21st Century Cures Act: Implications and Opportunities for States

The 21st Century Cures Act (“Cures”), signed into law on December 13, 2016, is being heralded as landmark legislation for biomedical innovation. Cures funds new research, streamlines the development of new drugs, and supports the interoperability of health information systems. State policymakers, however, may want to focus their attention on Cures’ myriad behavioral health provisions, which include some clarifications on Medicaid policy, a host of amendments to better address the needs of individuals with mental illness and corrections involvement; significant opportunities for state funding for substance use disorders and mental health treatment, and other provisions.

Cures takes on a few long-standing roadblocks in states’ efforts to create comprehensive and integrated systems:

  • Clarifies that there is no federal prohibition on same day billing for mental health and primary care services;
  • Specifies that as of January 2019 children in inpatient psychiatric hospitals are also eligible for the full range of early and periodic screening, diagnostic, and treatment (EPSDT) services;
  • Directs CMS to issue a State Medicaid Director letter in the coming year on opportunities to create innovative systems of care for individuals with serious mental illness under section 1115.

The act does not address barriers to payment for Institutions of Mental Disease, the so-called IMD exclusion; it does direct CMS to study and report out on this issue, both in the context of Medicaid managed care and on results from the state Medicaid Emergency Psychiatric Demonstration Project.

Cures also includes new requirements for Medicaid-funded home health and personal care services, mandating that states implement electronic visit verification (EVV) systems to more closely monitor in-home service delivery. Many states already use EVV systems or are considering them in order to curb improper payments in this growing sector of health care. States that fail to comply (by 2019 for personal care; 2023 for home health) will face incremental reductions in their federal match.

Mental Health and Corrections
Cures provides state policymakers with additional tools to address the growing problem of individuals with behavioral health conditions and corrections involvement:

  • It includes a host of amendments to Department of Justice and other grant-funded programs, giving state and local governments more flexibility to use these resources to support individuals with substance use disorders and mental illness.
  • It reauthorizes critical programs, such as the Mentally Ill Offender Treatment and Crime Reduction Act, and authorizes new funding for programs to reduce recidivism and support reentry for individuals with mental illness and substance use disorders.

Grant Funding to States in Key Areas
Cures creates significant new resources in the State Response to the Opioid Crisis program, providing $500,000,000 annually over the next two years to states for initiatives such as improving state prescription drug monitoring programs, implementing and evaluating strategies to prevent opioid abuse, training for health care practitioners, and supporting access to treatment services. The act also creates or reauthorizes a number of other grant funding opportunities for states and partner agencies on key behavioral health issues, including:

  • Community Crisis Response Systems: Establishes grants to states to strengthen community-based crisis response centers and develop, maintain, or enhance databases for tracking inpatient psychiatric facility beds, crisis stabilization units, and residential treatment facilities;
  • Assertive Community Treatment: Provides grants to develop, maintain, or expand assertive community treatment programs for adults with serious mental illness;
  • Assisted Outpatient Treatment (AOT): Increases and extends authorization for the AOT grant program;
  • Suicide Prevention: Establishes grants for adult suicide prevention and intervention programs. The grants can be used raise awareness, establish a referral process, and improve care and outcomes for those at risk.

Other Provisions
Cures contains other provisions that may affect how states administer current programs, such as changes to the Community Mental Health Services Block Grant (requiring that states expend no less than 10 percent of grant funds to support evidence based programs on early serious mental illness), and amendments to Title IV-E to support reunification and kinship care. The act signals important changes at the federal level as well, creating a new Assistant Secretary for Mental Health and Substance Use to head the Substance Abuse and Mental Health Services Administration (SAMHSA and requiring that the agency have a Chief Medical Officer, one with real-life experience in the field. Cures establishes an Inter-Departmental Serious Mental Illness Coordinating Committee, which will include membership from CMS, the Departments of Justice, Housing and Urban Development, Labor and others, and will report to congress on how to better coordinate services across government.

Cures offers states a number of opportunities to focus on critical behavioral health policy issues – especially with regard to substance use disorders and corrections; much of its impact will depend on how these varied initiatives are actually funded and implemented. As these highlights suggest, the act relies heavily on grant-funded initiatives, with fewer substantive changes to Medicaid, the major payer and policy driver for behavioral health treatment in states. NASHP will continue to track these grant-funded initiatives to see whether they will provide a catalyst for more broad-based reforms in state behavioral health systems.