H.R. 8487 — Ensuring Excellence in Mental Health Act

This section revises the criteria under Medicaid (SSA §1905(jj)(2)) for a clinic to qualify as a certified community behavioral health clinic (CCBHC) eligible for enhanced federal matching payments by: (1) expanding the requirement to furnish certain services described in paragraph (1)(B) to include providing or referring such services through formal relationships, as applicable; (2) requiring states, by agreement with the Secretary, to access relevant data via the system described in section 340J–3 of the Public Health Service Act; and (3) permitting, at state option beginning January 1, 2026, accreditation by a body approved under section 340J–4 of the Public Health Service Act. (CCBHCs provide comprehensive mental health and substance use disorder treatment services and participate in a federal demonstration program offering states enhanced Medicaid payments to expand access.)

This section establishes a prospective payment system (PPS) for Medicaid certified community behavioral health clinic (CCBHC) services (i.e., comprehensive mental health and substance use disorder treatment, crisis intervention, and related services) furnished by CCBHCs, effective for services provided on or after January 1, 2026, in states that elect CCBHC coverage under section 1905(a)(31) of the Social Security Act. (As background, CCBHCs originated under a demonstration program authorized by section 223 of the Protecting Access to Medicare Act of 2014 to improve access to coordinated behavioral health care for Medicaid enrollees.) The PPS must use daily or monthly visits (excluding repeat visits by the same individual) as the unit of payment and, consistent with prior guidance, may include (1) separate rates for special populations, (2) outlier payments for high-cost cases, or (3) distinct rates for crisis services (e.g., mobile crisis teams, emergency intervention, or stabilization) based on segregated cost reports. For the initial year, payments equal 100% of a clinic's reasonable costs from the prior fiscal year base period (or, at state option in states with prior CCBHC demonstrations, the prior demonstration rate); subsequent annual payments equal the prior year's amount increased by the percentage specified in section 1834(aa)(3)(C) of the Social Security Act (i.e., the Medicare outpatient hospital PPS update factor) and adjusted for changes in service scope. For new CCBHCs lacking base-year data, initial payments use estimated/projected costs, rates from similar nearby clinics, or reasonable projected per-visit costs, transitioning to actual costs in year two and the standard formula thereafter; states may periodically rebase rates (no less frequently than specified).

This section expands the Certified Community Behavioral Health Clinic (CCBHC) Medicaid demonstration program—under Section 223 of the Protecting Access to Medicare Act of 2014—to require provision of both required CCBHC services (i.e., the original nine behavioral health services, such as crisis intervention and peer support, which may be provided directly or via formal referral relationships) and additional CCBHC services (i.e., other services furnished directly by the clinic to meet population health needs, which may include primary health services under section 330(b)(1)(A) of the Public Health Service Act, such as preventive care and basic screenings). (As background, the CCBHC demonstration enables states to reimburse certified clinics for comprehensive, person-centered behavioral health care to individuals with serious mental illness or substance use disorders.) It further (1) replaces references to "mental health services" with "certified community behavioral health clinic services" and (2) defines the latter term to encompass both required and elected additional services. The amendments apply to services furnished on or after October 1, 2026.

This section revises the definition of certified community behavioral health clinic (CCBHC) services under Medicaid to include, in addition to the nine required services (e.g., crisis services, outpatient therapy, peer support), additional services that are appropriate to the population served and may include primary health services defined in section 330(b)(1) of the Public Health Service Act (i.e., basic medical services such as preventive care typically provided by federally qualified health centers). (As background, CCBHCs are Medicaid-certified clinics offering comprehensive mental health and substance use disorder treatment.) The amendments apply to services furnished on or after October 1, 2026.

This section establishes Medicare Part B coverage for certified community behavioral health clinic (CCBHC) services (as defined in SSA §1861(aa)(8), cross-referencing SSA §1905(jj)) furnished on or after January 1, 2027. CCBHCs are clinics certified to provide comprehensive, evidence-based mental health and substance use disorder services (e.g., crisis intervention, outpatient therapy, peer support, and care coordination).

This section establishes Medicare Part B payment for certified community behavioral health clinic (CCBHC) services (as defined in SSA section 1861(aa)(8)) at 80% of the lesser of the actual charge or a prospective payment system (PPS) amount under new SSA section 1834(aa). (As background, CCBHCs furnish comprehensive outpatient mental health and substance use disorder services—such as crisis intervention, screenings, and care coordination—initially under a Medicaid demonstration program.) Under the PPS, which the Secretary must develop by taking into account service type, intensity, and duration (with possible geographic adjustments) and using an appropriate unit of service to ensure continued access, payments are computed as follows: (1) for 2027, based on average reasonable costs of CCBHCs (determined without per-visit limits or productivity screens and prior to Medicare bad debt adjustments) related to services described in SSA section 1905(jj)(1)(B), using the two most recent audited fiscal year cost reports (or estimated data, at the Secretary's discretion); (2) for 2028, the 2027 amount increased by the Medicare Economic Index (MEI); and (3) for 2029 and subsequent years, the prior-year amount increased by a CCBHC services market basket index (or the FQHC market basket index, if unavailable). The Secretary may periodically adjust PPS rates before annual updates to account for changes in service intensity or costs per unit, among other factors.

This section provides that the Medicare Part B annual deductible does not apply to certified community behavioral health clinic (CCBHC) services (in addition to Federally qualified health center services). (CCBHCs are clinics certified to deliver comprehensive, integrated mental health and substance use disorder services, primarily to underserved Medicare and Medicaid beneficiaries.)

This section expands eligibility to seek review of Medicare cost reports from the Provider Reimbursement Review Board to certified community behavioral health clinics (CCBHCs), in addition to federally qualified health centers (FQHCs). (CCBHCs provide comprehensive mental health and substance use disorder services to Medicaid and Medicare enrollees under a demonstration program.)

This section extends the Anti-Kickback Statute safe harbor authorizing Federally Qualified Health Centers (FQHCs) to waive coinsurance for certain patients to Certified Community Behavioral Health Clinics (CCBHCs). (Thus, CCBHCs—which provide comprehensive mental health and substance use disorder treatment under a Medicaid demonstration program—may waive coinsurance without violating the statute.)

This section establishes a grant program under the Public Health Service Act for operating grants of up to five years to certified community behavioral health clinics (CCBHCs)—which deliver comprehensive outpatient behavioral health services (as defined in section 1905(jj) of the Social Security Act)—or community behavioral health clinics seeking certification by meeting criteria under section 223(a) of the Protecting Access to Medicare Act of 2014 (as of March 2023 and subsequent updates). In selecting grantees, the Secretary may require accreditation (per section 340J–4(a)), prioritize clinics serving children, youth, or veterans (with referral arrangements for community access), and emphasize geographic distribution, high-need communities, full-service readiness, and state program alignment. Grant funds must support provision of required CCBHC services and certification efforts and may cover (1) cost reductions, access/quality improvements, or community health enhancements and (2) infrastructure costs (e.g., buildings, equipment, data systems, staff training, or construction if specified in the grant notice). Grantees must submit an implementation plan within 120 days of selection, and award amounts account for state/local funding, expected reimbursements, and program costs. Nongrant funds may support similar purposes.

This section extends Federal Tort Claims Act (FTCA) protection to clinicians in certified community behavioral health clinics (CCBHCs, as defined in section 1905(jj)(2) of the Social Security Act). (As background, FTCA protection under the Public Health Service Act deems such clinicians federal employees for medical malpractice liability purposes, allowing tort claims against the United States rather than individual providers; CCBHCs deliver comprehensive mental health and substance use disorder services, primarily to Medicaid enrollees.)