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[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4810 Introduced in House (IH)]

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.

    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 ``Integrated Child Health Care Network 
Act of 1994''.

SEC. 2. LIMITATION ON MANAGED CARE WAIVERS AFFECTING CHILDREN UNDER 
              MEDICAID.

    (a) Requiring Medical Assistance for Children Furnished Through 
Managed Care to be Furnished Through Integrated Networks.--Section 1915 
of the Social Security Act (42 U.S.C. 1396n) is amended by adding at 
the end the following new subsection:
    ``(i)(1) The Secretary may not grant a waiver under this section, 
section 1115, or any provision of this Act that includes a waiver of 
the requirements of section 1902(a)(23) to permit a State to restrict 
the medical assistance furnished under the State plan to a child to 
assistance furnished through a primary care case-management plan under 
subsection (b)(1) or a capitated managed care plan unless such a plan--
            ``(A) furnishes such assistance to the individual through 
        an integrated child health network described in paragraph (2);
            ``(B) provides assurances that the capitated payments made 
        to providers for assistance furnished to children enrolled in 
        the plan are determined on the basis of children's health care 
        needs and utilization of services; and
            ``(C) submits reports (at such intervals as the Secretary 
        may require) to the Secretary and the State containing such 
        information as the Secretary and the State may require to 
        assure that the plan meets the requirements of subparagraphs 
        (A) and (B), and makes the reports available to the public.
    ``(2) In this subsection:
            ``(A) A `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.
            ``(B) A `child' is an individual under 18 years of age.
            ``(C) An `integrated child health network' means a network 
        of providers with expertise in providing services to children 
        that meets the following requirements (together with any other 
        requirements that Secretary may impose):
                    ``(i) The network includes (but is not limited 
                to)--
                            ``(I) pediatricians and pediatric 
                        specialists, family practice physicians, and 
                        other pediatric health professionals;
                            ``(II) community-based clinics that provide 
                        services of providers described in subclause 
                        (I); and
                            ``(III) hospitals with pediatric units 
                        which are a distinct part of the hospital (as 
                        defined by the Secretary), hospitals whose 
                        inpatients are predominantly children, and 
                        specialty hospitals whose inpatients are 
                        predominantly children (including 
                        rehabilitation and long-term care hospitals).
                    ``(ii) The network has an explicit mission of 
                meeting the health care needs of children.
                    ``(iii) The network participates in graduate 
                medical education programs for primary and specialty 
                pediatric care services.
                    ``(iv) The network provides for the coordination of 
                pediatric specialty and subspecialty care for children 
                with special health care needs, including (but not 
                limited to)--
                            ``(I) children eligible for supplemental 
                        security income under title XVI;
                            ``(II) children described in section 
                        501(a)(1)(D); and
                            ``(III) children described in section 
                        1902(e)(3).''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to quarters beginning on or after the expiration of the 6-month 
period that begins on the date of the enactment of this Act.

SEC. 3. GRANTS FOR ESTABLISHMENT OF INTEGRATED CHILD HEALTH NETWORKS 
              APPLYING SEPARATE CAPITATED PAYMENT RATE FOR CHILDREN.

    (a) Availability of Grants.--
            (1) In general.--The Secretary of Health and Human Services 
        shall make grants to eligible entities over a 3-year period for 
        the establishment, initial operation, and the continuing 
        operation of integrated child health networks using different 
        payment models, including grants to demonstrate the operation 
        of networks applying a separate capitated payment rate with 
        respect to children enrolled with the network. The previous 
        sentence shall apply to demonstrations of such networks 
        initiated by States.
            (2) Integrated child health network defined.--In this 
        section, the term ``integrated child health network'' has the 
        meaning given such term in section 1915(i)(2)(C) of the Social 
        Security Act (as added by section 2(a)).
    (b) Eligibility of Entities.--An entity is eligible to receive a 
grant under subsection (a) if the entity submits to the Secretary (at 
such time and in such form as the Secretary may require) an application 
containing--
            (1) assurances that the entity has established or is in the 
        process of establishing an integrated child health network;
            (2) assurances that the entity will submit reports on the 
        activities of the entity that are funded through the grant; and
            (3) such other information and assurances as the Secretary 
        may require.
    (c) Authorization of Appropriations.--There are authorized to be 
appropriated such sums as may be necessary for grants under subsection 
(a).
    (d) Report to Congress.--Not later than 3 years after the first 
grant is awarded under subsection (a), the Secretary shall submit a 
report to Congress on the grants made under subsection (a) and the 
activities funded through such grants.
                                 <all>
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