S.F. 2351 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 229.1, subsection 20, Code 2018, is amended 8 by adding the following new paragraph: 9 NEW PARAGRAPH . d. Has a history of lack of compliance with 10 treatment and any of the following apply: 11 (1) Lack of compliance has been a significant factor in the 12 need for emergency hospitalization. 13 (2) Lack of compliance has resulted in one or more acts of 14 serious physical injury to the person’s self or others or an 15 attempt to physically injure the person’s self or others. 16 Sec. 3. Section 229.13, subsection 7, paragraph a, 17 subparagraphs (2) and (3), Code 2018, are amended to read as 18 follows: 19 (2) Once in protective custody, the respondent shall be 20 given the choice of being treated by the appropriate medication 21 which may include the use of oral medicine or injectable 22 antipsychotic medicine by a mental health professional acting 23 within the scope of the mental health professional’s practice 24 at an outpatient psychiatric clinic, hospital, or other 25 suitable facility or being placed for treatment under the 26 care of a hospital or other suitable facility for inpatient 27 treatment. 28 (3) If the respondent chooses to be treated by the 29 appropriate medication which may include the use of oral 30 medicine or injectable antipsychotic medicine but the mental 31 health professional acting within the scope of the mental 32 health professional’s practice at the outpatient psychiatric 33 clinic, hospital, or other suitable facility determines that 34 the respondent’s behavior continues to be likely to result in 35 -1- LSB 5837SV (3) 87 hb/rh 1/ 15

S.F. 2351 physical injury to the respondent’s self or others if allowed 1 to continue, the mental health professional acting within 2 the scope of the mental health professional’s practice shall 3 comply with the provisions of subparagraph (1) and, following 4 notice and hearing held in accordance with the procedures in 5 section 229.12 , the court may order the respondent treated 6 on an inpatient basis requiring full-time custody, care, and 7 treatment in a hospital until such time as the chief medical 8 officer reports that the respondent does not require further 9 treatment for serious mental impairment or has indicated the 10 respondent is willing to submit to treatment on another basis 11 as ordered by the court. 12 Sec. 4. Section 229.13, subsection 7, paragraph b, Code 13 2018, is amended to read as follows: 14 b. A region shall contract with mental health professionals 15 to provide the appropriate treatment including treatment by 16 the use of oral medicine or injectable antipsychotic medicine 17 pursuant to this section . 18 Sec. 5. Section 331.391, subsection 4, Code 2018, is amended 19 by striking the subsection and inserting in lieu thereof the 20 following: 21 4. For the fiscal years beginning on or after July 1, 22 2018, if a region is meeting the financial obligations for 23 implementation of its regional service system management plan 24 for a fiscal year and residual funding is anticipated, the 25 regional administrator shall reserve an adequate amount for 26 cash flow of expenditure obligations in the next fiscal year. 27 The cash flow amount shall not exceed thirty percent of the 28 gross expenditures budgeted for the combined account or for all 29 regional accounts for the fiscal year in progress. Residual 30 funding remaining after the cash flow amount is reserved shall 31 be used to expand the region’s core services under section 32 331.397, subsections 4 and 5, and then to make additional 33 core service domains available in the region as enumerated in 34 section 331.397, subsection 7. 35 -2- LSB 5837SV (3) 87 hb/rh 2/ 15

S.F. 2351 Sec. 6. Section 331.393, subsection 3, Code 2018, is amended 1 to read as follows: 2 3. a. Each region shall submit an annual report to the 3 department on or before December 1. The annual report shall 4 provide information on the actual numbers of persons served, 5 moneys expended, and outcomes achieved. 6 b. Each region shall submit a quarterly report to the 7 department. Each quarterly report shall provide information 8 on the accessibility of intensive mental health services 9 described in section 331.397, subsection 5, and the progress 10 the region has made in meeting the region’s milestones for 11 compliance with such service requirements, using forms and 12 procedures established by the department. If a region fails 13 to meet the milestones in the region’s plan for compliance 14 with access requirements for intensive mental health services 15 described in section 331.397, subsection 5, the department 16 shall require the region to submit a plan of correction to 17 the department to address deficiencies in the region’s plan. 18 The department shall ensure the region’s plan of correction 19 addresses deficiencies in the region’s plan. The department 20 shall combine and analyze the quarterly reports and make the 21 results of the reports public within thirty days of receipt of 22 all reports on a quarterly basis. 23 Sec. 7. Section 331.397, Code 2018, is amended to read as 24 follows: 25 331.397 Regional core services. 26 1. For the purposes of this section , unless the context 27 otherwise requires, “domain” means a set of similar services 28 that can be provided depending upon a person’s service needs. 29 2. a. (1) A region shall work with service providers to 30 ensure that services in the required core service domains in 31 subsections 4 and 5 are available to residents of the region, 32 regardless of potential payment source for the services. 33 (2) Subject to the available appropriations, the director 34 of human services shall ensure the initial core service domains 35 -3- LSB 5837SV (3) 87 hb/rh 3/ 15

S.F. 2351 listed in subsection subsections 4 and 5 are covered services 1 for the medical assistance program under chapter 249A to the 2 greatest extent allowable under federal regulations. The 3 medical assistance program shall reimburse Medicaid enrolled 4 providers for Medicaid covered services under subsections 4 5 and 5 when the services are medically necessary, no other 6 third-party payer is responsible for reimbursement of such 7 services, and the Medicaid enrolled provider submits an 8 appropriate claim for such services. Within funds available, 9 the region shall pay for such services for eligible persons 10 when payment through the medical assistance program or another 11 third-party payment is not available, unless the person is on a 12 waiting list for such payment or it has been determined that 13 the person does not meet the eligibility criteria for any such 14 service. 15 b. Until funding is designated for other service 16 populations, eligibility for the service domains listed in this 17 section shall be limited to such persons who are in need of 18 mental health or intellectual disability services. However, if 19 a county in a region was providing services to an eligibility 20 class of persons with a developmental disability other than 21 intellectual disability or a brain injury prior to formation of 22 the region, the class of persons shall remain eligible for the 23 services provided when the region is was formed , provided that 24 funds are available to continue such services without limiting 25 or reducing core services . 26 c. It is the intent of the general assembly to address 27 the need for funding so that the availability of the service 28 domains listed in this section may be expanded to include such 29 persons who are in need of developmental disability or brain 30 injury services. 31 3. Pursuant to recommendations made by the director of human 32 services, the state commission shall adopt rules as required by 33 section 225C.6 to define the services included in the initial 34 and additional core service domains listed in this section . 35 -4- LSB 5837SV (3) 87 hb/rh 4/ 15

S.F. 2351 The rules shall provide service definitions, service provider 1 standards, service access standards, and service implementation 2 dates, and shall provide consistency, to the extent possible, 3 with similar service definitions under the medical assistance 4 program. 5 a. The rules relating to the credentialing of a person 6 directly providing services shall require all of the following: 7 a. (1) The person shall provide services and represent the 8 person as competent only within the boundaries of the person’s 9 education, training, license, certification, consultation 10 received, supervised experience, or other relevant professional 11 experience. 12 b. (2) The person shall provide services in substantive 13 areas or use intervention techniques or approaches that 14 are new only after engaging in appropriate study, training, 15 consultation, and supervision from a person who is competent in 16 those areas, techniques, or approaches. 17 c. (3) If generally recognized standards do not exist 18 with respect to an emerging area of practice, the person 19 shall exercise careful judgment and take responsible steps, 20 including obtaining appropriate education, research, training, 21 consultation, and supervision, in order to ensure competence 22 and to protect from harm the persons receiving the services in 23 the emerging area of practice. 24 b. The rules relating to the availability of services shall 25 provide for all of the following: 26 (1) Twenty-two assertive community treatment teams. 27 (2) Six access centers. 28 (3) Intensive residential service homes that provide 29 services to up to one hundred twenty persons statewide. 30 4. The initial core service domains shall include the 31 following: 32 a. Treatment designed to ameliorate a person’s condition, 33 including but not limited to all of the following: 34 (1) Assessment and evaluation. 35 -5- LSB 5837SV (3) 87 hb/rh 5/ 15

S.F. 2351 (2) Mental health outpatient therapy. 1 (3) Medication prescribing and management. 2 (4) Mental health inpatient treatment. 3 b. Basic crisis response provisions, including but not 4 limited to all of the following: 5 (1) Twenty-four-hour access to crisis response. 6 (2) Evaluation. 7 (3) Personal emergency response system. 8 c. Support for community living, including but not limited 9 to all of the following: 10 (1) Home health aide. 11 (2) Home and vehicle modifications. 12 (3) Respite. 13 (4) Supportive community living. 14 d. Support for employment or for activities leading to 15 employment providing an appropriate match with an individual’s 16 abilities based upon informed, person-centered choices made 17 from an array of options, including but not limited to all of 18 the following: 19 (1) Day habilitation. 20 (2) Job development. 21 (3) Supported employment. 22 (4) Prevocational services. 23 e. Recovery services, including but not limited to all of 24 the following: 25 (1) Family support. 26 (2) Peer support. 27 f. Service coordination including coordinating physical 28 health and primary care, including but not limited to all of 29 the following: 30 (1) Case management. 31 (2) Health homes. 32 5. a. To the extent federal matching funds are available 33 under the Iowa health and wellness plan pursuant to chapter 34 249N, the following intensive mental health core services shall 35 -6- LSB 5837SV (3) 87 hb/rh 6/ 15

S.F. 2351 be provided in strategic locations throughout the state no 1 later than July 1, 2021, within the following core service 2 domains: 3 (1) Access centers that are located in crisis residential 4 and subacute residential settings with sixteen beds or fewer 5 that provide immediate, short-term assessments for persons with 6 serious mental illness or substance use disorders who do not 7 need inpatient psychiatric hospital treatment, but who do need 8 significant amounts of supports and services not available in 9 the persons’ homes or communities. 10 (2) Assertive community treatment services. 11 (3) Comprehensive facility and community-based crisis 12 services, including all of the following: 13 (a) A single statewide twenty-four-hour crisis hotline. 14 (b) A mobile response. 15 (c) Twenty-three-hour crisis observation and holding. 16 (d) Crisis stabilization community-based services. 17 (e) Crisis stabilization residential services. 18 (f) Warmline services. 19 (4) Subacute services provided in facility and 20 community-based settings. 21 (5) Intensive residential service homes for persons 22 with severe and persistent mental illness in scattered site 23 community-based residential settings. 24 b. The department shall accept arrangements between multiple 25 regions sharing intensive mental health services under this 26 subsection when determining compliance to access standards for 27 such services. 28 5. 6. A region shall ensure that access is available 29 to providers of core services that demonstrate competencies 30 necessary for all of the following: 31 a. Serving persons with co-occurring conditions. 32 b. Providing evidence-based services. 33 c. Providing trauma-informed care that recognizes the 34 presence of trauma symptoms in persons receiving services. 35 -7- LSB 5837SV (3) 87 hb/rh 7/ 15

S.F. 2351 6. 7. A region shall ensure that services within the 1 following additional core service domains are available 2 to persons not eligible for the medical assistance program 3 under chapter 249A or receiving other third-party payment for 4 the services, when public funds are made available for such 5 services: 6 a. Comprehensive facility and community-based crisis 7 services, including but not limited to all of the following: 8 (1) Twenty-four-hour crisis hotline. 9 (2) Mobile response. 10 (3) Twenty-three-hour crisis observation and holding, and 11 crisis stabilization facility and community-based services. 12 (4) Crisis residential services. 13 b. Subacute services provided in facility and 14 community-based settings. 15 c. a. Justice system-involved services, including but not 16 limited to all of the following: 17 (1) Jail diversion. 18 (2) Crisis intervention training. 19 (3) Civil commitment prescreening. 20 d. b. Advances in the use of evidence-based treatment, 21 including but not limited to all of the following: 22 (1) Positive behavior support. 23 (2) Assertive community treatment. 24 (3) (2) Peer self-help drop-in centers. 25 7. 8. A regional service system may provide funding for 26 other appropriate services or other support and may implement 27 demonstration projects for an initial period of up to three 28 years to model the use of research-based practices. In 29 considering whether to provide such funding, a region may 30 consider the following criteria for research-based practices: 31 a. Applying a person-centered planning process to identify 32 the need for the services or other support. 33 b. The efficacy of the services or other support is 34 recognized as an evidence-based practice, is deemed to be an 35 -8- LSB 5837SV (3) 87 hb/rh 8/ 15

S.F. 2351 emerging and promising practice, or providing the services is 1 part of a demonstration and will supply evidence as to the 2 services’ effectiveness. 3 c. A determination that the services or other support 4 provides an effective alternative to existing services that 5 have been shown by the evidence base to be ineffective, to not 6 yield the desired outcome, or to not support the principles 7 outlined in Olmstead v. L.C., 527 U.S. 581 (1999). 8 Sec. 8. Section 331.424A, subsection 1, paragraph b, Code 9 2018, is amended by striking the paragraph. 10 Sec. 9. Section 331.424A, subsection 4, Code 2018, is 11 amended by striking the subsection and inserting in lieu 12 thereof the following: 13 4. An amount of unobligated and unencumbered funds, as 14 specified in the regional governance agreement entered into 15 by the county under section 331.392, shall be reserved in the 16 county services fund to address cash flow obligations. 17 Sec. 10. Section 331.424A, subsection 9, Code 2018, is 18 amended to read as follows: 19 9. a. For the fiscal year beginning July 1, 2017, and each 20 subsequent fiscal year, the county budgeted amount determined 21 for each county shall be the amount necessary to meet the 22 county’s financial obligations for the payment of services 23 provided under the regional service system management plan 24 approved pursuant to section 331.393 , not to exceed an amount 25 equal to the product of the regional per capita expenditure 26 target amount multiplied by the county’s population , and, for 27 fiscal years beginning on or after July 1, 2021, reduced by 28 the amount of the county’s cash flow reduction amount for the 29 fiscal year calculated under subsection 4 , if applicable . 30 b. If a county officially joins a different region, the 31 county’s budgeted amount shall be the amount necessary to meet 32 the county’s financial obligations for payment of services 33 provided under the new region’s regional service system 34 management plan approved pursuant to section 331.393, not to 35 -9- LSB 5837SV (3) 87 hb/rh 9/ 15

S.F. 2351 exceed an amount equal to the product of the new region’s 1 regional per capita expenditure target amount multiplied by the 2 county’s population. 3 Sec. 11. MENTAL HEALTH AND DISABILITY SERVICES REGIONS —— 4 FY 2018 ANNUAL REPORTS. Each mental health and disability 5 services region’s annual report due to the department of human 6 services on or before December 1, 2018, pursuant to section 7 331.393, subsection 3, paragraph “a”, shall include a plan 8 that identifies milestones for meeting intensive mental health 9 service requirements described in section 331.397, subsection 10 5, no later than July 1, 2021. The plan shall, at a minimum, 11 include information relating to processes, implementation time 12 frames, plans for collaboration with other regions and the 13 Medicaid program, and the region’s associated budget plan. 14 Sec. 12. EMERGENCY RULES. If specifically authorized 15 by a provision of this Act, the department of human services 16 or the mental health and disability services commission may 17 adopt administrative rules under section 17A.4, subsection 3, 18 and section 17A.5, subsection 2, paragraph “b”, to implement 19 provisions of this Act and the rules shall become effective 20 immediately upon filing or on a later effective date specified 21 in the rules, unless the effective date of the rules is 22 delayed or the applicability of the rules is suspended by the 23 administrative rules review committee. Any rules adopted in 24 accordance with this section shall not take effect before 25 the rules are reviewed by the administrative rules review 26 committee. The delay authority provided to the administrative 27 rules review committee under section 17A.4, subsection 7, and 28 section 17A.8, subsection 9, shall be applicable to a delay 29 imposed under this section, notwithstanding a provision in 30 those sections making them inapplicable to section 17A.5, 31 subsection 2, paragraph “b”. Any rules adopted in accordance 32 with the provisions of this section shall also be published as 33 a notice of intended action as provided in section 17A.4. 34 EXPLANATION 35 -10- LSB 5837SV (3) 87 hb/rh 10/ 15

S.F. 2351 The inclusion of this explanation does not constitute agreement with 1 the explanation’s substance by the members of the general assembly. 2 This bill relates to mental health and disability services 3 and funding. 4 Under current law, the department of inspections and appeals 5 is required to issue a license to an applicant for a subacute 6 mental health care facility if the department of inspections 7 and appeals has ascertained that the applicant’s facilities and 8 staff are adequate to provide the care and services required 9 of a subacute care facility. The bill strikes additional 10 conditions for licensure requiring the department of human 11 services to submit written approval of the application based 12 upon the process used by the department of human services 13 to identify the best qualified providers, prohibiting the 14 department of human services from approving an application 15 which would cause the number of publicly funded subacute 16 care facility beds to exceed 75 beds, and requiring that the 17 subacute care facility beds identified be new beds located in 18 hospitals and facilities licensed as a subacute care facility 19 under Code chapter 135G. 20 Under Code chapter 229 (hospitalization of persons with 21 mental illness), a person may be committed for treatment 22 if the person is seriously mentally impaired. A person 23 is seriously mentally impaired if the person has a mental 24 illness, and because of that illness lacks sufficient judgment 25 to make responsible decisions with respect to the person’s 26 hospitalization or treatment, and because of that illness is 27 likely to physically injure the person’s self or others, is 28 likely to seriously emotionally injure others, or is unable 29 to satisfy the person’s basic needs. The bill expands the 30 definition of seriously mentally impaired to include a person 31 who has a mental illness, because of that illness lacks 32 sufficient judgment to make responsible decisions with respect 33 to the person’s hospitalization or treatment, and who because 34 of that illness has a history of a lack of compliance with 35 -11- LSB 5837SV (3) 87 hb/rh 11/ 15

S.F. 2351 treatment and the lack of compliance has been a significant 1 factor in the need for emergency hospitalization or resulted 2 in one or more acts of serious physical injury to the person’s 3 self or others or an attempt to seriously physically injure the 4 person’s self or others. 5 Under current law, if a respondent has been ordered to 6 undergo outpatient treatment and fails to comply, and the 7 failure to comply is likely to result in physical injury, 8 a court shall order the person to be taken into physical 9 custody. A respondent may choose to be treated by the 10 appropriate medication which may include the use of injectable 11 antipsychotic medicine. The bill provides that appropriate 12 medication may also include the use of oral medicine. 13 Under current law, each mental health and disability 14 services region is required to submit an annual report to the 15 department of human services on or before December 1. The 16 annual report is required to provide information on the actual 17 numbers of persons served, moneys expended, and outcomes 18 achieved. The bill provides each region shall additionally 19 submit a quarterly report to the department. Each quarterly 20 report shall provide information on the accessibility of 21 intensive mental health services and the progress the region 22 has made in meeting the region’s milestones for compliance 23 with such service requirements using forms and procedures 24 established by the department. If a region fails to meet the 25 milestones in the region’s plan for compliance with such access 26 requirements, the department shall require the region to submit 27 a plan of correction to the department to address deficiencies 28 in the region’s plan. The department shall ensure the region’s 29 plan of correction addresses deficiencies in the region’s plan. 30 The department shall combine and analyze the quarterly reports 31 and make the results of the reports public within 30 days of 32 receipt of all reports on a quarterly basis. 33 Under current law, subject to available appropriations, 34 the director of human services shall ensure that a mental 35 -12- LSB 5837SV (3) 87 hb/rh 12/ 15

S.F. 2351 health and disability services region’s core service domains 1 are covered services for the medical assistance program under 2 Code chapter 249A to the greatest extent allowable under 3 federal regulations. The bill provides the medical assistance 4 program shall reimburse Medicaid enrolled providers for 5 Medicaid covered core services when the services are medically 6 necessary, and the Medicaid enrolled provider submits an 7 appropriate claim for such services. No other third-party 8 payer is responsible for reimbursement of such services. 9 The bill provides that the administrative rules of the state 10 mental health and disability services commission relating to 11 the availability of mental health and disability services 12 shall, in addition to other mental health and disability 13 service requirements, provide for 22 assertive community 14 treatment teams, six access centers, and intensive residential 15 service homes that serve up to 120 persons statewide. 16 The bill provides that, to the extent matching federal 17 funding is available under the Iowa health and wellness plan, 18 intensive mental health core services shall be provided in 19 strategic locations throughout the state on or before July 1, 20 2021, within certain core service domains including access 21 centers that are located in crisis residential and subacute 22 residential settings, assertive community treatment services, 23 comprehensive facility and community-based crisis services, 24 subacute services, and intensive residential service homes. 25 The bill provides the department of human services shall 26 accept arrangements between multiple regions sharing intensive 27 mental health services when determining compliance with access 28 standards for such services. 29 Current Code section 331.391 establishes requirements 30 related to the permissible amount of cash flow for each mental 31 health and disability services region. For fiscal years 32 beginning July 1, 2017, July 1, 2018, and July 1, 2019, that 33 portion of each region’s cash flow amount that exceeds 25 34 percent of the gross expenditures from the region’s combined 35 -13- LSB 5837SV (3) 87 hb/rh 13/ 15

S.F. 2351 account or from all separate county accounts under the control 1 of the governing board in the fiscal year preceding the fiscal 2 year in progress are required to be used in whole or in part 3 to fund the payment of mental health and disabilities services 4 provided under the regional service system management plan. 5 Current law also imposes similar requirements for the amount of 6 unobligated and unencumbered funds that are reserved in each 7 county’s county services fund to address cash flow obligations 8 in the next fiscal year, imposes annual reporting requirements 9 for region and county cash flow amounts, and imposes, for 10 fiscal years beginning on or after July 1, 2021, either a 20 11 or 25 percent limitation on each county or region’s cash flow 12 amount based on the region’s population. Current law also 13 requires that for fiscal years beginning on or after July 1, 14 2021, of a county’s cash flow amount maintained in the county 15 services fund or of the region’s cash flow amount attributable 16 to the county, the county budgeted amount, used to limit the 17 amount of property taxes levied by the county, is reduced 18 by the county’s cash flow reduction amount. The cash flow 19 reduction amount is equal to the amount of the county’s cash 20 flow in excess of the permissible percentage limits based on 21 population of the region. 22 The bill strikes the requirement for fiscal years beginning 23 July 1, 2017, July 1, 2018, and July 1, 2019, that the portion 24 of each county’s or region’s cash flow amount that exceeds 25 the 25 percent limitation be used in whole or in part to fund 26 the payment of mental health and disability services provided 27 under a region’s regional service system management plan. The 28 bill also strikes the reporting requirements for counties and 29 regions and eliminates the reduction in a county’s budgeted 30 amount due to the county’s cash flow reduction amount for 31 fiscal years beginning on or after July 1, 2021. The bill 32 establishes a limitation on the cash flow amount of a region 33 equal to 30 percent of the gross expenditures budgeted for 34 the fiscal year in progress for the combined account of the 35 -14- LSB 5837SV (3) 87 hb/rh 14/ 15

S.F. 2351 region or for all regional accounts and requires residual 1 funding remaining in excess of such limitation to be used to 2 expand the region’s core services and then make additional core 3 services available. The bill also provides that an amount of 4 unobligated or unencumbered funds, as specified in the regional 5 governance agreement, is required to be reserved in each 6 county’s county services fund to address cash flow obligations. 7 Under the bill, if a county officially joins a different 8 mental health and disability services region, that county’s 9 budgeted amount shall be the amount necessary to meet the 10 county’s financial obligations for payment of services provided 11 under the new region’s regional service system management 12 plan, not to exceed an amount equal to the product of the 13 new region’s regional per capita expenditure target amount 14 multiplied by the county’s population. 15 The bill provides that each mental health and disability 16 services region, in the region’s annual report due to the 17 department of human services on or before December 1, 2018, 18 shall include a plan that identifies milestones for meeting 19 intensive mental health service requirements described in Code 20 section 331.397(5), no later than July 1, 2021. The plan 21 shall, at a minimum, include information relating to processes, 22 implementation time frames, plans for collaboration with other 23 regions and the Medicaid program, and the region’s associated 24 budget plan. 25 The bill provides that the department of human services or 26 the mental health and disability services commission may adopt 27 emergency rules to implement the provisions of the bill. 28 -15- LSB 5837SV (3) 87 hb/rh 15/ 15