42 U.S.C. § 1396w-4
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.
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.
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.
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-
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.
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.
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.
The total amount of payments made to States under this paragraph shall not exceed $25,000,000.
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.
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:
For purposes of this subparagraph, the Secretary shall specify all applicable measures for determining quality, access, and expenditures.
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.
For purposes of this paragraph:
The term "SUD-eligible individual" means, with respect to a State, an individual who satisfies all of the following:
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.
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.
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.
A State shall include in the State plan amendment-
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.
In this section:
Subject to subparagraph (B), the term "eligible individual with chronic conditions" means an individual who-
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.
The term "chronic condition" has the meaning given that term by the Secretary and shall include, but is not limited to, the following:
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.
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.
The services described in this subparagraph are-
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-
The term "team of health care professionals" means a team of health professionals (as described in the State plan amendment) that may-
The term "health team" has the meaning given such term for purposes of section 256a-1 of this title.
42 U.S.C. § 1396w-4
EDITORIAL NOTES
REFERENCES IN TEXT Section 5001 of Public Law 111-5 referred to in subsec. (c)(3)(B), is section 5001, Feb. 17, 2009 of Pub. L. 111-5, 123 Stat. 496, which was formerly set out as a note under section 1396d of this title.
AMENDMENTS2018-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."
- Secretary
- The term "Secretary" means the Secretary of Housing and Urban Development.1See References in Text note below.
- practices
- The term "practices" means design, financing, permitting, construction, commissioning, operation and maintenance, and other practices that contribute to achieving zero-net-energy buildings or facilities.