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[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[S. 4863 Introduced in Senate (IS)]

<DOC>

116th CONGRESS
  2d Session
                                S. 4863

 To amend title XIX of the Social Security Act to provide States with 
the option to provide coordinated care through a pregnancy medical home 
         for high-risk pregnant women, and for other purposes.

_______________________________________________________________________

                   IN THE SENATE OF THE UNITED STATES

             October 26 (legislative day, October 19), 2020

  Mr. Portman (for himself and Ms. Stabenow) introduced the following 
  bill; which was read twice and referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL

 
 To amend title XIX of the Social Security Act to provide States with 
the option to provide coordinated care through a pregnancy medical home 
         for high-risk pregnant women, 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 ``Harnessing Effective and Appropriate 
Long Term Health for Moms On Medicaid Act of 2020'' or the ``HEALTH for 
MOM Act of 2020''.

SEC. 2. STATE OPTION TO PROVIDE COORDINATED CARE THROUGH A PREGNANCY 
              MEDICAL HOME FOR HIGH-RISK PREGNANT WOMEN.

    Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) is 
amended by inserting after section 1945A the following new section:

``SEC. 1945B. STATE OPTION TO PROVIDE COORDINATED CARE THROUGH A 
              PREGNANCY MEDICAL HOME FOR HIGH-RISK PREGNANT WOMEN.

    ``(a) In General.--Notwithstanding section 1902(a)(1) (relating to 
statewideness) and section 1902(a)(10)(B) (relating to comparability), 
beginning October 1, 2022, a State, at its option as a State plan 
amendment, may provide for medical assistance under this title to high-
risk pregnant women who choose to--
            ``(1) enroll in a pregnancy medical home under this section 
        by selecting a designated provider, a team of health care 
        professionals operating with such a provider, or a health team 
        as the woman's pregnancy medical home for purposes of providing 
        the woman with high-risk pregnancy coordinated care services; 
        or
            ``(2) receive such services from a designated provider, a 
        team of health care professionals operating with such a 
        provider, or a health team that has opted to participate in a 
        pregnancy medical home for high-risk pregnant women.
    ``(b) Qualification Standards.--The Secretary shall establish 
standards for qualification as a pregnancy medical home or as a 
designated provider, team of health care professionals operating with 
such a provider, or a health team eligible for participation in a 
pregnancy medical 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 
(designated a pregnancy medical home) to demonstrate to the State the 
ability to do the following:
            ``(1) Coordinate prompt care for high-risk pregnant women.
            ``(2) Develop an individualized, comprehensive, patient-
        centered care plan for high-risk pregnant women that 
        accommodates patient preferences.
            ``(3) Work in a culturally and linguistically appropriate 
        manner with the high-risk pregnant woman to develop and 
        incorporate into the woman's care plan, in a manner consistent 
        with the needs of the woman, ongoing home care, community-based 
        primary care, inpatient care, social support services, and 
        local hospital emergency care.
            ``(4) Coordinate access to necessary maternity care 
        services and programs for high-risk pregnant women.
            ``(5) Collect and report information under subsection 
        (f)(1).
    ``(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 high-risk pregnancy and postpartum coordinated 
        care services, to each high-risk pregnant woman that selects 
        such provider, team of health care professionals, or health 
        team as the woman's pregnancy medical home or care provider. 
        Payments made to a pregnancy medical home or care provider 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 high-risk 
                pregnancy coordinated care services or treatment during 
                a high-risk pregnancy. Such methodology for determining 
                payment--
                            ``(i) may be based on--
                                    ``(I) a per-member per-month basis 
                                for each high-risk pregnant woman 
                                enrolled in the pregnancy medical home; 
                                or
                                    ``(II) an alternate model of 
                                payment proposed by the State and 
                                approved by the Secretary;
                            ``(ii) may be tiered to reflect, with 
                        respect to each high-risk pregnant woman--
                                    ``(I) the severity of the risks 
                                associated with the woman's pregnancy; 
                                and
                                    ``(II) the level or amount of time 
                                of care coordination required with 
                                respect to the woman; and
                            ``(iii) shall be established consistent 
                        with section 1902(a)(30)(A).
                    ``(B) Distribution of financing.--For purposes of a 
                methodology under this section, the methodology shall 
                identify how any reimbursement or payment as made 
                available under this section to a pregnancy medical 
                home will be equitably shared among respective, 
                contributing members of the pregnancy medical home or 
                the designated provider, team of health care 
                professionals with such a provider, or health team.
    ``(d) Coordinating Care.--
            ``(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 in the case 
        of a high-risk pregnant woman that seeks treatment in the 
        emergency department of such hospital for--
                    ``(A) providing the woman with information, 
                including following discharge, about pregnancy medical 
                homes and opportunities for the woman to access the 
                pregnancy medical home and its associated benefits; and
                    ``(B) notifying the pregnancy medical home in which 
                the woman is enrolled, or the designated provider, team 
                of health care professionals operating with such a 
                provider, or health team treating the woman, of the 
                woman's treatment in the emergency department and of 
                the protocols for the pregnancy medical home, 
                designated provider, or team to be involved in the 
                woman's emergency care or post-discharge care.
            ``(2) Education with respect to availability of a pregnancy 
        medical home.--
                    ``(A) In general.--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--
                            ``(i) educating providers participating in 
                        the State plan (or a waiver of such plan) on 
                        the availability of pregnancy medical homes for 
                        high-risk pregnant women, including the process 
                        by which such providers can participate in or 
                        refer high-risk pregnant women to an approved 
                        pregnancy medical home or a designated 
                        provider, team of health care professionals 
                        operating such a provider, or health team; and
                            ``(ii) educating high-risk pregnant women 
                        on the availability of pregnancy medical homes.
                    ``(B) Outreach.--The process established by the 
                State under subparagraph (A) shall include the 
                participation of entities or other public or private 
                organizations or entities that provide outreach and 
                information on the availability of health care items 
                and services to families of individuals eligible to 
                receive medical assistance under the State plan (or a 
                waiver of such plan).
            ``(3) 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 health 
        conditions and substance use disorder among high-risk pregnant 
        women.
            ``(4) Social and support services.--A State with a State 
        plan amendment approved under this section shall consult and 
        coordinate, as appropriate, with the Secretary in establishing 
        means to connect high-risk pregnant women receiving high-risk 
        pregnancy coordinated care services under this section with 
        social and support services, including services made available 
        under maternal, infant, and early childhood home visiting 
        programs established under section 511, and services made 
        available under section 330 H or title X of the Public Health 
        Service Act.
    ``(e) 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 a pregnancy medical home under this section and 
        improving service delivery and coordination across the care 
        continuum; and
            ``(3) a methodology for tracking prompt and timely access 
        to medically necessary care for high-risk pregnant women from 
        out-of-State providers.
    ``(f) Data Collection.--
            ``(1) Provider reporting requirements.--In order to receive 
        payments from a State under subsection (c), a pregnancy medical 
        home, or a designated 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 or the Secretary, the 
        following information:
                    ``(A) With respect to each such designated 
                provider, team of health care professionals operating 
                with such a provider, and health team (designated as a 
                pregnancy medical home), the name, National Provider 
                Identification number, address, and specific health 
                care services offered to be provided to high-risk 
                pregnant women who have selected such provider, team of 
                health care professionals, or health team as the 
                women's pregnancy medical home.
                    ``(B) Information on all applicable measures for 
                determining the quality of services provided by such 
                provider, team of health care professionals, or health 
                team, including, to the extent applicable, maternal 
                health quality measures and measures for centers of 
                excellence for high-risk pregnant women developed under 
                this title.
                    ``(C) Such other information as the Secretary shall 
                specify in guidance.
            ``(2) State reporting requirements.--
                    ``(A) Comprehensive report.--A State with a State 
                plan amendment approved under this section shall report 
                to the Secretary (and, upon request, to the Medicaid 
                and CHIP Payment and Access Commission), at such time, 
                but at a minimum frequency of every 12 months, and in 
                such form and manner determined by the Secretary to be 
                reasonable and minimally burdensome, the following 
                information:
                            ``(i) Information described in paragraph 
                        (1).
                            ``(ii) The number of high-risk pregnant 
                        women who have enrolled in a pregnancy medical 
                        home pursuant to this section.
                            ``(iii) The nature, number, and prevalence 
                        of causes for identified high-risk pregnancies 
                        among such women.
                            ``(iv) The type of delivery systems and 
                        payment models used to provide services to such 
                        women under this section.
                            ``(v) The number and characteristics of the 
                        designated providers, teams of health care 
                        professionals operating with such providers, 
                        and health teams participating in the option 
                        established under this section, including the 
                        number and characteristics of out-of-State 
                        providers, teams of health care professionals 
                        operating with such providers, and health teams 
                        who have provided health care items and 
                        services to high-risk pregnant women enrolled 
                        in a pregnancy medical home pursuant to this 
                        section.
                            ``(vi) The extent to which such women 
                        receive health care items and services under 
                        the State plan before, during, and after the 
                        women's enrollment in such a pregnancy medical 
                        home.
                            ``(vii) Quality measures developed 
                        specifically with respect to health care items 
                        and services provided to high-risk pregnant 
                        women.
                            ``(viii) Where applicable, mortality data 
                        and data for the associated causes of death for 
                        high-risk pregnant women enrolled in a 
                        pregnancy medical home, in accordance with 
                        subsection (g). Such data shall include deaths 
                        that occur while enrolled in a pregnancy 
                        medical home and for deaths that occur after 
                        the conclusion of participation in a pregnancy 
                        medical home but occur up to one year 
                        postpartum. For deaths occurring postpartum, 
                        such data shall distinguish between deaths 
                        occurring up to 42 days postpartum and deaths 
                        occurring between 43 days to up to 1 year 
                        postpartum. Where applicable, data reported 
                        under this clause shall be reported alongside 
                        comparable data from a State's maternal 
                        mortality review committee, as established in 
                        accordance with section 317K(d) of the Public 
                        Health Service Act, for purposes of further 
                        identifying and comparing statewide trends in 
                        maternal mortality among populations 
                        participating in the pregnancy medical home 
                        under this section.
                    ``(B) Implementation report.--Not later than 18 
                months after a State has a State plan amendment 
                approved under this section, the State shall submit to 
                the Secretary, and make publicly available on the 
                appropriate State website, a report on how the State is 
                implementing the option established under this section, 
                including through any best practices adopted by the 
                State.
    ``(g) Confidentiality.--A State with a State plan amendment under 
this section shall establish confidentiality protections for the 
purposes of subsection (f)(2)(A)(viii) to ensure, at a minimum, that 
there is no disclosure by the State of any identifying information 
about any specific maternal mortality case.
    ``(h) Rule of Construction.--Nothing in this section shall be 
construed to require--
            ``(1) a high-risk pregnant woman to enroll in a pregnancy 
        medical home under this section; or
            ``(2) a designated provider or health team to act as a 
        pregnancy medical home and provide services in accordance with 
        this section if the provider or health team does not 
        voluntarily agree to act as a pregnancy medical home.
    ``(i) Planning Grants.--
            ``(1) In general.--Beginning January 1, 2021, the Secretary 
        may award planning grants to States for purposes of developing 
        a payment model for a State plan amendment under this section. 
        A planning grant awarded to a State under this paragraph shall 
        remain available until expended.
            ``(2) State contribution.--A State awarded a planning grant 
        shall contribute an amount equal to the State percentage 
        applicable to the State under section 1905(b) for each fiscal 
        year for which the grant is awarded.
            ``(3) Limitation.--The total amount of payments made to 
        States under this subsection shall not exceed $5,000,000.
    ``(j) Definitions.--In this section:
            ``(1) Designated provider.--The term `designated provider' 
        means a physician (including an obstetrician-gynecologist), 
        hospital, clinical practice or clinical group practice, prepaid 
        inpatient health plan or prepaid ambulatory health plan (as 
        defined by the Secretary), rural clinic, community health 
        center, community mental health center, home health agency, or 
        any other entity or provider that is determined by the State 
        and approved by the Secretary to be qualified to be a pregnancy 
        medical home on the basis of documentation evidencing that the 
        entity has the systems, expertise, and infrastructure in place 
        to provide high-risk pregnancy coordinated care services. Such 
        term may include providers who are employed by, or affiliated 
        with, a hospital.
            ``(2) Pregnancy medical home.--The term `pregnancy medical 
        home' means a designated provider (including a provider that 
        operates in coordination with a team of health care 
        professionals) or a health team that is selected by a high-risk 
        pregnant woman to provide high-risk pregnancy and postpartum 
        coordinated care services.
            ``(3) Health team.--The term `health team' has the meaning 
        given such term for purposes of section 3502 of Public Law 111-
        148.
            ``(4) High-risk pregnancy coordinated care services.--
                    ``(A) In general.--The term `high-risk pregnancy 
                coordinated care 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 (designated as a pregnancy 
                medical home).
                    ``(B) Services described.--The services described 
                in this subparagraph shall include--
                            ``(i) with respect to a State electing to 
                        the State plan amendment option under this 
                        section, any medical assistance for which 
                        payment is available under the State plan or 
                        under a waiver of such plan;
                            ``(ii) any item or service related to the 
                        treatment of a high-risk pregnant woman;
                            ``(iii) comprehensive care management;
                            ``(iv) care coordination, health promotion, 
                        and providing access to the full range of 
                        maternal, obstetric and gynecologic services, 
                        including services from out-of-State providers;
                            ``(v) comprehensive transitional care, 
                        including appropriate follow-up, from inpatient 
                        to other settings;
                            ``(vi) patient and family support 
                        (including authorized representatives);
                            ``(vii) referrals to community and social 
                        support services, if relevant; and
                            ``(viii) use of health information 
                        technology to link services, as feasible and 
                        appropriate.
            ``(5) High-risk pregnant woman.--
                    ``(A) In general.--The term `high-risk pregnant 
                woman' means an individual who--
                            ``(i) is eligible for medical assistance 
                        under the State plan (or under a waiver of such 
                        plan);
                            ``(ii) is pregnant; and
                            ``(iii) meets the definition of a high-risk 
                        pregnancy under section 199.2 of title 32, Code 
                        of Federal Regulations (or any successor 
                        regulation).
                    ``(B) Continuation of eligibility.--An individual 
                described in subparagraph (A) shall be deemed to be 
                described in such subparagraph through the earlier of--
                            ``(i) the end of the month in which the 
                        individual's eligibility for medical assistance 
                        under the State plan (or waiver) ends; and
                            ``(ii) the last day of the 1-year period 
                        that begins on the last day of the individual's 
                        pregnancy.
            ``(6) Team of health care professionals.--The term `team of 
        health care professionals' means a team of health care 
        professionals (as described in the State plan amendment under 
        this section) that may--
                    ``(A) include--
                            ``(i) physicians and other professionals, 
                        such as gynecologist-obstetrician, nurses, 
                        nurse care coordinators, dietitians, 
                        nutritionists, social workers, behavioral 
                        health professionals, physical therapists, 
                        occupational therapists, or any professionals 
                        that assist in prenatal care, delivery, or 
                        post-partum care determined to be appropriate 
                        by the State and approved by the Secretary;
                            ``(ii) an entity or individual who is 
                        designated to coordinate such a team; and
                            ``(iii) community health workers, 
                        interpreters, and other individuals with 
                        culturally appropriate expertise; and
                    ``(B) provide care at a facility that is 
                freestanding, 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 
                determined to be appropriate by the State and approved 
                by the Secretary.''.
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