I

103D CONGRESS

2D SESSION H. R. 4810

To amend title XIX of the Social Security Act to prohibit the Secretary

of Health and Human Services from granting a waiver under the medicaid program to permit a State to require children enrolled in the program

to receive medical assistance under the program through managed care

plans unless such assistance is provided through an integrated child

health care network, and for other purposes.

IN THE HOUSE OF REPRESENTATIVES

JULY 21, 1994

Ms. SCHENK (for herself and Mr. LEHMAN) 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 prohibit

the Secretary of Health and Human Services from granting a waiver under the medicaid program to permit a

State to require children enrolled in the program to

receive medical assistance under the program through

managed care plans unless such assistance is provided

through an integrated child health care network, and

for other purposes.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,
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1 SECTION 1. SHORT TITLE.

2 This Act may be cited as the ‘‘Integrated Child

3 Health Care Network Act of 1994’’.

4 SEC. 2. LIMITATION ON MANAGED CARE WAIVERS AFFECT5 ING CHILDREN UNDER MEDICAID.

6 (a) REQUIRING MEDICAL ASSISTANCE FOR CHIL7 DREN FURNISHED THROUGH MANAGED CARE TO BE

8 FURNISHED THROUGH INTEGRATED NETWORKS.—Sec9 tion 1915 of the Social Security Act (42 U.S.C. 1396n)

10 is amended by adding at the end the following new sub11 section:

12 ‘‘(i)(1) The Secretary may not grant a waiver under

13 this section, section 1115, or any provision of this Act that

14 includes a waiver of the requirements of section

15 1902(a)(23) to permit a State to restrict the medical as16 sistance furnished under the State plan to a child to as17 sistance furnished through a primary care case-manage18 ment plan under subsection (b)(1) or a capitated managed

19 care plan unless such a plan—

20 ‘‘(A) furnishes such assistance to the individual

21 through an integrated child health network described

22 in paragraph (2);

23 ‘‘(B) provides assurances that the capitated

24 payments made to providers for assistance furnished

25 to children enrolled in the plan are determined on
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1 the basis of children’s health care needs and utiliza2 tion of services; and

3 ‘‘(C) submits reports (at such intervals as the

4 Secretary may require) to the Secretary and the

5 State containing such information as the Secretary

6 and the State may require to assure that the plan

7 meets the requirements of subparagraphs (A) and

8 (B), and makes the reports available to the public.

9 ‘‘(2) In this subsection:

10 ‘‘(A) A ‘capitated managed care plan’ means an

11 entity which—

12 ‘‘(i) has a contract with the State agency

13 under which such entity is paid a fixed amount

14 for providing or arranging for the provision of

15 health care items or services specified in such

16 contract to an individual eligible for medical as17 sistance under the State plan and enrolled with

18 such entity, regardless of whether such items or

19 services are furnished to such individual; and

20 ‘‘(ii) is liable for all or part of the cost of

21 furnishing any of such items or services, re22 gardless of whether such cost exceeds such fixed

23 payment.

24 ‘‘(B) A ‘child’ is an individual under 18 years

25 of age.
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1 ‘‘(C) An ‘integrated child health network’

2 means a network of providers with expertise in pro3 viding services to children that meets the following

4 requirements (together with any other requirements

5 that Secretary may impose):

6 ‘‘(i) The network includes (but is not lim7 ited to)—

8 ‘‘(I) pediatricians and pediatric spe9 cialists, family practice physicians, and

10 other pediatric health professionals;

11 ‘‘(II) community-based clinics that

12 provide services of providers described in

13 subclause (I); and

14 ‘‘(III) hospitals with pediatric units

15 which are a distinct part of the hospital

16 (as defined by the Secretary), hospitals

17 whose inpatients are predominantly chil18 dren, and specialty hospitals whose inpa19 tients are predominantly children (includ20 ing rehabilitation and long-term care hos21 pitals).

22 ‘‘(ii) The network has an explicit mission

23 of meeting the health care needs of children.
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1 ‘‘(iii) The network participates in graduate

2 medical education programs for primary and

3 specialty pediatric care services.

4 ‘‘(iv) The network provides for the coordi5 nation of pediatric specialty and subspecialty

6 care for children with special health care needs,

7 including (but not limited to)—

8 ‘‘(I) children eligible for supplemental

9 security income under title XVI;

10 ‘‘(II) children described in section

11 501(a)(1)(D); and

12 ‘‘(III) children described in section

13 1902(e)(3).’’.

14 (b) EFFECTIVE DATE.—The amendment made by

15 subsection (a) shall apply to quarters beginning on or

16 after the expiration of the 6-month period that begins on

17 the date of the enactment of this Act.

18 SEC. 3. GRANTS FOR ESTABLISHMENT OF INTEGRATED

19 CHILD HEALTH NETWORKS APPLYING SEPA20 RATE CAPITATED PAYMENT RATE FOR CHIL21 DREN.

22 (a) AVAILABILITY OF GRANTS.—

23 (1) IN GENERAL.—The Secretary of Health and

24 Human Services shall make grants to eligible enti25 ties over a 3-year period for the establishment, ini-
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1 tial operation, and the continuing operation of inte2 grated child health networks using different payment

3 models, including grants to demonstrate the oper4 ation of networks applying a separate capitated pay5 ment rate with respect to children enrolled with the

6 network. The previous sentence shall apply to dem7 onstrations of such networks initiated by States.

8 (2) INTEGRATED CHILD HEALTH NETWORK DE9 FINED.—In this section, the term ‘‘integrated child

10 health network’’ has the meaning given such term in

11 section 1915(i)(2)(C) of the Social Security Act (as

12 added by section 2(a)).

13 (b) ELIGIBILITY OF ENTITIES.—An entity is eligible

14 to receive a grant under subsection (a) if the entity sub15 mits to the Secretary (at such time and in such form as

16 the Secretary may require) an application containing—

17 (1) assurances that the entity has established

18 or is in the process of establishing an integrated

19 child health network;

20 (2) assurances that the entity will submit re21 ports on the activities of the entity that are funded

22 through the grant; and

23 (3) such other information and assurances as

24 the Secretary may require.
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1 (c) AUTHORIZATION OF APPROPRIATIONS.—There

2 are authorized to be appropriated such sums as may be

3 necessary for grants under subsection (a).

4 (d) REPORT TO CONGRESS.—Not later than 3 years

5 after the first grant is awarded under subsection (a), the

6 Secretary shall submit a report to Congress on the grants

7 made under subsection (a) and the activities funded

8 through such grants.

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