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REGIONAL MH/DS SERVICES: 2018 Session Review

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Legislators from both parties came together this year to pass a bill to address gaps in services to Iowans with complex mental health, disability, and substance use needs. The legislation was based on the recommendations of a work group, and it makes a lot of changes to the state's regional MH/DS system.  There were a few other changes made to the regional system in other bills, including how new regions are formed. Here's a quick review of the changes made this year in the regional MH/DS system:

MH/DS Region Services:

  • All of the existing crisis services provided by MH/DS regions are moved to the list of "core services." Mobile response, 23-hour crisis observation and holding, crisis residential services, subacute and crisis stabilization community-based services are no longer considered optional services. The existing subacute bed cap is removed, so regions are free to develop these beds based on the needs of their community. Justice system services (jail diversion, crisis intervention training, civil commitment prescreening) and advancements in evidence-based treatment (positive behavior support, peer self-help drop-in centers) are still considered "additional core” services and are still optional.  
  • Regions are expected to build out three new core services and work together to ensure that they are available throughout the state.  These include:
     
    • Access Centers to provide short-term care for those in crisis, and provide resources needed to get Iowans back home to their families (at least six statewide).

    • Assertive Community Treatment (ACT) teams to provide individualized treatment and support to individuals with mental illness in their homes, 365 days a year (at least 22 teams statewide).
       
    • Intensive Residential Service Homes will provide individuals with severe and persistent mental illness with the chance to live in smaller community-based settings close to home, while receiving the 24-hour intensive services needed to address their individual needs. There are up to 120 beds available statewide (to be scattered, with facilities preferably serving no more than four individuals at each site, although each site may serve up to 16 individuals).
  • It is important to note that Medicaid is now expected to pay for these new core services if the person is enrolled in or eligible for Medicaid.  Regions will continue to pay for others who are not eligible for Medicaid (to the extent funding is available).  Regions do not yet have a good idea how much it will cost to provide these services, so they cannot say if their current funding is sufficient.  The cost to Medicaid increases substantially next year – legislators will need to find another $5-6 million to cover the expected costs once the services are operational. 
     
  • Regions are no longer required to fund a 24-hour crisis hotline service.  A single statewide 24-hour crisis hotline will replace the ones managed by each individual MH/DS region, but it will continue to connect people to the local resources they need.

MH/DS Regional Funding: 

  • The Legislative Council has been asked to appoint an interim committee to look at the funding of these regional services, including the new services added this year.  In every redesign, funding has always been the one thing that never quite gets addressed.  If approved, this interim committee will look at levies, budgets, per capita expenditure targets, and fund balances, and make recommendations in time for action in the 2019 session.  Unfortunately, legislative leaders that sit on the Legislative Council do not have to approve every request for an interim study.  This is an important one – so you may want to ask your legislator to lobby their leaders to get this interim committee approved!  We've made it easy to do - just go to our Action Center and send a message now!

  • Regions are still required to spend down excess fund balances before July 1, 2021.  After that time, county levies within the region will be lowered.

  • The Polk County MH/DS Region is allowed to use other funds to pay for regional services if the MH/DS levy is not sufficient.  Polk County already gets $6.3 million in funds/in-kind services from its county hospital (Broadlawns) to cover some of its shortfall, but estimates they are still about $1-2 million short.  They will have to report back on the funds used by September 1, 2019.
     
  • DHS will review reimbursement rates for ACT teams over the interim and make recommendations by 12/15/18. 

Formation of New MH/DS Regions:

  • New single county regions are no longer allowed. This will not impact the existing single-county region (Polk), but will stop other counties from trying to form their own region.  Similarly, DHS will no longer be able to waive the three-county minimum requirement (so no two-county regions either).

  • New regions must include bordering counties only.  DHS will no longer be able to waive the requirement that counties in a region be contiguous.  

  • DHS is allowed to approve the formation of a new region with counties wanting to leave the 22-county County Social Services RegionNew regions must now meet the following new minimum requirements before being approved by DHS: population must be at least 100,000, must include a city with a population of more than 24,000, must be able to meet all core service requirements by February 1, 2019 and be in full operation by July 1, 2019.  DHS is directed to work with any counties having difficulty joining a new region and allows DHS to assign a county to a region if they have not joined one by February 1, 2019.  The new requirements apply to new regions only; existing regions are not affected.

  • New regions are allowed to reset their per capita expenditure targets (the amount of money the county can levy per resident), but they cannot go over the statewide cap.  Expenditure targets cannot be increased after July 1, 2020.  

The MH/DS Commission and DHS have already started to write the rules on these new laws.  Administrative rules are important here, because they will more fully define these services, set service provider standards, establish reimbursement rates (always key to making services available), access standards, implementation dates, and possibly even location of the services.  While DHS has been asked to get rules noticed in August, it will still need to go through the normal rules process that includes many opportunities for input, including public hearings, public comment period, required responses to comments, and a review by a legislative panel (called the Administrative Rules Review Committee).  During that final legislative review, stakeholders are also able to provide comment, and legislators can stop rules if they feel public comments have not been adequately addressed.  So lots of opportunity for input; we'll make sure you know about these as this gets started!