§1396w–4a State option to provide coordinated care through a health home for children with medically complex conditions

Summary

Starting October 1, 2022, a state can choose to let children with medically complex conditions join a “health home” under Medicaid. A health home is a doctor, a team of health workers, or a health team picked by the child or family to arrange care. The federal government will set rules for who can be a health home. Qualified health homes must be able to arrange fast care (including access to pediatric emergency care any time), make a family-centered care plan, work with families in culturally and language-appropriate ways, connect to needed pediatric specialists and palliative care if the State covers it, coordinate out-of-State care when needed, and collect and report required information. States must pay health homes for these services. For the first two fiscal year quarters after a State plan amendment starts, the federal share of those payments is 15 percentage points higher but cannot go above 90 percent. A State must explain how it will set payments (it can use tiers or other models and is not limited to per-member-per-month). The Secretary may give planning grants starting October 1, 2022; the State must provide its usual Medicaid match (the State percentage under section 1396d(b)) for each year the grant is awarded. The total of these planning grants cannot exceed $5,000,000. Hospitals must notify a child’s health home if the child goes to the emergency department. States must describe how they will teach providers how to refer children to health homes and how they will tell families about the option, using family-to-family groups or similar organizations. States must work with the Secretary on mental health and substance-use concerns for these children. The Secretary had to issue guidance by October 1, 2020 (and update it) about using and coordinating out-of-State providers, reducing barriers, and streamlining enrollment. States’ plan amendments must say how they will track fewer inpatient days and total cost of care, how they will use health IT, and how they will track timely access to out-of-State care. Providers and health homes must report identifying and quality information to the State. States must report program data to the Secretary and, within 90 days after approval, publish how they are using the out-of-State guidance. Enrollment in a health home is optional. Families keep their choice of qualified health homes. This program does not reduce children’s existing Medicaid screening, diagnostic, and treatment rights. Definitions (one line each): child with medically complex conditions — a person under 21 on Medicaid who has very serious lasting health problems that affect multiple body systems or a life‑limiting illness or rare pediatric disease; chronic condition — a serious long-term physical, mental, or developmental illness (examples include cerebral palsy, cystic fibrosis, HIV/AIDS, sickle cell disease, muscular dystrophy, spina bifida, epilepsy, severe autism, and serious mental health conditions); health home — the chosen provider, provider-led team, or health team that delivers health home services; health home services — comprehensive care management, care coordination (including specialty and out-of-State care when needed), transitional care, family support, referrals to community services, and use of health IT; designated provider — a qualified doctor, children’s hospital, clinic, or other entity approved by the State and Secretary; team of health care professionals — a group of medical and support professionals approved by the State and Secretary; health team — as defined under the referenced health law.