[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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