Chronic care improvement demonstration program for Medicaid beneficiaries with severe mental illnesses

(a)

Definitions

In this section: (1)

Chronic care improvement program operator

(A)

In general

Subject to subparagraph (B), the term chronic care improvement program operator means a qualified community program under section 1913(b)(1) of the Public Health Service Act that has entered into a chronic care improvement program operator agreement that meets the requirements of subsection (e) with a participating State to carry out, directly or through contracts with subcontractors, a severe mental illness chronic care improvement demonstration program for targeted beneficiaries in the State. (B)

Other entities permitted

Subject to approval by the Secretary, such term may include any other entity that a participating State determines is appropriate to carry out a severe mental illness chronic care improvement demonstration program for targeted beneficiaries in the State. (2)

Medicaid

The term Medicaid means the Federal-State medical assistance program established under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.). (3)

Participating state

The term participating State means a State with an approved application that has entered into a chronic care improvement demonstration agreement with the Secretary to conduct a severe mental illness chronic care improvement demonstration program under this section. (4)

Secretary

The term Secretary means the Secretary of Health and Human Services. (5)

Severe mental illness chronic care improvement demonstration program

The term severe mental illness chronic care improvement demonstration program means a program described in subsection (d) that is conducted pursuant to a chronic care improvement demonstration agreement between the Secretary and a participating State. (6)

State

The term State has the meaning given that term for purposes of Medicaid. (7)

Threshold condition

(A)

In general

The term threshold condition means a chronic mental illness such as schizophrenia, schizoaffective disorder, bipolar disorder, major clinical depression, or such conditions with co-occurring substance abuse disorders. (B)

Other state-specified conditions

Such term includes other conditions contained in the Diagnostic and Statistical Manual of Mental Disorders IV published by the American Psychiatric Association (or any successor publication by such Association) selected by the participating State as appropriate criteria for selection of targeted beneficiaries for participation in a severe mental illness chronic care improvement demonstration program. (8)

Targeted beneficiary

(A)

In general

The term targeted beneficiary means an adult individual who— (i)is entitled to benefits under the State Medicaid plan (or a waiver of such plan); (ii)has 1 or more of the threshold conditions; and (iii)has been identified by the State as likely to benefit from participation in a severe mental illness chronic care improvement demonstration program. (B)

Voluntary participation

A targeted beneficiary may participate in a severe mental illness chronic care improvement demonstration program on a voluntary basis and may terminate participation at any time. (b)

Authority To conduct demonstration program

(1)

Chronic care improvement demonstration agreements

(A)

In general

The Secretary shall enter into chronic care improvement demonstration agreements with States that submit approved applications under this section to provide for the development, testing, evaluation, and implementation of severe mental illness chronic care improvement demonstration programs in accordance with this section. (B)

Period

A chronic care improvement demonstration agreement entered into by the Secretary and a participating State shall be for a period of 4 years. (C)

Deadline for initial agreements

Not later than October 1, 2010, the Secretary shall enter into chronic care improvement demonstration agreements with not more than 10 participating States to conduct a severe mental illness chronic care improvement demonstration program under this section. (2)

Chronic care improvement program operator agreements

A chronic care improvement demonstration agreement entered into between the Secretary and a participating State shall require the participating State to enter into chronic care improvement program operator agreements, consistent with subsection (e), with chronic care improvement program operators to carry out the severe mental illness chronic care improvement demonstration program in the State. (3)

Post-demonstration plan for continuity of services

A State desiring to conduct a severe mental illness chronic care improvement demonstration program under this section shall include in its application to be selected as a participating State a plan for ensuring continuity of services for targeted beneficiaries who are participating in the program on any date (expected or unexpected) that the demonstration program ceases to be conducted in the State. (c)

Payments; funding

(1)

In general

Beginning October 1, 2010, the Secretary shall provide for payments for not more than 10 participating States to conduct a severe mental illness chronic care improvement demonstration program in accordance with the requirements of this section. (2)

Manner of payment

Payment to a State under this section shall be made in the same manner as other payments are made to the State under section 1903(a) of the Social Security Act (42 U.S.C. 1396b(a)). (3)

No state match required

No State shall be required to provide State matching funds as a condition for receiving payments under this section. (4)

Funding

(A)

Limitation on funds

The total amount of payments under this section shall not exceed $250,000,000 for the period of fiscal years 2011 through 2014. (B)

Budget authority

This section constitutes budget authority in advance of appropriations Acts and represents the obligation of the Secretary to provide for the payment of amounts provided under this section. (C)

Limitation on payments

In no case may— (i)the aggregate amount of payments made by the Secretary to a participating State for administrative expenses relating to conducting a severe mental illness chronic care improvement demonstration program under this section exceed 10 percent of the aggregate amount of payments made to the State under this section; and (ii)payments be provided by the Secretary under this section for services provided under a severe mental illness chronic care improvement demonstration program conducted under this section for any fiscal year after fiscal year 2014. (d)

Severe mental illness chronic care improvement demonstration program

(1)

In general

A severe mental illness chronic care improvement demonstration program shall be designed to improve the health outcomes and satisfaction of targeted beneficiaries participating in the program and shall— (A)provide such beneficiaries with regular screening, registry tracking, and outcome measurement processes at the time of psychiatric visits for, among other purposes, developing an individualized, goal-oriented care management plan that satisfies the requirements of paragraph (2); (B)provide each such beneficiary with such a plan; and (C)carry out such plan and other chronic care improvement activities carried out by the State; (2)

Elements of care management plan

A care management plan for a targeted beneficiary shall be developed with the beneficiary using person-centered planning principles and shall, to the extent appropriate, include the following: (A)Explicit general health care goals, measured on a regular basis, such as— (i)improved access to primary care services; (ii)improved prevention; (iii)early identification and intervention to avoid serious health issues; and (iv)better management of chronic diseases, including but not limited to hypertension, diabetes, obesity, and cardiovascular disease. (B)A designated point of contact responsible for communications with the beneficiary and for facilitating communications with other health care and related community providers under the plan. (C)Coordination and communication with family members who are actively engaged in supporting the targeted beneficiary's participation in the program. (D)Self-care education for the beneficiary in recognizing and managing symptoms of threshold conditions, educating parents and family members, and educating physicians and medical specialists as appropriate. (E)Education for physicians and other community providers on required collaboration to enhance communication of relevant clinical information. (F)Active coordination of supportive community services, including peer support, transportation, day care, personal assistance, housing, primary care (including accompanying targeted beneficiaries to medical appointments), mental health care, and other required services. (G)The use of monitoring technologies that enable patient guidance through the exchange of pertinent clinical information. (e)

Terms and conditions of chronic care improvement program operator agreements

(1)

Requirements

A chronic care improvement program operator agreement entered into under this section between a participating State and a chronic care improvement program operator shall require the operator, with respect to targeted beneficiaries enrolled in the program and covered by the agreement, to— (A)guide the beneficiaries in managing their health (including all co-occurring medical or surgical conditions, relevant health care services, and pharmaceutical needs) and in performing activities as specified under each such beneficiaries care management plan; (B)use decision-support tools, such as evidence-based practice guidelines, medication algorithms, or other criteria as determined by the Secretary; (C)arrange for core medical home team staff members, such as medical nurse practitioners, primary care supervising physicians, and embedded nurse care managers; (D)initiate wellness activities, including smoking cessation and weight management and physical exercise programs; (E)participate with the State to develop a clinical information database to track and monitor the beneficiaries across settings and to evaluate outcomes; (F)monitor and report to the participating State, in a manner specified by the Secretary, on health care quality, cost, outcomes, and clinical milestones in achieving recovery from mental illnesses and co-occurring addiction disorders; (G)meet medical home quality standards, as promulgated by the National Committee on Quality Assurance (NCQA) or such other quality assurance organizations as the Secretary may specify; (H)meet such clinical, quality improvement, financial, and other requirements as the participating State deems to be appropriate for the targeted beneficiaries to be served; and (I)comply with such additional requirements as the participating State may specify. (2)

Optional services

The chronic care improvement program operator agreement may permit a chronic care improvement program operator to— (A)use intake assessment, health examination, medication management, vital signs monitoring, preventive healthcare, disease specific goals implementation, patient health education, or other primary care or general healthcare services as deemed appropriate by the operator to carry out the program; (B)be recognized as a patient-centered medical home in accordance with paragraph (4); and (C)where feasible, to collaborate with primary care providers, including federally qualified health centers or other community health centers, to provide the services described in clause (i). (3)

Manner of payment

The chronic care improvement program operator agreement shall provide that the State shall pay the chronic care improvement program operator in accordance with a methodology developed by the Secretary for determining payment. (4)

Patient-centered medical home recognition

The Secretary shall enter into an agreement with the National Committee for Quality Assurance (NCQA), or other quality assurance organization with appropriate experience evaluating patient-centered medical homes as the Secretary may specify, for the purposes of granting patient-centered medical home status to qualified chronic care improvement operator sites. (f)

Independent evaluation

(1)

In general

The Secretary shall conduct an independent evaluation of the severe mental chronic care improvement demonstration programs conducted under this section. Such evaluation shall be done by grant, contract, or interagency agreement with an entity with knowledge of severe mental illness chronic care improvement programs and demonstrated experience in the evaluation of such programs. The evaluation shall include an assessment of whether the State demonstration programs conducted under this section— (A)enhance coordination and integration of primary care and community mental health and substance use disorder services; (B)improve prevention, early identification, and intervention to avoid serious health issues, including chronic diseases; (C)improve the overall health status of targeted beneficiaries using a patient-centered approach; and (D)produce financial outcomes, including any cost savings to Medicaid. (2)

Inclusion of family members

The Secretary shall ensure that the evaluation collects and assesses information from family members who are involved with supporting a targeted beneficiary's participation in a severe mental illness chronic care improvement demonstration program conducted under this section with respect to the results of the beneficiary's participation in the program. (3)

Report to congress

The Secretary shall submit a report to Congress on the results of the evaluation conducted under this subsection. The report shall include such recommendations as the Secretary determines appropriate to— (A)guide the development of future programs that provide comprehensive and integrated behavioral and physical health care services to the severely mentally ill; (B)assist pediatric populations (with adjustments made based on age-related clinical profiles); and (C)assist Medicare beneficiaries under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.). (g)

Rules of construction

Nothing in this section shall be construed as— (1)expanding the amount, duration, or scope of benefits under a State Medicaid plan (or waiver of such plan); (2)providing an individual entitlement to participate in a severe mental illness chronic care improvement demonstration program; or (3)providing any hearing or appeal rights with respect to a severe mental illness chronic care improvement demonstration program established under this section. (h)

Clarification of medicaid reimbursement for integrated mental health and primary care services

Not later than October 1, 2010, the Secretary shall provide, by regulation, for changes to requirements under Medicaid relating to reimbursement for primary care and behavioral health services to the same patient, on the same day, at the same service site, so as to permit payment for the provision of both types of services on the same day to the same patient. (i)

Secretarial oversight and coordination

The Secretary shall establish procedures to promote active and effective coordination, collaboration, and communication among the agencies, administrations, and centers of the Department of Health and Human Services that are responsible for any matter relating to the conduct or evaluation of the severe mental illness chronic care improvement demonstration programs carried out under this section.