§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 may choose to let Medicaid pay for a special “health home” for children with medically complex conditions. If a State adds this option to its Medicaid plan, eligible children (or their families) can pick a designated provider, a team of health professionals, or a health team to coordinate their care. The federal government must set rules for who can be a health home. Health homes must arrange quick access to care (including 24/7 pediatric emergency access), make family-centered care plans, work in a culturally and language-appropriate way, link home, community, hospital, and specialty services (including palliative care if the State covers it), coordinate with out-of-State providers when needed, and report certain information to the State. States must pay the chosen health homes and may get an extra 15 percentage points of federal match for those payments during the first two fiscal year quarters the State plan change is in effect, but that federal share cannot be more than 90 percent. States must explain how they will set payment rates (they can use tiers or other models), may get planning grants (totaling no more than $5,000,000) but must provide their normal Medicaid matching share for those grants, and must require hospitals to notify the child’s health home if an enrolled child goes to the emergency room. States also must describe how they will tell providers and families about the program, coordinate on mental health, follow nationwide guidance on out-of-State care (guidance to be issued by October 1, 2020), track inpatient days and total cost of care, use health IT, and report data to the federal government. Participation is voluntary for families and does not reduce other Medicaid rights or services for these children. States must also file a report on best practices within 90 days after approval and make it public. Key defined terms (one line each): Child with medically complex conditions — a Medicaid-eligible person under 21 with either severe chronic conditions affecting three or more organ systems or a life‑limiting illness or rare pediatric disease. Chronic condition — a serious long-term physical, mental, or developmental disease (examples given include cerebral palsy, cystic fibrosis, HIV/AIDS, sickle cell, muscular dystrophy, spina bifida, epilepsy, severe autism, and serious mental health conditions). Health home — the chosen provider, provider-led team, or health team that coordinates the child’s services. Health home services — comprehensive care management, care coordination (including specialty and out-of-State care), transitional care, family support, referrals to social services, and use of health IT. Designated provider — types of qualified providers or facilities the State approves to be a health home. Team of health care professionals — a multi‑disciplinary group (doctors, nurses, therapists, care coordinators, community health workers, translators, etc.) that works together to be a health home. Health team — the term as used elsewhere in federal law.