[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4930 Introduced in House (IH)]

113th CONGRESS
  2d Session
                                H. R. 4930

   To amend titles XIX and XXI of the Social Security Act to provide 
States with the option of providing services to children with medically 
  complex conditions under the Medicaid program and Children's Health 
   Insurance Program through a care coordination program focused on 
     improving health outcomes for children with medically complex 
         conditions and lowering costs, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             June 20, 2014

 Mr. Barton (for himself, Ms. Castor of Florida, Ms. Herrera Beutler, 
Mr. Gene Green of Texas, and Ms. Eshoo) introduced the following bill; 
       which was referred to the Committee on Energy and Commerce

_______________________________________________________________________

                                 A BILL


 
   To amend titles XIX and XXI of the Social Security Act to provide 
States with the option of providing services to children with medically 
  complex conditions under the Medicaid program and Children's Health 
   Insurance Program through a care coordination program focused on 
     improving health outcomes for children with medically complex 
         conditions and lowering costs, and for other purposes.

    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 ``Advancing Care for Exceptional Kids 
Act of 2014'' or the ``ACE Kids Act of 2014''.

SEC. 2. FINDINGS.

    Congress finds the following:
            (1) Approximately 3,000,000 children in the United States 
        suffer from medically complex conditions and approximately 
        2,000,000 of such children are enrolled in State plans under 
        the Medicaid program under title XIX of the Social Security 
        Act.
            (2) Such children account for an estimated 6 percent of 
        Medicaid enrollees and approximately 40 percent of children's 
        Medicaid spending is due to the severity of the illnesses of 
        such children.
            (3) The creation of nationally designated children's 
        hospital networks focused upon better coordination and 
        integration of care for such pediatric population will result 
        in improved health outcomes and savings under the Medicaid 
        program and the Children's Health Insurance Program under title 
        XXI of the Social Security Act.

SEC. 3. ESTABLISHMENT OF MEDICAID AND CHIP CARE COORDINATION PROGRAM 
              FOR CHILDREN WITH MEDICALLY COMPLEX CONDITIONS AS 
              MEDICAID STATE OPTION.

    (a) Medicaid.--Title XIX of the Social Security Act (42 U.S.C. 1396 
et seq.) is amended--
            (1) in section 1905(a) (42 U.S.C. 1396d(a))--
                    (A) by striking ``and'' at the end of paragraph 
                (27);
                    (B) by redesignating paragraph (29) as paragraph 
                (30); and
                    (C) by inserting after paragraph (28) the following 
                new paragraph:
            ``(29) items and services furnished under an MCCC program 
        under section 1947 to eligible children enrolled in an MCCC 
        program under such section.''; and
            (2) by adding at the end the following new section:

``SEC. 1947. MEDICAID CHILDREN'S CARE COORDINATION PROGRAMS FOR 
              CHILDREN WITH COMPLEX MEDICAL CONDITIONS.

    ``(a) Establishment.--
            ``(1) In general.--Beginning January 1, 2015, a State, at 
        its option as a State plan amendment, may elect to provide 
        medical assistance for items and services furnished to eligible 
        children enrolled in an MCCC program that meets the 
        requirements of this section. As a condition on an eligible 
        child's receipt of medical assistance under this title, the 
        State shall require, under such an amendment, that the eligible 
        child be enrolled in an MCCC program that meets the 
        requirements of this section. 
    ``(b) MCCC Program Requirements.--An MCCC program meets the 
requirements of this section if the MCCC program--
            ``(1) coordinates, integrates, and provides for the 
        furnishing of the full range of MCCC program services to 
        eligible children enrolled in the program;
            ``(2) enrolls eligible children in accordance with 
        subsection (c);
            ``(3) is operating under a program agreement that meets the 
        requirements of subsection (d); and
            ``(4) meets the pediatric network adequacy standards 
        developed under subsection (e).
    ``(c) Eligibility Determinations; Assignment.--
            ``(1) Enrollment.--Subject to the assignment requirements 
        of paragraph (2), the enrollment and disenrollment of eligible 
        children in an MCCC program shall be carried out in accordance 
        with regulations issued by the Secretary and the applicable 
        program agreement.
            ``(2) Network assignment.--
                    ``(A) In general.--Eligible children shall be 
                prospectively enrolled in an MCCC program by initially 
                assigning such eligible children to a nationally 
                designated children's hospital network for a period of 
                not less than 90 days beginning on the date on which 
                the child is initially assigned to such hospital 
                network.
                    ``(B) Basis for initial assignment.--Such an 
                assignment shall be based upon any of the following 
                factors (or a combination thereof):
                            ``(i) The prevalence of visits by the child 
                        to a pediatrician or other specialist who is 
                        participating in the nationally designated 
                        children's hospital network.
                            ``(ii) The selection of the child's family.
                            ``(iii) The location of the primary 
                        residence of the child.
                            ``(iv) The proximity of the child to 
                        regional referral networks established by the 
                        nationally designated children's hospital 
                        network.
                    ``(C) Limitation on certain assignments.--An 
                assignment of a child under clause (iii) or (iv) of 
                subparagraph (B) may only be made in the case of a 
                nationally designated children's hospital network that 
                offers medical home access within 30 miles of the 
                primary residence of the child.
                    ``(D) Reassignment.--Following the 90-day period 
                referred to in subparagraph (A), the child may elect--
                            ``(i) to be assigned to the nationally 
                        designated children's hospital network of their 
                        choice that has an MCCC program agreement in 
                        effect with respect to an MCCC program in which 
                        the child is eligible to enroll; or
                            ``(ii) to not participate in any MCCC 
                        program and receive care through enrollment in 
                        the State plan under this title or the State 
                        child health plan under title XXI.
    ``(d)  Program Agreements.--
            ``(1) In general.--The Secretary, in close cooperation with 
        the State administering agencies electing to provide the 
        medical assistance described in subsection (a), shall establish 
        procedures for entering into, extending, and terminating 
        program agreements under this section.
            ``(2) Terms.--
                    ``(A) In general.--A program agreement entered into 
                under this section by the Secretary, a State 
                administering agency, and a nationally designated 
                children's hospital network shall provide for each of 
                the following terms:
                            ``(i) The agreement shall designate the 
                        service area of the MCCC program that is the 
                        subject of the agreement.
                            ``(ii) The agreement shall be effective for 
                        a contract year, but may be extended for 
                        additional contract years in the absence of a 
                        notice by a party to terminate, and is subject 
                        to termination by the Secretary and the State 
                        administering agency at any time for cause (as 
                        provided under the agreement).
                            ``(iii) The agreement shall require that 
                        the nationally designated children's hospital 
                        network submit care management network and 
                        coverage plans to the Secretary that are 
                        centered around medical home models and that 
                        describe the governance of the network. 
                            ``(iv) The agreement shall require the 
                        hospital network to meet all applicable 
                        requirements imposed by State and local laws.
                            ``(v) The agreement shall require such 
                        State, in the case of eligible children who are 
                        residents of the State, to make payments to the 
                        hospital network, regardless of whether MCCC 
                        program services are furnished to such eligible 
                        children in another State.
                            ``(vi) The agreement shall require that the 
                        standards and measures developed under 
                        subsection (e) be applied to the hospital 
                        network, including measures requiring, with 
                        respect to network adequacy standards, that the 
                        hospital network establish such provider 
                        networks for primary, secondary, and tertiary 
                        care as are necessary to ensure the adequate 
                        furnishing of MCCC program services to eligible 
                        children enrolled in the MCCC program that is 
                        the subject of the agreement. 
                            ``(vii) The agreement shall require the 
                        hospital network to comply with the data 
                        collection and recordkeeping requirements of 
                        subparagraph (C).
                            ``(viii) The agreement shall require the 
                        hospital network to accept as payment any 
                        payment made using the risk-based methodology 
                        developed under subsection (g). 
                            ``(ix) The agreement shall contain such 
                        additional terms and conditions as the parties 
                        may agree to, so long as such terms and 
                        conditions are consistent with this section.
                    ``(B) Service area overlap.--In designating a 
                service area under subparagraph (A)(i), the Secretary 
                (in consultation with the relevant State administering 
                agency) shall consider the impacts of designating an 
                area that is already covered under another program 
                agreement, for purposes of avoiding the unnecessary 
                duplication of services and the impairment of the 
                financial and service viability of another MCCC 
                program.
                    ``(C) Data and recordkeeping requirements.--The 
                data collection and recordkeeping requirements under 
                this subparagraph, with respect to a nationally 
                designated children's hospital network, are as follows:
                            ``(i) The hospital network shall collect 
                        claims data on claims submitted with respect to 
                        eligible children who are furnished MCCC 
                        program services under an MCCC program. Such 
                        data shall be reported in a standardized format 
                        and made available to the public for purposes 
                        of establishing a national database on such 
                        claims. 
                            ``(ii) The hospital network shall maintain, 
                        and provide the Secretary and the State 
                        administering agency access to, the records 
                        relating to the MCCC program operated by the 
                        hospital network, including pertinent 
                        financial, medical, and personnel records.
                            ``(iii) The hospital network shall submit 
                        to the Secretary and the State administering 
                        agency such reports as the Secretary finds (in 
                        consultation with the State administering 
                        agency) necessary to monitor the operation, 
                        cost, and effectiveness of the MCCC program 
                        operated by the hospital network.
            ``(3) Termination of agreements.--The Secretary shall issue 
        regulations establishing the circumstances under which--
                    ``(A) the Secretary or a State administering agency 
                may terminate an MCCC program agreement for cause; and
                    ``(B) a nationally designated children's hospital 
                network may terminate such an agreement after 
                appropriate notice to the Secretary, the State 
                administering agency, and enrollees.
    ``(e) Quality Assurance.--
            ``(1) Development of standards and measures.--The Secretary 
        shall, in consultation with nationally designated children's 
        hospital networks and national pediatric policy organizations 
        (such as the Children's Hospital Association and the American 
        Academy of Pediatrics)--
                    ``(A) establish a national set of quality assurance 
                and improvement protocols and procedures to apply under 
                MCCC programs;
                    ``(B) develop pediatric quality measures;
                    ``(C) develop pediatric network adequacy standards 
                for access by eligible children to MCCC program 
                services; and
                    ``(D) develop criteria for national pediatric-
                focused care coordination for eligible children.
            ``(2) Use of pqmp measures.--In carrying out subparagraph 
        (A), the Secretary shall apply, to the extent applicable, child 
        health quality measures and measures for centers of excellence 
        for children with complex needs developed under this title, 
        title XXI, and section 1139A and take into account HEDIS 
        quality measures as required under section 1852(e)(3) and other 
        quality measures.
    ``(f) Standard Medicaid Data Set.--
            ``(1) In general.--The Secretary, the States, and the 
        nationally designated children's hospital networks shall 
        collaborate to obtain consistent and verifiable Medicaid 
        Analytic Extract data or a comparable data set and shall 
        establish data-sharing agreements to further support 
        collaborative planning and care coordination for medically 
        complex children.
            ``(2) Claims analysis.--The Secretary shall--
                    ``(A) perform claims analysis on the data set 
                developed under paragraph (1) to determine the 
                utilization of items and services furnished under an 
                MCCC program to eligible children; and
                    ``(B) submit to Congress and make publicly 
                available on the Internet site of the Centers for 
                Medicare and Medicaid services, a report on such claims 
                in a standardized format for purposes of building a 
                national database.
            ``(3) Payment for reporting incentives.--The Secretary may 
        provide for pay-for-reporting incentives during the first two 
        years of any MCCC program agreement entered into under this 
        section to ensure participation and analysis of consistent data 
        under this paragraph to enable the development of an 
        appropriate risk-based payment methodology under subsection 
        (g).
    ``(g) Payments to Nationally Designated Children's Hospital 
Networks.--
            ``(1) In general.--The State plan shall provide for payment 
        to nationally designated children's hospital networks pursuant 
        to the terms of an MCCC program agreement using a risk-based 
        payment methodology (or methodologies) established by the 
        Secretary in accordance with this subsection.
            ``(2) Transition from fee-for-service to risk-based payment 
        model.--
                    ``(A) In general.--Payment to nationally designated 
                children's hospital networks under this subsection 
                shall be based initially on a fee-for-service payment 
                model and shall gradually transition, over a 5-year 
                period, to an equitable, risk-based payment model using 
                a methodology developed under paragraph (3). For the 
                first two years of such period, a nationally designated 
                children's hospital network may receive, in addition to 
                any fee-for-service payments made to such hospital 
                network, per capita care coordination payments with 
                respect to expenditures for items and services 
                furnished to eligible children enrolled in the MCCC 
                program operated by the hospital network through 
                medical home programs and other care coordination 
                activities for which an all-inclusive payment model is 
                more suitable than fee-for-service reimbursement.
                    ``(B) Data analysis during initial period.--During 
                the first two years of the implementation of an MCCC 
                program, the Secretary shall analyze data collected 
                under subsection (f) for purposes of developing a risk-
                based payment methodology that would be implemented 
                beginning with the third year of implementation of the 
                MCCC program.
            ``(3) Development of risk-based payment methodology.--The 
        Secretary shall develop payment methodologies under this 
        subsection in coordination with the Medicaid and CHIP Payment 
        and Access Commission and the pediatric health care provider 
        community that--
                    ``(A) take into account the data analyzed under 
                paragraph (2)(B);
                    ``(B) are actuarially sound, as determined by the 
                Secretary and the relevant State administering agency, 
                in coordination with National Association of Insurance 
                Commissioners, using an actuarial methodology that is 
                adopted using historic pediatric claims data;
                    ``(C) include--
                            ``(i) a risk adjustment method, re-
                        insurance system, and risk-corridor procedure 
                        to account for variations in acuity of the 
                        eligible children enrolled in MCCC programs; 
                        and
                            ``(ii) a shared-savings component; and
                    ``(D) may provide for an model for making payments 
                other than payments made on a per-member, per-month 
                basis.
    ``(h) Waivers of Requirements.--With respect to carrying out an 
MCCC program under this section, the following provisions of law shall 
not apply:
            ``(1) Section 1902(a)(1), relating to statewideness.
            ``(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.
            ``(4) Section 1903(m)(2)(A), insofar as such section would 
        prohibit a nationally designated children's hospital network 
        from receiving certain payments.
            ``(5) Such other provisions of this title, title XVIII, 
        sections 1128A and 1128B, and any provisions of the Federal 
        antitrust laws as the Secretary determines are inapplicable or 
        the waiver of which are necessary for purposes of carrying out 
        an MCCC program under this section.
    ``(i) Preemption of State Law.--A State may not impose any 
requirement on the nationally qualified children's hospital network's 
operation of an MCCC program under a program agreement that meets the 
requirements of this section that is inconsistent with or would 
otherwise impede the satisfaction by such hospital network of the 
requirements of this section (including the requirements of such 
program agreement).
    ``(j) Definitions.--In this section:
            ``(1) Eligible child.--The term `eligible child' means, 
        with respect to an MCCC program, an individual who is under the 
        age of 18 and who--
                    ``(A) is eligible for medical assistance under the 
                State plan under this title or child health assistance 
                under the State child health plan under title XXI; and
                    ``(B) has, or is at a heightened risk of 
                developing, a chronic, physical, developmental, 
                behavioral, or emotional condition that--
                            ``(i) affects two or more body systems;
                            ``(ii) requires intensive care coordination 
                        to avoid excessive hospitalizations or 
                        emergency department visits; or
                            ``(iii) meets the criteria for medical 
                        complexity using risk adjustment methodologies 
                        (such as Clinical Risk Groups) agreed upon by 
                        the Secretary in coordination with a national 
                        panel of pediatric experts.
            ``(2) MCCC program.--The term `MCCC program' means a 
        Medicaid coordinated care program that provides eligible 
        children with MCCC program services through a nationally 
        designated children's hospital network in accordance with a 
        program agreement that meets the requirements of subsection 
        (d).
            ``(3) MCCC program services.--The term `MCCC program 
        services' means the full range of items and services for which 
        medical assistance is available under a State plan for 
        children, including pediatric care management services and 
        pediatric-focused care coordination and health promotion, as 
        specified in the program agreement.
            ``(4) Qualified children's hospital.--The term `qualified 
        children's hospital' means a children's hospital that--
                    ``(A) qualifies to receive payment under section 
                340E of the Public Health Service Act (relating to 
                children's hospitals that operate graduate medical 
                education programs); or
                    ``(B) meets 3 or more of the following criteria:
                            ``(i) Minimum pediatric discharges.--The 
                        hospital has at least 5,000 annual pediatric 
                        discharges (including neonates, but excluding 
                        obstetrics and normal newborns) for the most 
                        recent cost reporting period for which data are 
                        available.
                            ``(ii) Minimum number of beds.--The 
                        hospital has 100 licensed pediatric beds, not 
                        including beds in neonatal intensive care units 
                        but including beds in pediatric intensive care 
                        units and other acute care beds.
                            ``(iii) Access to pediatric emergency 
                        services.--The hospital has access (through 
                        ownership or otherwise) to pediatric emergency 
                        services.
                            ``(iv) Medicaid reliant.--At least 30 
                        percent of the pediatric discharges or 
                        inpatient days (excluding observation days) in 
                        the hospital for the most recent cost reporting 
                        period for which data are available were 
                        children eligible for medical assistance under 
                        this title or for children's health assistance 
                        under title XXI.
                            ``(v) Affiliation with accredited pediatric 
                        residency training program.--The hospital 
                        sponsors or is affiliated with a pediatric 
                        residency program that is accredited by the 
                        Accreditation Council for Graduate Medical 
                        Education.
                            ``(vi) Pediatric medical home programs.--
                        The hospital has established and implemented 
                        demonstrable pediatric medical home programs 
                        dedicated to medically complex children.
            ``(5) Nationally designated children's hospital network.--
        The term `nationally designated children's hospital network' 
        means a network of hospitals and health care providers--
                    ``(A) anchored by a qualified children's hospital 
                or hospitals with principal governance responsibility 
                over the hospital network;
                    ``(B) in which the full complement of health care 
                providers needed to provide the best care for children 
                in the network participate; and
                    ``(C) that represents the interests of physicians, 
                other health care providers, parents of medically 
                complex children, and other relatives of such children.
            ``(6) Program agreement.--The term `program agreement' 
        means, with respect to a nationally designated children's 
        hospital network, an agreement, between the hospital network, 
        the Secretary, and a State administering agency for the 
        operation of an MCCC program by the hospital network in the 
        State that meets the requirements of this section.
            ``(7) State administering agency.--The term `State 
        administering agency' means, with respect to the operation of 
        an MCCC program 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 
        administering program agreements under this section.''.
    (b) Application Under CHIP.--Section 2107(e)(1) of the Social 
Security Act (42 U.S.C. 1397gg(e)(1)) is amended by adding at the end 
the following new subparagraph:
                    ``(P) Section 1947 (relating to Medicaid children's 
                care coordination programs for children with complex 
                medical conditions).''.
    (c) Regulations.--Not later than 120 days after the date of the 
enactment of this Act, the Secretary of Health and Human Services shall 
make rules on the record, after opportunity for an agency hearing to 
carry out the amendments made by this section in accordance with 
sections 556 and 557 of title 5, United States Code.
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