychologist or psychiatrist. All of SAMHSA s authority is SAMHSA under Asst. Sec., no transfer of authorities transferred to this office, and the resulting agency No 2 nd or 3 rd prevention, less focus on is given greater authority than the existing SMI, some mention of SED SAMHSA to oversee federal mental health Workforce not just focused on crisis programs in general. The office focuses on Focus on state and consumer level research and evaluation, an emphasis on coordination to improve communitybased services and distributing promising integration of care, treatment and secondary and tertiary prevention for serious mental illness and evidence-based practices, but not on (SMI), and workforce development with an improving availability and quality of emphasis on crisis intervention. There are a treatment in general. variety of new requirements for grant review, Priority on reducing incarceration. including that the reviewers must be providers or Ongoing workforce strategy, includes others with expertise in the program. more licensures, also focus on reducing incarceration. No grant review requirements so no pieces about being evidence-based or having certain kinds of reviewers The Office must also conduct a number of reports and issue recommendations to Congress, which include: (1) public disclosure of federal parity investigation actions, (2) best practices for peers but specifies only those supervised by clinicians and has an emphasis on certain training and services, (3) how state funds were used behavioral health and what were the related outcomes, with a focus on treatment of SMI and outcomes around assisted outpatient treatment (AOT), and (4) with the Institute of Medicine, the current burden of paperwork for behavioral health providers. It also establishes a National Mental Health Policy Laboratory (NHMPL), with a staffing focus on doctorate-level clinical and research experience. The NMHPL runs, evaluates, and disseminates the results of several new grant programs including Innovation Grants, No parity report (moved to the end). Peer report in treatment one year prior, pre-crisis not de-escalation, no psychopharmacology competency suggestion. Instead of AOT outcomes reporting, comparative effectiveness of outpatient treatment programs and a health outcome included. TITLE II GRANT REFORM AND RESTRUCTURING Focus on family inclusion for grant priorities. Mentions Specialized Treatment Early in Psychosis program rather than North American Prodromal Longitudinal Study No standards section for the grant
Demonstration Grants, and Early Childhood Intervention and Treatment grants. Across the grant programs there is a focus on individuals with SMI as the target population, integration of services, and coordination between systems as priorities. While the demonstration grants focus nearly exclusively on the expansion and replication of evidence-based programs and policies, the innovation grants are intended to support promising programs (a concession to our advocacy). The innovation grants focus on screening, diagnosis and treatment, and integrated services, with one-third of the funding reserved for services to individuals under the age of 18. The demonstration grants also emphasize screening, with half the dollars reserved for services to individuals under the age of 26, although may not be used for primary prevention. The early childhood grants are focused on infants and children under the age of ten with an emphasis on specialized early education programs. There is also a mechanism by which the NHMPL can make a rule to scale up evidence-based models as being a part of the block grants. The bill does not intend to mandate that states have AOT programs as a condition of receiving block grant dollars. Instead, it intends to expand funding for existing AOT programs and provides a 2% boost in block grant funding for states that adopt AOT laws. It also amends the Public Health Service Act (Sec 1912) to include a more extensive and updated exposition on the kinds of mental health services that must be included in state plans, with a focus on SMI. It specifically references AOT in the section describing the block grants and in the requirements for state plans under the block grants, which may create some confusion as to whether AOT must be included in the public health plan, even if the state programs, so less focus on evaluation and public reporting. Instead of 20%/20%/20% for staffing, just says staff shall include individuals with clinical and research experience and mentions MDs, PhDs, and MSWs, but leaves open for others no Congressional appointments. $10 million for each grant program. Innovation grant includes SED and prevention. No longitudinal study for early childhood grants. Early childhood ages are 3-12 instead of 1-10. Equally but differently unclear as to whether it needs to be a segregated program, for example, it seems like you now need to provide day services and education, whereas in 2646 you only had to facilitate education. Also less psychiatrist focused. $483 million (up from $450m) for block grant through 2019 Adds legal services to support services in PHSA. Does not specify outcomes of services like homelessness and joblessness, but does require service and resource outcomes. No Congressional approval needed for Asst. Sec. to scale up evidence-based model. Still extends the AOT pilot for 2 years and additional $5 million No reference to AOT when amending PHSA. Also less specific reporting requirements in general, and no specific reporting on individuals eligible for AOT. 2% boost based on reports in Mental Health in the States report, no AOT language. Outreach and engagement requirement for grantees more recovery oriented and no mention of AOT. Names a bunch of examples like ACT and WRAP. Includes psychiatric advanced directives
doesn t have an AOT program. as a requirement, including access to legal counsel. Also in this section are a number of additional grant programs, including grants for: (1) telehealth for consultation between primary care No training of primary care grants or general telehealth grants Instead has the child psychiatry access grants. and a psychiatrist or psychologist, and training of primary care physicians in screening and referral, No Child Traumatic Stress Initiative grants. (2) indemnification of behavioral health clinician $44 million for behavioral health volunteers, (3) minority behavioral health workforce, including peers. fellowships, (4) loan forgiveness for physicians No law enforcement training grant. going into child and adolescent psychiatry, (5) No stigma reduction grants. law enforcement training in behavioral health, (6) No Garrett Lee Smith, only suicide continuation of the National Child Traumatic prevention lifeline. Stress Initiative, (7) an initiative on stigma $50 million for 5 years for full primary reduction, and (8) Garrett Lee Smith care integration, including colocation and reauthorization. use of care teams. TITLE III INTERAGENCY SERIOUS MENTAL ILLNESS COORDINATING COMMITTEE It establishes a broad-based Interagency SMI Coordinating Committee to advise the Assistant Slightly more recovery focused, slightly less science/etiology focused. Secretary and to report and make recommendations to Congress. The Committee s More comprehensive strategic plans with recommendations. strategic plan focuses on SMI research, federal More HHS representation, including spending, public participation, and public CMS. utilization of effective mental health services and Added nurse and social worker. compliance with treatment. The Committee will Focus on cultural competency and be made up of a number of federal agencies and a minority attention rather than community variety of mental health stakeholders, which mental health. includes advocate and peer representation. Less focus on accounting and program costs. TITLE IV HIPAA AND FERPA CAREGIVERS It revises HIPAA to permit the sharing of dates of services, diagnosis codes, treatment plans, appointment schedules, and medication orders with caregivers, but requires six conditions all to be met at the same time for this to happen. These conditions include: necessary to protect the health and safety of the public or the individual; disclosure benefits treatment of a co-occurring chronic or acute medical condition; necessary to continuity of treatment; the absence of the information will lead to a worsening of the condition; and the individual has diminished capacity to follow the medical treatment plan and will become gravely disabled if it is not followed. No exception to HIPAA based on certain conditions, just gives several factors to consider in applying the privacy rule. $5 million to develop and disseminate a model training program for HIPAA.
It also specifically states that providers can listen to caregivers and that providers should be trained on disclosure to caregivers. FERPA is amended to allow for disclosure to caregiver when mental health provider reasonably believes that it is necessary to protect the health, safety, or welfare of such student or the safety of one or more other individuals. It also allows for information sharing within integrated health care systems. No FERPA provision. Same TITLE V MEDICARE AND MEDICAID REFORMS Same It allows for same day billing between primary care services and certain behavioral health services at specified health centers. It provides for a limited relaxation of the IMD exclusion for state hospitals and private hospitals with an average length of stay of less than 30 days, but only if this is scored as budget neutral. Also provides for some reporting on how to use funds for community-based services and requires discharge planning from psychiatric inpatient stays under Medicare. It increases coverage for mental health drugs under Medicare and Medicaid. It eliminates the 190-day lifetime limit on coverage of inpatient psychiatric hospital services under Medicare if this provision is certified as budget neutral. 20 days instead of 30. This is missing. This is missing. It initiates 10 more certified community This is missing. behavioral health center demonstration projects. TITLE VI RESEARCH BY NATIONAL INSTITUTE OF MENTAL HEALTH Increases funding for NIMH to study determinants and prevention of violence along with brain research through the Brain Research Through Advancing Innovative Neurotechnologies Initiative. Same TITLE VII BEHAVIORAL HEALTH INFORMATION TECHNOLOGY Extends assistance for use of health information technology to certain behavioral health providers, psychiatric hospitals, and community mental health centers, and provides incentives for meaningful use of health IT for psychologists and specified psychiatric inpatient and outpatient treatment centers. This is missing. TITLE VIII SAMHSA REAUTHORIZATION AND REFORMS Subtitle A Organization and General Authorities
Requires SAMHSA s peer-review groups to be made up of 50% physicians and psychologists and requires notice to Congress of all peer-review group compositions and grant decisions. The National Advisory Mental Health Council must be made up of 50% mental health providers. Added in MSW and NP. None of the additional requirements about not having ever been a grant recipient. $5 million over 5 years for jail diversion programs (down from $10m under its previous authorization). $65 million for homelessness transition programs for 5 years (down from $75m under its previous authorization). $117m for SED programs for 5 years (up from $100m under its previous authorization). $370 million for 5 years priority mental health needs of regional and national significance (up from $300m under its previous authorization). Subtitle B Protection and Advocacy for Individuals With Mental Illness This has been removed. It retains the PAIMI (Protection and Advocacy program) but contains: (1) a total prohibition on lobbying, (2) a focus on access to consumer information for caregivers, (3) confining advocacy to cases of abuse or neglect, (4) an additional grievance procedure, and (5) a provision on ensuring access to evidence-based treatments. It directs the GAO to report on parity compliance, along with federal efforts on parity oversight and education to the states on parity oversight. TITLE IX REPORTING Public reporting of parity investigations. Requires HHS to put out additional guidance about what analyses health plans must be performing to determine whether they are in compliance, along with in depth disclosure requirements that allows for external verification. Contains additional provisions for enforcement, including auditing and disclosure to support public enforcement.