SB 5209
As of January 29, 2021
Title: An act relating to statewide enhancement and expansion of behavioral health and suicide prevention crisis response services.
Brief Description: Enhancing and expanding behavioral health and suicide prevention crisis response services.
Sponsors: Senators Dhingra, Darneille, Das, Keiser, Kuderer, Lovelett, Randall, Conway, Frockt, Hasegawa, Liias, Nguyen, Pedersen, Wagoner and Wilson, C..
Brief History:
Committee Activity: Health & Long Term Care: 1/20/21 [w/oRec-BH].
Behavioral Health Subcommittee to Health & Long Term Care: 1/29/21.
Brief Summary of Bill
  • Creates a 988 crisis hotline to respond to behavioral health crises statewide, using interoperable technology across crisis and emergency response systems.
  • Requires the 988 system to dispatch community-based rapid mobile crisis response services with embedded peers and behavioral health teams.
  • Requires the 988 system to track local responses, monitor real-time statewide bed availability, and to provide same-day or next-day behavioral health appointments to all callers. 
  • Establishes a 55-member implementation coalition with a Legislative co-chair to meet until December 2022 to make recommendations to implement the 988 crisis system.
  • Imposes a tax on radio access lines and interconnected voice over Internet protocol service lines to fund the 988 crisis system and behavioral health crisis services.
Staff: Kevin Black (786-7747)

Behavioral Health Crisis Services.  Crisis mental health services are intended to stabilize a person in 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 (BH-ASOs) 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.  Each BH-ASO 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).  The Lifeline is a national network of about 180 crisis centers that are linked by a single toll-free number.  The 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, SAMHSA and the Department of Veterans Affairs have established the Veterans Crisis Line which links veterans with suicide prevention coordinators.  In Washington, there are currently three local crisis centers participating in the Lifeline.
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 the Lifeline and the Veterans Crisis Line.  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.

Summary of Bill:

988 Crisis Hotline.  The Governor must appoint a 988 crisis hotline system director to direct and oversee implementation of the 988 crisis hotline and assure coordination and communication. 


The Department of Health (DOH) must provide adequate funding for the use of crisis lifeline call centers before July 16, 2022, after estimating increased call volume based on the implementation of the 988 crisis hotline.


The 988 crisis hotline must, before July 16, 2022, provide crisis intervention and crisis care coordination to persons in every jurisdiction of Washington, 24 hours a day, seven days a week.


DOH must designate 988 crisis hotline centers (988 centers) that can receive information through calls, texts, chats, and similar methods of communication.


DOH must establish best practice guidelines for 988 centers based on National Suicide Prevention Lifeline requirements.  988 centers must:

  • access real-time information relevant to coordination of behavioral health services from managed care organizations (MCOs), BH-ASOs, and other health care players, and coordinate access to those services, including linguistically and culturally competent care;
  • assign and track local response to calls, including capacity and authority to rapidly deploy mobile crisis teams and co-responder teams;
  • arrange same-day and next-day appointments and follow up appointments with appropriate providers;
  • track and provide real-time bed availability to crisis responders;
  • assure follow-up services to individuals who call; 
  • provide data and reports and participate in evaluations;
  • use interoperable technology across crisis and emergency systems across the state;
  • collaborate actively with MCOs, BH-ASOs and other providers to coordinate linkages;
  • establish requirements for high-risk and special populations to promote behavioral health equity; and
  • collaborate with DOH, the National Suicide Prevention Hotline, and Veterans Crisis Line to assure consistency of public messaging.


The Health Care Authority (HCA) must:

  • establish agreements between 988 centers, MCOs, BH-ASOs, and other providers after consultation with county authorities;
  • require each BH-ASO to have community-based mobile rapid crisis response team services that must:
    1. include embedded peers and behavioral health teams;
    2. collaborate with law enforcement;
    3. include police as co-responders only when public safety is an issue and the situation cannot be managed without law enforcement assistance;
    4. be designed in partnership with community members;
    5. be staffed by personnel that reflect the demographics of the community served; and
    6. collect race, ethnicity, and other demographic data from the people served;
  • require BH-ASOs to offer peer respite services and crisis stabilization services;
  • require BH-ASOs to offer care coordination, diversion services, and discharge planning for individuals in crisis stabilization services;
  • require BH-ASOs to provide an adequate network of secure withdrawal management and stabilization service to ensure access to treatment by July 1, 2026;
  • create specialized mobile rapid crisis teams to respond to the unique needs of youth and the geriatric population;
  • consult with tribes to create tribal mobile rapid crisis response teams;
  • adopt rules for 988 centers that assure that non-English speaking callers will receive assistance in their own language;
  • adopt rules requiring behavioral health agencies and hospitals to provide real-time bed availability information;
  • develop a plan to equally distribute crisis stabilization services, peer respite services, and behavioral heath urgent care around the state; and
  • require MCOs and BH-ASOs to assign a care coordinator for persons who are uninsured to provide same-day or next-day appointments in the behavioral health system.


Commercial health plans must include coverage of a care coordinator and provide same-day and next-day appointments for their enrollees who seek behavioral health services by January 1, 2022.


The state enhanced 911 coordination office must collaborate with the state military department to assure that callers of 911 and 988 receive consistency and equity of care, by applying consistent procedures across systems, including use of deescalation techniques.


Implementation Coalition.  The Governor must convene an implementation coalition staffed by the William D. Ruckelshaus Center, or another neutral party, to make recommendations to implement the 988 crisis hotline and the provisions of this act, and to improve behavioral health crisis response services.  The coalition must include four appointed legislative members, four appointed alternate legislative members, and at least 47 members representing different constituencies, agencies, and groups, plus a representative of tribal governments.  The coalition must choose three co-chairs that include one legislative member, one executive member, and one additional person.  Executive agency representatives must be nonvoting members.  The coalition must provide reports by December 1, 2021, and November 1, 2022.


Annual Report.  DOH and HCA must provide an annual report starting in November 2023 describing 988 crisis hotline usage, call outcomes, and crisis services.  DOH and HCA must also submit information to the Federal Communication Commission regarding fee accountability reports.


Statewide 988 Behavioral Health Crisis Response Line Tax.  A monthly tax is imposed on radio access lines and interconnected voice over Internet protocol service lines, effective July 1, 2022, increasing from $0.30 to $0.75 per line by July 1, 2024.  Starting March 1, 2025, the amount of the tax must be revised every two years using the fiscal growth factor.  The tax must be collected by radio communications service companies and sellers of prepaid wireless telecommunications service companies and deposited into a Statewide 988 Behavioral Health Crisis Response Line Account located within the State Treasury.  The tax must be collected from subscribers and stated separately on the billing statement which is sent to the subscriber.  A company that fails to remit the tax is guilty of a gross misdemeanor.  Collection may be enforced by the Department of Revenue.


Moneys deposited in the Statewide 988 Behavioral Health Crisis Response Line Account must be appropriated.  Moneys may only be used for routing calls to the 988 crisis hotline to a crisis hotline center and for crisis services in response to 988 crisis calls, but may not be used for Medicaid services.

Appropriation: The bill contains a section or sections to limit implementation to the availability of amounts appropriated for that specific purpose.
Fiscal Note: Available.
Creates Committee/Commission/Task Force that includes Legislative members: Yes.
Effective Date: The bill contains several effective dates, including an emergency clause relating to the implementation coalition which takes effect immediately. Please refer to the bill.
Staff Summary of Public Testimony:

PRO:  This bill is the product of a lot of work over the summer.  In our state, persons with behavioral health disorders are more likely found in jails and prisons not hospitals.  A behavioral health crisis is a cry for help, and this bill is about how the state should respond.  As a prosecutor I saw cases every day in the criminal justice system which did not need to be there, because of failure in our behavioral health system.  Families try to get help for years until their child ends up in a state hospital or in jail.  This is something the community wants and has been asking for for years.  It is time for a statewide crisis response system staffed by individuals who are trained to respond appropriately.  Law enforcement should not respond except when they are needed.  This bill will not create a duplicate system, because the national suicide prevention lifeline centers already exist alongside the county crisis lines.  The call volume will increase based on the change to 988 and advertising.  We must reform our system to be responsive and prevent overdoses and suicide.  County crisis lines do not meet accreditation standards and cannot mount the lines to answer the 988 calls.  The system does not have enough crisis stabilization or mobile crisis response teams.  We need to find the courage together to do this important system transformation.  I experienced repeated crises and it is a miracle I am alive.  No one can make it alone.  We need to lend a helping hand sooner.  Suicide is the 10th leading cause of death in the U.S.  We have answered lifeline calls since 2005.  Please look at enhancing existing regional models which already provide the functions in the bill.  Changing the system would cause confusion in communities.  If we invest in behavioral health community supports it will lead to less crime making our neighborhoods safer.  We are in the midst of a mental health crisis made dangerously worse by COVID.  Youth survey data is disheartening.  988 will be easy to remember and the service less fragmented.  Crisis hotlines paired with services reduce reliance on emergency rooms, reduce hospitalization, and save lives.  My wife died by suicide after the system failed our family.  The way she was treated was traumatizing, and they would not hold her for treatment or observation.  We need a bill that makes sense, is not watered down, that makes a difference to the people who are struggling every day.  Without training and education, law enforcement response can add to the trauma.  911 receives calls with behavioral health components every day.  Behavioral health calls have specialized requirements that 911 operators are not always equipped to handle effectively.  911 representation should be included to work out many design questions.  Please use the term 911 public safety telecommunicator.  Please remove references to a Washington youth tip line.


OTHER:  We support the intent but have many substantive and technical concerns.  The bill establishes two parallel duplicative crisis systems with competing regulatory authority and funding mechanisms.  Counties already have crisis hotlines governed by the Health Care Authority (HCA) and have worked out processes and relationships with existing providers.  These systems can meet many of the bill's expectations.  We should provide additional resources to existing hotlines to meet the 988 demand, rather than create new layers of call centers managed by DOH.  To have enough resources, calls must remain Medicaid reimbursable, and funding must be provided on a capacity basis, not fee for service.  The workgroup should go first to iron out the technical challenges.  Investment in crisis services is woefully short and needs to be improved.  The implementation coalition must listen to longtime crisis system operators, and should do a careful inventory of the systems already in place.  Governance by a statewide official will strain the local connection.  We cannot provide same-day and next-day appointments because the necessary providers do not exist.  Medicaid enrollees can refuse care coordination.  The timeline is concerning.  There is not much funding to support the back end of the system and ensure that needed levels of care are available.  This bill assumes a fully developed continuum of care, which is not where we are at today.  Current crisis systems are paid for by HCA under contract with BH-ASOs, with 70 percent of the funding through Medicaid.  But for those seeking services, only 50 percent have Medicaid.  How can we fix this funding model to serve everyone?  We are concerned about concentrating funding at the point of crisis rather than the broader mental health system.  This change cannot happen without a work plan, timeline, and deliverables.  Planning is needed for the technology.  This is an opportunity to build a world class tool with state of the art technology to address suicide and crisis response.  The crisis system overhaul is not beholden to the 988 time line.  It is important to step back and look at the gaps in the current system thoughtfully.  A year is not enough time to create the infrastructure to unify the statewide crisis system due to the wide variation in electronic systems.  More funding is needed for the entire community behavioral health system so we can help people before they are in crisis.  We have ideas how to phase the implementation.  The 911 system handles 6 million calls per years, and over 16,400 calls on an average day.  Coordination between 911 and 988 will be crucial to success.  Please add the 911 coordination office to the implementation coalition.

Persons Testifying: PRO: Senator Manka Dhingra, Prime Sponsor; Jennifer Stuber, Forefront Suicide Prevention University of Washington; Taylor Richards, citizen; Patricia Morris, Volunteers of America Western Washington; James McMahan, Washington Association of Sheriffs & Police Chiefs; Eric Bruns, citizen; Abraham Dairi, citizen; Phoebe Terhaar, citizen; Karl Hatton, Washington APCO-NENA; Tanya Aggar, Washington State PTA.

OTHER:  Juliana Roe, Washington State Association of Counties; Brad Banks, Behavioral Health Administrative Services Organizations; Joe Valentine, North Sound Behavioral Health Administrative Services Organization; Chris Bandoli, Association of Washington Healthcare Plans; Caitlin Stafford, Amerigroup Washington Inc.; Katie Kolan, Washington State Hospital Association, Washington State Psychiatric Association; Shawn O'Neill, Washington State Health Care Authority; Joan Miller, Washington Council for Behavioral Health; Adam Wasserman, Washington Military Department, Emergency Management Division; Justine McClure, American Foundation for Suicide Prevention.
Persons Signed In To Testify But Not Testifying: PRO:  Phoebe Walker,  Associated Students of the University of Washington Seattle; Hannah Sieben, Graduate and Professional Student Senate; David Johnson, Crisis Connections.
OTHER:  Gerry Keegan, Cellular Telecommunications and Internet Association.