Behavioral Health Crisis Services. 
Crisis mental health services are intended to stabilize a person in mental health crisis to prevent further deterioration, provide immediate treatment and intervention, and provide treatment services in the least restrictive environment available.  Substance use disorder detoxification services are provided to persons to assist with the safe and effective withdrawal from substances.  Behavioral health crisis services include:  crisis telephone support, crisis outreach services, crisis stabilization services, crisis peer support services, withdrawal management services, and emergency involuntary detention services.
 
Behavioral health administrative services organizations (BHASOs) are entities contracted with the Health Care Authority to administer certain behavioral health services and programs for all individuals within a regional service area, including behavioral health crisis services and the administration of the Involuntary Treatment Act.  In addition, each BHASO must maintain a behavioral health crisis hotline for its region.
 
National Suicide Prevention Hotline.
The Substance Abuse and Mental Health Services Administration (SAMHSA) partially funds the National Suicide Prevention Lifeline (Lifeline).  Lifeline is a national network of about 180 crisis centers that are linked by a single toll-free number.  In Washington, there are three local crisis centers participating in Lifeline.  Lifeline is available to people in suicidal crisis or emotional distress.  When a person calls the number, the call is routed to a local crisis center based upon the caller's area code.  Counselors at the local crisis center assess callers for suicidal risk, provide crisis counseling services and crisis intervention, engage emergency services when necessary, and offer referrals to behavioral health services.  In addition, the SAMHSA and the Department of Veterans Affairs have established the Veterans Crisis Line which links veterans with suicide prevention coordinators. 
 
In October 2020 Congress passed the National Suicide Hotline Designation Act of 2020 (Act).  The Act designates the number 988 as the universal telephone number within the United States for the purpose of accessing the National Suicide Prevention and Mental Health Crisis Hotline system that is maintained by Lifeline and the Veterans Crisis Line.  In addition, the Act expressly authorizes states to collect a fee on commercial mobile services or Internet protocol-enabled voice services for:  (1) ensuring the efficient and effective routing of calls made to the 988 National Suicide Prevention and Mental Health Crisis Hotline to an appropriate crisis center; and (2) personnel and the provision of acute mental health crisis outreach and stabilization services by directly responding to calls to the crisis centers.

Behavioral Health Crisis Response and Suicide Prevention System.
Crisis Hotline Centers and Crisis Call Center Hubs.
The Department of Health (Department) must provide adequate funding for an expected increase in the use of the state's crisis lifeline call centers once the 988 hotline number is established.  The funding must be established at a level anticipated to achieve an in-state call response rate of at least 90 percent by July 22, 2022.  The level of funding must be determined by considering call volume predictions, cost per call predictions provided by the National Suicide Prevention Lifeline (Lifeline), guidance on call center performance metrics, and necessary call center upgrades.  
 
By July 1, 2023, the Department must adopt rules with standards that crisis call centers must meet to become designated as crisis call center hubs.  A "crisis call center hub" is defined as a state-designated center participating in the Lifeline network to respond to statewide or regional 988 calls.  The Department must collaborate with other agencies in developing the rules and must consider recommendations from the Crisis Response Improvement Strategy Committee (Strategy Committee) and guidelines from national organizations. 
 
By July 1, 2024, the Department must designate crisis call center hubs to provide persons who access the 988 Crisis Hotline within Washington with crisis intervention services, triage, care coordination, referrals, and connections.  To be designated as a crisis call center hub, an entity must contract to provide crisis call center hub services.  The contracts must require the crisis call center hubs to participate in the Lifeline network; meet operational, clinical, and reporting standards established by the Department; and collaborate with the Health Care Authority (Authority), the Lifeline, and the Veterans Crisis Line to assure consistent messaging.  In addition, the contracts must require crisis call center hubs to employ highly qualified, skilled, and trained clinical staff to provide empathy to callers, de-escalate crises, assess behavioral health disorders and suicide risk, triage to system partners, and provide case management and documentation. 
 
Behavioral Health Crisis Response System and Suicide Prevention Technologies.
The Department and the Authority must coordinate to develop the technology and platforms needed to manage and operate the behavioral health crisis response and suicide prevention system.  The technologies must include: (1) a new technologically advanced behavioral health and suicide prevention crisis call center system platform for use in crisis call center hubs that has technology that is interoperable with other crisis and emergency response systems statewide and (2) a behavioral health integrated client referral system that coordinates system information with the crisis call center hubs and behavioral health entities.  The agencies must designate a primary technology system to provide:

• access to real-time information relevant to the coordination of behavioral health crisis response and suicide prevention services, including real-time bed availability for all behavioral health bed types and real-time information relevant to the coordination of behavioral health crisis response and suicide prevention services;
• the means to request deployment of appropriate crisis response services and track local response through global positioning technology;
• the means to track the outcome of a 988 call to enable appropriate follow up, cross-system coordination, and accountability;
• a means to facilitate actions to verify and document whether the person's transition to follow up noncrisis care was completed and which services were offered;
• the means to provide geographically, culturally, and linguistically appropriate services to persons who are in high-risk populations or have a need for specialized services or accommodations; and
• consultation with tribal governments to ensure coordinated care in government-to-government relationships and access to dedicated services to tribal members.

 
In developing and implementing the technology and platforms, the Department and the Authority must create a technical and operational plan for the development of technology and platforms for the call center hub system.  Except for the initial planning phase, prior to beginning a new information technology development following the initial planning phase, the agencies must submit the technical and operational plan to the Governor, the Office of Financial Management, the steering committee of the Strategy Committee, and the appropriate committees of the Legislature.  The technical and operational plan must be approved by the Office of the Chief Information Officer, the Office of Financial Management, and the steering committee of the Strategy Committee before the expenditure of funds beyond the initial planning phase.  A draft technical and operational plan is due by January 1, 2022, and a final plan by August 31, 2022.  The plan must address data management, data security, data flow, data access and permissions, protocols for health information privacy procedures, cybersecurity requirements, service level agreements by vendor, maintenance and operations costs, identification of applicable software as a service product, integration limitations by system, data analytic and performance metrics, liability, identification of the agency to host the electronic health record software, identification of the regulatory agency, the timeline from initiation to implementation of the solutions, efficient use of state resources and maximization of federal financial participation, and a comprehensive business plan analysis.
 
State Agency Responsibilities.
The Department is assigned the primary responsibility for establishing and designating the crisis call center hubs and the Authority is assigned the primary responsibility for developing and implementing the crisis response system and services to support the work of the crisis call center hubs.  It is the stated expectation that the agencies will collaborate to ensure seamless, continuous, and effective service delivery with the statewide crisis system.  In addition, the Department must collaborate with the State Enhanced 911 Coordination Office, Emergency Management Division, and Military Department to use technology that is interoperable between the 988 Crisis Hotline system and crisis and emergency response systems used throughout the state, to assure cohesive interoperability, to develop training programs and operations for both 911 public safety telecommunicators and crisis line workers, to develop suicide and behavioral health crisis assessments and intervention strategies, and to establish efficient and equitable access to resources via crisis hotlines.
 
The Authority is assigned specific duties related to:  (1) collaborating with counties and behavioral health administrative services organizations (BHASOs) to develop dispatch procedures; (2) establishing agreements with managed care organization and BHASOs to provide services and coordination regarding crisis services, including arranging next-day appointments; (3) creating best practice guidelines to deploy crisis response services to 988 hotline callers; (4) developing procedures regarding information sharing and communication between and across crisis and emergency response systems; and (5) establishing guidelines to serve high-risk populations.
 
The Department and the Authority must provide an annual report of the 988 Crisis Hotline's usage and call outcomes, as well as information about crisis services, including mobile rapid response crisis teams and crisis stabilization services.  The report must also include information about fund deposits to and expenditures from the Statewide 988 Behavioral Health Crisis Response and Suicide Prevention Line Account (988 Account).  Beginning in 2023, the report must be submitted each November to the Governor and the appropriate committees of the Legislature.  The Joint Legislative Audit and Review Committee must conduct an audit once the act has been fully implemented to focus on the use of funds from the Account and submit a report by November 1, 2027.
 
The Governor must appoint a 988 Hotline and Behavioral Health Crisis System Coordinator to provide project coordination and oversight for the implementation and administration of the 988 Crisis Hotline.  The coordinator must oversee the collaboration between the Department and the Authority, coordinate and facilitate communication between stakeholders, review the development of training for crisis call center personnel, and coordinate the implementation of other behavioral health initiatives.
 
When acting in their statutory capacities, the state, the Department, the Authority, the State Enhanced 911 Coordination Office, the Emergency Management Division, the Military Department, and other state agencies and their employees are deemed to be carrying out duties owed to the public and not any individual person or class of persons.  Crisis call center hubs are deemed to be independent contractors, separate and apart from the state.
 
Crisis Response Improvement Strategy Committee.
The Strategy Committee is established to develop an integrated behavioral health crisis response and suicide prevention system.  The Office of Financial Management must contract with the Behavioral Health Institute at Harborview Medical Center to facilitate and provide staff support to the Strategy Committee.
 
The Strategy Committee includes the Director of the Authority, or the Director's designee; the Secretary of the Department, or the Secretary's designee; a representative of the Office of the Governor; the Insurance Commissioner, or the Commissioner's designee; up to two members representing federally recognized tribes, one from Eastern Washington and one from Western Washington; two members of the House of Representatives; two members from the Senate; the Director to the Department of Veterans Affairs, or the Director's designee; the State Enhanced 911 Coordinator, or the Coordinator's designee; a member with lived experience of a suicide attempt; a member with lived experience of a suicide loss; a member with experience of participation in the crisis system related to a mental health disorder; a member with experience of participation in the crisis system related to a substance use disorder; a member from each crisis call center in Washington that is contracted with the Lifeline; up to two members representing BHASOs, one from an urban region and one from a rural region; a member from the Washington Council for Behavioral Health; a member from the Association of Alcoholism and Addiction Programs of Washington State; a member from the Washington State Hospital Association; a member from the National Alliance on Mental Illness of Washington; two members representing the behavioral health interests of persons of color, one recommended by Sea Mar Community Health Centers and one recommended by Asian Counseling and Referral Service; a member representing law enforcement; a member representing a university-based suicide prevention center of excellence; a member representing an emergency medical services department with a Community Assistance Referral and Education Services program; a member representing Medicaid managed care organizations; a member representing commercial health insurers; a member from the Washington Association of Designated Crisis Responders; a member from the Children and Youth Behavioral Health Work Group; a member from a social justice organization addressing police accountability and the use of deadly force; and a member from an organization specializing in facilitating behavioral health services for LGBTQ populations.
 
The Strategy Committee must submit its work to a steering committee of the full Strategy Committee.  The steering committee consists of the Director of the Authority, or the Director's designee, the Secretary of the Department, or the Secretary's designee, a representative of the Office of the Governor, one of the members from the House of Representatives, and one of the members from the Senate.  The steering committee must convene the Strategy Committee, select three co-chairs,  schedule meetings, and establish agendas. The steering committee must also form several specified subcommittees pertaining to tribal issues, credentialing and training, technology, cross-system crisis response collaboration, and confidential information and coordination.  The steering committee may form other subcommittees and the participants on the subcommittees are not required to be Strategy Committee members and each subcommittee must have at least one member representing rural interests, urban interests, and the interests of youth. 

The steering committee must monitor and make recommendations related to funding crisis response services from the 988 Account, including analysis of projected expenditures, the cost of providing statewide coverage of mobile rapid response crisis teams, options to reduce the tax, and the viability of funding mobile rapid response crisis services from the 988 Account.  The steering committee must submit a preliminary report to the Governor and the Legislature on the analysis of the account by January 1, 2022, and a final report by January 1, 2023.
 
By January 1, 2022, the steering committee must develop a comprehensive assessment of the behavioral health crisis response and suicide prevention system, including an inventory of existing services and resources.   The comprehensive assessment must identify statewide and regional insufficiencies in necessary services and resources, goals for the provision of statewide and regional behavioral health crisis services and resources, a process for establishing outcome measures and improvement targets for the crisis response system, and potential funding sources.
 
The steering committee must develop a report that considers the comprehensive assessment and discussions with the Strategy Committee and reports from subcommittees.  The report must include:

• a recommended vision for an integrated crisis network, including the integration of the 988 Crisis Hotline and crisis call center hubs, mobile rapid response crisis teams, mobile crisis response units, a range of crisis stabilization services, an integrated involuntary treatment system, peer and respite services, and data resources;
• recommendations to promote equity in services for individuals of diverse circumstances of culture, race, ethnicity, gender, socioeconomic status, sexual orientation, and for individuals in tribal, urban, and rural communities;
• a work plan for implementing local responses to calls to the 988 Crisis Hotline;
• the components of the new technologically advanced behavioral health crisis call center system platform and the new behavioral health integrated client referral system for assigning and tracking responses to behavioral health crisis calls and providing real-time bed and outpatient appointment availability;
• a work plan to enhance and expand the availability of community-based mobile rapid response crisis teams in every BHASO, including specialized teams to respond to the unique needs of particular populations;
• a work plan for crisis call center hubs to integrate Spanish language interpreters and Spanish-speaking call center staff into their operations and to ensure the availability of resources to meet the needs of persons in the agricultural community who are experiencing mental health stresses;
• the systems and capabilities needed to report, maintain, and update real-time information regarding the availability of behavioral health beds and outpatient appointments;
• the identification of other behavioral health challenges that the 988 Crisis Hotline may address in addition to suicide response and behavioral health crises;
• the development of a plan for the statewide equal distribution of crisis stabilization services, behavioral health beds, and peer-run respite services;
• recommendations for how health plans, managed care organizations, and BHASOs will assign care coordinators and next-day appointments to enrollees who contact the behavioral health crisis system;
• the allocation of funding responsibilities among managed care organizations, commercial insurers, and BHASOs;
• cost estimates for each of the components of the integrated behavioral health crisis response and suicide prevention system; and
• the recommended composition of a statewide behavioral health crisis response and suicide prevention oversight board.

The steering committee must provide to the Governor and the appropriate committees of the Legislature: a progress report by January 1, 2022, a second progress report that includes recommendations related to call center hubs by  January 1, 2023, and a final report by January 1, 2024.  
 
Health Insurance Coverage.
Health plans must make next-day appointments available to enrollees with urgent, symptomatic behavioral health conditions by January 1, 2023.  The appointment does not need to be with a behavioral health professional as long as it is with a licensed provider acting within the provider's scope of practice.  The appointment may be provided through telemedicine.
 
Statewide 988 Behavioral Health Crisis Response and Suicide Prevention Line Tax.
The Statewide 988 Behavioral Health Crisis Response and Suicide Prevention Line Tax (988 Tax) is imposed on all radio access lines, interconnected voice over Internet protocol (VoIP) service lines, and switched access lines.  A "radio access line" is a telephone number assigned to or used by a subscriber for two-way local wireless voice service from a radio communications company, including cellular telephone service, personal communications services, and network radio access lines.  A "VoIP service line" is a service that enables real-time, two way voice communications using a broadband connection.  "Switched access line" means the telephone service line that connects a subscriber's main telephone or equivalent main telephone to the local exchange company's switching office.  The 988 Tax amount for each of these lines is phased in so that the tax is 24 cents per line per month between October 1, 2021, and December 31, 2022, and is increased to 40 cents per line per month beginning January 1, 2023.
 
Proceeds from the 988 Tax must be deposited into the 988 Account.  The 988 Account is an appropriated account in the State Treasury.  Money from the 988 Account may only be used for the routing of calls from the 988 Crisis Hotline to an appropriate crisis hotline center and for personnel and the provision of acute behavioral health, crisis outreach, stabilization services and follow-up case management.
 
Cities and counties are prohibited from imposing a tax on radio access lines, interconnected voice over Internet protocol service lines, or switched access lines for the purpose of routing calls made to the 988 Crisis Hotline to a crisis hotline center or crisis call center hub or for responding to 988 Crisis Hotline calls.
 
Appropriations.
For the 2021-23 fiscal biennium, the Department is appropriated:

• $23,016,000 from the 988 Account to route calls to and contract for the operations of call centers and call center hubs;
• $1,000,000 from the 988 Account to contract for the development and operations of a tribal crisis line;
• $189,000 from the 988 Account and $80,000 from the General Fund-Federal to provide staff support to analyze the planning, development, and implementation of technology solutions to create the technical and operational plan; and
• $420,000 from the 988 Account to participate in and provide support to the Strategy Committee and the steering committee.

 
For the 2021-23 fiscal biennium, the Authority is appropriated:

• $770,000 from the 988 Account and $326,000 from the General Fund-Federal to provide staff and contracted support to analyze the planning, development, and implementation of technology solutions to create the technical and operational plan;
• $664,000 from the 988 Account and $127,000 from the General Fund-Federal to participate in and provide support to the Strategy Committee and the steering committee;
• $381,000 from the 988 Account and $381,000 from the General Fund-Federal to collaborate with managed care organizations, county authorities, and BHASOs with respect to crisis services and the development of processes and best practices for crisis services.

 
For the 2021-23 fiscal biennium, the Office of Financial Management is appropriated $200,000 from the 988 Account to provide staff and contracted services support to the Strategy Committee and the steering committee.