PUBLIC LAW 116–16—APR. 18, 2019 MEDICAID SERVICES INVESTMENT AND ACCOUNTABILITY ACT OF 2019 VerDate Sep 11 2014 11:51 Aug 14, 2019 Jkt 089139 PO 00016 Frm 00001 Fmt 6579 Sfmt 6579 E:\PUBLAW\PUBL016.116 PUBL016 dkrause on DSKBC28HB2PROD with PUBLAWS 133 STAT. 852 PUBLIC LAW 116–16—APR. 18, 2019 Public Law 116–16 116th Congress An Act To amend title XIX to extend protection for Medicaid recipients of home and commu- nity-based services against spousal impoverishment, establish a State Medicaid option to provide coordinated care to children with complex medical conditions through health homes, prevent the misclassification of drugs for purposes of the Medicaid drug rebate program, and for other purposes. Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, SECTION 1. SHORT TITLE. This Act may be cited as the ‘‘Medicaid Services Investment and Accountability Act of 2019’’. SEC. 2. EXTENSION OF PROTECTION FOR MEDICAID RECIPIENTS OF HOME AND COMMUNITY-BASED SERVICES AGAINST SPOUSAL IMPOVERISHMENT. (a) IN GENERAL.—Section 2404 of Public Law 111–148 (42 U.S.C. 1396r–5 note), as amended by section 3(a) of the Medicaid Extenders Act of 2019 (Public Law 116–3), is amended by striking ‘‘March 31, 2019’’ and inserting ‘‘September 30, 2019’’. (b) RULE OF CONSTRUCTION.— (1) PROTECTING STATE SPOUSAL INCOME AND ASSET DIS- REGARD FLEXIBILITY UNDER WAIVERS AND PLAN AMENDMENTS.— Nothing in section 2404 of Public Law 111–148 (42 U.S.C. 1396r–5 note) or section 1924 of the Social Security Act (42 U.S.C. 1396r–5) shall be construed as prohibiting a State from disregarding an individual’s spousal income and assets under a State waiver or plan amendment described in paragraph (2) for purposes of making determinations of eligibility for home and community-based services or home and community- based attendant services and supports under such waiver or plan amendment. (2) STATE WAIVER OR PLAN AMENDMENT DESCRIBED.—A State waiver or plan amendment described in this paragraph is any of the following: (A) A waiver or plan amendment to provide medical assistance for home and community-based services under a waiver or plan amendment under subsection (c), (d), or (i) of section 1915 of the Social Security Act (42 U.S.C. 1396n) or under section 1115 of such Act (42 U.S.C. 1315). (B) A plan amendment to provide medical assistance for home and community-based services for individuals by reason of being determined eligible under section 1902(a)(10)(C) of such Act (42 U.S.C. 1396a(a)(10)(C)) or by reason of section 1902(f) of such Act (42 U.S.C. 1396a(f)) 42 USC 1396r–5 note. Medicaid Services Investment and Accountability Act of 2019. 42 USC 1305 note. Apr. 18, 2019 [H.R. 1839] VerDate Sep 11 2014 11:51 Aug 14, 2019 Jkt 089139 PO 00016 Frm 00002 Fmt 6580 Sfmt 6581 E:\PUBLAW\PUBL016.116 PUBL016 dkrause on DSKBC28HB2PROD with PUBLAWS 133 STAT. 853 PUBLIC LAW 116–16—APR. 18, 2019 or otherwise on the basis of a reduction of income based on costs incurred for medical or other remedial care under which the State disregarded the income and assets of the individual’s spouse in determining the initial and ongoing financial eligibility of an individual for such services in place of the spousal impoverishment provisions applied under section 1924 of such Act (42 U.S.C. 1396r–5). (C) A plan amendment to provide medical assistance for home and community-based attendant services and sup- ports under section 1915(k) of such Act (42 U.S.C. 1396n(k)). SEC. 3. STATE OPTION TO PROVIDE COORDINATED CARE THROUGH A HEALTH HOME FOR CHILDREN WITH MEDICALLY COM- PLEX CONDITIONS. Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) is amended by inserting after section 1945 the following new section: ‘‘SEC. 1945A. STATE OPTION TO PROVIDE COORDINATED CARE THROUGH A HEALTH HOME FOR CHILDREN WITH MEDI- CALLY COMPLEX CONDITIONS. ‘‘(a) IN GENERAL.—Notwithstanding section 1902(a)(1) (relating to statewideness) and section 1902(a)(10)(B) (relating to com- parability), beginning October 1, 2022, a State, at its option as a State plan amendment, may provide for medical assistance under this title to children with medically complex conditions who choose to enroll in a health home under this section by selecting a des- ignated provider, a team of health care professionals operating with such a provider, or a health team as the child’s health home for purposes of providing the child with health home services. ‘‘(b) HEALTH HOME QUALIFICATION STANDARDS.—The Secretary shall establish standards for qualification as a health home for purposes of this section. Such standards shall include requiring designated providers, teams of health care professionals operating with such providers, and health teams to demonstrate to the State the ability to do the following: ‘‘(1) Coordinate prompt care for children with medically complex conditions, including access to pediatric emergency services at all times. ‘‘(2) Develop an individualized comprehensive pediatric family-centered care plan for children with medically complex conditions that accommodates patient preferences. ‘‘(3) Work in a culturally and linguistically appropriate manner with the family of a child with medically complex conditions to develop and incorporate into such child’s care plan, in a manner consistent with the needs of the child and the choices of the child’s family, ongoing home care, community- based pediatric primary care, pediatric inpatient care, social support services, and local hospital pediatric emergency care. ‘‘(4) Coordinate access to— ‘‘(A) subspecialized pediatric services and programs for children with medically complex conditions, including the most intensive diagnostic, treatment, and critical care levels as medically necessary; and ‘‘(B) palliative services if the State provides such serv- ices under the State plan (or a waiver of such plan). ‘‘(5) Coordinate care for children with medically complex conditions with out-of-State providers furnishing care to such Coordination. Effective date. 42 USC 1396w–4a. VerDate Sep 11 2014 11:51 Aug 14, 2019 Jkt 089139 PO 00016 Frm 00003 Fmt 6580 Sfmt 6581 E:\PUBLAW\PUBL016.116 PUBL016 dkrause on DSKBC28HB2PROD with PUBLAWS 133 STAT. 854 PUBLIC LAW 116–16—APR. 18, 2019 children to the maximum extent practicable for the families of such children and where medically necessary, in accordance with guidance issued under subsection (e)(1) and section 431.52 of title 42, Code of Federal Regulations. ‘‘(6) Collect and report information under subsection (g)(1). ‘‘(c) PAYMENTS.— ‘‘(1) IN GENERAL.—A State shall provide a designated pro- vider, 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 child with medically complex conditions that selects such provider, team of health care profes- sionals, or health team as the child’s health home. Payments made to a designated provider, a team of health care profes- sionals 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 2 fiscal year quarters that the State plan amendment is in effect, the Federal medical assistance percentage applicable to such payments shall be increased by 15 percentage points, but in no case may exceed 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 serv- ices. Such methodology for determining payment— ‘‘(i) may be tiered to reflect, with respect to each child with medically complex conditions provided such services by a designated provider, a team of health care professionals operating with such a provider, or a health team, the severity or number of each such child’s chronic conditions, life-threatening illnesses, disabilities, or rare diseases, 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 method- ology 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 October 1, 2022, the Sec- retary 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 plan- ning 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 $5,000,000. ‘‘(d) COORDINATING CARE.— Effective date. VerDate Sep 11 2014 11:51 Aug 14, 2019 Jkt 089139 PO 00016 Frm 00004 Fmt 6580 Sfmt 6581 E:\PUBLAW\PUBL016.116 PUBL016 dkrause on DSKBC28HB2PROD with PUBLAWS 133 STAT. 855 PUBLIC LAW 116–16—APR. 18, 2019 ‘‘(1) HOSPITAL NOTIFICATION.—A State with a State plan amendment approved under this section shall require each hospital that is a participating provider under the State plan (or a waiver of such plan) to establish procedures for, in the case of a child with medically complex conditions who is enrolled in a health home pursuant to this section and seeks treatment in the emergency department of such hospital, notifying the health home of such child of such treatment. ‘‘(2) EDUCATION WITH RESPECT TO AVAILABILITY OF HEALTH HOME SERVICES.—In order for a State plan amendment to be approved under this section, a State shall include in the State plan amendment a description of the State’s process for edu- cating providers participating in the State plan (or a waiver of such plan) on the availability of health home services for children with medically complex conditions, including the process by which such providers can refer such children to a designated provider, team of health care professionals oper- ating such a provider, or health team for the purpose of estab- lishing a health home through which such children may receive such services. ‘‘(3) FAMILY EDUCATION.—In order for a State plan amend- ment to be approved under this section, a State shall include in the State plan amendment a description of the State’s process for educating families with children eligible to receive health home services pursuant to this section of the availability of such services. Such process shall include the participation of family-to-family entities or other public or private organizations or entities who provide outreach and information on the avail- ability of health care items and services to families of individ- uals eligible to receive medical assistance under the State plan (or a waiver of such plan). ‘‘(4) MENTAL HEALTH COORDINATION.—A State with a State plan amendment approved under this section shall consult and coordinate, as appropriate, with the Secretary in addressing issues regarding the prevention and treatment of mental illness and substance use among children with medically complex conditions receiving health home services under this section. ‘‘(e) GUIDANCE ON COORDINATING CARE FROM OUT-OF-STATE PROVIDERS.— ‘‘(1) IN GENERAL.—Not later than October 1, 2020, the Secretary shall issue (and update as the Secretary determines necessary) guidance to State Medicaid directors on— ‘‘(A) best practices for using out-of-State providers to provide care to children with medically complex conditions; ‘‘(B) coordinating care for such children provided by such out-of-State providers (including when provided in emergency and non-emergency situations); ‘‘(C) reducing barriers for such children receiving care from such providers in a timely fashion; and ‘‘(D) processes for screening and enrolling such pro- viders in the respective State plan (or a waiver of such plan), including efforts to streamline such processes or reduce the burden of such processes on such providers. ‘‘(2) STAKEHOLDER INPUT.—In carrying out paragraph (1), the Secretary shall issue a request for information to seek input from children with medically complex conditions and their families, States, providers (including children’s hospitals, Deadline. Consultation. Procedures. VerDate Sep 11 2014 11:51 Aug 14, 2019 Jkt 089139 PO 00016 Frm 00005 Fmt 6580 Sfmt 6581 E:\PUBLAW\PUBL016.116 PUBL016 dkrause on DSKBC28HB2PROD with PUBLAWS 133 STAT. 856 PUBLIC LAW 116–16—APR. 18, 2019 hospitals, pediatricians, and other providers), managed care plans, children’s health groups, family and beneficiary advo- cates, and other stakeholders with respect to coordinating the care for such children provided by out-of-State providers. ‘‘(f) MONITORING.—A State shall include in the State plan amendment— ‘‘(1) a methodology for tracking reductions in inpatient days and reductions in the total cost of care resulting from improved care coordination and management under this section; ‘‘(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); and ‘‘(3) a methodology for tracking prompt and timely access to medically necessary care for children with medically complex conditions from out-of-State providers. ‘‘(g) DATA COLLECTION.— ‘‘(1) PROVIDER REPORTING REQUIREMENTS.—In order to receive payments from a State under subsection (c), a des- ignated provider, a team of health care professionals operating with such a provider, or a health team shall report to the State, at such time and in such form and manner as may be required by the State, the following information: ‘‘(A) With respect to each such provider, team of health care professionals, or health team, the name, National Provider Identification number, address, and specific health care services offered to be provided to children with medi- cally complex conditions who have selected such provider, team of health care professionals, or health team as the health home of such children. ‘‘(B) Information on all applicable measures for deter- mining the quality of health home services provided by [Text truncated for display. Full text available on Congress.gov.]