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:

1944.

Children’s program of all-inclusive coordinated care

(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).