§1396w–4 — Title 42 The Public Health and Welfare | U.S. Code

Summary

States may choose, starting January 1, 2011, to let people on Medicaid who have chronic health problems pick a “health home.” A health home can be a single approved doctor or clinic, a team of health workers working with that provider, or a health team. The federal government will set rules for which providers can be a health home. States must pay those providers for health home services. Those payments count as Medicaid and get a 90% federal share for the first 8 fiscal year quarters the state program is in place. States must describe how they will set payments in their plan. Payments can be tiered by how sick people are or by provider ability, and do not have to be only a per-person per-month rate. The federal government may give planning grants starting January 1, 2011; states must contribute an amount equal to the State percentage under section 1396d(b) for each year the grant runs, and total planning grants cannot exceed $25,000,000. States must include rules in their plan so hospitals refer eligible patients in emergency departments to designated providers. States should work with the Substance Abuse and Mental Health Services Administration on mental health and substance use issues. States must track avoidable hospital readmissions and related savings and explain how they will use health IT (including wireless patient tech). Providers must report quality measures as required, and use health IT when practical. Key meanings: an eligible individual with chronic conditions is a Medicaid person with at least two chronic conditions, or one chronic condition and risk for another, or one serious persistent mental illness; chronic conditions include things like mental illness, substance use disorder, asthma, diabetes, heart disease, and being overweight (BMI over 25). A designated provider can be a doctor, clinic, community health center, home health agency, or other approved entity. For states with an SUD-focused plan approved on or after October 1, 2018, the 90% federal share can be extended for SUD-eligible people for 2 more fiscal quarters, those states must report on quality, access, and total costs, and CMS must publish SUD best practices by October 1, 2020.

Title 42, §1396w–4

The Public Health and Welfare — Source: USLM XML via OLRC

(a)Notwithstanding section 1396a(a)(1) of this title (relating to statewideness), section 1396a(a)(10)(B) of this title (relating to comparability), and any other provision of this subchapter for which the Secretary determines it is necessary to waive in order to implement this section, beginning January 1, 2011, a State, at its option as a State plan amendment, may provide for medical assistance under this subchapter to eligible individuals with chronic conditions who select a designated provider (as described under subsection (h)(5)), a team of health care professionals (as described under subsection (h)(6)) operating with such a provider, or a health team (as described under subsection (h)(7)) as the individual’s health home for purposes of providing the individual with health home services.

(b)The Secretary shall establish standards for qualification as a designated provider for the purpose of being eligible to be a health home for purposes of this section.

(c)(1)A State shall provide a designated provider, a team of health care professionals operating with such a provider, or a health team with payments for the provision of health home services to each eligible individual with chronic conditions that selects such provider, team of health care professionals, or health team as the individual’s health home. Payments made to a designated provider, a team of health care professionals operating with such a provider, or a health team for such services shall be treated as medical assistance for purposes of section 1396b(a) of this title, except that, subject to paragraph (4), during the first 8 fiscal year quarters that the State plan amendment is in effect, the Federal medical assistance percentage applicable to such payments shall be equal to 90 percent.

(2)(A)The State shall specify in the State plan amendment the methodology the State will use for determining payment for the provision of health home services. Such methodology for determining payment—

(i)may be tiered to reflect, with respect to each eligible individual with chronic conditions provided such services by a designated provider, a team of health care professionals operating with such a provider, or a health team, as well as the severity or number of each such individual’s chronic conditions or the specific capabilities of the provider, team of health care professionals, or health team; and

(ii)shall be established consistent with section 1396a(a)(30)(A) of this title.

(B)The methodology for determining payment for provision of health home services under this section shall not be limited to a per-member per-month basis and may provide (as proposed by the State and subject to approval by the Secretary) for alternate models of payment.

(3)(A)Beginning January 1, 2011, the Secretary may award planning grants to States for purposes of developing a State plan amendment under this section. A planning grant awarded to a State under this paragraph shall remain available until expended.

(B)A State awarded a planning grant shall contribute an amount equal to the State percentage determined under section 1396d(b) of this title (without regard to section 5001 of Public Law 111–5) for each fiscal year for which the grant is awarded.

(C)The total amount of payments made to States under this paragraph shall not exceed $25,000,000.

(4)(A)In the case of a State with an SUD-focused State plan amendment approved by the Secretary on or after October 1, 2018, the Secretary may, at the request of the State, extend the application of the Federal medical assistance percentage described in paragraph (1) to payments for the provision of health home services to SUD-eligible individuals under such State plan amendment, in addition to the first 8 fiscal year quarters the State plan amendment is in effect, for the subsequent 2 fiscal year quarters that the State plan amendment is in effect. Nothing in this section shall be construed as prohibiting a State with a State plan amendment that is approved under this section and that is not an SUD-focused State plan amendment from additionally having approved on or after such date an SUD-focused State plan amendment under this section, including for purposes of application of this paragraph.

(B)In the case of a State with an SUD-focused State plan amendment for which the application of the Federal medical assistance percentage has been extended under subparagraph (A), such State shall, at the end of the period of such State plan amendment, submit to the Secretary a report on the following, with respect to SUD-eligible individuals provided health home services under such State plan amendment:

(i)The quality of health care provided to such individuals, with a focus on outcomes relevant to the recovery of each such individual.

(ii)The access of such individuals to health care.

(iii)The total expenditures of such individuals for health care.

(C)Not later than October 1, 2020, the Secretary shall make publicly available on the internet website of the Centers for Medicare & Medicaid Services best practices for designing and implementing an SUD-focused State plan amendment, based on the experiences of States that have State plan amendments approved under this section that include SUD-eligible individuals.

(D)For purposes of this paragraph:

(i)The term “SUD-eligible individual” means, with respect to a State, an individual who satisfies all of the following:

(I)The individual is an eligible individual with chronic conditions.

(II)The individual is an individual with a substance use disorder.

(III)The individual has not previously received health home services under any other State plan amendment approved for the State under this section by the Secretary.

(ii)The term “SUD-focused State plan amendment” means a State plan amendment under this section that is designed to provide health home services primarily to SUD-eligible individuals.

(d)A State shall include in the State plan amendment a requirement for hospitals that are participating providers under the State plan or a waiver of such plan to establish procedures for referring any eligible individuals with chronic conditions who seek or need treatment in a hospital emergency department to designated providers.

(e)A State shall consult and coordinate, as appropriate, with the Substance Abuse and Mental Health Services Administration in addressing issues regarding the prevention and treatment of mental illness and substance abuse among eligible individuals with chronic conditions.

(f)A State shall include in the State plan amendment—

(1)a methodology for tracking avoidable hospital readmissions and calculating savings that result from improved chronic care coordination and management under this section; and

(2)a proposal for use of health information technology in providing health home services under this section and improving service delivery and coordination across the care continuum (including the use of wireless patient technology to improve coordination and management of care and patient adherence to recommendations made by their provider).

(g)As a condition for receiving payment for health home services provided to an eligible individual with chronic conditions, a designated provider shall report to the State, in accordance with such requirements as the Secretary shall specify, on all applicable measures for determining the quality of such services. When appropriate and feasible, a designated provider shall use health information technology in providing the State with such information.

(h)In this section:

(1)(A)Subject to subparagraph (B), the term “eligible individual with chronic conditions” means an individual who—

(i)is eligible for medical assistance under the State plan or under a waiver of such plan; and

(ii)has at least—

(I)2 chronic conditions;

(II)1 chronic condition and is at risk of having a second chronic condition; or

(III)1 serious and persistent mental health condition.

(B)Nothing in this paragraph shall prevent the Secretary from establishing higher levels as to the number or severity of chronic or mental health conditions for purposes of determining eligibility for receipt of health home services under this section.

(2)The term “chronic condition” has the meaning given that term by the Secretary and shall include, but is not limited to, the following:

(A)A mental health condition.

(B)Substance use disorder.

(C)Asthma.

(D)Diabetes.

(E)Heart disease.

(F)Being overweight, as evidenced by having a Body Mass Index (BMI) over 25.

(3)The term “health home” means a designated provider (including a provider that operates in coordination with a team of health care professionals) or a health team selected by an eligible individual with chronic conditions to provide health home services.

(4)(A)The term “health home services” means comprehensive and timely high-quality services described in subparagraph (B) that are provided by a designated provider, a team of health care professionals operating with such a provider, or a health team.

(B)The services described in this subparagraph are—

(i)comprehensive care management;

(ii)care coordination and health promotion;

(iii)comprehensive transitional care, including appropriate follow-up, from inpatient to other settings;

(iv)patient and family support (including authorized representatives);

(v)referral to community and social support services, if relevant; and

(vi)use of health information technology to link services, as feasible and appropriate.

(5)The term “designated provider” means a physician, clinical practice or clinical group practice, rural clinic, community health center, community mental health center, home health agency, or any other entity or provider (including pediatricians, gynecologists, and obstetricians) that is determined by the State and approved by the Secretary to be qualified to be a health home for eligible individuals with chronic conditions on the basis of documentation evidencing that the physician, practice, or clinic—

(A)has the systems and infrastructure in place to provide health home services; and

(B)satisfies the qualification standards established by the Secretary under subsection (b).

(6)The term “team of health care professionals” means a team of health professionals (as described in the State plan amendment) that may—

(A)include physicians and other professionals, such as a nurse care coordinator, nutritionist, social worker, behavioral health professional, or any professionals deemed appropriate by the State; and

(B)be free standing, virtual, or based at a hospital, community health center, community mental health center, rural clinic, clinical practice or clinical group practice, academic health center, or any entity deemed appropriate by the State and approved by the Secretary.

(7)The term “health team” has the meaning given such term for purposes of section 256a–1 of this title.

Notes & Related Subsidiaries

Editorial Notes

References in Text

section 5001 of Public Law 111–5, referred to in subsec. (c)(3)(B), is section 5001 of Pub. L. 111–5, div. B, title V, Feb. 17, 2009, 123 Stat. 496, which was formerly set out as a note under section 1396d of this title.

Amendments

2018—Subsec. (c)(1). Pub. L. 115–271, § 1006(a)(1), inserted “subject to paragraph (4),” after “except that,”. Subsec. (c)(4). Pub. L. 115–271, § 1006(a)(2), added par. (4).

Statutory Notes and Related Subsidiaries

Survey and Interim Report Pub. L. 111–148, title II, § 2703(b)(2), Mar. 23, 2010, 124 Stat. 322, provided that: “(A) In general.—Not later than January 1, 2014, the Secretary of Health and Human Services shall survey States that have elected the option under section 1945 of the Social Security Act [42 U.S.C. 1396w–4] (as added by subsection (a)) and report to Congress on the nature, extent, and use of such option, particularly as it pertains to—“(i) hospital admission rates; “(ii) chronic disease management; “(iii) coordination of care for individuals with chronic conditions; “(iv) assessment of program implementation; “(v) processes and lessons learned (as described in subparagraph (B)); “(vi) assessment of quality improvements and clinical outcomes under such option; and “(vii) estimates of cost savings. “(B) Implementation reporting.—A State that has elected the option under section 1945 of the Social Security Act (as added by subsection (a)) shall report to the Secretary, as necessary, on processes that have been developed and lessons learned regarding provision of coordinated care through a health home for Medicaid beneficiaries with chronic conditions under such option.”

§1396w–4 State option to provide coordinated care through a health home for individuals with chronic conditions