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2703 - State Option to Provide Health Homes for Enrollees with Chronic Conditions

 
Implementation Status 
Statutory Text 

Summary

Beginning January 1, 2011, creates a Medicaid state plan amendment (SPA) option for states to cover eligible individuals with chronic conditions who select a designated provider, a team of health care professionals operating with such a provider, or a health team as the individual’s health home for purposes of providing the individual with health home services.  Eligible individuals include those covered by Medicaid and who have at least: 2 chronic conditions (as defined in the statute); 1 chronic condition and is at risk of having a second chronic condition; or 1 serious and persistent mental health condition.

Provides for a 90% FMAP for states electing this option during the first 8 FY quarters that the option is in effect.  Also authorizes HHS to award up to $25 million in planning grants (up to $500,000 per state, according to CMS) pursuant to this provision beginning January 1, 2011 (with mandatory state contributions).

Requires states, as part of electing the option, to include a requirement in its SPA regarding hospital referrals.  Also requires states to consult and coordinate with SAMHSA as appropriate in developing such plan and to include in the SPA monitoring-related activities (e.g., relative to tracking hospital readmissions and use of health IT).  Further requires states to report on quality measures.

Specifies the mandated services required of health homes, such as comprehensive care management and transitional care.  Also defines the team of health care professionals.

Directs HHS to conduct an independent evaluation – which is to examine the impact of the SPA option on such metrics as hospital readmissions, ER visits, and SNF admissions – by January 1, 2017; a related interim report is due by January 1, 2014.

#Care Coordination, #Chronic Diseases, #Hospitals, #Prevention, #Quality

Implementation Status

 
Summary 
Statutory Text 

CMS developed a webpage that consolidates this and other information on the implementation of this provision.  More information on this option is also available here.

2010

In November 2010, CMS issued guidance pursuant to this provision, including an initial SMD/SHO letter and a follow-up informational bulletin containing further details regarding the SPA preprint/template.

2011

In June 2011, CMS issued a SMD letter regarding coverage and service design opportunities for individuals living with HIV in which the agency highlighted this model, among others.

2013

On January 15, CMS issued a SMD letter recommending a core set of health care quality measures for Medicaid health homes. The SMD letter is a precursor to more formal rulemaking on the topic.

On May 7, CMS and SAMHSA issued a joint informational bulletin in which the agencies addressed coverage options, including these provisions under the ACA, for children, youth, and young adults with significant mental health conditions.

On July 5, CMS issued a final rule implementing a number of ACA Medicaid eligibility, benefit and premium and cost sharing provisions, among others related to Exchanges, while explicitly noting a focus only on those “most critical for implementation” by Jan. 1, 2014, and thus deferring the finalization of other proposals from a January 22, 2013, proposed rule – such as Exchange eligibility appeals, proposed CHIPRA provisions, Exchange certified application counselors and coordination of SHOPs with individual market Exchanges – to future rule-making. A CMS press release is available here.  Please also see CMS’ July 5 informational bulletin regarding related IT changes – i.e., Medicaid Information Technology Architecture (MITA) Draft Eligibility and Enrollment Supplement, Version 3.0 – as a result of certain Medicaid eligibility requirements resulting from the ACA.

On a related note, on July 12, SAMHSA announced two new Challenges under which it will provide up to $100,000 in collective prizes for communications-related methodologies and materials to reduce enrollee “churn,” which may stem from eligibility-related changes or other breaks in coverage that SAMHSA notes have a “disproportionate impact” on individuals with behavioral health conditions, including enrollees who are Medicaid-eligible due to a disability.  Submissions were due August 31, 2013.

On July 24, CMS issued an informational bulletin outlining ways in which states and providers are working together under innovative Medicaid “super-utilizer” care delivery and payment models, which are focused on delivering cost-effective, quality care to Medicaid beneficiaries with complex medical needs – individuals who are often frequent users of acute health care in light of the multitude of health care issues they face.  In particular, the bulletin reiterates the standing provision at section 2703 relative to Medicaid Health Homes.

On August 9, SAMHSA issued a 10-part technical assistance report, Medicaid Handbook: Interface with Behavioral Health Services, that broadly examines Medicaid’s role in financing mental health and substance abuse care.  Several “modules” that comprise the handbook – which span such topics as Medicaid State Plans and behavioral health service providers – relate to ACA implications; for example, the Medicaid expansion under section 2001; health home initiatives under section 2703; and Accountable Care Organizations under section 3022.

On a related note, on Nov. 22, 2013, CMS announced the release of a guidance letter to State Health Officials titled “Quality Considerations for Medicaid and CHIP Programs.”  This letter is the fourth in a series of letters on integrated care models, including ACOs, health homes, etc., that provides states with guidance on designing and implementing care delivery and payment reforms.  The letter provides a framework for quality improvement and measurement – developed in consultation with states – consistent with CMS’ approaches in areas including measuring, monitoring, and improving the quality of health care in value-based payment models.

2015

On Jan. 21, CMS released an issue brief titled, “Designing Medicaid Health Homes for Individuals with Opioid Dependency: Considerations for States.” The issue brief explores various options states can pursue to address opioid dependency among the Medicaid population, including through Medication Assisted Therapy (MAT) (refer to July 2014 HHS bulletin toward that end), as well as via the Medicaid health home SPA option. Regarding the latter, the issue brief explores some of the key features of three states – Maryland, Rhode Island, and Vermont – with approved SPAs (as of Dec. 2014) to implement opioid dependence-focused Medicaid health homes.

On Jan. 26, CMS issued an informational bulletin outlining new guidance for states in designing benefit packages to serve youth with substance abuse disorders (SUDs) and their families while complying with Medicaid’s EPSDT requirements. The bulletin points to the high rates of co-occurring mental health disorders and the formative research of a SAMHSA-led technical expert panel to help buttress this latest guidance. Among the options contemplated were Medicaid health homes pursuant to this provision of the ACA.

2016

In January, CMS released a set of FAQs clarifying the Medicaid Health Home State Plan Amendment (SPA) option. The FAQs are divided into the following sections: (1) Chronic Condition Definition; (2) Health Home Service Definitions; (3) Enrollment Standards; (4) Provider Certification Standards; (5) Provider Delivery System; (6) Quality Measurement and Evaluation; and (7) Payment.

2019

On a separate but related note, in April 2019, Congress passed H.R. 1839, the Medicaid Services Investment and Accountability Act, legislation authorizing states to provide (via a SPA) coordinated care through a health home for children with medically complex-conditions (i.e., the Advancing Care for Exceptional (ACE) Kids Act). The SPA option takes effect Oct. 1, 2022. HHS is required to issue guidance to states (along with a corresponding RFI for stakeholder input), among other requirements, by Oct. 1, 2020.

On a related note, in May, CMS issued an informational bulletin to states notifying them of the availability of an extension of the enhanced FMAP period for certain Medicaid health homes for individuals with Substance Use Disorders pursuant to the SUPPORT for Patients and Communities Act. Our summary is available here.

 

Statutory Text

 
Implementation Status 
Summary 

SEC. 2703. STATE OPTION TO PROVIDE HEALTH HOMES FOR ENROLLEES WITH CHRONIC CONDITIONS. (a) STATE PLAN AMENDMENT.—Title XIX of the Social Security Act (42 U.S.C. 1396a et seq.), as amended by sections 2201 and 2305, is amended by adding at the end the following new section: ‘‘SEC. 1945 [42 U.S.C. 1396w–4]. State Option To Provide Coordinated Care Through a Health Home for Individuals With Chronic Conditions.— ‘‘(a) IN GENERAL.—Notwithstanding section 1902(a)(1) (relating to statewideness), section 1902(a)(10)(B) (relating to comparability), and any other provision of this title 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 title 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) HEALTH HOME QUALIFICATION STANDARDS.—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) PAYMENTS.— ‘‘(1) IN GENERAL.—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 1903(a), except that, 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) METHODOLOGY.— ‘‘(A) IN GENERAL.—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 1902(a)(30)(A). ‘‘(B) ALTERNATE MODELS OF 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. ‘‘(3) PLANNING GRANTS.— ‘‘(A) IN GENERAL.—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) STATE CONTRIBUTION.—A State awarded a planning grant shall contribute an amount equal to the State percentage determined under section 1905(b) (without regard to section 5001 of Public Law 111–5) for each fiscal year for which the grant is awarded. ‘‘(C) LIMITATION.—The total amount of payments made to States under this paragraph shall not exceed $25,000,000. ‘‘(d) HOSPITAL REFERRALS.—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) COORDINATION.—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) MONITORING.—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) REPORT ON QUALITY MEASURES.—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) DEFINITIONS.—In this section: ‘‘(1) ELIGIBLE INDIVIDUAL WITH CHRONIC CONDITIONS.— ‘‘(A) IN GENERAL.—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) RULE OF CONSTRUCTION.—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) CHRONIC CONDITION.—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) HEALTH HOME.—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) HEALTH HOME SERVICES.— ‘‘(A) IN GENERAL.—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) SERVICES DESCRIBED.—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) DESIGNATED PROVIDER.—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) TEAM OF HEALTH CARE PROFESSIONALS.—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) HEALTH TEAM.—The term ‘health team’ has the meaning given such term for purposes of section 3502 of the Patient Protection and Affordable Care Act.’’. (b) EVALUATION.— (1) INDEPENDENT EVALUATION.— (A) IN GENERAL.—The Secretary shall enter into a contract with an independent entity or organization to conduct an evaluation and assessment of the States that have elected the option to provide coordinated care through a health home for Medicaid beneficiaries with chronic conditions under section 1945 of the Social Security Act (as added by subsection (a)) for the purpose of determining the effect of such option on reducing hospital admissions, emergency room visits, and admissions to skilled nursing facilities. (B) EVALUATION REPORT.—Not later than January 1, 2017, the Secretary shall report to Congress on the evaluation and assessment conducted under subparagraph (A). (2) SURVEY AND INTERIM REPORT.— (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 (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.

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