Sec. 102. Health homes and medical homes
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health home Title XVIII of the Social Security Act is amended by adding at the end the following new section: In the case of a State that has amended its State plan under title XIX in accordance with the option described in section 1945, the Secretary may contract with the State medical assistance agency with a program under such section to serve eligible individuals with chronic conditions who select a designated provider, a team of health care professionals operating with such a provider, or a health team as the individual’s health home for purposes of providing the individual with health home services in the same manner as provided under its State plan amendment.
The standards established by the Secretary under section 1945(b) for qualification as a designated provider shall apply under this section for the purpose of being eligible to be a health home for purposes of section 1945. Payments shall be made under this section in the same manner to a provider or team as payments are made under subsection
(c)of section 1945, including the use of the payment methodology described in paragraph
(2)of such subsection. Hospitals that are participating providers under this section shall establish procedures for referring any eligible individuals with chronic conditions who seek or need treatment in a hospital emergency department to designated providers in the same manner as required under section 1945(d). The methodology and proposal required under subsection
(f)of section 1945 and the report on quality measures under subsection
(f)of such section shall also apply under this section. As a condition for receiving payment for health home services provided to an eligible individual with chronic conditions, a designated provider shall report, in accordance with such requirements as the Secretary shall specify, including a plan for the use of remote patient monitoring, on all applicable measures for determining the quality of such services. When appropriate and feasible, a designated provider shall use health information technology in providing the Secretary with such information. In this section, the provisions and definitions contained in subsection
(h)of section 1945 shall also apply for purposes of this section except that, instead of the requirement specified in clause
(i)of subsection (h)(1)(A) of such section, an individual must be eligible for services under parts A and B and covered for medical assistance for health home services under section 1945 in order to be an eligible individual with chronic conditions. In contracting with a State under this section, the State— shall follow evidence-based guidelines for chronic care; and shall report at least by the end of every month data specified by the Secretary, including an assessment of the use of remote patient monitoring and quality measures of process, outcome, and structure. The limitations on telehealth under section 1834(m) shall not apply for purposes of this section. The Secretary may waive such other requirements of this title and title XIX as may be necessary to carry out the provisions of this section. . Not later than 2 years after the date of the enactment of this Act, the Secretary of Health and Human Services shall survey States contracting under section 1899B of the Social Security Act, as added by paragraph (1), on the nature, extent, and use of the option under such section particularly as it pertains to— hospital admission rates; chronic disease management; coordination of care for individuals with chronic conditions; assessment of program implementation; processes and lessons learned (as described in subparagraph (B)); assessment of quality improvements and clinical outcomes under such option; and estimates of cost savings. Such a State shall report to the Secretary, as necessary, on processes that have been developed and lessons learned regarding provision of coordinated care through a health home for beneficiaries with chronic conditions under such option. Title XVIII of the Social Security Act, as amended by subsection (a), is further amended by adding at the end the following new section: Beginning not later than 30 days after the date of the enactment of this section, the Secretary may contract with a national or multi-state regional center of excellence with a network of affiliated local providers to provide through one or more medical homes for targeted, accessible, continuous, and coordinated care to individuals under this title and title XIX with a long-term illness or medical condition that requires regular medical treatment, advising, and monitoring. In this section, the term medical home means a medical entity that— specializes in the care for a specific long-term illness or medical condition, including related comorbidities; leads the development of related evidence-based clinical standards and research; has a network of affiliated personal physicians and patient treatment facilities; maintains an online Web site for patient and provider communication and collaboration and patient access to the patient’s health information; has a plan for use of health information technology in providing services under this section and improving service delivery and coordination across the care continuum (including the use of wireless patient technology to improve coordination and remote patient monitoring management of care and patient adherence to recommendations made by their provider); provides deidentified demographic data sets for clinical, statistical, and social science research to develop culturally competent best practices and clinical decision support mechanisms for the long-term illness or medical condition; uses a health assessment tool for the individuals targeted, including a means for identifying those most likely to benefit from remote patient monitoring; and provides training programs for personnel involved in the coordination of care. In this section, the term personal physician means a physician (as defined in section 1861(r)(1)) who meets the requirements described in paragraphs
(2)and (3). Nothing in this paragraph shall be construed as preventing a personal physician from being a specialist or subspecialist for an individual requiring ongoing care for a specific chronic condition or multiple chronic conditions or for an individual with a long-term illness or medical condition. The requirements described in this paragraph for a personal physician for care of an individual are as follows: The physician is board certified for care of the specific illness or condition of the individual and manages continuous care for the individual. The physician has the staff and resources to manage the comprehensive and coordinated health care of such individual. The requirements described in this paragraph for a personal physician are as follows: The personal physician advocates for and provides ongoing support, oversight, and guidance to implement a plan of care that provides an integrated, coherent, cross-discipline plan for ongoing medical care developed in partnership with patients and including all other physicians furnishing care to the patient involved and other appropriate medical personnel or agencies (such as home health agencies). The personal physician uses evidence-based medicine and clinical decision support tools to guide decisionmaking at the point-of-care based on patient-specific factors. The personal physician is in compliance with the standards for meaningful use of electronic health records under this title. The personal physician participates with the State’s health information exchange, as available, or the federally sponsored Direct Project. The personal physician uses health information technology, including appropriate remote monitoring, to monitor and track the health status of patients and to provide patients with enhanced and convenient access to health care services. The personal physician uses electronic prescribing and provides medication management. The personal physician encourages patients to engage in the management of their own health through education and support systems. The personal physician utilizes the services of related health professionals, including nurse practitioners and physician assistants. In this section, the term long-term illness or medical condition — includes a chronic condition which meets criteria specified by the Secretary for a specialized MA plan for special needs individuals; and also includes another condition that the Secretary determines would provide a beneficial focus for an effective and efficient medical home. Except as provided in paragraph (2)— Under this section the Secretary shall provide for payment under section 1848 of a care management fee to the medical home and may include performance incentives. The medical home shall arrange for payment for the services of affiliated physicians and facilities. The Secretary shall provide for payment under this section of a medical home based on the payment methodology applied to health group practices under section 1866A. Under such methodology, 80 percent of the reductions in expenditures under this title and title XIX resulting fro m participation of individuals that are attributable to the medical home (as reduced by the total care management fees paid to the medical home under this section) shall be paid to the medical home. The amount of such reductions in expenditures shall be determined by using assumptions with respect to reductions in the occurrence of health complications, hospitalization rates, medical errors, and adverse drug reactions. The Secretary may provide for payment under this paragraph instead of the amounts otherwise payable under paragraph (1). For purposes of this paragraph, the Secretary shall compute an estimated annual spending target based on the amount the Secretary estimates would have been spent in the absence of this section, for items and services covered under parts A and B furnished to applicable beneficiaries for each qualifying medical home under this section. Such spending targets shall be determined on a per capita basis. Such spending targets shall include a risk corridor that takes into account normal variation in expenditures for items and services covered under parts A and B furnished to such beneficiaries with the size of the corridor being related to the number of applicable beneficiaries furnished services by each medical home. The spending targets may also be adjusted for such other factors as the Secretary determines appropriate. Subject to performance on quality measures, a qualifying medical home is eligible to receive an incentive payment under this section if actual expenditures for a year for the applicable beneficiaries it enrolls are less than the estimated spending target established under subparagraph
(B)for such year. An incentive payment for such year shall be equal to a portion (as determined by the Secretary) of the amount by which actual expenditures (including incentive payments under this paragraph) for applicable beneficiaries under parts A and B for such year are estimated to be less than 95 percent of the estimated spending target for such year, as determined under subparagraph (B). Payments paid under this section shall be made in appropriate proportions (as specified by the Secretary) from the Hospital Insurance Trust Fund, the Federal Supplementary Medical Insurance Trust Fund, and funds appropriated to carry out title XIX. The contracting entity shall follow evidence-based guidelines for care of the long-term illness or medical condition under this section. The contracting entity shall report at least by the end of every month data specified by the Secretary on the operation of this section, including quality measures of process, outcome, and structure. The limitations on telehealth under section 1834(m) shall not apply for purposes of this section. The Secretary may waive such other requirements of this title and title XIX as may be necessary to carry out the provisions of this section. .