[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1117 Introduced in House (IH)]

111th CONGRESS
  1st Session
                                H. R. 1117

To amend title XIX of the Social Security Act to establish a State plan 
 option under Medicaid to provide an all-inclusive program of care for 
    children who are medically fragile or have one or more chronic 
           conditions that impede their ability to function.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           February 23, 2009

Ms. Baldwin (for herself, Mr. Brown of South Carolina, and Mr. Spratt) 
 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 establish a State plan 
 option under Medicaid to provide an all-inclusive program of care for 
    children who are medically fragile or have one or more chronic 
           conditions that impede their ability to function.

    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 ``Medically Fragile Children's Act of 
2009''.

SEC. 2. ESTABLISHMENT OF PROGRAM OF ALL-INCLUSIVE CARE FOR MEDICALLY 
              FRAGILE CHILDREN AS A MEDICAID STATE OPTION.

    (a) In General.--Title XIX of the Social Security Act is amended--
            (1) in section 1902(a)(10)(A)(ii) (42 U.S.C. 
        1396b(a)(10)(A)(ii))--
                    (A) in subclause (XVIII) by striking ``or'' at the 
                end;
                    (B) in subclause (XIX), by adding ``or'' after the 
                semicolon; and
                    (C) by inserting after subclause (XIX) the 
                following:
                                    ``(XX) who are medically fragile 
                                children described in section 1942;'';
            (2) in section 1905(a) (42 U.S.C. 1396d(a)), in the matter 
        preceding paragraph (1)--
                    (A) in clause (xii), by striking ``or'' at the end;
                    (B) in clause (xiii), by adding ``or'' after the 
                comma; and
                    (C) by inserting after clause (xiii) the following:
                            ``(xiv) medically fragile children 
                        described in section 1942;''; and
            (3) by adding at the end the following:

     ``program of all-inclusive care for medically fragile children

    ``Sec. 1942.  (a) State Option To Establish All-Inclusive Care for 
Medically Fragile Children.--
            ``(1) State plan amendment.--
                    ``(A) In general.--A State may elect through a 
                State plan amendment to provide medical assistance and 
                other services described under this section by means of 
                a program of all-inclusive care described in subsection 
                (b) for eligible children described in paragraph (2). 
                In the case of an eligible child enrolled with an all-
                inclusive care program pursuant to such an election--
                            ``(i) the child shall receive benefits 
                        under the plan, as well as items and services 
                        described in section 1905(r) solely through 
                        such programs; and
                            ``(ii) program providers shall receive an 
                        all-inclusive payment in accordance with a 
                        program agreement for the provision of such 
                        care that meets the requirements of this 
                        section.
                    ``(B) Option to limit enrollment.--A State may 
                establish a numerical limit on the number of eligible 
                children who may be enrolled in an all-inclusive care 
                program under a program agreement under this section.
            ``(2) Definition of eligible child; program provider.--In 
        this section,
                    ``(A) Eligible child.--The term `eligible child' 
                means an individual who--
                            ``(i) has not attained age 25;
                            ``(ii) is--
                                    ``(I) determined by the State to be 
                                medically fragile based on health 
                                status and related indicators (such as 
                                medical diagnoses and measures of 
                                activities of daily living, 
                                instrumental activities of daily 
                                living, and cognitive impairment); or
                                    ``(II) diagnosed as having 1 or 
                                more chronic conditions;
                            ``(iii) requires daily monitoring of a 
                        significant medical condition necessitating 
                        overall care planning in order to achieve or 
                        maintain optimum health and developmental 
                        status, achieve community integration to the 
                        maximum extent possible, and requires both 
                        medical assistance and at least 2 additional 
                        services furnished under an all-inclusive 
                        program as a result of functional deficits;
                            ``(iv) resides in the service area of a 
                        program provider with a program agreement under 
                        this section; and
                            ``(v) meets such other eligibility 
                        requirements (including eligibility standards 
                        related to family income and resources) as the 
                        State may establish pursuant to section 
                        1902(r)(2).
                    ``(B) Program provider.--The term `program 
                provider' means an organization with an agreement with 
                the State to provide a program of all-inclusive care 
                for eligible children enrolled with the organization in 
                accordance with this section and the terms of such 
                agreement.
    ``(b) Program Requirements.--In order to satisfy the requirements 
of this section, a program of all-inclusive care for eligible children 
shall include, subject to subsection (d), the following:
            ``(1) Comprehensive benefits.--The program shall provide 
        items, benefits, and services to eligible children enrolled in 
        the program through an all-inclusive and comprehensive, 
        multidisciplinary health and social services delivery system. 
        Each participating system in a State shall have the 
        demonstrated ability to undertake the following:
                    ``(A) Medical assistance.--Furnish or arrange for 
                the items and services described in section 1905(r) 
                (early and periodic screening, diagnostic, and 
                treatment services), as well as any other item or 
                service for which Federal financial participation may 
                be available under this Act.
                    ``(B) Administrative activities to assure access to 
                preventive, acute, primary, specialized, and long term 
                care and medically appropriate utilization of care.--
                The administration activities described in section 
                1902(a)(43) (related to administrative activities to 
                assure receipt of services described in section 
                1905(r)) and section 1905(a)(19) (related to medical 
                assistance case management services).
                    ``(C) Additional services.--Social work services, 
                transportation services, family support services, care 
                coordination, coordination of program services with 
                educational, and social services for which the child is 
                eligible, nutrition assessment and counseling, personal 
                care services, respite care, and home and vehicle 
                modification services.
            ``(2) Availability of services.--Access to necessary 
        medical care for acute conditions 24 hours per day, every day 
        of the year.
            ``(3) Quality assurance; patient safeguards.--At a 
        minimum--
                    ``(A) for each enrolled child, a written plan of 
                quality assurance and improvement that is periodically 
                reviewed and updated, and procedures for implementing 
                such plan and monitoring and reviewing the quality of 
                care;
                    ``(B) coverage of emergency services described in 
                section 1932(b)(2);
                    ``(C) the provision of information to families 
                whose children are enrolled in the program in easily 
                understood form; and
                    ``(D) written safeguards regarding the rights of 
                enrolled eligible children (including a patients bill 
                of rights and written procedures for grievances and 
                appeals, which shall be no less stringent than 
                procedures applicable to entities participating in a 
                State plan for medical assistance pursuant to section 
                1932 of the Act).
            ``(4) Voluntary enrollment and disenrollment.--Voluntary 
        enrollment and disenrollment without cause at any time.
            ``(5) Transition assistance.--In the case of a child who is 
        enrolled under the program under this section and whose 
        enrollment ceases for any reason (including that the child no 
        longer qualifies as an eligible child), assistance to the child 
        in obtaining necessary transitional care through appropriate 
        referrals and making the child's medical records available to 
        new providers.
    ``(c) Provider Agreements; Use of All-Inclusive Payment 
Methodology.--
            ``(1) In general.--
                    ``(A) Provider agreements.--A State that elects the 
                option under this section shall enter into an agreement 
                with a program provider that has agreed to provide a 
                program of all-inclusive care in accordance with the 
                provisions of this section for eligible children who 
                reside in the geographic area served by the provider 
                (and specified in such agreement) and elect to enroll 
                with the provider.
                    ``(B) Choice and competition.--To the extent 
                feasible, the State shall enter into agreements with 
                multiple providers in a single geographic area, and 
                enter into agreements that provide coverage to as much 
                of the State as is practicable.
                    ``(C) Reporting requirement.--An agreement entered 
                into under subparagraph (A) shall require that a 
                program provider submit to the Secretary, in a form and 
                manner specified by the Secretary and for each eligible 
                child who is enrolled with the program provider under 
                such an agreement, the following:
                            ``(i) Service utilization data.
                            ``(ii) Expenditures.
                            ``(iii) Quality and health status measures 
                        (as identified by the Secretary).
            ``(2) Payment.--
                    ``(A) The State may utilize a negotiated, all-
                inclusive payment method that reflects the full range 
                of medical assistance and related administrative 
                activities recognized under section 1903 of the Act for 
                which the provider will assume responsibility.
                    ``(B) Such payment method shall provide for payment 
                in an all-inclusive amount (using such methods as a 
                per-member-per month or case payment arrangement) that 
                shall assures quality, efficiency in relation to an 
                all-inclusive approach to payment methods, access to 
                necessary care to achieve the purposes of this section, 
                and to the greatest degree possible, the integration of 
                care, services, and activities described in this 
                section with other funding related to the educational, 
                social and other services that an enrolled child may 
                receive.
            ``(3) Authority to contract.--The State may enter into an 
        agreement under this section with a program provider that is 
        not a Medicaid managed care organization (as defined in section 
        1903(m)(1)(A)) so long as the provider demonstrates the health 
        care expertise and infrastructure necessary to support the 
        delivery of a program of all-inclusive care in accordance with 
        the provisions of this section and satisfies such other 
        criteria as the State specifies in the State plan amendment 
        filed under this section.
    ``(d) Rules of Construction.--Nothing in this section shall be 
construed as--
            ``(1) preventing a program provider from entering into 
        contracts with other governmental or nongovernmental payers for 
        the care of eligible children enrolled with the provider; or
            ``(2) affecting the option of a State to offer services to 
        medically fragile children under a demonstration or waiver.''.
    (b) Conforming Amendment.--Section 1903(f)(4) of such Act (42 
U.S.C. 1936b(f)(4)) is amended in the matter preceding subparagraph (A) 
by inserting ``, 1942,'' after ``1905(p)(1)''.
    (c) Study and Report.--
            (1) Study.--The Secretary of Health and Human Services, in 
        consultation with State Medicaid agencies, annually shall 
        conduct a study of the quality and cost of providing medical 
        assistance for a program of all-inclusive care for eligible 
        children under section 1942 of the Social Security Act (as 
        added by subsection (a)). Such study shall include an analysis 
        of--
                    (A) the information submitted to the Secretary 
                under subsection (c)(1)(C) of such section 1942; and
                    (B) the extent to which the provision of such 
                assistance resulted in improved quality and health 
                status measures for eligible children.
            (2) Report.--Not later than 2 years after the date of the 
        enactment of this Act, and annually thereafter, the Secretary 
        of Health and Human Services shall submit a report to Congress 
        on the results of the study required under paragraph (1) that 
        includes such recommendations for legislative or administrative 
        action as the Secretary determines appropriate.
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