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[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4687 Introduced in House (IH)]

103d CONGRESS
  2d Session
                                H. R. 4687

To amend title XIX of the Social Security Act to prohibit a State from 
requiring any child with special health care needs to receive services 
under the State's plan for medical assistance under such title through 
 enrollment with a capitated managed care plan until the State adopts 
pediatric risk adjustment methodologies to take into account the costs 
to capitated managed care plans of providing services to such children, 
  and to direct the Secretary of Health and Human Services to develop 
    model pediatric risk adjustment methodologies for such purpose.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                              June 30, 1994

 Ms. Lambert 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 a State from 
requiring any child with special health care needs to receive services 
under the State's plan for medical assistance under such title through 
 enrollment with a capitated managed care plan until the State adopts 
pediatric risk adjustment methodologies to take into account the costs 
to capitated managed care plans of providing services to such children, 
  and to direct the Secretary of Health and Human Services to develop 
    model pediatric risk adjustment methodologies for such purpose.

    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 ``Children's Health Equity Act of 
1994''.

SEC. 2. PROHIBITING STATE MEDICAID PLANS FROM REQUIRING CHILDREN WITH 
              SPECIAL HEALTH CARE NEEDS TO ENROLL IN MANAGED CARE 
              PLANS.

    (a) In General.--Section 1903(m) of the Social Security Act (42 
U.S.C. 1396b(m)) is amended by inserting after paragraph (2) the 
following new paragraph:
    ``(3)(A) A State may not require a child with special health care 
needs who is eligible to receive any medical assistance under the State 
plan for any quarter to enroll with a capitated managed care plan to 
receive such assistance during the quarter, unless the State has 
adopted pediatric risk adjustment methodologies under which the State 
adjusts the payment rates for such plans to take into account the 
financial risks of enrolling such children.
    ``(B) In this paragraph--
            ``(i) the term `capitated managed care plan' means an 
        entity which--
                    ``(I) has a contract with the State agency under 
                which such entity is paid a fixed amount for providing 
                or arranging for the provision of health care items or 
                services specified in such contract to an individual 
                eligible for medical assistance under the State plan 
                and enrolled with such entity, regardless of whether 
                such items or services are furnished to such 
                individual, and
                    ``(II) is liable for all or part of the cost of 
                furnishing any of such items or services, regardless of 
                whether such cost exceeds such fixed payment; and
            ``(i) the term `child with special health care needs' means 
        any individual eligible for supplemental security income under 
        title XVI who is under 18 years of age, a child described under 
        section 501(a)(1)(D), or a child described in section 
        1902(e)(3).''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to quarters beginning on or after the date of the enactment of 
this Act.

SEC. 3. DEVELOPMENT OF MODEL PEDIATRIC RISK ADJUSTMENT METHODOLOGIES 
              UNDER MEDICAID TO TAKE INTO ACCOUNT ENROLLMENT OF 
              CHILDREN WITH SPECIAL HEALTH CARE NEEDS IN MANAGED CARE 
              PLANS.

    (a) In General.--The Secretary of Health and Human Services, acting 
through the Administrator of the Health Care Financing Administration, 
shall develop model pediatric risk adjustment methodologies under 
section 1903(m)(3) of the Social Security Act (as added by section 
2(a)) which State plans for medical assistance under title XIX of such 
Act may use to adjust payment rates for capitated managed care plans to 
take into account the financial risks to capitated managed care plans 
of enrolling children with special health care needs.
    (b) Report to Congress.--Not later than 2 years after the date of 
the enactment of this Act, the Secretary shall submit a report to 
Congress on the methodologies developed under subsection (a) and on the 
feasibility of applying the methodologies to State plans under title 
XIX of the Social Security Act for purposes of section 1903(m)(3) of 
such Act.
    (c) Definitions.--In this section, the terms ``capitated managed 
care plan'' and ``children with special health care needs'' have the 
meaning given such terms in section 1903(m)(3) of the Social Security 
Act (as added by section 2(a)).
                                 <all>
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