42 USC 1396w-4 - State option to provide coordinated care through a health home for individuals with chronic conditions

U.S Code last checked for updates: Nov 23, 2024

§ 1396w–4.

State option to provide coordinated care through a health home for individuals with chronic conditions

(a)

In general

(b)

Health home qualification standards

(c)

Payments

(1)

In general

(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 1396a(a)(30)(A) of this title.

(B)

Alternate models of payment

(3)

Planning grants

(A)

In general

(B)

State contribution

(C)

Limitation

(4)

Special rule relating to substance use disorder health homes

(A)

In general

(B)

Report requirements

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.

For purposes of this subparagraph, the Secretary shall specify all applicable measures for determining quality, access, and expenditures.

(C)

Best practices

(D)

Definitions

For purposes of this paragraph:

(i)

SUD-eligible individuals

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)

SUD-focused State plan amendment

(d)

Hospital referrals

(e)

Coordination

(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

(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

(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

(4)

Health home services

(A)

In general

(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

(Aug. 14, 1935, ch. 531, title XIX, § 1945, as added Pub. L. 111–148, title II, § 2703(a), Mar. 23, 2010, 124 Stat. 319; amended Pub. L. 115–271, title I, § 1006(a), Oct. 24, 2018, 132 Stat. 3913.)

cite as: 42 USC 1396w-4