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Section 4108

SEC. 4108. INCENTIVES FOR PREVENTION OF CHRONIC DISEASES IN MEDICAID.

[a] Initiatives-

[1] ESTABLISHMENT-

[A] IN GENERAL- The Secretary shall award grants to States to carry out initiatives to provide incentives to Medicaid beneficiaries who--

[i] successfully participate in a program described in paragraph [3]; and

[ii] upon completion of such participation, demonstrate changes in health risk and outcomes, including the adoption and maintenance of healthy behaviors by meeting specific targets [as described in subsection [c][2]].

[B] PURPOSE- The purpose of the initiatives under this section is to test approaches that may encourage behavior modification and determine scalable solutions.

[2] DURATION-

[A] INITIATION OF PROGRAM; RESOURCES- The Secretary shall awards grants to States beginning on January 1, 2011, or beginning on the date on which the Secretary develops program criteria, whichever is earlier. The Secretary shall develop program criteria for initiatives under this section using relevant evidence-based research and resources, including the Guide to Community Preventive Services, the Guide to Clinical Preventive Services, and the National Registry of Evidence-Based Programs and Practices.

[B] DURATION OF PROGRAM- A State awarded a grant to carry out initiatives under this section shall carry out such initiatives within the 5-year period beginning on January 1, 2011, or beginning on the date on which the Secretary develops program criteria, whichever is earlier. Initiatives under this section shall be carried out by a State for a period of not less than 3 years.

[3] PROGRAM DESCRIBED-

[A] IN GENERAL- A program described in this paragraph is a comprehensive, evidence-based, widely available, and easily accessible program, proposed by the State and approved by the Secretary, that is designed and uniquely suited to address the needs of Medicaid beneficiaries and has demonstrated success in helping individuals achieve one or more of the following:

[i] Ceasing use of tobacco products.

[ii] Controlling or reducing their weight.

[iii] Lowering their cholesterol.

[iv] Lowering their blood pressure.

[v] Avoiding the onset of diabetes or, in the case of a diabetic, improving the management of that condition.

[B] CO-MORBIDITIES- A program under this section may also address co-morbidities [including depression] that are related to any of the conditions described in subparagraph [A].

[C] WAIVER AUTHORITY- The Secretary may waive the requirements of section 1902[a][1] [relating to statewideness] of the Social Security Act for a State awarded a grant to conduct an initiative under this section and shall ensure that a State makes any program described in subparagraph [A] available and accessible to Medicaid beneficiaries.

[D] FLEXIBILITY IN IMPLEMENTATION- A State may enter into arrangements with providers participating in Medicaid, community-based organizations, faith-based organizations, public-private partnerships, Indian tribes, or similar entities or organizations to carry out programs described in subparagraph [A].

[4] APPLICATION- Following the development of program criteria by the Secretary, a State may submit an application, in such manner and containing such information as the Secretary may require, that shall include a proposal for programs described in paragraph [3][A] and a plan to make Medicaid beneficiaries and providers participating in Medicaid who reside in the State aware and informed about such programs.

[b] Education and Outreach Campaign-

[1] STATE AWARENESS- The Secretary shall conduct an outreach and education campaign to make States aware of the grants under this section.

[2] PROVIDER AND BENEFICIARY EDUCATION- A State awarded a grant to conduct an initiative under this section shall conduct an outreach and education campaign to make Medicaid beneficiaries and providers participating in Medicaid who reside in the State aware of the programs described in subsection [a][3] that are to be carried out by the State under the grant.

[c] Impact- A State awarded a grant to conduct an initiative under this section shall develop and implement a system to--

[1] track Medicaid beneficiary participation in the program and validate changes in health risk and outcomes with clinical data, including the adoption and maintenance of health behaviors by such beneficiaries;

[2] to the extent practicable, establish standards and health status targets for Medicaid beneficiaries participating in the program and measure the degree to which such standards and targets are met;

[3] evaluate the effectiveness of the program and provide the Secretary with such evaluations;

[4] report to the Secretary on processes that have been developed and lessons learned from the program; and

[5] report on preventive services as part of reporting on quality measures for Medicaid managed care programs.

[d] Evaluations and Reports-

[1] INDEPENDENT ASSESSMENT- The Secretary shall enter into a contract with an independent entity or organization to conduct an evaluation and assessment of the initiatives carried out by States under this section, for the purpose of determining--

[A] the effect of such initiatives on the use of health care services by Medicaid beneficiaries participating in the program;

[B] the extent to which special populations [including adults with disabilities, adults with chronic illnesses, and children with special health care needs] are able to participate in the program;

[C] the level of satisfaction of Medicaid beneficiaries with respect to the accessibility and quality of health care services provided through the program; and

[D] the administrative costs incurred by State agencies that are responsible for administration of the program.

[2] STATE REPORTING- A State awarded a grant to carry out initiatives under this section shall submit reports to the Secretary, on a semi-annual basis, regarding the programs that are supported by the grant funds. Such report shall include information, as specified by the Secretary, regarding--

[A] the specific uses of the grant funds;

[B] an assessment of program implementation and lessons learned from the programs;

[C] an assessment of quality improvements and clinical outcomes under such programs; and

[D] estimates of cost savings resulting from such programs.

[3] INITIAL REPORT- Not later than January 1, 2014, the Secretary shall submit to Congress an initial report on such initiatives based on information provided by States through reports required under paragraph [2]. The initial report shall include an interim evaluation of the effectiveness of the initiatives carried out with grants awarded under this section and a recommendation regarding whether funding for expanding or extending the initiatives should be extended beyond January 1, 2016.

[4] FINAL REPORT- Not later than July 1, 2016, the Secretary shall submit to Congress a final report on the program that includes the results of the independent assessment required under paragraph [1], together with recommendations for such legislation and administrative action as the Secretary determines appropriate.

[e] No Effect on Eligibility for, or Amount of, Medicaid or Other Benefits- Any incentives provided to a Medicaid beneficiary participating in a program described in subsection [a][3] shall not be taken into account for purposes of determining the beneficiary's eligibility for, or amount of, benefits under the Medicaid program or any program funded in whole or in part with Federal funds.

[f] Funding- Out of any funds in the Treasury not otherwise appropriated, there are appropriated for the 5-year period beginning on January 1, 2011, $100,000,000 to the Secretary to carry out this section. Amounts appropriated under this subsection shall remain available until expended.

[g] Definitions- In this section:

[1] MEDICAID BENEFICIARY- The term 'Medicaid beneficiary' means an individual who is eligible for medical assistance under a State plan or waiver under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] and is enrolled in such plan or waiver.

[2] STATE- The term 'State' has the meaning given that term for purposes of title XIX of the Social Security Act [42 U.S.C. 1396 et seq.].