[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[S. 1980 Introduced in Senate (IS)]
113th CONGRESS
2d Session
S. 1980
To amend titles XIX and XXI of the Social Security Act to provide for
12-month continuous enrollment under the Medicaid program and
Children's Health Insurance Program and to promote quality care.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
February 3, 2014
Mr. Rockefeller introduced the following bill; which was read twice and
referred to the Committee on Finance
_______________________________________________________________________
A BILL
To amend titles XIX and XXI of the Social Security Act to provide for
12-month continuous enrollment under the Medicaid program and
Children's Health Insurance Program and to promote quality care.
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 ``Medicaid and CHIP Continuous Quality
Act of 2014''.
SEC. 2. FINDINGS.
Congress finds the following:
(1) Every year millions of people are enrolled in Medicaid
and the Children's Health Insurance Program (in this section
referred to as ``CHIP''), but subsequently lose their coverage,
despite still being eligible, because of inefficient and
cumbersome paperwork and logistical requirements.
(2) Data show that the typical enrollee receives Medicaid
coverage for about three-quarters of the year. Coverage periods
are lower for non-elderly, non-disabled adults than for those
with disabilities, seniors, and children.
(3) Medicaid enrollees with coverage disruption are more
likely to be hospitalized for illnesses like asthma, diabetes,
or cardiovascular disease that can be effectively managed
through ongoing primary medical care and medication, are less
likely to be screened for breast cancer, and may have poorer
cancer outcomes.
(4) Children enrolled in CHIP also experience disruptions
in health coverage and care. For example, during just a one-
year period, over one-third of CHIP enrollees were also
enrolled in a State's Medicaid program. Transitions between
Medicaid and CHIP can cause disruptions in care because the
health care coverage and participating providers vary between
the two programs.
(5) Interruptions in coverage can impair the receipt of
effective primary care and lead to expensive hospitalizations
or emergency room visits.
(6) Unnecessary enrollment, disenrollment and reenrollment
in Medicaid and CHIP result in higher administrative expenses
for reenrollment and result in more people uninsured at any
given time.
(7) Stable coverage under Medicaid and CHIP lowers average
monthly medical costs. Continuous enrollment also permits
better prevention and disease management, leading to fewer
serious illnesses and hospitalizations.
(8) Children with stable coverage are less likely to have
unmet medical needs, allowing children to receive the
preventive care that is necessary to help them grow into
healthy adults.
(9) For the majority of Medicaid enrollees who are served
by Primary Care Case Management (PCCM) or fee-for-service
arrangements, there are no Federal requirements for comparable
quality monitoring or improvement. No structured oversight
exists for Medicaid enrollees when they move between fee-for-
service and capitated managed care plans. Thus, there currently
is no ability to make fair assessments across all modes of care
for Medicaid enrollees.
SEC. 3. 12-MONTH CONTINUOUS ENROLLMENT.
(a) Requirement of 12-Month Continuous Enrollment Under Medicaid.--
(1) In general.--Section 1902(e)(12) of the Social Security
Act (42 U.S.C. 1396a(e)), is amended to read as follows:
``(12) 12-month continuous enrollment.--
``(A) In general.--Notwithstanding any other
provision of this title, a State plan approved under
this title (or under any waiver of such plan approved
pursuant to section 1115 or section 1915), shall
provide that an individual who is determined to be
eligible for benefits under such plan (or waiver) shall
remain eligible and enrolled for such benefits through
the end of the month in which the 12-month period
(beginning on the date of determination of eligibility)
ends.
``(B) Promoting retention of eligible and enrolled
persons beyond 12 months.--The Secretary shall--
``(i) identify methods that promote the
retention of individuals who are enrolled under
the State plan and who remain eligible for
medical assistance beyond the 12-month period
described in subparagraph (A); and
``(ii) actively promote the adoption of
such enrollment retention methods by States,
which should include but not be limited to
issuing guidance and developing resources on
State best practices.
``(C) Enrollment and retention reporting.--
``(i) In general.--Not later than September
30, 2014, the Secretary shall publish the
procedures that States are expected to use to
provide annual enrollment and retention reports
beginning September 30, 2015.
``(ii) State reporting requirements.--At a
minimum, such reporting procedures shall
include a description of State eligibility
criteria and enrollment procedures under this
title, and data regarding enrollment and
retention using standardized reporting formats
determined by the Secretary.
``(iii) Secretary report and publication.--
The Secretary shall annually publish enrollment
and retention performance results for all
States beginning not later than June 30, 2016.
``(iv) Each such annual report shall
include estimates of Medicaid enrollment
continuity ratios for each State. In this
clause, the term `enrollment continuity ratio'
means, for a given group, the ratio of the
average monthly enrollment of that group in the
fiscal year divided by the total unduplicated
enrollment for that group in the fiscal year,
expressed as a percentage.
``(v) For purposes of such reports, the
Secretary shall develop both overall ratios for
all enrollees and separate ratios for the
following categories:
``(I) Children.
``(II) Individuals whose
eligibility category is related to
being equal to or over the age of 65.
``(III) Individuals whose
eligibility category is related to
disability or blindness.
``(IV) Individuals whose
eligibility category is related to
their status as parents and caretaker
relatives of children under 19 or who
are otherwise not elderly, blind or
disabled adults.''.
(b) Requirement of 12-Month Continuous Enrollment Under CHIP.--
(1) In general.--Section 2102(b) of the Social Security Act
(42 U.S.C. 1397bb(b)) is amended by adding at the end the
following new paragraph:
``(6) Requirement for 12-month continuous enrollment.--
Notwithstanding any other provision of this title, a State
child health plan that provides child health assistance under
this title through a means other than described in section
2101(a)(2), shall provide that an individual who is determined
to be eligible for benefits under such plan shall remain
eligible and enrolled for such benefits through the end of the
month in which the 12-month period (beginning on the date of
determination of eligibility) ends.''.
(2) Conforming amendment.--Section 2105(a)(4)(A) of the
Social Security Act (42 U.S.C. 1397ee(a)(4)(A)) is amended--
(A) by striking ``has elected the option of'' and
inserting ``is in compliance with the requirement
for''; and
(B) by striking ``applying such policy under its
State child health plan under this title'' and
inserting ``in compliance with section 2102(b)''.
(c) Effective Date.--
(1) In general.--Except as provided in paragraph (2) or
(3), the amendments made by subsections (a) and (b) shall apply
to determinations (and redeterminations) of eligibility made on
or after the date that is 18 months after the date of the
enactment of this Act.
(2) Extension of effective date for state law amendment.--
In the case of a State plan under title XIX or State child
health plan under title XXI of the Social Security Act (42
U.S.C. 1396 et seq., 42 U.S.C. 1397aa et seq.) which the
Secretary of Health and Human Services determines requires
State legislation (other than legislation appropriating funds)
in order for the respective plan to meet the additional
requirement imposed by the amendment made by subsection (a) or
(b), respectively, the respective plan shall not be regarded as
failing to comply with the requirements of such title solely on
the basis of its failure to meet such applicable additional
requirement before the first day of the first calendar quarter
beginning after the close of the first regular session of the
State legislature that begins after the date of enactment of
this Act. For purposes of the previous sentence, in the case of
a State that has a 2-year legislative session, each year of the
session is considered to be a separate regular session of the
State legislature.
(3) Option to implement 12-month continuous eligibility
prior to effective date.--A State may elect through a State
plan amendment under title XIX or XXI of the Social Security
Act (42 U.S.C. 1396 et seq., 42 U.S.C. 1397aa et seq.) to apply
the amendment made by subsection (a) or (b), respectively, on
any date prior to the 18-month date specified in paragraph (1),
but not sooner than the date of the enactment of this Act.
SEC. 4. PREVENTING THE APPLICATION UNDER CHIP OF COVERAGE WAITING
PERIODS.
(a) In General.--Section 2102(b)(1)(B) of the Social Security Act
(42 U.S.C. 1397bb(b)(1)(B)) is amended--
(1) in clause (iii)--
(A) by striking ``in the case of'' and inserting
``in the case of a targeted low-income child (including
a child provided dental-only supplemental coverage
under section 2110(b)(5)) or in the case of''; and
(B) by adding ``and'' after the semicolon;
(2) by striking clause (iv); and
(3) by redesignating clause (v) as clause (iv).
(b) Conforming Amendments.--Section 2105(c)(10) of the Social
Security Act (42 U.S.C. 1397ee(c)(10)) is amended by striking
subparagraph (F) and redesignating subparagraphs (G) through (M) as
subparagraphs (F) through (L), respectively.
(c) Effective Date.--The amendments made by this section shall take
effect on the date of enactment of this Act.
SEC. 5. PERFORMANCE BONUSES FOR ENROLLMENT AND RETENTION IMPROVEMENTS
FOR CERTAIN INDIVIDUALS.
(a) Medicaid.--Section 1903 of the Social Security Act (42 U.S.C.
1396b) is amended by adding at the end the following new subsection:
``(aa) Performance Bonuses for Enrollment and Retention of Low-
Income Individuals.--
``(1) In general.--In addition to performance bonuses for
enrollment and retention described in section 2105(a) (related
to children), a State may qualify for 1 or more performance
bonuses related to the enrollment and retention of individuals
described in section 1902(e)(12)(C)(iii)(III). For purposes of
this paragraph, a State meets the condition of this paragraph
for such individuals if, for each category of individuals
specified in section 1902(e)(12)(C)(iii)(III) and selected by
the State for additional enrollment and retention provisions,
the State is implementing at least 3 of the following
enrollment and retention provisions (treating each subparagraph
as a separate enrollment and retention provision) throughout
the entire fiscal year:
``(A) Aligning treatment of income under medicaid
with that of other insurance affordability programs.--
The State implements policies, including prorating
income over annual periods, so as to align its
treatment of income for purposes of a determination of
eligibility for medical assistance with that of other
affordability insurance programs with the goal of
eliminating inconsistent determinations among these
programs.
``(B) Maintaining coverage for individuals during
periods of transition.--
``(i) In general.--Upon determination that
an individual is no longer eligible for medical
assistance, the State implements policies to
maintain eligibility for medical assistance,
including enrollment in the managed care
organization in which the individual was
enrolled at the time of the determination of
ineligibility, during the period of time in
which--
``(I) eligibility-related
information is transmitted to the other
insurance affordability programs;
``(II) a determination is made as
to for which other insurance
affordability program the individual is
eligible; and
``(III) coverage in such program
and any related managed care
organization becomes effective.
``(ii) Managed care organization
continuity.--The State shall also implement
policies to enroll the individual in the
managed care organization in which the
individual was a member prior to the loss of
medical assistance eligibility, if such managed
care organization participates in the other
insurance affordability program, unless the
individual voluntarily selects a separate
managed care organization.
``(C) Enhanced data-sharing between agencies.--The
State utilizes findings from an American Health Benefit
Exchange, an Express Lane Agency (as identified by the
State and as described in section 1902(e)(13)(F)) or
the Social Security Administration or other agencies
administering employment, educational, or social
services programs as identified by the State, to
document income, assets, residency, age or other
relevant information in determining or renewing
eligibility.
``(D) Eligibility based on pending status.--The
State maintains eligibility for enrollees whose renewal
status has not yet been determined and for whom
eligibility based on alternative eligibility criteria
has not yet been ruled out.
``(E) Default reenrollment in managed care
organization.--In the case of individuals who are
determined to be eligible for medical assistance under
this title after the loss of eligibility for fewer than
6 months, and who previously had been members of a
managed care organization, the State re-enrolls the
individual in the managed care organization in which
the individual was a member prior to the loss of
eligibility, unless the individual voluntarily selects
a separate managed care organization.
``(2) Performance bonus payment to offset costs resulting
from 12-month continuous enrollment for medicaid enrollees.--
``(A) Authority to make bonus payments.--
``(i) In general.--In addition to the
payments provided under section 2105(a) of the
Social Security Act, subject to subparagraph
(C) the Secretary shall make payments to a
State (beginning with fiscal year 2016) that
satisfies the requirements of subparagraph (B).
``(ii) Regulations.--Payments to States
shall be allocated annually among States in
accordance with regulations promulgated by the
Secretary not later than July 1, 2015.
``(iii) Timing.--The payment under this
paragraph shall be made, to a State for a
fiscal year, as a single payment not later than
the last day of the first calendar quarter of
the following fiscal year to which the
performance payment applies.
``(B) State eligibility for bonus payments.--A
State shall be eligible for bonus payments under this
subsection if--
``(i) the State has adopted at least 3 of
the 5 policies described in subparagraphs (A)
through (E) of paragraph (1); and
``(ii) the State is able to demonstrate
improvement in the continuity of enrollment by
aged, blind, and disabled and adult
populations, compared to its baseline
performance in fiscal year 2013.
``(C) Amounts available for payments.--
``(i) In general.--The total amount of
payments under paragraphs (1) and (2) of this
section shall be equal to $500,000,000 for
fiscal year 2016 for making payments under this
paragraph, to be available until expended.
``(ii) Budget authority.--This subsection
constitutes budget authority in advance of
appropriations Acts and represents the
obligation of the Secretary to provide for the
payment of amounts provided under this
subsection.
``(D) Uses of enrollment and retention performance
bonuses.--Nothing in this section shall prohibit a
State from establishing criteria which would permit the
State to distribute a portion of the proceeds of any
performance bonuses received pursuant to this section
to financially support providers who have contributed
to improved enrollment and retention activities. For
purposes of allocation of Enrollment and Retention
Performance Bonuses the definition of provider shall
have the meaning given to it in a State Plan.''.
(b) Extension of CHIP Performance Bonus To Align With
Reauthorization of State Allotments.--Section 2105(a)(3) of the Social
Security Act (42 U.S.C. 1397ee(a)(3)) is amended--
(1) in subparagraph (A), by striking ``2013'' and inserting
``2015'';
(2) in subparagraph (E)(ii)--
(A) in the heading for subclause (I)(aa), by
striking ``2012'' and inserting ``2014'';
(B) in subclause (I)(aa)--
(i) by striking ``2012'' and inserting
``2014'';
(ii) by striking ``subsection (a)'' and
inserting ``section 2104(a)''; and
(iii) by striking ``subsection (m)'' and
inserting ``section 2104(m)'';
(C) in the heading for subclause (I)(bb), by
striking ``2013'' and inserting ``2015'';
(D) in subclause (I)(bb)--
(i) by striking ``fiscal year 2013'' and
inserting ``fiscal year 2015'';
(ii) by striking ``subsection (a)(16)(A)''
and inserting ``section 2104(a)(18)(A)'';
(iii) by striking ``October 1, 2012, and
ending on March 31, 2013'' and inserting
``October 1, 2014, and ending on March 31,
2015'';
(iv) by striking ``subsection (m)'' and
inserting ``section 2104(m)''; and
(v) by striking ``or set aside under
subsection (b)(2) of section 2111 for such
fiscal year'';
(E) in the heading for subclause (I)(cc), by
striking ``2013'' and inserting ``2015'';
(F) in subclause (I)(cc)--
(i) by striking ``2013'' each place it
appears and inserting ``2015'';
(ii) by striking ``subsection (a)(16)(B)''
and inserting ``section 2104(a)(18)(B)'';
(iii) by striking ``subsection (m)'' and
inserting ``section 2104(m)''; and
(iv) by striking ``or set aside under
subsection (b)(2) of section 2111 for such
fiscal year'';
(G) in subclause (II), by striking ``2013'' and
inserting ``2015''; and
(H) in subclause (III), by striking ``2013'' and
inserting ``2015''; and
(3) in subparagraph (F)(iii), by striking ``2013'' and
inserting ``2015''.
SEC. 6. MEASURING AND REPORTING ON COMPARABLE HEALTH CARE QUALITY
MEASURES FOR ALL PERSONS ENROLLED IN MEDICAID.
(a) Quality Assurance Standards.--Section 1932(c)(1) of the Social
Security Act (42 U.S.C. 1396u-2(c)(1)) is amended in subparagraph (A),
by inserting after ``1903(m)'' the following: ``or comparable primary
care case management services providers described in section 1905(t) as
well as health care services furnished in fee-for-service settings''.
(b) Adult Health Quality Measures.--Title XI of the Social Security
Act (42 U.S.C. 1301 et seq.), as amended by section 2701 of the Patient
Protection and Affordable Care Act (Public Law 111-148), is amended at
section 1139B (42 U.S.C. 1320b-9b)--
(1) by adding after (b)(3) the following:
``(4) Quality reporting for medicaid eligible adults.--
Beginning January 1, 2016, the Secretary shall require States
to use the measures and approaches identified in paragraph (3)
of this subsection to report on the initial core set of quality
measures for Medicaid eligible adults identified in paragraph
(2), subject to revisions made by (5)(B) of this subsection.'';
(2) by redesignating subsection (b)(4) as (b)(5) and (b)(5)
as (b)(6);
(3) in subsection (d)(1)(B) inserting after ``Section 1937
of this title'' the following: ``or comparable primary care
case management services providers described in section 1905(t)
as well as health care services furnished in fee-for-service
settings''; and
(4) in subsection (d)(2) by inserting after ``(1)'' the
following: ``including analysis of comparable quality measures
for Medicaid eligible adults who receive their health services
through managed care, primary care case management, and fee-
for-service settings''.
(c) Pediatric Health Care Measures.--
(1) In general.--Title XI of the Social Security Act, is
amended at section 1139A(a) (42 U.S.C. 1320b-9a(a)) by--
(A) inserting after paragraph (4) as if it were
included upon enactment:
``(5) Reporting of pediatric health care measures.--Not
later than five years after the date of enactment of the
Medicaid Continuous Quality Act of 2012, States shall use the
procedures and approaches identified in paragraph (4) to report
information on the initial core measurement set regarding the
quality of pediatric health care under titles XIX and XXI.'';
(B) redesignating paragraphs (5), (6), (7) and (8)
as (6), (7), (8) and (9), respectively; and
(C) in subsection (c)(1)(B), inserting after
``section 2103 of such Act'' the following: ``or
comparable primary care case management services
providers described in section 1905(t) as well as
health care services furnished in fee-for-service
settings''.
SEC. 7. PERFORMANCE BONUSES FOR SIGNIFICANT ACHIEVEMENT IN MEDICAID
QUALITY PERFORMANCE.
Section 1932(c)(1) of the Social Security Act (42 U.S.C. 1396u-
2(c)(1)) is amended by adding at the end the following new
subparagraph:
``(F) Performance bonus for quality performance
achievement.--
``(i) In general.--The Secretary shall
establish a Medicaid Quality Performance Bonus
fund for awarding performance bonuses to States
for high attainment and improvement on a core
set of quality measures related to the goals
and purposes of the Medicaid program.
``(ii) Quality performance bonus
methodology.--Not later than three years after
the date of enactment of this Act, the
Secretary shall establish a methodology for
awarding Medicaid Quality Performance bonuses
to States not less than annually which will be
based on the annual State reports required
under section 1138B of title XI of the Social
Security Act, in accordance with regulations
promulgated by the Secretary.
``(iii) Quality performance measurement
bonuses.--Medicaid Quality Performance Bonus
funds will be awarded to up to 10 States that
meet thresholds established by the Secretary
for--
``(I) the top five States achieving
the designation of superior quality
performing State; or
``(II) five States demonstrating
the greatest relative level of annual
improvement in quality performance.
``(iv) Initial appropriation.--The total
amount of payments under this subparagraph
shall be equal to $500,000,000 for making
payments under this subparagraph, to be
available until expended.
This subparagraph constitutes budget authority in
advance of appropriations Acts and represents the
obligation of the Secretary to provide for the payment
of amounts provided under this subparagraph.
``(v) Uses of quality performance bonus
funds.--
``(I) Designation for quality
improvement activities.--As a condition
of receiving a bonus fund award under
clause (iii), a State shall agree to
designate at least 75 percent of the
performance bonus funds for the
development and operation of quality-
related initiatives that will directly
benefit providers, including--
``(aa) provider pay-for-
performance programs;
``(bb) provider
collaboration initiatives that
have been demonstrated to
improve performance on quality;
``(cc) provider quality
improvement initiatives,
including those aimed at
improving care for special and
hard-to-reach populations; and
``(dd) Secretary-approved
activities and initiatives that
a State may pursue to encourage
quality improvement and
patient-focused high value
care.
Nothing in this subparagraph shall prohibit a
State from establishing criteria for the State
provider performance program that limits the
award to a particular provider type(s), that
limits application to a specific geographic
area, or that directs incentive programs for
quality-related activities for specific
populations, including individuals eligible
under this title and title XVIII of the Social
Security Act, hard-to-reach populations.
``(II) Remaining bonus funds.--
States may designate up to 25 percent
of the quality performance bonus award
for activities related to the goals and
purposes of the program.
``(vi) Definition of providers.--For
purposes of allocation of Medicaid Quality
Performance Bonuses the definition of provider
shall have the meaning given to it in a State
Plan. Nothing in this section shall prohibit a
State from investing bonus funds into quality
improvement activities for managed care
entities.''.
<all>