II 116th CONGRESS 2d Session S. 4863 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. 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 . 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: 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. .