This bill — the Medicaid Services Investment and Accountability Act of 2019 — would extend Medicaid recipients’ protections against spousal impoverishment; establish a state Medicaid option to provide coordinated care to children with complex medical conditions in health homes; prevent the misclassification of drugs in the Medicaid drug rebate program; and extend a number of public health programs.
Extension of Medicaid Recipients’ Protections Against Spousal Impoverishment
This section of the bill would extend an existing provision in the Medicaid Extenders Act of 2019 that disregards a spouse’s income when determining eligibility for home- and community-based services through September 30, 2019.
State Medicaid to Provide Coordinated Care for Children with Complex Medical Conditions in Health Homes
This section of the bill would permit state Medicaid plans to provide medical assistance to children with complex medical conditions through health home services, and provide two quarters of enhanced federal matching funds for states’ payments to health homes. This would entail selecting a designated provider, team of health care professionals operating under a designated provider, or a health team to serve as the child’s health home team.
It’d also establish procedures for the HHS Secretary to set standards for such programs, gather input from stakeholders to craft such programs, monitor such programs’ success, and collect data on such programs’ use. Additionally, the bill would establish state reporting requirements for states to report to the DHS Secretary, Medicaid, and the CHIP Payment and Access Commission on their program participation numbers and patient characteristics.
Children with “medically complex conditions” are defined as individuals under 21 years of age who are 1) eligible for state Medicaid assistance and 2) have one or more chronic conditions affecting three or more organ systems and which severely reduce cognitive or physical functions and require the use of medication, durable medical equipment, therapy, surgery, or other treatments or have one life-limiting illness or rare pediatric disease.
“Chronic conditions” would be defined as serious, long-term physical, mental, or developmental disabilities or diseases, including cerebral palsy, cystic fibrosis, HIV/AIDS, blood diseases (i.e., anemia or sickle cell disease), muscular dystrophy, spina bifida, epilepsy, severe autism spectrum disorder, and serious emotional disturbance or serious mental health issues.
“Home health services” includes comprehensive care management; care coordination, health promotion, and provision of access to the full range of pediatric speciality and subspecialty medical services, including services from out of state providers as medically necessary; comprehensive transitional care, including appropriate follow-up, from inpatient to other settings; patient and family support; referrals to community and social support services, if relevant; and use of health information technology to link services, as feasible and appropriate.
Extension of the Community Mental Health Services Demonstration Program
This section of this bill would extend the community mental health services demonstration program for another two years, or through June 30, 2019, whichever period is longer.
Additional Funding for the Money Follows the Person Rebalancing Demonstration
This section of the bill would provide an additional $20 million in funding for the Money Follows the Person Program.
Preventing the Misclassification of Drugs Under the Medicaid Drug Rebate Program
This section of this bill would establish a civil monetary policy for misclassifying covered outpatient drugs. Any manufacturer that knowingly misclassifies a covered outpatient drug, such as by knowingly submitting incorrect drug product information, would be subject to a civil monetary penalty of up to two times the amount of the difference between:
The total amount of rebates for the drug that the manufacturer paid to all states for all rebate periods during which the drug was misclassified; and
The total amount of rebates for the drug that the manufacturer would have been required to pay to all states for all rebate periods during which the drug was misclassified if it’d been correctly classified, as determined by the DHS Secretary. If a manufacturer paid a lower per-unit rebate because of a drug misclassification, regardless of whether it was done knowingly, the company would have to pay back the difference.
This bill would require HHS to notify manufacturers of any misclassified drugs, regardless of whether or not the classifications were intentional. Manufacturers would then be required to correct misclassifications in a timely manner. If a manufacturer failed to correct misclassifications in a timely manner, HHS could correct the misclassification on the manufacturer’s behalf, suspend Medicaid coverage of the drug in question, and/or impose additional civil monetary penalties of up to 23.1 percent of the drug’s average price.
Every year, the HHS Secretary would retain 25 percent of all civil money penalties collected under this section of this bill. This money would be used to: 1) improve drug data reporting systems; 2) evaluate and ensure manufacturer compliance with rebate obligations; and 3) fund oversight and enforcement to ensure that manufacturers accurately and fully report drug information, including data related to drug classification.
Extension of Third-Party Liability Period for Child Support Services
This section of the bill would extend the number of days that a state can delay Medicaid payments to providers for medical services provided to a child with a medical support order from 90 days to 100 days.
Denial for Medicaid Coverage for Certain Expenditures Relating to Vacuum Erection Systems and Penile Prosthetic Implants
This section of the bill would prohibit Medicaid payments for vacuum erection systems or penile implants, unless they’re medically necessary.