---
kind: "section"
citation: "42 U.S.C. § 1396w–4a"
title: "42"
title_heading: "The Public Health and Welfare"
number: "1396w–4a"
heading: "State option to provide coordinated care through a health home for children with medically complex conditions"
release: "119-102"
date: "2026-07-12"
url: "https://uscodex.org/usc/42/1396w-4a"
units:
  - "Chapter 7 — Social Security"
  - "Subchapter XIX — Grants to States for Medical Assistance Programs"
---

# §1396w–4a. State option to provide coordinated care through a health home for children with medically complex conditions

- (a) **In general—** Notwithstanding [section 1396a(a)(1) of this title](/usc/42/1396a.md?p=a-1) (relating to statewideness) and [section 1396a(a)(10)(B) of this title](/usc/42/1396a.md?p=a-10-B) (relating to comparability), beginning October 1, 2022, a [State](/usc/42/619.md?p=5), at its option as a [State](/usc/42/619.md?p=5) plan amendment, may provide for [medical assistance](/usc/42/1396d.md?p=a) under this subchapter to children with medically complex conditions who choose to enroll in a health home under this section by selecting a designated provider, a team of health care professionals operating with such a provider, or a health team as the [child](/usc/42/1382c.md?p=c)’s health home for purposes of providing the [child](/usc/42/1382c.md?p=c) with health home services.
- (b) **Health home qualification standards—** The [Secretary](/usc/42/1301.md?p=a-6) shall establish [standards](/usc/42/1320d.md?p=7) for qualification as a health home for purposes of this section. Such [standards](/usc/42/1320d.md?p=7) shall include requiring designated providers, teams of health care professionals operating with such providers, and health teams to demonstrate to the [State](/usc/42/619.md?p=5) the ability to do the following:
  - (1) Coordinate prompt care for children with medically complex conditions, [including](/usc/42/1301.md?p=b) access to pediatric emergency services at all times.
  - (2) Develop an individualized comprehensive pediatric family-centered care plan for children with medically complex conditions that accommodates patient preferences.
  - (3) Work in a culturally and linguistically appropriate manner with the family of a [child](/usc/42/1382c.md?p=c) with medically complex conditions to develop and incorporate into such [child](/usc/42/1382c.md?p=c)’s care plan, in a manner consistent with the needs of the [child](/usc/42/1382c.md?p=c) and the choices of the [child](/usc/42/1382c.md?p=c)’s family, ongoing home care, community-based pediatric [primary care](/usc/42/1396d.md?p=t-4), pediatric inpatient care, [social](/usc/42/1397j.md?p=20) support services, and local [hospital](/usc/42/300s–3.md?p=1) pediatric emergency care.
  - (4) Coordinate access to—
    - (A) subspecialized pediatric services and programs for children with medically complex conditions, [including](/usc/42/1301.md?p=b) the most intensive diagnostic, [treatment](/usc/42/11851.md?p=11), and critical care levels as medically necessary; and
    - (B) palliative services if the [State](/usc/42/619.md?p=5) provides such services under the [State](/usc/42/619.md?p=5) plan (or a waiver of such plan).
  - (5) Coordinate care for children with medically complex conditions with out-of-[State](/usc/42/619.md?p=5) providers furnishing care to such children to the maximum extent practicable for the families of such children and where medically necessary, in accordance with guidance issued under [subsection (e)(1)](#e-1) and section 431.52 of title 42, Code of Federal Regulations.
  - (6) Collect and report information under [subsection (g)(1)](#g-1).
- (c) **Payments—**
  - (1) **In general—** A [State](/usc/42/619.md?p=5) 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 health home services to each [child](/usc/42/1382c.md?p=c) with medically complex conditions that selects such provider, team of health care professionals, or health team as the [child](/usc/42/1382c.md?p=c)’s health home. 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](/usc/42/1396d.md?p=a) for purposes of [section 1396b(a) of this title](/usc/42/1396b.md?p=a), except that, during the first 2 [fiscal year](/usc/42/619.md?p=3) quarters that the [State](/usc/42/619.md?p=5) plan amendment is in effect, the [Federal medical assistance percentage](/usc/42/1396d.md?p=b) applicable to such payments shall be increased by 15 percentage points, but in no case may exceed 90 percent.
  - (2) **Methodology—**
    - (A) **In general—** The [State](/usc/42/619.md?p=5) shall specify in the [State](/usc/42/619.md?p=5) plan amendment the methodology the [State](/usc/42/619.md?p=5) will use for determining payment for the provision of health home services. Such methodology for determining payment—
      - (i) may be tiered to reflect, with respect to each [child](/usc/42/1382c.md?p=c) with medically complex conditions provided such services by a designated provider, a team of health care professionals operating with such a provider, or a health team, the severity or number of each such [child](/usc/42/1382c.md?p=c)’s chronic conditions, life-threatening illnesses, disabilities, or rare diseases, or the specific capabilities of the provider, team of health care professionals, or health team; and
      - (ii) shall be established consistent with [section 1396a(a)(30)(A) of this title](/usc/42/1396a.md?p=a-30-A).
    - (B) **Alternate models of payment—** The methodology for determining payment for provision of health home services under this section shall not be limited to a per-member per-month basis and may provide (as proposed by the [State](/usc/42/619.md?p=5) and subject to approval by the [Secretary](/usc/42/1301.md?p=a-6)) for alternate models of payment.
  - (3) **Planning grants—**
    - (A) **In general—** Beginning October 1, 2022, the [Secretary](/usc/42/1301.md?p=a-6) may award planning [grants](/usc/42/1397j.md?p=10) to [States](/usc/42/619.md?p=5) for purposes of developing a [State](/usc/42/619.md?p=5) plan amendment under this section. A planning [grant](/usc/42/1397j.md?p=10) awarded to a [State](/usc/42/619.md?p=5) under this paragraph shall remain available until expended.
    - (B) **State contribution—** A [State](/usc/42/619.md?p=5) awarded a planning [grant](/usc/42/1397j.md?p=10) shall contribute an amount equal to the [State](/usc/42/619.md?p=5) percentage determined under [section 1396d(b) of this title](/usc/42/1396d.md?p=b) (without regard to section 5001 of Public Law 111–5) for each [fiscal year](/usc/42/619.md?p=3) for which the [grant](/usc/42/1397j.md?p=10) is awarded.
    - (C) **Limitation—** The total amount of payments made to [States](/usc/42/619.md?p=5) under this paragraph shall not exceed $5,000,000.
- (d) **Coordinating care—**
  - (1) **Hospital notification—** A [State](/usc/42/619.md?p=5) with a [State](/usc/42/619.md?p=5) plan amendment approved under this section shall require each [hospital](/usc/42/300s–3.md?p=1) that is a participating provider under the [State](/usc/42/619.md?p=5) plan (or a waiver of such plan) to establish procedures for, in the case of a [child](/usc/42/1382c.md?p=c) with medically complex conditions who is enrolled in a health home pursuant to this section and seeks [treatment](/usc/42/11851.md?p=11) in the emergency department of such [hospital](/usc/42/300s–3.md?p=1), notifying the health home of such [child](/usc/42/1382c.md?p=c) of such [treatment](/usc/42/11851.md?p=11).
  - (2) **Education with respect to availability of health home services—** In order for a [State](/usc/42/619.md?p=5) plan amendment to be approved under this section, a [State](/usc/42/619.md?p=5) shall include in the [State](/usc/42/619.md?p=5) plan amendment a description of the [State](/usc/42/619.md?p=5)’s process for educating providers participating in the [State](/usc/42/619.md?p=5) plan (or a waiver of such plan) on the availability of health home services for children with medically complex conditions, [including](/usc/42/1301.md?p=b) the process by which such providers can refer such children to a designated provider, team of health care professionals operating such[^1] a provider, or health team for the purpose of establishing a health home through which such children may receive such services.
  - (3) **Family education—** In order for a [State](/usc/42/619.md?p=5) plan amendment to be approved under this section, a [State](/usc/42/619.md?p=5) shall include in the [State](/usc/42/619.md?p=5) plan amendment a description of the [State](/usc/42/619.md?p=5)’s process for educating families with children eligible to receive health home services pursuant to this section of the availability of such services. Such process shall include the participation of family-to-family entities or other public or private organizations or entities who provide outreach and information on the availability of health care items and services to families of individuals eligible to receive [medical assistance](/usc/42/1396d.md?p=a) under the [State](/usc/42/619.md?p=5) plan (or a waiver of such plan).
  - (4) **Mental health coordination—** A [State](/usc/42/619.md?p=5) with a [State](/usc/42/619.md?p=5) plan amendment approved under this section shall consult and coordinate, as appropriate, with the [Secretary](/usc/42/1301.md?p=a-6) in addressing issues regarding the prevention and [treatment](/usc/42/11851.md?p=11) of mental illness and substance use among children with medically complex conditions receiving health home services under this section.
- (e) **Guidance on coordinating care from out-of-State providers—**
  - (1) **In general—** Not later than October 1, 2020, the [Secretary](/usc/42/1301.md?p=a-6) shall issue (and update as the [Secretary](/usc/42/1301.md?p=a-6) determines necessary) guidance to [State](/usc/42/619.md?p=5) Medicaid [directors](/usc/42/11851.md?p=5) on—
    - (A) best [practices](/usc/42/17061.md?p=19) for using out-of-[State](/usc/42/619.md?p=5) providers to provide care to children with medically complex conditions;
    - (B) coordinating care for such children provided by such out-of-[State](/usc/42/619.md?p=5) providers ([including](/usc/42/1301.md?p=b) when provided in emergency and non-emergency situations);
    - (C) reducing barriers for such children receiving care from such providers in a timely fashion; and
    - (D) processes for screening and enrolling such providers in the respective [State](/usc/42/619.md?p=5) plan (or a waiver of such plan), [including](/usc/42/1301.md?p=b) efforts to streamline such processes or reduce the burden of such processes on such providers.
  - (2) **Stakeholder input—** In carrying out [paragraph (1)](#e-1), the [Secretary](/usc/42/1301.md?p=a-6) shall issue a request for information to seek input from children with medically complex conditions and their families, [States](/usc/42/619.md?p=5), providers ([including](/usc/42/1301.md?p=b) children’s [hospitals](/usc/42/300s–3.md?p=1), [hospitals](/usc/42/300s–3.md?p=1), pediatricians, and other providers), managed care plans, children’s health groups, family and beneficiary advocates, and other stakeholders with respect to coordinating the care for such children provided by out-of-[State](/usc/42/619.md?p=5) providers.
- (f) **Monitoring—** A [State](/usc/42/619.md?p=5) shall include in the [State](/usc/42/619.md?p=5) plan amendment—
  - (1) a methodology for tracking reductions in inpatient days and reductions in the total cost of care resulting from improved care coordination and management under this section;
  - (2) a proposal for use of [health information](/usc/42/1320d.md?p=4) technology in providing health home services under this section and improving service delivery and coordination across the care continuum ([including](/usc/42/1301.md?p=b) the use of wireless patient technology to improve coordination and management of care and patient adherence to recommendations made by their provider); and
  - (3) a methodology for tracking prompt and timely access to medically necessary care for children with medically complex conditions from out-of-[State](/usc/42/619.md?p=5) providers.
- (g) **Data collection—**
  - (1) **Provider reporting requirements—** In order to receive payments from a [State](/usc/42/619.md?p=5) under [subsection (c)](#c), a designated provider, a team of health care professionals operating with such a provider, or a health team shall report to the [State](/usc/42/619.md?p=5), at such time and in such form and manner as may be required by the [State](/usc/42/619.md?p=5), the following information:
    - (A) With respect to each such provider, team of health care professionals, or health team, the name, National Provider Identification number, address, and specific health care services offered to be provided to children with medically complex conditions who have selected such provider, team of health care professionals, or health team as the health home of such children.
    - (B) Information on all applicable measures for determining the quality of health home services provided by such provider, team of health care professionals, or health team, [including](/usc/42/1301.md?p=b), to the extent applicable, [child](/usc/42/1382c.md?p=c) health quality measures and measures for centers of excellence for children with complex needs developed under this subchapter, subchapter XXI, and [section 1320b–9a of this title](/usc/42/1320b–9a.md).
    - (C) Such other information as the [Secretary](/usc/42/1301.md?p=a-6) shall specify in guidance.

    When appropriate and feasible, such provider, team of health care professionals, or health team, as the case may be, shall use [health information](/usc/42/1320d.md?p=4) technology in providing the [State](/usc/42/619.md?p=5) with such information.

  - (2) **State reporting requirements—**
    - (A) **Comprehensive report—** A [State](/usc/42/619.md?p=5) with a [State](/usc/42/619.md?p=5) plan amendment approved under this section shall report to the [Secretary](/usc/42/1301.md?p=a-6) (and, upon request, to the Medicaid and CHIP Payment and Access Commission), at such time and in such form and manner determined by the [Secretary](/usc/42/1301.md?p=a-6) to be reasonable and minimally burdensome, the following information:
      - (i) Information reported under [paragraph (1)](#g-1).
      - (ii) The number of children with medically complex conditions who have selected a health home pursuant to this section.
      - (iii) The nature, number, and prevalence of chronic conditions, life-threatening illnesses, disabilities, or rare diseases that such children have.
      - (iv) The type of delivery systems and payment models used to provide services to such children under this section.
      - (v) The number and characteristics of designated providers, teams of health care professionals operating with such providers, and health teams selected as health homes pursuant to this section, [including](/usc/42/1301.md?p=b) the number and characteristics of out-of-[State](/usc/42/619.md?p=5) providers, teams of health care professionals operating with such providers, and health teams who have provided health care items and services to such children.
      - (vi) The extent to which such children receive health care items and services under the [State](/usc/42/619.md?p=5) plan.
      - (vii) Quality measures developed specifically with respect to health care items and services provided to children with medically complex conditions.
    - (B) **Report on best practices—** Not later than 90 days after a [State](/usc/42/619.md?p=5) has a [State](/usc/42/619.md?p=5) plan amendment approved under this section, such [State](/usc/42/619.md?p=5) shall submit to the [Secretary](/usc/42/1301.md?p=a-6), and make publicly available on the appropriate [State](/usc/42/619.md?p=5) website, a report on how the [State](/usc/42/619.md?p=5) is implementing guidance issued under [subsection (e)(1)](#e-1), [including](/usc/42/1301.md?p=b) through any best [practices](/usc/42/17061.md?p=19) adopted by the [State](/usc/42/619.md?p=5).
- (h) **Rule of construction—** Nothing in this section may be construed—
  - (1) to require a [child](/usc/42/1382c.md?p=c) with medically complex conditions to enroll in a health home under this section;
  - (2) to limit the choice of a [child](/usc/42/1382c.md?p=c) with medically complex conditions in selecting a designated provider, team of health care professionals operating with such a provider, or health team that meets the health home qualification [standards](/usc/42/1320d.md?p=7) established under [subsection (b)](#b) as the [child](/usc/42/1382c.md?p=c)’s health home; or
  - (3) to reduce or otherwise modify—
    - (A) the entitlement of children with medically complex conditions to [early and periodic screening, diagnostic, and treatment services](/usc/42/1396d.md?p=r) (as defined in [section 1396d(r) of this title](/usc/42/1396d.md?p=r)); or
    - (B) the informing, providing, arranging, and reporting requirements of a [State](/usc/42/619.md?p=5) under [section 1396a(a)(43) of this title](/usc/42/1396a.md?p=a-43).
- (i) **Definitions—** In this section:
  - (1) **Child with medically complex conditions—**
    - (A) **In general—** Subject to [subparagraph (B)](#i-1-B), the term “[child](/usc/42/1382c.md?p=c) with medically complex conditions” means an individual under 21 years of age who—
      - (i) is eligible for [medical assistance](/usc/42/1396d.md?p=a) under the [State](/usc/42/619.md?p=5) plan (or under a waiver of such plan); and
      - (ii) has at least—
        - (I) one or more chronic conditions that cumulatively affect three or more organ systems and severely reduces cognitive or physical functioning (such as the ability to eat, drink, or breathe independently) and that also requires the use of medication, durable medical equipment, therapy, surgery, or other [treatments](/usc/42/11851.md?p=11); or
        - (II) one life-limiting illness or rare pediatric disease (as defined in [section 360ff(a)(3) of title 21](/usc/21/360ff.md?p=a-3)).
    - (B) **Rule of construction—** Nothing in this paragraph shall prevent the [Secretary](/usc/42/1301.md?p=a-6) from establishing higher levels as to the number or severity of chronic, life threatening illnesses, disabilities, rare diseases or mental health conditions for purposes of determining eligibility for receipt of health home services under this section.
  - (2) **Chronic condition—** The term “chronic condition” means a serious, long-term physical, mental, or developmental disability or disease, [including](/usc/42/1301.md?p=b) the following:
    - (A) Cerebral palsy.
    - (B) Cystic fibrosis.
    - (C) HIV/AIDS.
    - (D) Blood diseases, such as anemia or sickle cell disease.
    - (E) Muscular dystrophy.
    - (F) Spina bifida.
    - (G) Epilepsy.
    - (H) Severe autism spectrum disorder.
    - (I) Serious emotional disturbance or serious mental health illness.
  - (3) **Health home—** The term “health home” means a designated provider ([including](/usc/42/1301.md?p=b) a provider that operates in coordination with a team of health care professionals) or a health team selected by a [child](/usc/42/1382c.md?p=c) with medically complex conditions (or the family of such [child](/usc/42/1382c.md?p=c)) to provide health home services.
  - (4) **Health home services—**
    - (A) **In general—** The term “health home services” means comprehensive and timely high-quality services described in [subparagraph (B)](#i-4-B) that are provided by a designated provider, a team of health care professionals operating with such a provider, or a health team.
    - (B) **Services described—** The services described in this subparagraph shall include—
      - (i) comprehensive care management;
      - (ii) care coordination, health promotion, and providing access to the full range of pediatric specialty and subspecialty medical services, [including](/usc/42/1301.md?p=b) services from out-of-[State](/usc/42/619.md?p=5) providers, as medically necessary;
      - (iii) comprehensive transitional care, [including](/usc/42/1301.md?p=b) appropriate follow-up, from inpatient to other settings;
      - (iv) patient and family support ([including](/usc/42/1301.md?p=b) authorized representatives);
      - (v) referrals to community and [social](/usc/42/1397j.md?p=20) support services, if relevant; and
      - (vi) use of [health information](/usc/42/1320d.md?p=4) technology to link services, as feasible and appropriate.
  - (5) **Designated provider—** The term “designated provider” means a [physician](/usc/42/1301.md?p=a-7) ([including](/usc/42/1301.md?p=b) a pediatrician or a pediatric specialty or subspecialty provider), children’s [hospital](/usc/42/300s–3.md?p=1), clinical practice or clinical group practice, prepaid inpatient [health plan](/usc/42/1320d.md?p=5) or prepaid ambulatory [health plan](/usc/42/1320d.md?p=5) (as defined by the [Secretary](/usc/42/1301.md?p=a-6)), rural clinic, community health center, community mental health center, home health [agency](/usc/42/1397n–12.md?p=1), or any other entity or provider that is determined by the [State](/usc/42/619.md?p=5) and approved by the [Secretary](/usc/42/1301.md?p=a-6) to be qualified to be a health home for children with medically complex conditions on the basis of documentation evidencing that the entity has the systems, expertise, and infrastructure in place to provide health home services. Such term may include providers who are employed by, or affiliated with, a children’s [hospital](/usc/42/300s–3.md?p=1).
  - (6) **Team of health care professionals—** The term “team of health care professionals” means a team of health care professionals (as described in the [State](/usc/42/619.md?p=5) plan amendment under this section) that may—
    - (A) include—
      - (i) [physicians](/usc/42/1301.md?p=a-7) and other professionals, such as pediatricians or pediatric specialty or subspecialty providers, nurse care coordinators, dietitians, nutritionists, [social](/usc/42/1397j.md?p=20) workers, behavioral health professionals, physical therapists, occupational therapists, speech pathologists, nurses, individuals with experience in medical supportive technologies, or any professionals determined to be appropriate by the [State](/usc/42/619.md?p=5) and approved by the [Secretary](/usc/42/1301.md?p=a-6);
      - (ii) an entity or individual who is designated to coordinate such a team; and
      - (iii) community health workers, translators, and other individuals with culturally-appropriate expertise; and
    - (B) be freestanding, virtual, or based at a children’s [hospital](/usc/42/300s–3.md?p=1), [hospital](/usc/42/300s–3.md?p=1), community health center, community mental health center, rural clinic, clinical practice or clinical group practice, academic health center, or any entity determined to be appropriate by the [State](/usc/42/619.md?p=5) and approved by the [Secretary](/usc/42/1301.md?p=a-6).
  - (7) **Health team—** The term “health team” has the meaning given such term for purposes of [section 256a–1 of this title](/usc/42/256a–1.md).

## Footnotes

[^1]: So in original. Probably should be preceded by “with”.

## Source credit

(Aug. 14, 1935, ch. 531, title XIX, § 1945A, as added Pub. L. 116–16, § 3, Apr. 18, 2019, 133 Stat. 853.)

## Notes

### Editorial Notes

### References in Text

Section 5001 of Public Law 111–5, referred to in subsec. (c)(3)(B), is section 5001 of Pub. L. 111–5, div. B, title V, Feb. 17, 2009, 123 Stat. 496, which was formerly set out as a note under section 1396d of this title.