‘‘(B) the proposed target population of ap-
plicable individuals with respect to which such 
innovations will be employed, including a de-
scription of the extent to which such population 
consists of applicable individuals described in 
subparagraph (A), (B), or (C) of subsection 
(f)(1); 
‘‘(C) the evidence-based data supporting a 
community’s status as a vulnerable community 
through sources, such as Bureau of the Census 
data and measures such as the Neighborhood 
Deprivation Index or the Child Opportunity 
Index; 
‘‘(D) community partners, such as non-
profit organizations, federally qualified health 
centers, rural health clinics, and units of local 
government (including law enforcement and ju-
dicial entities) that will participate in the imple-
mentation of such innovations; 
‘‘(E) how such innovations will address 
mental and physical health comorbidities and 
social determinants of health for the target pop-
ulation; 
‘‘(F) how such innovations may inform 
changes in payment and other policies under 
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this title and title XIX (such as care coordina-
tion reimbursement, mental health homes, im-
provements to home and community based serv-
ice portfolios, and coverage of supportive serv-
ices); 
‘‘(G) how such innovations might con-
tribute to a reduction in overall health care 
costs, including under this title and title XIX 
and for uninsured persons, through improve-
ments in population health, reductions in health 
care utilization (such as inpatient admissions, 
utilization of emergency departments, and 
boarding of patients), and otherwise; 
‘‘(H) how such innovations can be expected 
to improve the mental and physical health sta-
tus of minority populations; 
‘‘(I) how such innovations can be expected 
to reduce other non-medical public expendi-
tures; 
‘‘(J) metrics to track care quality, im-
provement in outcomes, and the impact of such 
innovations on health care and other public ex-
penditures; 
‘‘(K) how program outcomes will be as-
sessed and evaluated; and 
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‘‘(L) how the hospital will collect and orga-
nize data and fully participate in the learning 
collaborative established under subsection (e). 
‘‘(3) PARTICIPATION; PAYMENTS.—The Sec-
retary shall negotiate an annualized payment ar-
rangement with each eligible hospital participating 
in the program. Such arrangement may include an 
annual lump sum amount, capitated payment 
amount, or such other arrangement as determined 
appropriate by the Secretary, and which may include 
an arrangement that includes financial risk for the 
hospital, to support implementation of the innova-
tions specified in the plan described in paragraph 
(2). 
‘‘(e) LEARNING COLLABORATIVE.— 
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish a learning collaborative that shall convene eligi-
ble hospitals participating in the program and other 
interested parties on a regular basis to report on 
and share information regarding evidence-based in-
novations addressing mental and physical health 
comorbidities, innovations addressing social deter-
minants of health, and associated metrics and out-
comes. 
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‘‘(2) FOCUSED FORUMS.—The Secretary may 
establish different focused forums within the collabo-
rative, such as ones that specifically address dif-
ferent geographic regions (such as urban and rural), 
certain types of comorbidities, or as the Secretary 
otherwise determines appropriate based on the types 
of agreements entered into under subsection (d). 
‘‘(3) DISSEMINATION
OF
INFORMATION.—The 
Secretary shall provide for the dissemination to 
other health care providers and interested parties of 
information on promising and effective activities. 
‘‘(f) DEFINITIONS.—For purposes of this section: 
‘‘(1) APPLICABLE INDIVIDUAL.—The term ‘ap-
plicable individual’ means an individual with mental 
and physical health comorbidities who is— 
‘‘(A) a subsidy eligible individual (as de-
fined in section 1860D–14(a)(3)(A)) without 
regard to clause (i) of such section; 
‘‘(B) enrolled under a State plan (or waiv-
er of such plan) under title XIX; or 
‘‘(C) uninsured. 
‘‘(2) ELIGIBLE HOSPITAL.—The term ‘eligible 
hospital’ means a hospital that is— 
‘‘(A) a rural hospital with a dispropor-
tionate patient percentage of at least 35 percent 
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(as determined by the Secretary under section 
1886(d)(5)(F)(vi)) or would have a dispropor-
tionate patient percentage of at least 35 percent 
(as so determined) if the hospital were a sub-
section (d) hospital (or, a percentage of inpa-
tient days consisting of items and services fur-
nished to individuals entitled to benefits under 
part A that exceeds 85 percent of all such days) 
that is either a critical access hospital, a sole 
community hospital (as defined in section 
1886(d)(5)(D)(iii)), or a medicare-dependent, 
small rural hospital (as defined in section 
1886(d)(5)(G)(iv)); 
‘‘(B) a large subsection (d) teaching and 
tertiary hospital with more than 200 beds that 
as of, or subsequent to July 1, 2020, has an av-
erage Medicare case mix index of at least 1.5, 
an intern and resident-to-bed ratio of at least 
0.25 percent (or at least 150 full-time equiva-
lent interns, residents, and fellows), and is ei-
ther a public hospital with a disproportionate 
patient percentage of at least 35 percent (as de-
termined by the Secretary under section 
1886(d)(5)(F)(vi)) or a nonprofit hospital with 
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a disproportionate patient percentage of at least 
45 percent; or 
‘‘(C) a small subsection (d) urban safety 
net hospital (as determined by the Secretary) 
with less than 200 beds that is deemed to be 
a disproportionate share hospital under section 
1923(b). 
‘‘(3) INNOVATIONS ADDRESSING MENTAL AND 
PHYSICAL HEALTH COMORBIDITIES.—The term ‘in-
novations addressing mental and physical health 
comorbidities’ means innovations implemented by an 
eligible hospital that seek to promote holistic care 
and treatment of an applicable individual’s co-occur-
ring mental and physical health comorbidities, sup-
port early detection of such comorbidities, or prevent 
their onset, including the following: 
‘‘(A) Implementation of interdisciplinary 
integrative coordinated care team models, in-
cluding those that utilize mental health emer-
gency department in-reach staff (and other 
emergency-department interventions), care co-
ordination staff and social services support, and 
clinic-based services. 
‘‘(B) Integration of mental health services 
into medical homes, coordinated care organiza-
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tions, accountable care entities, and in-home 
services. 
‘‘(C) Incorporation of mental health and 
social risk screening into medical screening, 
particularly in child and adolescent populations. 
‘‘(D) Preventing adverse impacts on men-
tal health resulting from physical health treat-
ments or medications, or on physical health re-
sulting from mental health treatments or medi-
cations, through cross disciplinary provider edu-
cation, quality metrics, and other mechanisms. 
‘‘(E) Improvements in electronic health 
records and other technology platforms or net-
works to capture, track, and monitor mental 
and physical health treatments and medications 
provided across care settings and otherwise fa-
cilitate care coordination. 
‘‘(F) Piloting of reimbursement modifica-
tions that utilize site-neutral payments and that 
address conflicts and disincentives related to 
chronic care management and behavioral health 
management and differential treatment of inpa-
tient and outpatient settings. 
‘‘(G) Mitigating the incidence of admission 
and readmission into psychiatric inpatient set-
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tings of chronically ill elderly patients through 
methods such as active inpatient management, 
variations in initial length of stay, enhanced 
discharge planning, and psychosocial interven-
tions. 
‘‘(H) Delivering health behavior assess-
ments and interventions to improve physical 
health outcomes for patients and aid in the 
management of chronic health conditions. 
‘‘(I) In coordination with law enforcement 
agencies and judicial entities, interventions tar-
geted at providing mental and physical health 
services (including, as appropriate, substance 
use disorder services) to individuals convicted of 
criminal offenses for purposes of mitigating re-
cidivism. 
‘‘(4) INNOVATIONS ADDRESSING SOCIAL DETER-
MINANTS OF HEALTH.—The term ‘innovations ad-
dressing social determinants of health’ means inno-
vations implemented by an eligible hospital that seek 
to address social determinants of health that nega-
tively impact the health outcomes of applicable indi-
viduals, including the following: 
‘‘(A) Improvements in electronic health 
records to better integrate mental health, med-
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ical care, and social care (such as screening for 
social factors, facilitated or closed loop referral, 
risk stratification, and shared records with com-
munity based organizations). 
‘‘(B) Personnel-supported ‘wrap around’ 
services for at-risk individuals with mental and 
physical health comorbidities (such as nutrition 
and diet counseling, social services referral, res-
piratory therapy, medical-legal assistance, fi-
nancial counseling, consumer education, phar-
macy education, asthma education, and referral 
to food resources such as referral to the SNAP 
program, the WIC program, a food bank, case 
management assistance, employment or edu-
cation support, intimate partner violence, and 
behavioral health support). 
‘‘(C) Home and community-based services 
that provide collaborative care to address men-
tal and physical health comorbidities through 
health behavior services, nutrition support, 
medication management, transitional care, tele-
health, mobile integrated health care, para-
medic-based home visitation, or utilization of 
community health workers. 
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‘‘(D) Hospital-based interventions (such as 
same day primary care services, skilled nursing 
interventions, substance use disorder and be-
havioral health treatment coordination of care, 
collaborative care models, discharge planning 
and medication reconciliation, long-term care 
management, and post-traumatic injury man-
agement). 
‘‘(5) INDIVIDUAL WITH MENTAL AND PHYSICAL 
HEALTH
COMORBIDITIES.—The term ‘individual 
with mental and physical health comorbidities’ 
means an individual who is challenged by serious 
mental illness or serious emotional disturbance as 
well as 1 or more of the following conditions or char-
acteristics: 
‘‘(A) Has or is at risk for one or more 
chronic conditions (as defined by the Sec-
retary). 
‘‘(B) High-risk pregnancy. 
‘‘(C) History of high utilization of acute 
care services. 
‘‘(D) Frail elderly (defined by impairments 
in activities of daily living). 
‘‘(E) Disability, including traumatic brain 
injury. 
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‘‘(F) Critical illness or injury requiring 
long-term recovery. 
‘‘(6) VULNERABLE
COMMUNITY.—The term 
‘vulnerable community’ means a geographic area 
served by an eligible hospital characterized by a pop-
ulation that has a statistically significant number of 
individuals 
with 
mental 
and 
physical 
health 
comorbidities, indicators of poor population health 
status, low-income status, or status as a USDA-rec-
ognized food desert. 
‘‘(g) EVALUATION AND REPORT.—Not later than 1 
year after the date of completion of the program under 
this section, the Secretary shall submit to Congress a re-
port containing an evaluation of the activities supported 
by the program. Such report shall include the following: 
‘‘(1) A description of each such activity, includ-
ing— 
‘‘(A) the target population of such activity; 
‘‘(B) how such activity addressed the ad-
verse social determinants of health in such pop-
ulation; and 
‘‘(C) the role of community-based organi-
zations and other community partners (such as 
nonprofits and units of local government) in 
such activity. 
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