[Congressional Bills 110th Congress]
[From the U.S. Government Publishing Office]
[H.R. 6931 Introduced in House (IH)]
110th CONGRESS
2d Session
H. R. 6931
To amend title XIX of the Social Security Act to provide an option of
States to cover a children's program of all-inclusive coordinated care
(ChiPACC) under the Medicaid Program.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
September 17, 2008
Mr. Moran of Virginia (for himself and Mr. Tom Davis of Virginia)
introduced the following bill; which was referred to the Committee on
Energy and Commerce
_______________________________________________________________________
A BILL
To amend title XIX of the Social Security Act to provide an option of
States to cover a children's program of all-inclusive coordinated care
(ChiPACC) under the Medicaid Program.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``ChiPACC Act of 2008''.
SEC. 2. OPTIONAL MEDICAID COVERAGE OF CHILDREN'S PROGRAM OF ALL-
INCLUSIVE COORDINATED CARE (CHIPACC).
(a) In General.--Section 1905(a) of the Social Security Act (42
U.S.C. 1396d(a)) is amended--
(1) by striking ``and'' at the end of paragraph (27);
(2) by redesignating paragraph (28) as paragraph (29); and
(3) by inserting after paragraph (27) the following new
paragraph:
``(28) services furnished under a children's program of
all-inclusive coordinated care (ChiPACC) under section 1942;
and''.
(b) Children's Program of All-Inclusive Coordinated Care
(ChiPACC).--Title XIX of such Act is further amended by adding at the
end the following new section:
``children's program of all-inclusive coordinated care (chipacc)
``Sec. 1942. (a) State Option.--
``(1) In general.--A State may elect to provide medical
assistance under this section with respect to a children's
program of all-inclusive coordinated care to ChiPACC eligible
individuals who are eligible for medical assistance under the
State plan and who are enrolled in the program. In the case of
an individual enrolled in such a program pursuant to such an
election--
``(A) the individual shall receive benefits under
the plan solely through such program; and
``(B) the health care providers furnishing services
under such program shall receive payment in accordance
with the terms of such program for providing such
services.
``(2) Numerical and geographical limitations permitted.--A
State may establish--
``(A) a numerical limit on the number of
individuals who may be enrolled in the State's ChiPACC;
and
``(B) geographic limitations on the service areas
for a ChiPACC.
``(b) ChiPACC and Other Terms Defined.--In this section:
``(1) Children's program of all-inclusive coordinated care;
chipacc.--The terms `children's program of all-inclusive
coordinated care' and `ChiPACC' mean a program of coordinated
care for ChiPACC eligible children that is established by a
State under this section and meets the following requirements:
``(A) Operation.--The program is administered by a
single State agency. Such agency may provide for the
operation of the program through arrangements between
one or more other entities, such as a ChiPACC
coordinator, and such agency.
``(B) Comprehensive benefits.--
``(i) In general.--The program provides
comprehensive health care items and services to
ChiPACC eligible individuals in accordance with
this section and regulations.
``(ii) Scope and plan for services.--Such
items and services shall--
``(I) include items and services
described in subsection (c)(1)(A) to
the extent such items and services are
appropriate to the individual; and
``(II) be provided consistent with
a comprehensive care plan developed by
an interdisciplinary health
professional team.
``(iii) Qualifications of providers.--Such
items and services are provided through health
care providers that--
``(I) meet such certification or
other quality requirements as may be
necessary to participate in the program
of medical assistance under this title
or in the program under title XVIII;
and
``(II) maintain records on ChiPACC
eligible individuals enrolled in the
program and to whom the provider
furnishes services, reflecting both the
specific care and services furnished by
the provider and the relationship of
those services to the comprehensive
plan of care for that individual and to
the delivery of other services to the
individual through the program.
``(2) ChiPACC eligible individual.--The term `ChiPACC
eligible individual' means, with respect to a ChiPACC, an
individual--
``(A) who, at the time of enrollment in the ChiPACC
is a child (as defined under the State plan for this
purpose) and who is not older than such age as the
State may specify;
``(B) who suffers from a serious illness or health
condition that is life threatening;
``(C) for whom there is a reasonable likelihood
that the child's life will be threatened by such
illness or condition;
``(D) whose health status is expected to decline
because of such illness or condition before attaining
full adulthood (as defined under the State plan);
``(E) resides in the service area of the ChiPACC;
and
``(F) is eligible for medical assistance under the
State plan without regard to this section (or, but for
enrollment in a ChiPACC would, based on the
individual's illness or health condition or the
projected cost of treatment required for such illness
or condition, become so eligible).
The Secretary may waive the application of subparagraph (F)
with respect to eligibility for medical assistance under the
State plan without regard to this section in the case of
individuals if the State demonstrates to the satisfaction of
the Secretary that the sum of the additional expenditures under
this title resulting from such waiver in a fiscal year will not
exceed the aggregate savings in expenditures otherwise
resulting from the implementation of this section in the fiscal
year.
``(3) ChiPACC coordinator.--The term `ChiPACC coordinator'
means, with respect to a ChiPACC, an entity (which may be the
State administering agency or another entity under an
arrangement with such an agency) that directs, supervises, and
assures the coordination of comprehensive services to ChiPACC
eligible individuals enrolled in the ChiPACC consistent with
the following:
``(A) The entity must assure the direct and
continuous involvement of an interdisciplinary health
professional team in managing and coordinating the
provision of care and services within the coordinator's
responsibility to each such enrolled individual.
``(B) The entity must include on its staff, or
otherwise arrange for the provision of services,
through contracts or otherwise, of each of the types of
the health care professionals and other service
providers required to provide the items and services
required under subsection (c)(1)(A), to the extent such
items and services are necessary and appropriate to the
care of an enrolled individual.
``(C) To the extent consistent with provision of
the highest quality of care to enrolled individuals--
``(i) promote the utilization of volunteers
in the provision of care and services under the
ChiPACC, in accordance with standards set by
the Secretary, which standards shall ensure a
continuing level of effort to utilize such
volunteers; and
``(ii) ensure that records are maintained
on the use of such volunteers and the cost
savings and expansion of care and services
achieved through the use of such volunteers.
``(4) Interdisciplinary health professional team.--The term
`interdisciplinary health professional team' means, with
respect to a ChiPACC, a group of health professionals that--
``(A) includes at least--
``(i) one physician (as defined in section
1861(r)(1));
``(ii) one registered professional nurse;
and
``(iii) one social worker, pastoral
counselor, or other counselor;
``(B) develops a comprehensive plan of care for
ChiPACC eligible individuals enrolled with the ChiPACC
and furnishes, or supervises the provision of, care and
services described in subsection (c)(1) to an
individual enrolled in the ChiPACC; and
``(C) through direct action and communication with
health care providers furnishing services under the
ChiPACC, on behalf of or under the direction or
supervision of a State administering agency or a
ChiPACC coordinator, coordinates the care and services
furnished to such enrollees in a manner that takes into
account the best interests of each such enrollee and
the enrollee's family, as well as considerations of
cost and efficient use of available resources.
``(5) State administering agency.--The term `State
administering agency' means, with respect to the operation of a
ChiPACC in a State, the agency of that State (which may be the
single agency responsible for administration of the State plan
under this title in the State) responsible for the
implementation, either directly or through arrangements with
one or more ChiPACC coordinators, of the ChiPACC under this
section in the State.
``(6) Regulations.--Except as otherwise provided, the term
`regulations' refers to interim final or final regulations
promulgated under subsection (g).
``(c) Scope of Benefits; Beneficiary Safeguards.--
``(1) In general.--Under a ChiPACC of a State, the State
administering agency shall assure that--
``(A) individuals enrolled in the ChiPACC are
furnished, at a minimum--
``(i) all items and services that are
necessary and appropriate to their care and
that are covered under this title, and all
additional items and services specified in
regulations, but without any limitation or
condition as to amount, duration, or scope;
``(ii) access to covered items and
services, as needed, 24 hours per day, every
day of the year;
``(iii) services that include
comprehensive, integrated palliative and
curative services, expressive therapy and
counseling, and counseling and anticipatory
bereavement services to immediate family
members of the ChiPACC eligible individual, as
part of the services to the eligible
individual;
``(B) provision of such services to such
individuals through a comprehensive, interdisciplinary
and multidisciplinary health and social services
delivery system which integrates, as appropriate to the
individual recipient of services, acute and long-term
care services, palliative, respite and curative
treatment, counseling and support for family members
who are caretakers or otherwise relevant to appropriate
care and treatment of the individual, and such other
services as may be furnished pursuant to regulations
and the provisions of the applicable State plan; and
``(C) the ChiPACC is operated, and the services to
enrolled individuals are furnished, in a manner that is
consistent with Standards of Care and Practice
Guidelines developed by Children's Hospice
International for a Program of All-Inclusive Care for
Children (as in effect as of the date of the enactment
of this section or such later date as the Secretary may
specify).
``(2) Quality assurance; patient safeguards.--With respect
to a ChiPACC, the State administering agency shall assure the
following:
``(A) The provision of services under the ChiPACC
meets Federal and State guidelines for quality
assurance.
``(B) Necessary safeguards have been established to
protect the health and welfare of individuals enrolled
in the ChiPACC under this section.
``(C) There is financial accountability of funds
expended under this title with respect to such
services.
``(D) There is a written plan of quality assurance,
and procedures implementing such plan, in accordance
with regulations.
``(E) Written safeguards of the rights of
individuals enrolled in the ChiPACC, including a
patient bill of rights and procedures for grievances
and appeals, in accordance with regulations and with
other requirements of this title and Federal and State
law designed for the protection of patients.
``(F) There are in effect procedures for data
collection, record maintenance and retention, and the
development of outcome measures, and such other
policies, systems, and procedures as are sufficient to
afford the Secretary and the State administering agency
access to records and data relating to the ChiPACC,
including pertinent financial, medical, and personnel
records.
``(G) The agency shall submit to the Secretary such
reports as the Secretary finds (in consultation with
State administering agencies) necessary to monitor the
operation, cost, and effectiveness of ChiPACCs.
``(3) Cost-sharing waiver.--A State administering agency
may, in the case of a ChiPACC eligible individual enrolled in
the State's ChiPACC, waive deductibles, copayments,
coinsurance, or other cost-sharing that would otherwise apply
under the State plan under this title.
``(d) Eligibility Determinations.--
``(1) In general.--In determining whether an individual is
a ChiPACC eligible individual, the State administering agency
shall conduct an independent evaluation and assessment, which
shall include the following:
``(A) Where appropriate, consultation with the
individual's family, guardian, or other responsible
individual.
``(B) Consultation with appropriate treating and
consulting health and support professionals caring for
the individual.
``(C) An examination of the individual's relevant
history, medical records, and care and support needs,
guided by best practices and research on effective
strategies that result in improved health and quality
of life outcomes.
``(2) Certification.--Upon completion of the evaluation and
assessment described in paragraph (1), an individual meeting
the criteria of a ChiPACC eligible individual shall be
certified as such, pursuant to procedures specified in
regulations and the applicable State plan.
``(3) Continuation of eligibility.--An individual who is a
ChiPACC eligible individual may be deemed to continue to be
such an individual notwithstanding a determination that the
individual no longer meets the requirement of subsection
(b)(2)(B) if, in accordance with regulations, it is reasonably
foreseeable that, if the individual is not furnished services
under this section, the severity or impact of the individual's
illness or condition would increase to a degree that the
individual would again meet such requirement before the
individual attains adulthood or within the succeeding 12-month
period.
``(4) Annual reevaluations.--Subject to such limitations as
the Secretary may by regulation prescribe, the eligibility
determination made under this subsection shall be reevaluated
annually, except that such an annual evaluation may be waived,
in accordance with regulations, in a case where the
administering State agency determines that there is no
reasonable expectation of improvement or significant change in
the individual's illness or condition during a period to which
the reevaluation requirement would otherwise be applicable.
``(5) Enrollment and disenrollment.--
``(A) Voluntary disenrollment at any time.--The
enrollment and disenrollment of ChiPACC eligible
individuals in a ChiPACC shall be pursuant to
procedures specified in regulations and the State plan,
but shall permit an enrollee, or an enrollee's guardian
or other legal representative, acting on behalf of an
enrollee, to voluntarily disenroll for any reason at
any time.
``(B) Limitations on disenrollment.--
``(i) In general.--Regulations, and the
applicable State plan, shall provide that a
ChiPACC may not involuntarily disenroll a
ChiPACC eligible individual enrolled in the
ChiPACC except--
``(I) for disruptive or threatening
behavior by the enrollee, or by a
family member with whom a health care
provider providing services under the
ChiPACC necessarily has contact in the
provision of services, as defined in
provisions of regulations (developed in
close consultation with State
administering agencies); and
``(II) if there is a change in the
individual's medical condition,
residency or geographic location, or
financial situation such that the
individual no longer is a ChiPACC
eligible individual and paragraph (3)
does not apply to warrant continuation
of enrollment.
``(ii) No disenrollment for noncompliant
behavior.--Except as allowed under regulations,
a ChiPACC may not disenroll a ChiPACC eligible
individual on the ground that the individual
has engaged in noncompliant behavior if such
behavior is related to a mental or physical
condition of the individual. For purposes of
the preceding sentence, the term `noncompliant
behavior' includes repeated noncompliance with
medical advice and repeated failure to appear
for appointments.
``(iii) Timely review of proposed
nonvoluntary disenrollment.--A proposed
involuntary disenrollment under this
subparagraph shall be subject to timely review
and final determination by the Secretary or by
the State administering agency (as applicable),
prior to the proposed disenrollment becoming
effective, pursuant to procedures prescribed in
regulations.
``(C) Appeals.--If an individual is determined not
to be a ChiPACC eligible individual upon application,
any time after such services begin, or is disenrolled
from a ChiPACC for reasons described in subparagraph
(B)(i)(I), the State plan under this title shall allow
for an appeal of such determination. During the course
of the appeals process, an individual previously
enrolled in a ChiPACC shall continue to be so enrolled
and to receive benefits through the ChiPACC.
``(6) Construction.--The fact that a ChiPACC eligible
individual is enrolled under a ChiPACC shall not be construed
as adversely affecting the eligibility of the individual's
parents or caretaker relatives for medical assistance under
this title.
``(e) Payments to Health Care Providers Under ChiPACC.--
``(1) In general.--Payments to health care providers
furnishing items and services under a ChiPACC shall be paid on
a capitated or fee-for-service basis, according to regulations
and as specified in the applicable State plan consistent with
this subsection.
``(2) Use of integrated, budget-neutral financing.--
Payments under this subsection shall be made--
``(A) on a basis that permits provision for
integrated financing methodologies that allow providers
to pool payments received from public and private
programs and individuals; and
``(B) in amounts that are designed, according to
regulations, to ensure that aggregate payments under
this section for individuals enrolled in a ChiPACC,
whether made on a capitated basis or fee-for-service
basis, do not exceed on average the aggregate payments
that would have been paid under the State plan for such
individuals if they were not so enrolled, taking into
account the comparative case-mix of ChiPACC enrollees
and such other factors as the Secretary determines to
be appropriate.
``(f) Termination Procedures.--
``(1) In general.--Under regulations--
``(A) the Secretary may require a State
administering agency to terminate the participation of
a ChiPACC coordinator for cause; and
``(B) a State administering agency may terminate
operation of a ChiPACC after appropriate notice to the
Secretary and enrollees.
``(2) Causes for coordinator termination.--In accordance
with regulations establishing procedures for termination of
participation of ChiPACC coordinators, the Secretary may
require a State administering agency to terminate participation
of a ChiPACC coordinator for, among other reasons, the fact
that--
``(A) the Secretary determines that the ChiPACC
coordinator has failed to comply substantially with
requirements for a ChiPACC coordinator under this
section; and
``(B) the State administering agency has failed to
develop and successfully initiate, within 30 days of
the date of the receipt of written notice of such a
determination for the ChiPACC coordinator, a plan to
correct the coordinator's deficiencies, or has failed
to continue implementation of such a plan of
correction.
``(g) Regulations.--
``(1) In general.--The Secretary shall issue interim final
or final regulations to carry out this section.
``(2) Use of existing standards.--
``(A) In general.--In issuing such regulations, the
Secretary shall, to the extent appropriate and
consistent with the provisions of this section,
incorporate the standards and requirements applied to
Programs of All-Inclusive Care for Children
demonstration waiver programs that have been
implemented before (or as of) the date of the enactment
of this section, including standards of care and
practice guidelines applied under such programs.
``(B) Flexibility.--In order to provide for
reasonable flexibility in adapting the service delivery
model described in subparagraph (A) to the needs of
particular organizations (such as those in rural areas
or those that may determine it appropriate to use
nonstaff physicians according to State licensing law
requirements) under this section, the Secretary (in
close consultation with State administering agencies)
may modify or waive provisions described in
subparagraph (A) so long as any such modification or
waiver is not inconsistent with and would not impair
the essential elements, objectives, and requirements of
this section, but may not modify or waive any of the
following provisions:
``(i) The requirement of delivery of
comprehensive, integrated palliative, respite
and curative services, therapy, counseling and
other medical and psycho-social services for
ChiPACC eligible individual, to the extent such
services would benefit the individual.
``(ii) The requirement of delivery of
counseling and bereavement services to
immediate family members of the ChiPACC
enrollees as part of the services to the
enrollee.
``(iii) The requirement of an
interdisciplinary health professional team
approach to care management and service
delivery to ChiPACC eligible individuals.
``(iv) The provision of integrated
financing methodologies that allow for the
pooling of payments received from public and
private programs and individuals.
``(v) The limitation on average aggregate
payment under subsection (e)(2).
``(C) Continuation of modifications or waivers
operational requirements.--If a State agency
administering a program of all-inclusive coordinated
care for seriously ill children approved pursuant to
waiver authority under section 1115 or 1915(c) has
contractual or other operating arrangements relating to
such program which are not otherwise recognized in
regulation and which were in effect as of the date of
the enactment of this section, the Secretary shall
permit the agency to continue such arrangements so long
as such arrangements are found by the Secretary to be
reasonably consistent with the objectives of a ChiPACC.
``(3) Construction.--Nothing in this subsection shall be
construed as preventing the Secretary from including in
regulations provisions to ensure the health and safety of
individuals enrolled in a ChiPACC under this section that are
in addition to those otherwise provided under this section.
``(h) Waivers of Requirements.--With respect to carrying out a
ChiPACC under this section, the following requirements of this title
(and regulations relating to such requirements) shall not apply:
``(1) Section 1902(a)(1), relating to any requirement that
ChiPACCs or ChiPACC services be provided in all areas of a
State.
``(2) Section 1902(a)(10), insofar as such section relates
to comparability of services among different population groups.
``(3) Sections 1902(a)(23) and 1915(b)(4), relating to
freedom of choice of providers under a ChiPACC.
``(4) Section 1903(m)(2)(A), insofar as it restricts a
ChiPACC provider from receiving prepaid capitation payments.
``(5) Such other provisions of this title that the
Secretary determines are inapplicable to carrying out a ChiPACC
under this section.
``(i) Continued Demonstration Project Authority.--Nothing in this
section shall be construed as preventing a State from developing, or
the Secretary from approving, a project similar to or related to
ChiPACCs as described in this section, under existing authorities,
including demonstration project and waiver authorities under this title
or other provisions of this Act.''.
(c) Other Conforming Amendments.--Section 1905(r)(5) of such Act
(42 U.S.C. 1396d(r)(5)) is amended by inserting before the period at
the end the following: ``, other than items and services to the extent
such items and services are included under subsection (a) because of
the application of paragraph (28)''.
(d) Timely Issuance of Regulations; Effective Date.--The Secretary
of Health and Human Services shall promulgate regulations to carry out
the amendments made by this section in a timely manner, so as to assure
that it will be feasible for State agencies and entities to establish
and operate ChiPACCs for periods beginning not later than 1 year after
the date of the enactment of this Act.
(e) Funds for Technical Assistance .--The Secretary is authorized
to expend funds appropriated to carry out title XIX of the Social
Security Act to make grants to, or enter into contracts with, private
entities or organizations that are qualified to provide technical or
other assistance in developing and establishing ChiPACCs within the
States, except that--
(1) such funds may be expended solely for the purposes of
implementing this section; and
(2) a private entity or organization in receipt of such
funds must have demonstrated expertise and a minimum of 5 years
of experience in working with or assisting in the establishment
of programs for comprehensive care of children meeting the
description of ChiPACC eligible individuals under section
1942(b) of the Social Security Act, as added by subsection (b).
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