To amend title XIX of the Social Security Act to provide for a DSH redistribution pool from unexpended Medicaid DSH allotments in order to increase Medicaid DSH allotments for low DSH States and to provide grants for health access networks serving the uninsured.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Strengthening the Health Care Safety 
Net Act of 2009''.

SEC. 2. APPLICATION OF UNEXPENDED MEDICAID DSH ALLOTMENTS FOR INCREASED 
              ALLOTMENTS FOR LOW DSH STATES AND FOR HEALTH NETWORK 
              ACCESS GRANTS.

    (a) Establishment of DSH Redistribution Pool From Unexpended 
Medicaid DSH Allotments.--Subsection (f) of section 1923 of the Social 
Security Act (42 U.S.C. 1396r-4) is amended--
            (1) by redesignating paragraph (7) as paragraph (8); and
            (2) by inserting after paragraph (6) the following new 
        paragraph:
            ``(7) DSH redistribution pool from portion of unexpended 
        dsh allotments to fund increase in allotments for low dsh 
        states and health network access grants.--
                    ``(A) Establishment.--There is established a DSH 
                redistribution pool in the amount provided under this 
                paragraph. Such amount shall be determined by the 
                Secretary at the beginning of each fiscal year and the 
                Secretary may adjust such amount in subsequent fiscal 
                years to take into account errors in estimates made for 
                previous fiscal years. The amount in such pool shall be 
                available for obligation and expenditure without fiscal 
                year limitation.
                    ``(B) Addition of unexpended dsh allotments.--At 
                the beginning of each fiscal year (beginning with 
                fiscal year 2010), there shall be added to the DSH 
                redistribution pool an amount equal to the amount by 
                which--
                            ``(i) the total of the DSH allotments for 
                        all States for the third preceding fiscal year; 
                        exceeded
                            ``(ii) the total Federal financial 
                        participation under this title attributable to 
                        such allotments for such fiscal year.
                    ``(C) Reduction for expenditures resulting from 
                increased allotments for low dsh states and for health 
                network access grants.--At the beginning of each fiscal 
                year (beginning with fiscal year 2011), there shall be 
                subtracted from the DSH redistribution pool an amount 
                equal to the sum of--
                            ``(i) the aggregate increase in Federal 
                        financial participation under this title 
                        attributable to the amendments made by section 
                        2(b) of the Strengthening the Health Care 
                        Safety Net Act of 2009 for the previous fiscal 
                        year; and
                            ``(ii) the amount obligated on grants under 
                        subsection (k) for such previous fiscal 
                        year.''.
    (b) Increase in DSH Allotments for Low DSH States; Qualification of 
Low DSH States Based on Fiscal Year 2005 Data.--Subsection (f)(5) of 
such section is amended--
            (1) in subparagraph (B)--
                    (A) by striking ``and'' at the end of clause (ii);
                    (B) in clause (iii)--
                            (i) by striking ``2009'' and inserting 
                        ``2015'';
                            (ii) by inserting ``, subject to 
                        subparagraph (D),'' after ``shall be''; and
                            (iii) by redesignating such clause as 
                        clause (iv); and
                    (C) by inserting after clause (ii) the following 
                new clause:
                            ``(iii) each succeeding fiscal year before 
                        fiscal year 2015 shall be, subject to 
                        subparagraph (D), the DSH allotment for the 
                        State for the previous fiscal year increased by 
                        16 percent; and''; and
            (2) by adding at the end the following new subparagraphs:
                    ``(C) Additional states covered for fiscal year 
                2010 and subsequent years.--In the case of a State not 
                described in subparagraph (B) in which the total 
                expenditures under the State plan (including Federal 
                and State shares) for disproportionate share hospital 
                adjustments under this section for fiscal year 2005, as 
                reported to the Administrator of the Centers for 
                Medicare & Medicaid Services as of August 31, 2008, is 
                greater than 0 but less than 3 percent of the State's 
                total amount of expenditures under the State plan for 
                medical assistance during the fiscal year, the DSH 
                allotment for the State with respect to--
                            ``(i) fiscal year 2010 and any succeeding 
                        fiscal year before fiscal year 2015 shall be, 
                        subject to subparagraph (D), the DSH allotment 
                        for the State for the previous fiscal year 
                        increased by 16 percent; and
                            ``(ii) any subsequent fiscal year shall be, 
                        subject to subparagraph (D), the DSH allotment 
                        for the State for the previous fiscal year 
                        subject to an increase for inflation as 
                        provided in paragraph (3)(A).
                    ``(D) Limitation on increases to amount available 
                from dsh redistribution pool.--If the Secretary 
                estimates for a fiscal year (beginning with fiscal year 
                2010) that--
                            ``(i) the amount of additional expenditures 
                        in the fiscal year resulting from the 
                        application of an increase in DSH allotments 
                        under subparagraphs (B) and (C) beginning with 
                        fiscal year 2010 of 16 percent (instead of the 
                        application of an increase for inflation as 
                        provided in paragraph (3)(A)), exceeds
                            ``(ii) the amount available for obligation 
                        from the DSH redistribution pool under 
                        paragraph (7) for the fiscal year,
                the Secretary shall reduce the increase in the DSH 
                allotments otherwise provided under such subparagraphs 
                for the fiscal year in a pro-rata manner so that the 
                amount of additional expenditures in the fiscal year 
                resulting from the application of such subparagraphs is 
                equal to the amount described in clause (ii) for the 
                fiscal year. A reduction in a DSH allotment for a State 
                under this subparagraph shall not affect the 
                computation of the DSH allotment for the State under 
                subparagraph (B) or (C) for the subsequent fiscal 
                year.''.
    (c) Demonstration Grants to Health Access Networks.--Such section 
is further amended by adding at the end the following new subsection:
    ``(k) Demonstration Grants to Health Access Networks.--
            ``(1) In general.--From the amount of funds made available 
        under paragraph (6)(A) of this subsection from funds made 
        available under subsection (d)(7) for a fiscal year, the 
        Secretary shall award demonstration grants under this 
        subsection to health access networks for such fiscal year for 
        the purpose of improving access, quality, and continuity of 
        care for uninsured individuals through better coordination of 
        care by the network.
            ``(2) Health access network defined.--
                    ``(A) In general.--In this subsection, the term 
                `health access network' means an entity representing a 
                collection of safety net providers, including 
                hospitals, community health centers, public health 
                departments, physicians, safety net health plans, 
                federally qualified health centers, or other recognized 
                safety net providers, that--
                            ``(i) is organized for the purpose of 
                        restructuring and improving the access, 
                        quality, and continuity of care to the 
                        uninsured and underinsured; and
                            ``(ii) offers patients access to all levels 
                        of care, including primary, outpatient, 
                        specialty, certain ancillary services, and 
                        acute inpatient care, within a community or 
                        across a broad spectrum of providers across a 
                        service region or State.
                    ``(B) Inclusion of section 330 networks and 
                plans.--Such term includes networks and plans that meet 
                the requirements for funding under section 330(e)(1)(C) 
                of the Public Health Service Act (42 U.S.C. 
                254b(e)(1)(C)).
                    ``(C) Inclusion of integrated health care 
                systems.--
                            ``(i) In general.--Such term also includes 
                        an integrated health care system (including a 
                        pediatric system).
                            ``(ii) Definition.--For purposes of this 
                        subparagraph, the term `integrated health care 
                        system (including a pediatric system)' means a 
                        health care provider that--
                                    ``(I) is organized to provide care 
                                in a coordinated fashion; and
                                    ``(II) assures access to a full 
                                range of primary, specialty, and 
                                hospital care, to uninsured and under-
                                insured individuals, as appropriate.
            ``(3) Application and plan requirement.--
                    ``(A) In general.--In order to be eligible for a 
                grant under this subsection, a health access network 
                shall--
                            ``(i) submit an application, in such form 
                        and manner as the Secretary shall specify;
                            ``(ii) submit with such application a plan 
                        that meets the requirements of subparagraph 
                        (B);
                            ``(iii) identify in such plan measurable 
                        performance targets for at least 3 of the goals 
                        described in subparagraph (B); and
                            ``(iv) agree that a portion of the payment 
                        of grant funds for patient care services after 
                        the first year for which such payment is made 
                        shall be contingent upon the health access 
                        network demonstrating success in achieving such 
                        targets.
                    ``(B) Plan requirements.--A health access network 
                that desires a grant under this subsection shall submit 
                a plan to the Secretary that details how the network 
                intends through the grant--
                            ``(i) to manage costs associated with the 
                        provision of health care services to uninsured 
                        and underinsured individuals served by the 
                        network;
                            ``(ii) to improve access to, and the 
                        availability of, health care services provided 
                        to uninsured and underinsured individuals 
                        served by the network;
                            ``(iii) to enhance the quality and 
                        coordination of health care services provided 
                        to uninsured and underinsured individuals 
                        served by the network;
                            ``(iv) to improve the health status of 
                        uninsured and underinsured individuals served 
                        by the network; and
                            ``(v) to reduce health disparities in the 
                        population of uninsured and underinsured 
                        individuals served by the network.
                Nothing in this paragraph shall be construed as 
                requiring a health access network operating in a State 
                to operate on a statewide basis or otherwise to serve 
                all uninsured and underinsured individuals in area 
                served.
                    ``(C) Authority to limit number of grants.--In 
                awarding grants under this subsection, the Secretary 
                may limit the grants in a manner so that each grantee 
                is able to provide patient care services to the number 
                of uninsured individuals specified by each network in 
                its grant application.
            ``(4) Use of funds.--
                    ``(A) In general.--A health access network that 
                receives funds under a grant under this subsection 
                shall expend an amount equal to at least 90 percent of 
                such funds for the provision of (or payment for) direct 
                patient care services.
                    ``(B) Rule of construction regarding direct patient 
                care services.--For purposes of subparagraph (A), the 
                term `direct patient care services' means, with respect 
                to a health access network, services, such as specialty 
                medical care and diagnostic services, that are not 
                available or are insufficiently available through the 
                network's providers other than under a grant under this 
                subsection.
                    ``(C) Preference for services through safety net 
                providers.--In purchasing direct patient care services 
                for uninsured and underinsured individuals under a 
                grant under this subsection, health access networks 
                shall, to the maximum extent feasible, endeavor to 
                purchase such services from safety net providers.
            ``(5) Supplement, not supplant.--Funds paid to a health 
        access network under a grant under this subsection shall 
        supplement and not supplant, other Federal or State payments 
        that are made to the network to support the provision of health 
        care services to low-income or uninsured patients.
            ``(6) Funding.--
                    ``(A) Availability of funds from dsh redistribution 
                pool.--To carry out this subsection there is hereby 
                made available for each fiscal year (beginning with 
                fiscal year 2010 and ending with fiscal year 2014) and 
                appropriated from the DSH redistribution pool 
                established under subsection (d)(7), an amount equal 
                to--
                            ``(i) the amount available for obligation 
                        from such pool in such fiscal year, reduced by
                            ``(ii) the Secretary's estimate of the 
                        aggregate increase in Federal financial 
                        participation under this title for the fiscal 
                        year that will be attributable to the 
                        amendments made by section 2(b) of the 
                        Strengthening the Health Care Safety Net Act of 
                        2009.
                    ``(B) Treatment of grant funds.--Payments to a 
                health access network under a grant under this 
                subsection shall not be treated as a disproportionate 
                share hospital payment adjustments under this section 
                and shall not be counted against the DSH allotment for 
                any State.
                    ``(C) No state matching required.--Nothing in this 
                subsection shall be construed as requiring a State to 
                provide for any State matching funds to receive funds 
                under this subsection.
                    ``(D) Availability.--The amount of any grant to a 
                health access network under this subsection shall 
                remain available for expenditure under the grant 
                through the end of the third fiscal year after the 
                fiscal year in which the grant is made.''.
    (d) Conforming Date of Application of DSH Hospital Requirement to 
Availability of Funding for Low DSH States.--Subsection (d)(2)(A)(ii) 
of such section is amended by inserting before the period at the end 
the following: ``(or, in the case of a low DSH State described in 
subparagraph (B) or (C) of subsection (f)(5), the date of the enactment 
of the Strengthening the Safety Net Act of 2009)''.
    (e) Reporting Using Unified Reporting Document.--Not later than 60 
days after the date of the enactment of this Act, the Secretary of 
Health and Human Services shall develop a unified reporting document 
for all disproportionate share hospital (DSH) allocations and 
expenditures under section 1923 of the Social Security Act. Beginning 
in fiscal year 2010 each State receiving a DSH allocation under such 
section shall be required by the Secretary to report all expenditures 
against the allocation using such unified reporting document. This 
requirement shall apply to States regardless of whether the DSH 
expenditures occur through a waiver.
    (f) Effective Date.--The amendments made by this section shall 
apply beginning with fiscal year 2010.

Summary: Strengthening the Health Care Safety Net Act of 2009 - Amends title XIX (Medicaid) of the Social Security Act to establish a disproportionate share hospital (DSH) redistribution pool from unexpended Medicaid DSH allotments to fund an increase in allotments for low DSH states. Directs the Secretary of Health and Human Services to award demonstration grants to health access networks to improve access, quality, and continuity of care for uninsured individuals through better coordination of care by such networks.