II 115th CONGRESS 2d Session S. 3494 IN THE SENATE OF THE UNITED STATES September 25, 2018 Mr. Booker (for himself, Mrs. Gillibrand , Ms. Baldwin , Mr. Cardin , Mr. Blumenthal , and Ms. Harris ) introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To amend titles XIX and XXI of the Social Security Act to improve Medicaid and the Children's Health Insurance Program for low-income mothers.

1. Short title This Act may be cited as the Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services Act , or the MOMMIES Act . 2. Enhancing Medicaid and CHIP benefits for low-income pregnant women (a) Medicaid (1) State requirement to extend eligibility for medical assistance for low-income pregnant women (A) In general Section 1902(l)(1)(A) of the Social Security Act ( 42 U.S.C. 1396a(l)(1)(A) ) is amended by striking 60-day period and inserting 365-day period . (B) Conforming amendments (i) Section 1902(e)(6) of the Social Security Act ( 42 U.S.C. 1396a(e)(6) ) is amended by striking 60-day period and inserting 365-day period . (ii) Section 1903(v)(4)(A)(i) of the Social Security Act ( 42 U.S.C. 1396b(v)(4)(A)(i) ) is amended by striking 60-day period and inserting 365-day period . (2) No restriction on types of medical assistance available to low-income pregnant women Section 1902(a)(10) of the Social Security Act ( 42 U.S.C. 1396a(a)(10) ) is amended in the matter following subparagraph (G) by striking (VII) the medical assistance and all that follows through complicate pregnancy, . (3) Extension of postpartum eligibility for pregnant women Section 1902(e)(5) of the Social Security Act ( 42 U.S.C. 1396a(e)(5) ) is amended by striking 60-day period and inserting 365-day period . (b) CHIP Section 2112 of the Social Security Act ( 42 U.S.C. 1397ll ) is amended by striking 60-day period each place it appears and inserting 365-day period . (c) Maintenance of effort (1) Medicaid Section 1902 of the Social Security Act ( 42 U.S.C. 1396a ) is amended— (A) in paragraph (74), by striking subsection (gg); and and inserting subsections (gg) and (nn); ; and (B) by adding at the end the following new subsection: (nn) Maintenance of effort related to low-Income pregnant women For calendar quarters beginning on or after the date of enactment of this subsection, and before January 1, 2023, no Federal payment shall be made to a State under section 1903(a) for amounts expended under a State plan under this title or a waiver of such plan if the State— (1) has in effect under such plan eligibility standards, methodologies, or procedures (including any enrollment cap or other numerical limitation on enrollment, any waiting list, any procedures designed to delay the consideration of applications for enrollment, or similar limitation with respect to enrollment) for individuals described in subsection (l)(1) who are eligible for medical assistance under the State plan or waiver under subsection (a)(10)(A)(ii)(IX) that are more restrictive than the eligibility standards, methodologies, or procedures, respectively, for such individuals under such plan or waiver that are in effect on the date of the enactment of the Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services Act ; or (2) provides medical assistance to individuals described in subsection (l)(1) who are eligible for medical assistance under such plan or waiver under subsection (a)(10)(A)(ii)(IX) at a level that is less than the level at which the State provides such assistance to such individuals under such plan or waiver on the date of the enactment of the Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services Act . . (2) CHIP Section 2112 of the Social Security Act ( 42 U.S.C. 1397ll ), as amended by subsection (b), is further amended by adding at the end the following subsection: (g) Maintenance of effort For calendar quarters beginning on or after January 1, 2020, and before January 1, 2023, no payment may be made under section 2105(a) with respect to a State child health plan if the State— (1) has in effect under such plan eligibility standards, methodologies, or procedures (including any enrollment cap or other numerical limitation on enrollment, any waiting list, any procedures designed to delay the consideration of applications for enrollment, or similar limitation with respect to enrollment) for targeted low-income pregnant women that are more restrictive than the eligibility standards, methodologies, or procedures, respectively, under such plan that are in effect on the date of the enactment of the Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services Act ; or (2) provides pregnancy-related assistance to targeted low-income pregnant women under such plan at a level that is less than the level at which the State provides such assistance to such women under such plan on the date of the enactment of the Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services Act . . (d) Enhanced FMAP Section 1905 of the Social Security Act ( 42 U.S.C. 1396d ) is amended— (1) in subsection (b), by striking and (aa) and inserting (aa), and (ee) ; and (2) by adding at the end the following: (ee) Increased FMAP for additional expenditures for low-Income pregnant women For calendar quarters beginning on or after January 1, 2020, notwithstanding subsection (b), the Federal medical assistance percentage for a State, with respect to the additional amounts expended by such State for medical assistance under the State plan under this title or a waiver of such plan that are attributable to requirements imposed by the amendments made by the Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services Act (as determined by the Secretary), shall be equal to 100 percent. . (e) GAO study and report (1) In general Not later than 1 year after the date of the enactment of this Act, the Comptroller General of the United States shall submit to Congress a report on the gaps in coverage for— (A) pregnant women under the Medicaid program under title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq.) and the Children's Health Insurance Program under title XXI of the Social Security Act ( 42 U.S.C. 1397aa et seq.); and (B) postpartum women under the Medicaid program and the Children's Health Insurance Program who received assistance under either such program during their pregnancy. (2) Content of report The report required under this subsection shall include the following: (A) Information about the abilities and successes of State Medicaid agencies in determining whether pregnant and postpartum women are eligible under another insurance affordability program, and in transitioning any such women who are so eligible to coverage under such a program, pursuant to section 435.1200 of the title 42, Code of Federal Regulations (as in effect on September 1, 2018). (B) Information on factors contributing to gaps in coverage that disproportionately impact underserved populations, including low-income women, women of color, women who reside in a health professional shortage area (as defined in section 332(a)(1)(A) of the Public Health Service Act ( 42 U.S.C. 254e(a)(1)(A) )) or who are members of a medically underserved population (as defined by section 330(b)(3) of such Act ( 42 U.S.C. 254b(b)(3)(A) )). (C) Recommendations for addressing and reducing such gaps in coverage. (D) Such other information as the Comptroller General deems necessary. (f) Effective date The amendments made by subsections (a) and (b) shall take effect January 1, 2020. 3. Maternity care home demonstration project Title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq.) is amended by inserting the following new section after section 1943: 1944. Maternity care home demonstration project (a) In general Not later than 1 year after the date of the enactment of this section, the Secretary shall establish a demonstration project (in this section referred to as the demonstration project ) under which the Secretary shall provide grants to States to enter into arrangements with eligible entities to implement or expand a maternity care home model for eligible individuals. (b) Definitions In this section: (1) Eligible entity The term eligible entity means an entity or organization that provides medically accurate, comprehensive maternity services to individuals who are eligible for medical assistance under a State plan under this title or a waiver of such a plan, and may include: (A) A freestanding birth center. (B) An entity or organization receiving assistance under section 330 of the Public Health Service Act. (C) A federally qualified health center. (D) A rural health clinic. (E) A health facility operated by an Indian tribe or tribal organization (as those terms are defined in section 4 of the Indian Health Care Improvement Act). (2) Eligible individual The term eligible individual means a pregnant woman or a formerly pregnant woman during the 365-day period beginning on the last day of her pregnancy who is— (A) enrolled in a State plan under this title, a waiver of such a plan, or a State child health plan under title XXI; and (B) a patient of an eligible entity which has entered into an arrangement with a State under subsection (g). (c) Goals of demonstration project The goals of the demonstration project are the following: (1) To improve— (A) maternity and infant care outcomes; (B) communication by maternity, infant care, and social services providers; (C) care coordination between maternity, infant care, and social services providers within the community; (D) the quality and safety of maternity and infant care; (E) the experience of women receiving maternity care, including by increasing the ability of a woman to develop and follow her own birthing plan; and (F) access to adequate prenatal and postpartum care, including— (i) prenatal care that is initiated in a timely manner; (ii) not less than 2 post-pregnancy visits to a maternity care provider; and (iii) interpregnancy care. (2) To provide coordinated, evidence-based maternity care management. (3) To decrease— (A) severe maternal morbidity and maternal mortality; (B) overall health care spending; (C) unnecessary emergency department visits; (D) disparities in maternal and infant care outcomes, including racial, economic, and geographical disparities; (E) the rate of cesarean deliveries for low-risk pregnancies; (F) the rate of preterm births and infants born with low birth weight; and (G) the rate of avoidable maternal and newborn hospitalizations and admissions to intensive care units. (d) Consultation In designing and implementing the demonstration project the Secretary shall consult with stakeholders, including— (1) States; (2) organizations representing relevant health care professionals; (3) organizations representing consumers, including consumers that are disproportionately impacted by poor maternal health outcomes; (4) representatives with experience implementing other maternity care home models, including representatives from the Center for Medicare and Medicaid Innovation; and (5) community-based health care professionals and other stakeholders. (e) Application and selection of States (1) In general A State seeking to participate in the demonstration project shall submit an application to the Secretary at such time and in such manner as the Secretary shall require. (2) Selection of States (A) In general The Secretary may select 15 States to participate in the demonstration project. (B) Selection requirements In selecting States to participate in the demonstration project, the Secretary shall— (i) ensure that there is geographic diversity in the areas in which activities will be carried out under the project; and (ii) ensure that States with significant disparities in maternal health outcomes, including disparities based on race, income, and access to maternity care, are included. (f) Grants (1) In general From amounts appropriated under subsection (l), the Secretary shall award 1 grant for each year of the demonstration project to each State that is selected to participate in the demonstration project. (2) Use of grant funds A State may use funds received under this section to— (A) award grants or make payments to eligible entities as part of an arrangement described in subsection (g)(2); (B) provide financial incentives to health care professionals, including community health workers, who participate in the State's maternity care home model; (C) provide training for health care professionals, including community health workers, who participate in the State's maternity care home model, which may include training for cultural competency, racial bias, and health equity, particularly in regards to maternal health; (D) pay for personnel and administrative expenses associated with designing, implementing, and operating the State's maternity care home model; (E) pay for items and services that are furnished under the State's maternity care home model and for which payment is otherwise unavailable under this title; and (F) pay for other costs related to the State's maternity care home model, as determined by the Secretary. (3) Grant for national independent evaluator (A) In general From the amounts appropriated under subsection (l), prior to awarding any grants under paragraph (1), the Secretary shall enter into a contract with a national external entity to create a single, uniform process to— (i) ensure that States that receive grants under paragraph (1) comply with the requirements of this section; and (ii) evaluate the outcomes of the demonstration project in each participating State. (B) Annual report The contract described in subparagraph (A) shall require the national external entity to submit to the Secretary— (i) a yearly evaluation report for each year of the demonstration project; and (ii) a final impact report after the demonstration project has concluded. (C) Secretary's authority Nothing in this paragraph shall prevent the Secretary from making a determination that a State is not in compliance with the requirements of this section without the national external entity making such a determination. (g) Partnership with eligible entities (1) In general As a condition of receiving a grant under this section, a State shall enter into an arrangement with one or more eligible entities that meets the requirements of paragraph (2). (2) Arrangements with eligible entities Under an arrangement between a State and an eligible entity under this subsection, the eligible entity shall perform the following functions, with respect to eligible individuals enrolled with the entity under the State's maternity care home model— (A) provide culturally competent care, which may include prenatal care, family planning services, medical care, mental and behavioral care, and oral health care to such eligible individuals through a team of health care professionals, which may include obstetrician-gynecologists, maternal-fetal medicine specialists, family physicians, primary care providers, physician assistants, advanced practice registered nurses such as nurse practitioners and certified nurse midwives, certified midwives, social workers, doulas, lactation consultants, childbirth educators, community health workers, and other health care professionals; (B) conduct a risk assessment of each such eligible individual to determine if her pregnancy is high or low risk, and establish a tailored pregnancy care plan, which takes into consideration the individual's own pregnancy care and birthing plans, for each such eligible individual based on the results of such risk assessment; (C) assign each such eligible individual to a care coordinator, which may be a nurse, social worker, doula, community health worker, or other health care provider, who is responsible for ensuring that such eligible individual receives the necessary medical care and connections to essential support services; (D) provide, or arrange for the provision of, essential support services, such as services that address— (i) nutrition and exercise; (ii) smoking cessation; (iii) substance use disorder and addiction treatment; (iv) anxiety, depression, and other mental and behavioral health issues; (v) breast feeding; (vi) housing; (vii) transportation; (viii) intimate partner violence; (ix) home visiting services; (x) childbirth education; (xi) continuous labor support; and (xii) group prenatal care. (E) as appropriate, facilitate connections to a usual primary care provider, which may be a women's health provider; (F) refer to guidelines and opinions of medical associations when determining whether an elective delivery should be performed on an eligible individual before 39 weeks of gestation; (G) provide such eligible individuals with evidence-based education and resources to identify potential warning signs of postpartum complications and when and how to obtain medical attention; (H) provide eligible individuals with postpartum health services, including family planning services; (I) track and report birth outcomes of such eligible individuals and their children; and (J) ensure that care is patient-led, including by engaging eligible individuals in their own care, including through communication and education. (h) Term of demonstration project The Secretary shall conduct the demonstration project for a period of 5 years. (i) Waiver authority To the extent that the Secretary determines necessary in order to carry out the demonstration project, the Secretary may waive section 1902(a)(1) (relating to statewideness) and section 1902(a)(10)(B) (relating to comparability). (j) Technical assistance The Secretary shall establish a process to provide technical assistance to States that are awarded grants under this section and to eligible entities and other providers participating in a State maternity care home model funded by such a grant. (k) Report (1) In general Not later than 18 months after the date of the enactment of this section and annually thereafter for each year of the demonstration project term, the Secretary shall submit a report to Congress on the results of the demonstration project. (2) Final report As part of the final report required under paragraph (1), the Secretary shall include— (A) the results of the final report of the national external entity required under subsection (f)(3)(B)(ii); and (B) recommendations on whether the model studied in the demonstration project should be continued or more widely adopted, including by private health plans. (l) Authorization of appropriations There are authorized to be appropriated to the Secretary, for each of fiscal years 2019 through 2026, such sums as may be necessary to carry out this section. . 4. Reapplication of Medicare payment rate floor to primary care services furnished under Medicaid and inclusion of additional providers (a) Reapplication of payment floor; additional providers (1) In general Section 1902(a)(13) of the Social Security Act ( 42 U.S.C. 1396a(a)(13) ) is amended— (A) in subparagraph (B), by striking ; and and inserting a semicolon; (B) in subparagraph (C), by striking the semicolon and inserting ; and ; and (C) by adding at the end the following new subparagraph: (D) payment for primary care services (as defined in subsection (jj)(1)) furnished in the period that begins on the first day of the first month that begins after the date of enactment of the Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services Act by a provider described in subsection (jj)(2)— (i) at a rate that is not less than 100 percent of the payment rate that applies to such services and the provider of such services under part B of title XVIII (or, if greater, the payment rate that would be applicable under such part if the conversion factor under section 1848(d) for the year were the conversion factor under such section for 2009); (ii) in the case of items and services that are not items and services provided under such part, at a rate to be established by the Secretary; and (iii) in the case of items and services that are furnished in rural areas (as defined in section 1886(d)(2)(D)), health professional shortage areas (as defined in section 332(a)(1)(A) of the Public Health Service Act ( 42 U.S.C. 254e(a)(1)(A) )), or medically underserved areas (according to a designation under section 330(b)(3)(A) of the Public Health Service Act ( 42 U.S.C. 254b(b)(3)(A) )), at the rate otherwise applicable to such items or services under clause (i) or (ii) increased, at the Secretary's discretion, by not more than 25 percent; . (2) Conforming amendments (A) Section 1902(a)(13)(C) of the Social Security Act ( 42 U.S.C. 1396a(a)(13)(C) ) is amended by striking subsection (jj) and inserting subsection (jj)(1) . (B) Section 1905(dd) of the Social Security Act ( 42 U.S.C. 1396d(dd) ) is amended— (i) by striking Notwithstanding and inserting the following: (1) In general Notwithstanding ; (ii) by striking section 1902(a)(13)(C) and inserting subparagraph (C) of section 1902(a)(13) ; (iii) by inserting or for services described in subparagraph (D) of section 1902(a)(13) furnished during an additional period specified in paragraph (2), after 2015, ; (iv) by striking under such section and inserting under subparagraph (C) or (D) of section 1902(a)(13), as applicable ; and (v) by adding at the end the following: (2) Additional periods For purposes of paragraph (1), the following are additional periods: (A) The period that begins on the first day of the first month that begins after the date of enactment of the Maximizing Outcomes for Moms through Medicaid Improvement and Enhancement of Services Act . . (b) Improved targeting of primary care Section 1902(jj) of the Social Security Act ( 42 U.S.C. 1396a(jj) ) is amended— (1) by redesignating paragraphs (1) and (2) as clauses (i) and (ii), respectively and realigning the left margins accordingly; (2) by striking For purposes of subsection (a)(13)(C) and inserting the following: (1) In general (A) Definition For purposes of subparagraphs (C) and (D) of subsection (a)(13) ; and (3) by inserting after clause (ii) (as so redesignated) the following: (B) Exclusions Such term does not include any services described in subparagraph (A) or (B) of paragraph (1) if such services are provided in an emergency department of a hospital. (2) Additional providers For purposes of subparagraph (D) of subsection (a)(13), a provider described in this paragraph is any of the following: (A) A physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine, or obstetrics and gynecology. (B) An advanced practice clinician, as defined by the Secretary, that works under the supervision of— (i) a physician that satisfies the criteria specified in subparagraph (A); (ii) a nurse practitioner or a physician assistant (as such terms are defined in section 1861(aa)(5)(A)) who is working in accordance with State law; or (iii) or a certified nurse-midwife (as defined in section 1861(gg)) who is working in accordance with State law. (C) A rural health clinic, Federally-qualified health center, or other health clinic that receives reimbursement on a fee schedule applicable to a physician. (D) An advanced practice clinician supervised by a physician described in subparagraph (A), another advanced practice clinician, or a certified nurse-midwife. . (c) Ensuring payment by managed care entities (1) In general Section 1903(m)(2)(A) of the Social Security Act ( 42 U.S.C. 1396b(m)(2)(A) ) is amended— (A) in clause (xii), by striking and after the semicolon; (B) by realigning the left margin of clause (xiii) so as to align with the left margin of clause (xii) and by striking the period at the end of clause (xiii) and inserting ; and ; and (C) by inserting after clause (xiii) the following: (xiv) such contract provides that (I) payments to providers specified in section 1902(a)(13)(D) for primary care services defined in section 1902(jj) that are furnished during a year or period specified in section 1902(a)(13)(D) and section 1905(dd) are at least equal to the amounts set forth and required by the Secretary by regulation, (II) the entity shall, upon request, provide documentation to the State, sufficient to enable the State and the Secretary to ensure compliance with subclause (I), and (III) the Secretary shall approve payments described in subclause (I) that are furnished through an agreed upon capitation, partial capitation, or other value-based payment arrangement if the capitation, partial capitation, or other value-based payment arrangement is based on a reasonable methodology and the entity provides documentation to the State sufficient to enable the State and the Secretary to ensure compliance with subclause (I). . (2) Conforming amendment Section 1932(f) of the Social Security Act ( 42 U.S.C. 1396u–2(f) ) is amended— (A) by striking section 1902(a)(13)(C) and inserting subsections (C) and (D) of section 1902(a)(13) ; and (B) by inserting and clause (xiv) of section 1903(m)(2)(A) before the period. 5. MACPAC report and CMS guidance on increasing access to doula care for Medicaid beneficiaries (a) MACPAC Report (1) In general Not later than 1 year after the date of the enactment of this Act, the Medicaid and CHIP Payment and Access Commission (referred to in this section as MACPAC ) shall publish a report on the coverage of doula care under State Medicaid programs, which shall at a minimum include the following: (A) Information about coverage for doula care under State Medicaid programs that currently provide coverage for such care, including the type of doula care offered (such as prenatal, labor and delivery, and postpartum care). (B) An analysis of barriers to covering doula care under State Medicaid programs. (C) An identification of effective strategies to increase the use of doula care in order to provide better care and achieve better maternal and infant health outcomes. (D) Recommendations for legislative and administrative actions to increase access to doula care in State Medicaid programs. (2) Stakeholder consultation In developing the report required under paragraph (1), MACPAC shall consult with relevant stakeholders, including— (A) States; (B) organizations representing consumers, including those that are disproportionately impacted by poor maternal health outcomes; (C) organizations and individuals representing doula care providers, including those who serve underserved communities; and (D) organizations representing health care providers. (b) CMS guidance (1) In general Not later than 1 year after the date that MACPAC publishes the report required under subsection (a)(1), the Administrator of the Centers for Medicare & Medicaid Services shall issue guidance to States on increasing access to doula care under Medicaid. Such guidance shall at a minimum include— (A) options for States to provide medical assistance for doula care services under State Medicaid programs; (B) best practices for ensuring that doulas receive reimbursement for doula care services provided under a State Medicaid program, which may include allowing organizations such as doula collectives to receive reimbursement directly for doula care services provided under the State Medicaid program; and (C) best practices for increasing access to doula care services under State Medicaid programs. (2) Stakeholder consultation In developing the guidance required under paragraph (1), the Administrator of the Centers for Medicare & Medicaid Services shall consult with MACPAC and other relevant stakeholders, including— (A) State Medicaid officials; (B) organizations representing consumers, including those that are disproportionately impacted by poor maternal health outcomes; (C) organizations representing doula care providers, including those who serve underserved communities; and (D) organizations representing health care professionals. 6. GAO report on State Medicaid programs' use of telemedicine to increase access to maternity care Not later than 1 year after the date of the enactment of this Act, the Comptroller General of the United States shall submit a report to Congress on State Medicaid programs' use of telemedicine to increase access to maternity care. Such report shall include the following: (1) The number of State Medicaid programs that utilize telemedicine to increase access to maternity care. (2) With respect to State Medicaid programs that utilize telemedicine to increase access to maternity care, information about— (A) common characteristics of such programs' approaches to utilizing telemedicine to increase access to maternity care; and (B) what is known about— (i) the demographic characteristics of the individuals enrolled in such programs who use telemedicine to access maternity care; (ii) health outcomes for such individuals as compared to individuals with similar characteristics who did not use telemedicine to access maternity care; (iii) the services provided to individuals through telemedicine, including family planning services; (iv) the quality of maternity care provided through telemedicine, including whether maternity care provided through telemedicine is culturally competent; (v) the level of patient satisfaction with maternity care provided through telemedicine to individuals enrolled in State Medicaid programs; and (vi) the impact of utilizing telemedicine to increase access to maternity care on spending, cost savings, access to care, and utilization of care under State Medicaid programs. (3) An identification and analysis of the barriers to using telemedicine to increase access to maternity care under State Medicaid programs. (4) Recommendations for such legislative and administrative actions related to increasing access to telemedicine maternity services under Medicaid as the Comptroller General deems appropriate.