II 

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. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Harnessing Effective 

5 and Appropriate Long Term Health for Moms On Med6 icaid Act of 2020’’ or the ‘‘HEALTH for MOM Act of 

7 2020’’. 

2 

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1 SEC. 2. STATE OPTION TO PROVIDE COORDINATED CARE 

2 THROUGH A PREGNANCY MEDICAL HOME 

3 FOR HIGH-RISK PREGNANT WOMEN. 

4 Title XIX of the Social Security Act (42 U.S.C. 1396 

5 et seq.) is amended by inserting after section 1945A the 

6 following new section: 

7 ‘‘SEC. 1945B. STATE OPTION TO PROVIDE COORDINATED 

8 CARE THROUGH A PREGNANCY MEDICAL 

9 HOME FOR HIGH-RISK PREGNANT WOMEN. 

10 ‘‘(a) IN GENERAL.—Notwithstanding section 

11 1902(a)(1) (relating to statewideness) and section 

12 1902(a)(10)(B) (relating to comparability), beginning Oc13 tober 1, 2022, a State, at its option as a State plan 

14 amendment, may provide for medical assistance under this 

15 title to high-risk pregnant women who choose to— 

16 ‘‘(1) enroll in a pregnancy medical home under 

17 this section by selecting a designated provider, a 

18 team of health care professionals operating with 

19 such a provider, or a health team as the woman’s 

20 pregnancy medical home for purposes of providing 

21 the woman with high-risk pregnancy coordinated 

22 care services; or 

23 ‘‘(2) receive such services from a designated 

24 provider, a team of health care professionals oper25 ating with such a provider, or a health team that 

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1 has opted to participate in a pregnancy medical 

2 home for high-risk pregnant women. 

3 ‘‘(b) QUALIFICATION STANDARDS.—The Secretary 

4 shall establish standards for qualification as a pregnancy 

5 medical home or as a designated provider, team of health 

6 care professionals operating with such a provider, or a 

7 health team eligible for participation in a pregnancy med8 ical home for purposes of this section. Such standards 

9 shall include requiring designated providers, teams of 

10 health care professionals operating with such providers, 

11 and health teams (designated a pregnancy medical home) 

12 to demonstrate to the State the ability to do the following: 

13 ‘‘(1) Coordinate prompt care for high-risk preg14 nant women. 

15 ‘‘(2) Develop an individualized, comprehensive, 

16 patient-centered care plan for high-risk pregnant 

17 women that accommodates patient preferences. 

18 ‘‘(3) Work in a culturally and linguistically ap19 propriate manner with the high-risk pregnant 

20 woman to develop and incorporate into the woman’s 

21 care plan, in a manner consistent with the needs of 

22 the woman, ongoing home care, community-based 

23 primary care, inpatient care, social support services, 

24 and local hospital emergency care. 

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1 ‘‘(4) Coordinate access to necessary maternity 

2 care services and programs for high-risk pregnant 

3 women. 

4 ‘‘(5) Collect and report information under sub5 section (f)(1). 

6 ‘‘(c) PAYMENTS.— 

7 ‘‘(1) IN GENERAL.—A State shall provide a des8 ignated provider, a team of health care professionals 

9 operating with such a provider, or a health team 

10 with payments for the provision of high-risk preg11 nancy and postpartum coordinated care services, to 

12 each high-risk pregnant woman that selects such 

13 provider, team of health care professionals, or health 

14 team as the woman’s pregnancy medical home or 

15 care provider. Payments made to a pregnancy med16 ical home or care provider for such services shall be 

17 treated as medical assistance for purposes of section 

18 1903(a), except that, during the first 2 fiscal year 

19 quarters that the State plan amendment is in effect, 

20 the Federal medical assistance percentage applicable 

21 to such payments shall be increased by 15 percent22 age points, but in no case may exceed 90 percent. 

23 ‘‘(2) METHODOLOGY.— 

24 ‘‘(A) IN GENERAL.—The State shall speci25 fy in the State plan amendment the methodVerDate Sep 11 2014 18:48 Nov 03, 2020 Jkt 019200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S4863.IS S4863
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1 ology the State will use for determining pay2 ment for the provision of high-risk pregnancy 

3 coordinated care services or treatment during a 

4 high-risk pregnancy. Such methodology for de5 termining payment— 

6 ‘‘(i) may be based on— 

7 ‘‘(I) a per-member per-month 

8 basis for each high-risk pregnant 

9 woman enrolled in the pregnancy 

10 medical home; or 

11 ‘‘(II) an alternate model of pay12 ment proposed by the State and ap13 proved by the Secretary; 

14 ‘‘(ii) may be tiered to reflect, with re15 spect to each high-risk pregnant woman— 

16 ‘‘(I) the severity of the risks as17 sociated with the woman’s pregnancy; 

18 and 

19 ‘‘(II) the level or amount of time 

20 of care coordination required with re21 spect to the woman; and 

22 ‘‘(iii) shall be established consistent 

23 with section 1902(a)(30)(A). 

24 ‘‘(B) DISTRIBUTION OF FINANCING.—For 

25 purposes of a methodology under this section, 

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1 the methodology shall identify how any reim2 bursement or payment as made available under 

3 this section to a pregnancy medical home will 

4 be equitably shared among respective, contrib5 uting members of the pregnancy medical home 

6 or the designated provider, team of health care 

7 professionals with such a provider, or health 

8 team. 

9 ‘‘(d) COORDINATING CARE.— 

10 ‘‘(1) HOSPITAL NOTIFICATION.—A State with a 

11 State plan amendment approved under this section 

12 shall require each hospital that is a participating 

13 provider under the State plan (or a waiver of such 

14 plan) to establish procedures in the case of a high15 risk pregnant woman that seeks treatment in the 

16 emergency department of such hospital for— 

17 ‘‘(A) providing the woman with informa18 tion, including following discharge, about preg19 nancy medical homes and opportunities for the 

20 woman to access the pregnancy medical home 

21 and its associated benefits; and 

22 ‘‘(B) notifying the pregnancy medical home 

23 in which the woman is enrolled, or the des24 ignated provider, team of health care profes25 sionals operating with such a provider, or 

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1 health team treating the woman, of the wom2 an’s treatment in the emergency department 

3 and of the protocols for the pregnancy medical 

4 home, designated provider, or team to be in5 volved in the woman’s emergency care or post6 discharge care. 

7 ‘‘(2) EDUCATION WITH RESPECT TO AVAIL8 ABILITY OF A PREGNANCY MEDICAL HOME.— 

9 ‘‘(A) IN GENERAL.—In order for a State 

10 plan amendment to be approved under this sec11 tion, a State shall include in the State plan 

12 amendment a description of the State’s process 

13 for— 

14 ‘‘(i) educating providers participating 

15 in the State plan (or a waiver of such 

16 plan) on the availability of pregnancy med17 ical homes for high-risk pregnant women, 

18 including the process by which such pro19 viders can participate in or refer high-risk 

20 pregnant women to an approved pregnancy 

21 medical home or a designated provider, 

22 team of health care professionals operating 

23 such a provider, or health team; and 

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1 ‘‘(ii) educating high-risk pregnant 

2 women on the availability of pregnancy 

3 medical homes. 

4 ‘‘(B) OUTREACH.—The process established 

5 by the State under subparagraph (A) shall in6 clude the participation of entities or other pub7 lic or private organizations or entities that pro8 vide outreach and information on the avail9 ability of health care items and services to fami10 lies of individuals eligible to receive medical as11 sistance under the State plan (or a waiver of 

12 such plan). 

13 ‘‘(3) MENTAL HEALTH COORDINATION.—A 

14 State with a State plan amendment approved under 

15 this section shall consult and coordinate, as appro16 priate, with the Secretary in addressing issues re17 garding the prevention and treatment of mental 

18 health conditions and substance use disorder among 

19 high-risk pregnant women. 

20 ‘‘(4) SOCIAL AND SUPPORT SERVICES.—A State 

21 with a State plan amendment approved under this 

22 section shall consult and coordinate, as appropriate, 

23 with the Secretary in establishing means to connect 

24 high-risk pregnant women receiving high-risk preg25 nancy coordinated care services under this section 

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1 with social and support services, including services 

2 made available under maternal, infant, and early 

3 childhood home visiting programs established under 

4 section 511, and services made available under sec5 tion 330 H or title X of the Public Health Service 

6 Act. 

7 ‘‘(e) MONITORING.—A State shall include in the 

8 State plan amendment— 

9 ‘‘(1) a methodology for tracking reductions in 

10 inpatient days and reductions in the total cost of 

11 care resulting from improved care coordination and 

12 management under this section; 

13 ‘‘(2) a proposal for use of health information 

14 technology in providing a pregnancy medical home 

15 under this section and improving service delivery 

16 and coordination across the care continuum; and 

17 ‘‘(3) a methodology for tracking prompt and 

18 timely access to medically necessary care for high19 risk pregnant women from out-of-State providers. 

20 ‘‘(f) DATA COLLECTION.— 

21 ‘‘(1) PROVIDER REPORTING REQUIREMENTS.— 

22 In order to receive payments from a State under 

23 subsection (c), a pregnancy medical home, or a des24 ignated provider, a team of health care professionals 

25 operating with such a provider, or a health team, 

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1 shall report to the State, at such time and in such 

2 form and manner as may be required by the State 

3 or the Secretary, the following information: 

4 ‘‘(A) With respect to each such designated 

5 provider, team of health care professionals oper6 ating with such a provider, and health team 

7 (designated as a pregnancy medical home), the 

8 name, National Provider Identification number, 

9 address, and specific health care services of10 fered to be provided to high-risk pregnant 

11 women who have selected such provider, team 

12 of health care professionals, or health team as 

13 the women’s pregnancy medical home. 

14 ‘‘(B) Information on all applicable meas15 ures for determining the quality of services pro16 vided by such provider, team of health care pro17 fessionals, or health team, including, to the ex18 tent applicable, maternal health quality meas19 ures and measures for centers of excellence for 

20 high-risk pregnant women developed under this 

21 title. 

22 ‘‘(C) Such other information as the Sec23 retary shall specify in guidance. 

24 ‘‘(2) STATE REPORTING REQUIREMENTS.— 

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1 ‘‘(A) COMPREHENSIVE REPORT.—A State 

2 with a State plan amendment approved under 

3 this section shall report to the Secretary (and, 

4 upon request, to the Medicaid and CHIP Pay5 ment and Access Commission), at such time, 

6 but at a minimum frequency of every 12 

7 months, and in such form and manner deter8 mined by the Secretary to be reasonable and 

9 minimally burdensome, the following informa10 tion: 

11 ‘‘(i) Information described in para12 graph (1). 

13 ‘‘(ii) The number of high-risk preg14 nant women who have enrolled in a preg15 nancy medical home pursuant to this sec16 tion. 

17 ‘‘(iii) The nature, number, and preva18 lence of causes for identified high-risk 

19 pregnancies among such women. 

20 ‘‘(iv) The type of delivery systems and 

21 payment models used to provide services to 

22 such women under this section. 

23 ‘‘(v) The number and characteristics 

24 of the designated providers, teams of 

25 health care professionals operating with 

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1 such providers, and health teams partici2 pating in the option established under this 

3 section, including the number and charac4 teristics of out-of-State providers, teams of 

5 health care professionals operating with 

6 such providers, and health teams who have 

7 provided health care items and services to 

8 high-risk pregnant women enrolled in a 

9 pregnancy medical home pursuant to this 

10 section. 

11 ‘‘(vi) The extent to which such women 

12 receive health care items and services 

13 under the State plan before, during, and 

14 after the women’s enrollment in such a 

15 pregnancy medical home. 

16 ‘‘(vii) Quality measures developed spe17 cifically with respect to health care items 

18 and services provided to high-risk pregnant 

19 women. 

20 ‘‘(viii) Where applicable, mortality 

21 data and data for the associated causes of 

22 death for high-risk pregnant women en23 rolled in a pregnancy medical home, in ac24 cordance with subsection (g). Such data 

25 shall include deaths that occur while enVerDate Sep 11 2014 18:48 Nov 03, 2020 Jkt 019200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\S4863.IS S4863
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1 rolled in a pregnancy medical home and for 

2 deaths that occur after the conclusion of 

3 participation in a pregnancy medical home 

4 but occur up to one year postpartum. For 

5 deaths occurring postpartum, such data 

6 shall distinguish between deaths occurring 

7 up to 42 days postpartum and deaths oc8 curring between 43 days to up to 1 year 

9 postpartum. Where applicable, data re10 ported under this clause shall be reported 

11 alongside comparable data from a State’s 

12 maternal mortality review committee, as 

13 established in accordance with section 

14 317K(d) of the Public Health Service Act, 

15 for purposes of further identifying and 

16 comparing statewide trends in maternal 

17 mortality among populations participating 

18 in the pregnancy medical home under this 

19 section. 

20 ‘‘(B) IMPLEMENTATION REPORT.—Not 

21 later than 18 months after a State has a State 

22 plan amendment approved under this section, 

23 the State shall submit to the Secretary, and 

24 make publicly available on the appropriate 

25 State website, a report on how the State is imVerDate Sep 11 2014 18:48 Nov 03, 2020 Jkt 019200 PO 00000 Frm 00013 Fmt 6652 Sfmt 6201 E:\BILLS\S4863.IS S4863
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1 plementing the option established under this 

2 section, including through any best practices 

3 adopted by the State. 

4 ‘‘(g) CONFIDENTIALITY.—A State with a State plan 

5 amendment under this section shall establish confiden6 tiality protections for the purposes of subsection 

7 (f)(2)(A)(viii) to ensure, at a minimum, that there is no 

8 disclosure by the State of any identifying information 

9 about any specific maternal mortality case. 

10 ‘‘(h) RULE OF CONSTRUCTION.—Nothing in this sec11 tion shall be construed to require— 

12 ‘‘(1) a high-risk pregnant woman to enroll in a 

13 pregnancy medical home under this section; or 

14 ‘‘(2) a designated provider or health team to 

15 act as a pregnancy medical home and provide serv16 ices in accordance with this section if the provider 

17 or health team does not voluntarily agree to act as 

18 a pregnancy medical home. 

19 ‘‘(i) PLANNING GRANTS.— 

20 ‘‘(1) IN GENERAL.—Beginning January 1, 

21 2021, the Secretary may award planning grants to 

22 States for purposes of developing a payment model 

23 for a State plan amendment under this section. A 

24 planning grant awarded to a State under this para25 graph shall remain available until expended. 

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1 ‘‘(2) STATE CONTRIBUTION.—A State awarded 

2 a planning grant shall contribute an amount equal 

3 to the State percentage applicable to the State under 

4 section 1905(b) for each fiscal year for which the 

5 grant is awarded. 

6 ‘‘(3) LIMITATION.—The total amount of pay7 ments made to States under this subsection shall not 

8 exceed $5,000,000. 

9 ‘‘(j) DEFINITIONS.—In this section: 

10 ‘‘(1) DESIGNATED PROVIDER.—The term ‘des11 ignated provider’ means a physician (including an 

12 obstetrician-gynecologist), hospital, clinical practice 

13 or clinical group practice, prepaid inpatient health 

14 plan or prepaid ambulatory health plan (as defined 

15 by the Secretary), rural clinic, community health 

16 center, community mental health center, home 

17 health agency, or any other entity or provider that 

18 is determined by the State and approved by the Sec19 retary to be qualified to be a pregnancy medical 

20 home on the basis of documentation evidencing that 

21 the entity has the systems, expertise, and infrastruc22 ture in place to provide high-risk pregnancy coordi23 nated care services. Such term may include pro24 viders who are employed by, or affiliated with, a hos25 pital. 

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1 ‘‘(2) PREGNANCY MEDICAL HOME.—The term 

2 ‘pregnancy medical home’ means a designated pro3 vider (including a provider that operates in coordina4 tion with a team of health care professionals) or a 

5 health team that is selected by a high-risk pregnant 

6 woman to provide high-risk pregnancy and 

7 postpartum coordinated care services. 

8 ‘‘(3) HEALTH TEAM.—The term ‘health team’ 

9 has the meaning given such term for purposes of 

10 section 3502 of Public Law 111–148. 

11 ‘‘(4) HIGH-RISK PREGNANCY COORDINATED

12 CARE SERVICES.— 

13 ‘‘(A) IN GENERAL.—The term ‘high-risk 

14 pregnancy coordinated care services’ means 

15 comprehensive and timely high-quality services 

16 described in subparagraph (B) that are pro17 vided by a designated provider, a team of health 

18 care professionals operating with such a pro19 vider, or a health team (designated as a preg20 nancy medical home). 

21 ‘‘(B) SERVICES DESCRIBED.—The services 

22 described in this subparagraph shall include— 

23 ‘‘(i) with respect to a State electing to 

24 the State plan amendment option under 

25 this section, any medical assistance for 

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1 which payment is available under the State 

2 plan or under a waiver of such plan; 

3 ‘‘(ii) any item or service related to the 

4 treatment of a high-risk pregnant woman; 

5 ‘‘(iii) comprehensive care manage6 ment; 

7 ‘‘(iv) care coordination, health pro8 motion, and providing access to the full 

9 range of maternal, obstetric and 

10 gynecologic services, including services 

11 from out-of-State providers; 

12 ‘‘(v) comprehensive transitional care, 

13 including appropriate follow-up, from inpa14 tient to other settings; 

15 ‘‘(vi) patient and family support (in16 cluding authorized representatives); 

17 ‘‘(vii) referrals to community and so18 cial support services, if relevant; and 

19 ‘‘(viii) use of health information tech20 nology to link services, as feasible and ap21 propriate. 

22 ‘‘(5) HIGH-RISK PREGNANT WOMAN.— 

23 ‘‘(A) IN GENERAL.—The term ‘high-risk 

24 pregnant woman’ means an individual who— 

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1 ‘‘(i) is eligible for medical assistance 

2 under the State plan (or under a waiver of 

3 such plan); 

4 ‘‘(ii) is pregnant; and 

5 ‘‘(iii) meets the definition of a high6 risk pregnancy under section 199.2 of title 

7 32, Code of Federal Regulations (or any 

8 successor regulation). 

9 ‘‘(B) CONTINUATION OF ELIGIBILITY.—An 

10 individual described in subparagraph (A) shall 

11 be deemed to be described in such subpara12 graph through the earlier of— 

13 ‘‘(i) the end of the month in which the 

14 individual’s eligibility for medical assist15 ance under the State plan (or waiver) 

16 ends; and 

17 ‘‘(ii) the last day of the 1-year period 

18 that begins on the last day of the individ19 ual’s pregnancy. 

20 ‘‘(6) TEAM OF HEALTH CARE PROFES21 SIONALS.—The term ‘team of health care profes22 sionals’ means a team of health care professionals 

23 (as described in the State plan amendment under 

24 this section) that may— 

25 ‘‘(A) include— 

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1 ‘‘(i) physicians and other profes2 sionals, such as gynecologist-obstetrician, 

3 nurses, nurse care coordinators, dietitians, 

4 nutritionists, social workers, behavioral 

5 health professionals, physical therapists, 

6 occupational therapists, or any profes7 sionals that assist in prenatal care, deliv8 ery, or post-partum care determined to be 

9 appropriate by the State and approved by 

10 the Secretary; 

11 ‘‘(ii) an entity or individual who is 

12 designated to coordinate such a team; and 

13 ‘‘(iii) community health workers, in14 terpreters, and other individuals with cul15 turally appropriate expertise; and 

16 ‘‘(B) provide care at a facility that is free17 standing, virtual, or based at a hospital, com18 munity health center, community mental health 

19 center, rural clinic, clinical practice or clinical 

20 group practice, academic health center, or any 

21 entity determined to be appropriate by the 

22 State and approved by the Secretary.’’. 

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