Sec. 763. HIV integrated services delivery model demonstration
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Consistent with the National HIV/AIDS Strategy for the United States and in accordance with this section, the Secretary of Health and Human Services acting through the Center for Medicare & Medicaid Innovation and in cooperation with CDC, HRSA, SAMHSA, and HUD, shall conduct a 3-year demonstration project that is designed to integrate services and funding under the Medicare and Medicaid programs, under HIV-related programs conducted by the CDC, and under the Ryan White HIV/AIDS Program, to reduce new HIV infections, to increase the proportion of people who know their status, to increase access to care, to improve health outcomes, to reduce HIV-related health disparities among Medicaid and Medicare beneficiaries, and to reduce the cost of care provided to HIV positive Medicare and Medicaid beneficiaries.
The objectives of the demonstration are the following: To ensure the early identification of HIV positive beneficiaries to reduce costly HIV-related clinical conditions through HIV screening and rapid linkage to high quality HIV medical care. To reduce new HIV infections among Medicaid and Medicare beneficiaries through routine HIV testing, prevention services for HIV negative beneficiaries, and intensive “prevention for positive” services for HIV positive beneficiaries. To reduce morbidity, mortality, and high cost inpatient and specialty care among HIV positive beneficiaries by ensuring access to high quality HIV medical care, HIV medications, and support services.
To promote HIV treatment adherence and retention in care through intensive case management, treatment education, and outreach services. To effectively treat behavioral health conditions among HIV positive beneficiaries that impair their HIV treatment adherence and lead to secondary HIV infections through services funded under Medicare and Medicaid and programs administered by SAMHSA. To promote independence, treatment adherence, and stable housing for HIV positive beneficiaries through highly coordinated HIV health, housing, and support services funded by HRSA and HUD.
The Secretary shall design the demonstration to test both— the service delivery model described in paragraph (2); and the payment model described in paragraph (3). Under the service delivery model described in this paragraph, the demonstration shall test comprehensive HIV testing, linkage to care, HIV medical care, and ancillary services to individuals enrolled under Medicare, Medicaid, or both. The service delivery model will integrate services furnished under Medicare and Medicaid with prevention services funded by CDC for HIV positive beneficiaries, intensive case management services funded by HRSA, behavioral services funded by SAMHSA, and housing assistance services funded through HUD.
The model under this paragraph shall have the following 8 core elements: HIV testing services that apply the CDC’s 2006 recommendations for universal opt-out testing among Medicare and Medicaid beneficiary populations. Rapid linkage from HIV testing settings to treatment for HIV positive beneficiaries to ensure they are engaged in care in a timely basis. Access to high quality HIV experienced medical care, laboratory monitoring, HIV medications, and other required services. Routine screening and treatment for HIV-related and other chronic conditions, including behavioral health.
Prevention and treatment education services, including an adapted Medication Therapy Management
(MTM)program model, to optimize the benefit of HIV therapeutics. Risk-stratified medical case management. Provision of preventive care, including counseling to prevent secondary HIV infection. Wrap-around support and housing services. Under the payment model described in this paragraph, the demonstration shall test the following: A prepaid capitated payment model that adjusts payment for HIV and behavioral health acuity, to be applied under contracts with managed care organizations with demonstrated HIV experience. Use of funds under the Ryan White HIV/AIDS Program to purchase capitated services from the contracted managed care organizations. Provision of additional funds to support services to the extent that Medicaid and Medicare coverage is limited, including for services such as HIV testing (for Medicaid beneficiaries), medical case management, prevention case management, treatment education, case finding, behavioral health services, and housing assistance. Beneficiaries eligible for participation in the demonstration are the following: Fee-for-service Medicaid beneficiaries 18 years of age or older. Individuals who are— entitled to medical assistance under Medicaid; and entitled to benefits under part A, and enrolled under part B, of Medicare but are not enrolled under a Medicare Advantage plan under Medicare. Consistent with the National HIV/AIDS Strategy for the United States, Federal agencies shall coordinate their funding for the selected States or cities covered under the demonstration to provide resources to fund the delivery of services within the demonstration. In carrying out the demonstration, the Secretary shall— design the application process; solicit applications from 5 to 7 State Medicaid agencies to host the demonstration; with respect to the service delivery model described in subsection (c)(2), collaborate with the CDC, HRSA, and the National Institutes of Health to design a minimum service delivery model that reflects the current standard of care as established by the Public Health Service and CDC guidelines and recommendations; and fund an evaluation of the demonstration to ensure collection of system, provider, and beneficiary-level data to address their routine reporting requirements. The Secretary may carry out the Secretary’s authority under this paragraph through CMMI. The CDC shall collaborate with the Secretary and CDC-funded HIV prevention grantees in the selected States and cities to provide technical assistance to design cost-effective HIV and sexually transmitted infection
(STI)screening and testing services for Medicaid and Medicare beneficiaries, including partner notification services and communicable disease reporting. CDC and CMS shall determine the extent to which testing funds shall be supported jointly or separately by these agencies. HRSA shall allocate funds available through the Special Projects of National Significance
(SPNS)Initiative Program (under subpart I of part F of the Ryan White HIV/AIDS Program) to support wrap-around core and support services not covered under Medicare or Medicaid and shall authorize the use of Ryan White HIV/AIDS Program funds to purchase services through capitated managed care programs that meet or exceed the services covered by the Ryan White HIV/AIDS Program at rates that are no greater than current per capita expenditures. HRSA is authorized to use funds under SPNS, and to waive such requirements of SPNS as may be necessary, to carry out the demonstration. SAMHSA shall allocate funds through the Minority HIV/AIDS Initiative or other programs to support behavioral health services not covered under Medicare or Medicaid. HUD shall directly allocate funds under the Housing Opportunities for People With AIDS (HOPWA) program to the States or cities participating in the demonstration to provide supportive housing and other housing assistance to beneficiaries who otherwise meet HOPWA eligibility criteria. HUD is authorized to use such HOPWA funds, and to waive such requirements under HOPWA as may be necessary, to carry out the demonstration. Single State agencies responsible for administration of the Medicaid program for individuals who are accepted to participate in the demonstration shall— collaborate with CMS to design or refine a prepaid capitated payment model, to allocate and award contracts with capitated managed care plans, to ensure such plans meet State statutory or regulatory requirements, to contract with a coordinating agency to organize and deliver integrated HIV testing, medical care, support, and housing services funded under Medicare and Medicaid, other Federal, State, and local government sponsors, and to coordinate their activities with the State HIV/AIDS program; and identify and contract with a coordinating agency to organize the demonstration in the State, to establish a coordinating body representing State, local, and provider agencies participating in the demonstration, to establish systems of care that integrate HIV prevention, testing, treatment, support, and housing services, to establish mechanisms to gather evaluation data for reporting to CMMI and other participating Federal agencies, and to establish a quality management program to monitor provider performance in delivering the services provided to participating beneficiaries under the demonstration. Capitated managed care organizations participating in the demonstration shall organize and deliver services as specified by the minimum service delivery model established by CMMI through a network of providers with demonstrated HIV experience, high quality, and sufficient provider capacity. In this section: The term CDC means the Director of the Centers for Disease Control and Prevention. The term CMMI means the Director of the Center for Medicare & Medicaid Innovation. The term CMS means the Administrator of the Centers for Medicare & Medicaid Services. The term demonstration means the demonstration conducted under this section. The term HRSA means the Administrator of the Health Resources and Services Administration. The term HUD means the Secretary of Housing and Urban Development. The terms Medicare and Medicaid mean the programs under titles XVIII and XIX, respectively, of the Social Security Act. The term National HIV/AIDS Strategy for the United States has the meaning given such term under section 241A(b) of the Public Health Service Act. The term Ryan White HIV/AIDS Program means the program under title XXVI of the Public Health Service Act. The term SAMHSA means the Substance Abuse and Mental Health Services Administration. The term Secretary means the Secretary of Health and Human Services, acting through CMMI.