[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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