1.This Act may be cited as the
ChiPACC Act of
2011
.
2.Optional Medicaid
coverage of Children’s Program of All-Inclusive Coordinated Care
(ChiPACC)
(a)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 CareTitle XIX of such Act is further amended by
inserting after section 1943 the following new section:
1944.Children’s
Program of All-Inclusive Coordinated Care
(a)
(1)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 permittedA 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 definedIn this
section:
(1)Children’s
program of all-inclusive coordinated care; ChiPACCThe 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)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)
(i)The program provides comprehensive health care items and
services to ChiPACC eligible individuals in accordance with this section and
regulations (as such term is defined in paragraph (6)).
(ii)Scope and plan
for servicesSuch 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.
(iii)Qualifications
of providersSuch 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
individualThe 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)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).
(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 teamThe
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.
(5)State
administering agencyThe 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)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)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, 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 safeguardsWith 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)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 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)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
eligibilityAn 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)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 timeThe 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)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); or
(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 behaviorExcept 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 disenrollmentA 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)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)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)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 financingPayments 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)
(1)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 terminationIn 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)
(1)The Secretary shall issue interim final or final
regulations to carry out this section.
(2)Use of existing
standards
(A)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)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 requirementsIf 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)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)Applicability of
RequirementsWith 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 authoritySection 1944 of the Social Security Act, as
added by
subsection (b) shall not be construed as
preventing a State from developing, or the Secretary 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 this
title or other provisions of this Act.
(d)Other conforming
amendmentsSection 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 dateThe 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 assistanceThe 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).