Sec. 201. Medicaid option for high-risk pregnancies and births
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/bill/113/s/2662/is/section-201A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Title XIX of the Social Security Act is amended by adding at the end the following new section: Notwithstanding section 1902(a)(1) (relating to statewideness), section 1902(a)(10)(B) (relating to comparability), and any other provision of this title for which the Secretary determines it is necessary to waive in order to implement this section, beginning 6 months after the date of the enactment of this section, a State, at its option as a State plan amendment, may provide for medical assistance under this title to eligible individuals for maternal-fetal and neonatal care who select a designated provider (as described under subsection (h)(5)), a team of health care professionals (as described under subsection (h)(6)) operating with such a provider, or a health team (as described under subsection (h)(7)) as the individual’s birthing network for purposes of providing the individual with pregnancy-related services.
The Secretary shall establish standards for qualification as a designated provider for the purpose of being eligible to be a birthing network for purposes of this section. 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 birthing network services to each eligible individual for maternal-fetal and neonatal care that selects such provider, team of health care professionals, or health team as the individual’s birthing network.
Payments made to a designated provider, a team of health care professionals operating with such a provider, or a health team for such services shall be treated as medical assistance for purposes of section 1903(a), except that, during the first 8 fiscal year quarters that the State plan amendment is in effect, the Federal medical assistance percentage applicable to such payments shall be equal to 90 percent. As a condition for approval of a State plan amendment and payment methodology under this section, the State shall provide the Secretary with assurances that the amendment and methodology shall be projected to reduce the amount of expenditures for pregnancy-related services otherwise made under this title by one percent for each 4-calendar-quarter period during the first 40 calendar quarters in which the amendment is in effect.
The State shall specify in the State plan amendment the methodology the State will use for determining payment for the provision of birthing network services. Such methodology for determining payment shall be established consistent with section 1902(a)(30)(A). The methodology for determining payment for provision of birthing network services under this section shall not be limited to a per-member per-month basis and may provide (as proposed by the State and subject to approval by the Secretary) for alternate models of payment, including bundled per episode, performance incentives, and shared savings.
Beginning 30 days after the date of the enactment of this section, the Secretary may award planning grants to States for purposes of developing a State plan amendment under this section. A planning grant awarded to a State or a multi-state collaborative under this paragraph shall remain available until expended. The total amount of payments made to States under this paragraph shall not exceed $25,000,000. As a condition for receiving payment for birthing network services provided to an eligible individual for maternal-fetal and neonatal care, a designated provider shall report monthly to the State, in accordance with such requirements as the Secretary shall specify, 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 State with such information. The birthing network shall adapt, update, and follow evidence-based guidelines for maternal-fetal and neonatal care. In this section: Subject to subparagraph (B), the term eligible individual means an individual who— is eligible for medical assistance under the State plan or under a waiver of such plan; and is pregnant (or was pregnant during the immediately preceding 30 day period); or is the child of an individual described in clause
(i)and under 30 days old. Nothing in this paragraph shall prevent the Secretary from establishing other requirements for purposes of determining eligibility for receipt of birthing network services under this section. The term birthing network means a designated provider (including a provider that operates in coordination with a team of health care professionals) or a health team selected by an eligible individual to provide birthing network services. The term birthing network 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 and are identified in a provider registry. The services described in this subparagraph are— comprehensive care coordination; health promotion; a call center to offer 24-hour physician support for consultations with maternal-fetal medicine specialists, when requested, regarding patient management issues; newborn screening, including for heart defects and to reduce newborn hospital readmissions; patient and family support (including authorized representatives); referral to community and social support services, if relevant; and use of health information technology to link services and provide monitoring, as feasible and appropriate. The term designated provider means a physician, clinical practice or clinical group practice, rural clinic, community health center, public health agency, home health agency, or any other entity or provider (including pediatricians, gynecologists, and obstetricians) that is determined by the State and approved by the Secretary to be qualified to be a birthing network for eligible individuals on the basis of documentation evidencing that the physician, practice, or clinic— has the systems and infrastructure in place to provide birthing network services; and satisfies the qualification standards established by the Secretary under subsection
(b)and paragraph (7)(B). The term team of health care professionals means a team of health professionals (as described in the State plan amendment) that may— include physicians and other professionals, such as a nurse care coordinator, midwife, nutritionist, social worker, behavioral health professional, or any professionals deemed appropriate by the State; and be free standing, virtual, or based at a hospital, community health center, rural clinic, clinical practice or clinical group practice, academic health center, or any entity deemed appropriate by the State and approved by the Secretary. The term health team has the meaning given such term for purposes of section 3502 of the Patient Protection and Affordable Care Act. A State shall include in the State plan amendment a proposal for use of health information technology in providing birthing network 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 management of care and patient adherence to recommendations made by their provider). The birthing network shall— be in compliance with the Medicaid standards for meaningful use of electronic health records; participate with the State’s health information exchange, as available, or operate an exchange among the birthing network; collect demographic information on participating newborns and mothers; use demographic and event-based data to identify patients that are likely going to need short or long-term follow-up; and providing de-identified demographic data sets for statistical and social science research to develop culturally competent best practices and clinical decision support mechanisms for maternal-fetal and neonatal care. . Not later than 3 years after the date of the enactment of this Act, the Secretary of Health and Human Services shall survey States that have elected the option under section 1947 of the Social Security Act, as added by section (a), on the nature, extent, and use of such option, particularly as it pertains to— terms of pregnancies; use of prenatal fetal monitoring; use of Caesarean section procedures; use of neonatal intensive care services; incidence of birthing complications; incidence of infant and maternal mortality; coordination of maternal-fetal and neonatal care for individuals; assessment of program implementation; processes and lessons learned (as described in subparagraph (B)); assessment of quality improvements and clinical outcomes under such option; and participating mothers’ assessment of performance, quality, convenience, and satisfaction. A State that has elected the option under such section shall report to the Secretary, as necessary, on processes that have been developed and lessons learned regarding provision of coordinated care through a birthing network for Medicaid beneficiaries for maternal-fetal and neonatal care under such option.