S.F. 2252 Section 1. Section 135G.6, Code 2018, is amended by striking 1 the section and inserting in lieu thereof the following: 2 135G.6 Inspection —— conditions for issuance. 3 The department shall issue a license to an applicant under 4 this chapter if the department has ascertained that the 5 applicant’s facilities and staff are adequate to provide the 6 care and services required of a subacute care facility. 7 Sec. 2. Section 331.391, subsection 4, Code 2018, is amended 8 by striking the subsection and inserting in lieu thereof the 9 following: 10 4. For the fiscal years beginning on or after July 1, 11 2018, if a region is meeting the financial obligations for 12 implementation of its regional service system management plan 13 for a fiscal year and residual funding is anticipated, the 14 regional administrator shall reserve an adequate amount for 15 cash flow of expenditure obligations in the next fiscal year. 16 The cash flow amount shall not exceed thirty percent of the 17 gross expenditures budgeted for the combined account or for all 18 regional accounts for the fiscal year in progress. Residual 19 funding remaining after the cash flow amount is reserved shall 20 be used to expand the region’s core services under section 21 331.397, subsections 4 and 5, and then to make additional 22 core service domains available in the region as enumerated in 23 section 331.397, subsection 7. 24 Sec. 3. Section 331.393, subsection 3, Code 2018, is amended 25 to read as follows: 26 3. a. Each region shall submit an annual report to the 27 department on or before December 1. The annual report shall 28 provide information on the actual numbers of persons served, 29 moneys expended, and outcomes achieved. 30 b. Each region shall submit a quarterly report to the 31 department. Each quarterly report shall provide information 32 on the accessibility of intensive mental health services 33 described in section 331.397, subsection 5, and the progress 34 the region has made in meeting the region’s milestones for 35 -1- LSB 5837XS (8) 87 hb/rh 1/ 13

S.F. 2252 compliance with such service requirements, using forms and 1 procedures established by the department. If a region fails 2 to meet the milestones in the region’s plan for compliance 3 with access requirements for intensive mental health services 4 described in section 331.397, subsection 5, the department 5 shall require the region to submit a plan of correction to 6 the department to address deficiencies in the region’s plan. 7 The department shall ensure the region’s plan of correction 8 addresses deficiencies in the region’s plan. The department 9 shall combine and analyze the quarterly reports and make the 10 results of the reports public within thirty days of receipt of 11 all reports on a quarterly basis. 12 Sec. 4. Section 331.397, Code 2018, is amended to read as 13 follows: 14 331.397 Regional core services. 15 1. For the purposes of this section , unless the context 16 otherwise requires, “domain” means a set of similar services 17 that can be provided depending upon a person’s service needs. 18 2. a. (1) A region shall work with service providers to 19 ensure that services in the required core service domains in 20 subsections 4 and 5 are available to residents of the region, 21 regardless of potential payment source for the services. 22 (2) Subject to the available appropriations, the director 23 of human services shall ensure the initial core service domains 24 listed in subsection subsections 4 and 5 are covered services 25 for the medical assistance program under chapter 249A to the 26 greatest extent allowable under federal regulations. The 27 medical assistance program shall reimburse Medicaid enrolled 28 providers for Medicaid covered services under subsections 4 29 and 5 when the services are medically necessary, no other 30 third-party payer is responsible for reimbursement of such 31 services, and the Medicaid enrolled provider submits an 32 appropriate claim for such services. Within funds available, 33 the region shall pay for such services for eligible persons 34 when payment through the medical assistance program or another 35 -2- LSB 5837XS (8) 87 hb/rh 2/ 13

S.F. 2252 third-party payment is not available, unless the person is on a 1 waiting list for such payment or it has been determined that 2 the person does not meet the eligibility criteria for any such 3 service. 4 b. Until funding is designated for other service 5 populations, eligibility for the service domains listed in this 6 section shall be limited to such persons who are in need of 7 mental health or intellectual disability services. However, if 8 a county in a region was providing services to an eligibility 9 class of persons with a developmental disability other than 10 intellectual disability or a brain injury prior to formation of 11 the region, the class of persons shall remain eligible for the 12 services provided when the region is was formed , provided that 13 funds are available to continue such services without limiting 14 or reducing core services . 15 c. It is the intent of the general assembly to address 16 the need for funding so that the availability of the service 17 domains listed in this section may be expanded to include such 18 persons who are in need of developmental disability or brain 19 injury services. 20 3. Pursuant to recommendations made by the director of human 21 services, the state commission shall adopt rules as required by 22 section 225C.6 to define the services included in the initial 23 and additional core service domains listed in this section . 24 The rules shall provide service definitions, service provider 25 standards, service access standards, and service implementation 26 dates, and shall provide consistency, to the extent possible, 27 with similar service definitions under the medical assistance 28 program. 29 a. The rules relating to the credentialing of a person 30 directly providing services shall require all of the following: 31 a. (1) The person shall provide services and represent the 32 person as competent only within the boundaries of the person’s 33 education, training, license, certification, consultation 34 received, supervised experience, or other relevant professional 35 -3- LSB 5837XS (8) 87 hb/rh 3/ 13

S.F. 2252 experience. 1 b. (2) The person shall provide services in substantive 2 areas or use intervention techniques or approaches that 3 are new only after engaging in appropriate study, training, 4 consultation, and supervision from a person who is competent in 5 those areas, techniques, or approaches. 6 c. (3) If generally recognized standards do not exist 7 with respect to an emerging area of practice, the person 8 shall exercise careful judgment and take responsible steps, 9 including obtaining appropriate education, research, training, 10 consultation, and supervision, in order to ensure competence 11 and to protect from harm the persons receiving the services in 12 the emerging area of practice. 13 b. The rules relating to the availability of services shall 14 provide for all of the following: 15 (1) Twenty-two assertive community treatment teams. 16 (2) Six access centers. 17 (3) Intensive residential service homes that provide 18 services to up to one hundred twenty persons statewide. 19 4. The initial core service domains shall include the 20 following: 21 a. Treatment designed to ameliorate a person’s condition, 22 including but not limited to all of the following: 23 (1) Assessment and evaluation. 24 (2) Mental health outpatient therapy. 25 (3) Medication prescribing and management. 26 (4) Mental health inpatient treatment. 27 b. Basic crisis response provisions, including but not 28 limited to all of the following: 29 (1) Twenty-four-hour access to crisis response. 30 (2) Evaluation. 31 (3) Personal emergency response system. 32 c. Support for community living, including but not limited 33 to all of the following: 34 (1) Home health aide. 35 -4- LSB 5837XS (8) 87 hb/rh 4/ 13

S.F. 2252 (2) Home and vehicle modifications. 1 (3) Respite. 2 (4) Supportive community living. 3 d. Support for employment or for activities leading to 4 employment providing an appropriate match with an individual’s 5 abilities based upon informed, person-centered choices made 6 from an array of options, including but not limited to all of 7 the following: 8 (1) Day habilitation. 9 (2) Job development. 10 (3) Supported employment. 11 (4) Prevocational services. 12 e. Recovery services, including but not limited to all of 13 the following: 14 (1) Family support. 15 (2) Peer support. 16 f. Service coordination including coordinating physical 17 health and primary care, including but not limited to all of 18 the following: 19 (1) Case management. 20 (2) Health homes. 21 5. a. To the extent federal matching funds are available 22 under the Iowa health and wellness plan pursuant to chapter 23 249N, the following intensive mental health core services shall 24 be provided in strategic locations throughout the state no 25 later than July 1, 2021, within the following core service 26 domains: 27 (1) Access centers that are located in crisis residential 28 and subacute residential settings with sixteen beds or fewer 29 that provide immediate, short-term assessments for persons with 30 serious mental illness or substance use disorders who do not 31 need inpatient psychiatric hospital treatment, but who do need 32 significant amounts of supports and services not available in 33 the persons’ homes or communities. 34 (2) Assertive community treatment services. 35 -5- LSB 5837XS (8) 87 hb/rh 5/ 13

S.F. 2252 (3) Comprehensive facility and community-based crisis 1 services, including all of the following: 2 (a) A single statewide twenty-four-hour crisis hotline. 3 (b) A mobile response. 4 (c) Twenty-three-hour crisis observation and holding. 5 (d) Crisis stabilization community-based services. 6 (e) Crisis stabilization residential services. 7 (f) Warmline services. 8 (4) Subacute services provided in facility and 9 community-based settings. 10 (5) Intensive residential service homes for persons 11 with severe and persistent mental illness in scattered site 12 community-based residential settings. 13 b. The department shall accept arrangements between multiple 14 regions sharing intensive mental health services under this 15 subsection when determining compliance to access standards for 16 such services. 17 5. 6. A region shall ensure that access is available 18 to providers of core services that demonstrate competencies 19 necessary for all of the following: 20 a. Serving persons with co-occurring conditions. 21 b. Providing evidence-based services. 22 c. Providing trauma-informed care that recognizes the 23 presence of trauma symptoms in persons receiving services. 24 6. 7. A region shall ensure that services within the 25 following additional core service domains are available 26 to persons not eligible for the medical assistance program 27 under chapter 249A or receiving other third-party payment for 28 the services, when public funds are made available for such 29 services: 30 a. Comprehensive facility and community-based crisis 31 services, including but not limited to all of the following: 32 (1) Twenty-four-hour crisis hotline. 33 (2) Mobile response. 34 (3) Twenty-three-hour crisis observation and holding, and 35 -6- LSB 5837XS (8) 87 hb/rh 6/ 13

S.F. 2252 crisis stabilization facility and community-based services. 1 (4) Crisis residential services. 2 b. Subacute services provided in facility and 3 community-based settings. 4 c. a. Justice system-involved services, including but not 5 limited to all of the following: 6 (1) Jail diversion. 7 (2) Crisis intervention training. 8 (3) Civil commitment prescreening. 9 d. b. Advances in the use of evidence-based treatment, 10 including but not limited to all of the following: 11 (1) Positive behavior support. 12 (2) Assertive community treatment. 13 (3) (2) Peer self-help drop-in centers. 14 7. 8. A regional service system may provide funding for 15 other appropriate services or other support and may implement 16 demonstration projects for an initial period of up to three 17 years to model the use of research-based practices. In 18 considering whether to provide such funding, a region may 19 consider the following criteria for research-based practices: 20 a. Applying a person-centered planning process to identify 21 the need for the services or other support. 22 b. The efficacy of the services or other support is 23 recognized as an evidence-based practice, is deemed to be an 24 emerging and promising practice, or providing the services is 25 part of a demonstration and will supply evidence as to the 26 services’ effectiveness. 27 c. A determination that the services or other support 28 provides an effective alternative to existing services that 29 have been shown by the evidence base to be ineffective, to not 30 yield the desired outcome, or to not support the principles 31 outlined in Olmstead v. L.C., 527 U.S. 581 (1999). 32 Sec. 5. Section 331.424A, subsection 1, paragraph b, Code 33 2018, is amended by striking the paragraph. 34 Sec. 6. Section 331.424A, subsection 4, Code 2018, is 35 -7- LSB 5837XS (8) 87 hb/rh 7/ 13

S.F. 2252 amended by striking the subsection and inserting in lieu 1 thereof the following: 2 4. An amount of unobligated and unencumbered funds, as 3 specified in the regional governance agreement entered into 4 by the county under section 331.392, shall be reserved in the 5 county services fund to address cash flow obligations. 6 Sec. 7. Section 331.424A, subsection 9, Code 2018, is 7 amended to read as follows: 8 9. a. For the fiscal year beginning July 1, 2017, and each 9 subsequent fiscal year, the county budgeted amount determined 10 for each county shall be the amount necessary to meet the 11 county’s financial obligations for the payment of services 12 provided under the regional service system management plan 13 approved pursuant to section 331.393 , not to exceed an amount 14 equal to the product of the regional per capita expenditure 15 target amount multiplied by the county’s population , and, for 16 fiscal years beginning on or after July 1, 2021, reduced by 17 the amount of the county’s cash flow reduction amount for the 18 fiscal year calculated under subsection 4 , if applicable . 19 b. If a county officially joins a different region, the 20 county’s budgeted amount shall be the amount necessary to meet 21 the county’s financial obligations for payment of services 22 provided under the new region’s regional service system 23 management plan approved pursuant to section 331.393, not to 24 exceed an amount equal to the product of the new region’s 25 regional per capita expenditure target amount multiplied by the 26 county’s population. 27 Sec. 8. MENTAL HEALTH AND DISABILITY SERVICES REGIONS —— 28 FY 2018 ANNUAL REPORTS. Each mental health and disability 29 services region’s annual report due to the department of human 30 services on or before December 1, 2018, pursuant to section 31 331.393, subsection 3, paragraph “a”, shall include a plan 32 that identifies milestones for meeting intensive mental health 33 service requirements described in section 331.397, subsection 34 5, no later than July 1, 2021. The plan shall, at a minimum, 35 -8- LSB 5837XS (8) 87 hb/rh 8/ 13

S.F. 2252 include information relating to processes, implementation time 1 frames, plans for collaboration with other regions and the 2 Medicaid program, and the region’s associated budget plan. 3 Sec. 9. EMERGENCY RULES. If specifically authorized by 4 a provision of this Act, the department of human services 5 or the mental health and disability services commission may 6 adopt administrative rules under section 17A.4, subsection 3, 7 and section 17A.5, subsection 2, paragraph “b”, to implement 8 provisions of this Act and the rules shall become effective 9 immediately upon filing or on a later effective date specified 10 in the rules, unless the effective date of the rules is 11 delayed or the applicability of the rules is suspended by the 12 administrative rules review committee. Any rules adopted in 13 accordance with this section shall not take effect before 14 the rules are reviewed by the administrative rules review 15 committee. The delay authority provided to the administrative 16 rules review committee under section 17A.4, subsection 7, and 17 section 17A.8, subsection 9, shall be applicable to a delay 18 imposed under this section, notwithstanding a provision in 19 those sections making them inapplicable to section 17A.5, 20 subsection 2, paragraph “b”. Any rules adopted in accordance 21 with the provisions of this section shall also be published as 22 a notice of intended action as provided in section 17A.4. 23 EXPLANATION 24 The inclusion of this explanation does not constitute agreement with 25 the explanation’s substance by the members of the general assembly. 26 This bill relates to mental health and disability services 27 and funding. 28 Under current law, the department of inspections and appeals 29 is required to issue a license to an applicant for a subacute 30 mental health care facility if the department of inspections 31 and appeals has ascertained that the applicant’s facilities and 32 staff are adequate to provide the care and services required 33 of a subacute care facility. The bill strikes additional 34 conditions for licensure requiring the department of human 35 -9- LSB 5837XS (8) 87 hb/rh 9/ 13

S.F. 2252 services to submit written approval of the application based 1 upon the process used by the department of human services 2 to identify the best qualified providers, prohibiting the 3 department of human services from approving an application 4 which would cause the number of publicly funded subacute 5 care facility beds to exceed 75 beds, and requiring that the 6 subacute care facility beds identified be new beds located in 7 hospitals and facilities licensed as a subacute care facility 8 under Code chapter 135G. 9 Under current law, each mental health and disability 10 services region is required to submit an annual report to the 11 department of human services on or before December 1. The 12 annual report is required to provide information on the actual 13 numbers of persons served, moneys expended, and outcomes 14 achieved. 15 The bill provides each region shall additionally submit 16 a quarterly report to the department. Each quarterly report 17 shall provide information on the accessibility of intensive 18 mental health services and the progress the region has made 19 in meeting the region’s milestones for compliance with such 20 service requirements using forms and procedures established by 21 the department. If a region fails to meet the milestones in 22 the region’s plan for compliance with such access requirements, 23 the department shall require the region to submit a plan of 24 correction to the department to address deficiencies in the 25 region’s plan. The department shall ensure the region’s plan 26 of correction addresses deficiencies in the region’s plan. The 27 department shall combine and analyze the quarterly reports 28 and make the results of the reports public within 30 days of 29 receipt of all reports on a quarterly basis. 30 Under current law, subject to available appropriations, 31 the director of human services shall ensure that a mental 32 health and disability services region’s core service domains 33 are covered services for the medical assistance program under 34 Code chapter 249A to the greatest extent allowable under 35 -10- LSB 5837XS (8) 87 hb/rh 10/ 13

S.F. 2252 federal regulations. The bill provides the medical assistance 1 program shall reimburse Medicaid enrolled providers for 2 Medicaid covered core services when the services are medically 3 necessary, and the Medicaid enrolled provider submits an 4 appropriate claim for such services. No other third-party 5 payer is responsible for reimbursement of such services. 6 The bill provides that the administrative rules of the state 7 mental health and disability services commission relating to 8 the availability of mental health and disability services 9 shall, in addition to other mental health and disability 10 service requirements, provide for 22 assertive community 11 treatment teams, six access centers, and intensive residential 12 service homes that serve up to 120 persons statewide. 13 The bill provides that, to the extent matching federal 14 funding is available under the Iowa health and wellness plan, 15 intensive mental health core services shall be provided in 16 strategic locations throughout the state on or before July 1, 17 2021, within certain core service domains including access 18 centers that are located in crisis residential and subacute 19 residential settings, assertive community treatment services, 20 comprehensive facility and community-based crisis services, 21 subacute services, and intensive residential service homes. 22 The bill provides the department of human services shall 23 accept arrangements between multiple regions sharing intensive 24 mental health services when determining compliance with access 25 standards for such services. 26 Current Code section 331.391 establishes requirements 27 related to the permissible amount of cash flow for each mental 28 health and disability services region. For fiscal years 29 beginning July 1, 2017, July 1, 2018, and July 1, 2019, that 30 portion of each region’s cash flow amount that exceeds 25 31 percent of the gross expenditures from the region’s combined 32 account or from all separate county accounts under the control 33 of the governing board in the fiscal year preceding the fiscal 34 year in progress are required to be used in whole or in part 35 -11- LSB 5837XS (8) 87 hb/rh 11/ 13

S.F. 2252 to fund the payment of mental health and disabilities services 1 provided under the regional service system management plan. 2 Current law also imposes similar requirements for the amount of 3 unobligated and unencumbered funds that are reserved in each 4 county’s county services fund to address cash flow obligations 5 in the next fiscal year, imposes annual reporting requirements 6 for region and county cash flow amounts, and imposes, for 7 fiscal years beginning on or after July 1, 2021, either a 20 8 or 25 percent limitation on each county or region’s cash flow 9 amount based on the region’s population. Current law also 10 requires that for fiscal years beginning on or after July 1, 11 2021, of a county’s cash flow amount maintained in the county 12 services fund or of the region’s cash flow amount attributable 13 to the county, the county budgeted amount, used to limit the 14 amount of property taxes levied by the county, is reduced 15 by the county’s cash flow reduction amount. The cash flow 16 reduction amount is equal to the amount of the county’s cash 17 flow in excess of the permissible percentage limits based on 18 population of the region. 19 The bill strikes the requirement for fiscal years beginning 20 July 1, 2017, July 1, 2018, and July 1, 2019, that the portion 21 of each county’s or region’s cash flow amount that exceeds 22 the 25 percent limitation be used in whole or in part to fund 23 the payment of mental health and disability services provided 24 under a region’s regional service system management plan. The 25 bill also strikes the reporting requirements for counties and 26 regions and eliminates the reduction in a county’s budgeted 27 amount due to the county’s cash flow reduction amount for 28 fiscal years beginning on or after July 1, 2021. The bill 29 establishes a limitation on the cash flow amount of a region 30 equal to 30 percent of the gross expenditures budgeted for 31 the fiscal year in progress for the combined account of the 32 region or for all regional accounts and requires residual 33 funding remaining in excess of such limitation to be used to 34 expand the region’s core services and then make additional core 35 -12- LSB 5837XS (8) 87 hb/rh 12/ 13

S.F. 2252 services available. The bill also provides that an amount of 1 unobligated or unencumbered funds, as specified in the regional 2 governance agreement, is required to be reserved in each 3 county’s county services fund to address cash flow obligations. 4 Under the bill, if a county officially joins a different 5 mental health and disability services region, that county’s 6 budgeted amount shall be the amount necessary to meet the 7 county’s financial obligations for payment of services provided 8 under the new region’s regional service system management 9 plan, not to exceed an amount equal to the product of the 10 new region’s regional per capita expenditure target amount 11 multiplied by the county’s population. 12 The bill provides that each mental health and disability 13 services region, in the region’s annual report due to the 14 department of human services on or before December 1, 2018, 15 shall include a plan that identifies milestones for meeting 16 intensive mental health service requirements described in Code 17 section 331.397(5), no later than July 1, 2021. The plan 18 shall, at a minimum, include information relating to processes, 19 implementation time frames, plans for collaboration with other 20 regions and the Medicaid program, and the region’s associated 21 budget plan. 22 The bill provides that the department of human services or 23 the mental health and disability services commission may adopt 24 emergency rules to implement the provisions of the bill. 25 -13- LSB 5837XS (8) 87 hb/rh 13/ 13