[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4605 Introduced in House (IH)]
113th CONGRESS
2d Session
H. R. 4605
To amend title XIX of the Social Security Act to provide States an
option to cover a children's program of all-inclusive coordinated care
(ChiPACC) under the Medicaid program.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
May 8, 2014
Mrs. Ellmers (for herself and Mr. Moran) 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 States an
option 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 2014''.
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 (28);
(2) by redesignating paragraph (29) as paragraph (30); and
(3) by inserting after paragraph (28) the following new
paragraph:
``(29) services furnished under a children's program of
all-inclusive coordinated care (ChiPACC) under section 1944;
and''.
(b) Children's Program of All-Inclusive Coordinated Care.--Title
XIX of such Act is further amended by inserting after section 1943 (42
U.S.C. 1396w-3) the following new section:
``children's program of all-inclusive coordinated care
``Sec. 1944.
``(a) State Option.--
``(1) In general.--A State may elect to provide medical
assistance under this section to ChiPACC eligible individuals
who are eligible for medical assistance under the State plan
under this title and who choose to enroll in a children's
program of all-inclusive coordinated care. In the case of an
individual who chooses to enroll in such a program pursuant to
such an election--
``(A) the individual shall receive benefits under
the State plan solely through such program; and
``(B) the health care providers furnishing services
under such program shall receive payment for providing
such services in accordance with the terms of such
program.
``(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 (as defined in paragraph (3)) and such
agency.
``(B) Comprehensive benefits.--
``(i) In general.--The program provides
comprehensive health care items and services to
ChiPACC eligible individuals (as defined in
paragraph (2)) 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 for the individual; and
``(II) be provided consistent with
a comprehensive care plan developed by
an interdisciplinary health
professional team (as defined in
paragraph (4)).
``(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 resides in the service area of the
ChiPACC;
``(C) who 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);
``(D) who suffers from a serious illness or health
condition;
``(E) for whom there is a reasonable likelihood
that the individual's life will be threatened by such
illness or condition; and
``(F) whose health status is expected to decline
because of such illness or condition before attaining
full adulthood (as defined under the State plan).
The Secretary may waive the application of subparagraph (C)
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).
``(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));
``(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.
``(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 (f).
``(c) Scope of Benefits; Beneficiary Safeguards.--
``(1) In general.--Under a ChiPACC of a State, the State
administering agency shall assure that--
``(A) an individual enrolled in the ChiPACC is
covered for, at a minimum--
``(i) all items and services that are
covered for any individual 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; and
``(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 and
interdisciplinary 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 all
of the following:
``(A) The provision of services under the ChiPACC
meets all applicable 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 a written plan of quality assurance,
and procedures implementing such plan, in accordance
with regulations.
``(D) 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.
``(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 at least 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 requirements of subparagraphs
(D), (E), and (F) of subsection (b)(2), 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) 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) Appeals.--
``(i) Upon application.--If an individual
is determined not to be a ChiPACC eligible
individual upon application, then the State
plan under this title shall allow for an appeal
of such determination. During the course of
such appeal, the individual shall not begin to
receive benefits through the ChiPACC unless and
until the appeal is resolved favorably for the
individual.
``(ii) Subsequently.--If an individual is
determined not to be a ChiPACC eligible
individual at any time after enrollment in a
ChiPACC, or is otherwise disenrolled from a
ChiPACC, then the State plan under this title
shall allow for an appeal of such
determination. During the course of such
appeal, the individual shall continue to be
enrolled in the ChiPACC and to receive benefits
through the ChiPACC.
``(5) 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 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) Regulations.--
``(1) In general.--The Secretary shall issue such
regulations, including interim final regulations, as may be
necessary to carry out this section.
``(2) 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.
``(g) Applicability 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) Section 1905(o), limiting the scope of hospice care.
``(6) Such other provisions of this title that the
Secretary determines are inapplicable to carrying out a ChiPACC
under this section.''.
(c) Continued Demonstration Project Authority.--Section 1944 of the
Social Security Act, as added by subsection (b), shall not be construed
as preventing a State from developing, or the Secretary of Health and
Human Services from approving, a project similar to or related to
ChiPACCs (as described in such section) under existing authorities,
including demonstration project and waiver authorities under title XIX
of such Act or other provisions of such Act.
(d) 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 that are only
covered as section 1944 ChiPACC benefits''.
(e) 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.
(f) 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
1944(b) of the Social Security Act, as added by subsection (b).
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