II 

114TH CONGRESS 

1ST SESSION S. 2097 

To amend title XIX of the Social Security Act to provide for payment 

for Medicaid services furnished by Ryan White part C grantees under 

a cost-based prospective payment system. 

IN THE SENATE OF THE UNITED STATES 

SEPTEMBER 29, 2015 

Ms. BALDWIN introduced the following bill; which was read twice and referred 

to the Committee on Finance 

A BILL 

To amend title XIX of the Social Security Act to provide 

for payment for Medicaid services furnished by Ryan 

White part C grantees under a cost-based prospective 

payment system. 

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

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘HIV Clinical Services 

5 Improvement Act’’. 


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1 SEC. 2. MEDICAID PAYMENT FOR SERVICES FURNISHED BY 

2 RYAN WHITE PART C GRANTEES ON A COST3 BASED PROSPECTIVE PAYMENT SYSTEM. 

4 (a) IN GENERAL.—Section 1902 of the Social Secu5 rity Act (42 U.S.C. 1396a) is amended— 

6 (1) in subsection (a)(15), by inserting before 

7 the semicolon at the end the following: ‘‘and provide 

8 for payment for services described in section 1905(a) 

9 provided by a recipient of a grant under part C of 

10 title XXVI of the Public Health Service Act in ac11 cordance with subsection (ll)’’; and 

12 (2) by adding at the end the following new sub13 section: 

14 ‘‘(ll) PAYMENT FOR SERVICES PROVIDED BY RYAN

15 WHITE PART C GRANTEES.— 

16 ‘‘(1) IN GENERAL.—Beginning with fiscal year 

17 2016 with respect to services furnished on or after 

18 January 1, 2016, and each succeeding fiscal year, 

19 the State plan shall provide for payment for services 

20 described in section 1905(a) (in this subsection re21 ferred to as ‘Medicaid covered services’) furnished by 

22 a recipient of a grant under part C of title XXVI 

23 of the Public Health Service Act (in this subsection 

24 referred to as a ‘grantee’) in accordance with the 

25 provisions of this subsection. 


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1 ‘‘(2) FISCAL YEAR 2016.—Subject to paragraph 

2 (4), for services furnished on and after January 1, 

3 2016, during fiscal year 2016, the State plan shall 

4 provide for payment for such services in an amount 

5 (calculated on a per visit or similar basis as specified 

6 by the Secretary) that is equal to 100 percent of the 

7 average of the costs of the grantee of furnishing 

8 such services during fiscal years 2014 and 2015 

9 which are reasonable and related to the cost of fur10 nishing such services, or based on such other tests 

11 of reasonableness as the Secretary prescribes in reg12 ulations under section 1833(a)(3), or, in the case of 

13 services to which such regulations do not apply, the 

14 same methodology used under section 1833(a)(3), 

15 adjusted to take into account any increase or de16 crease in the scope of such services furnished by the 

17 grantee during fiscal year 2016. 

18 ‘‘(3) FISCAL YEAR 2017 AND SUCCEEDING FIS19 CAL YEARS.—Subject to paragraph (4), for services 

20 furnished during fiscal year 2017 or a succeeding 

21 fiscal year, the State plan shall provide for payment 

22 for such services in an amount (calculated on a per 

23 visit or similar basis) that is equal to the amount 

24 calculated for such services under this subsection for 

25 the preceding fiscal year— 


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1 ‘‘(A) increased by the percentage increase 

2 in the MEI (as defined in section 1842(i)(3)) 

3 applicable to primary care services (as defined 

4 in section 1842(i)(4)) for that fiscal year; and 

5 ‘‘(B) adjusted to take into account any in6 crease or decrease in the scope of such services 

7 furnished by the grantee during that fiscal year. 

8 ‘‘(4) ESTABLISHMENT OF INITIAL YEAR PAY9 MENT AMOUNT FOR NEW GRANTEES.—In any case 

10 in which an entity first becomes a grantee after fis11 cal year 2015, the State plan shall provide for pay12 ment for Medicaid covered services furnished by the 

13 entity in the first fiscal year in which the entity so 

14 qualifies in an amount (calculated on a per visit or 

15 similar basis) that is equal to 100 percent of the 

16 costs of furnishing such services during such fiscal 

17 year based on the rates established under this sub18 section for the fiscal year for other such grantees lo19 cated in the same or adjacent area with a similar 

20 case load or, in the absence of such a grantee, in ac21 cordance with the regulations and methodology re22 ferred to in paragraph (2) or based on such other 

23 tests of reasonableness as the Secretary may specify. 

24 For each fiscal year following the fiscal year in 

25 which the entity first qualifies, the State plan shall 


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1 provide for the payment amount to be calculated in 

2 accordance with paragraph (3). 

3 ‘‘(5) ADMINISTRATION IN THE CASE OF MAN4 AGED CARE.— 

5 ‘‘(A) IN GENERAL.—In the case of services 

6 furnished by a grantee pursuant to a contract 

7 between the grantee and a managed care entity 

8 (as defined in section 1932(a)(1)(B)), the State 

9 plan shall provide for payment to the grantee 

10 by the State of a supplemental payment equal 

11 to the amount (if any) by which the amount de12 termined under paragraphs (2), (3), and (4) ex13 ceeds the amount of the payments provided 

14 under the contract. 

15 ‘‘(B) PAYMENT SCHEDULE.—The supple16 mental payment required under subparagraph 

17 (A) shall be made pursuant to a payment 

18 schedule agreed to by the State and the grant19 ee, but in no case less frequently than every 4 

20 months. 

21 ‘‘(6) ALTERNATIVE PAYMENT METHODOLO22 GIES.—Notwithstanding any other provision of this 

23 section, the State plan may provide for payment in 

24 any fiscal year to a grantee for Medicaid covered 


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1 services in an amount which is determined under an 

2 alternative payment methodology that— 

3 ‘‘(A) is agreed to by the State and the 

4 grantee; and 

5 ‘‘(B) results in payment to the grantee of 

6 an amount which is at least equal to the 

7 amount otherwise required to be paid to the 

8 grantee under this subsection. 

9 ‘‘(7) QUALITY MANAGEMENT AND REPORTING

10 REQUIREMENTS.—The Secretary shall require that, 

11 as appropriate, a grantee shall be subject to quality 

12 management and reporting requirements comparable 

13 to those imposed on federally qualified health cen14 ters, including reporting of encounter data, clinical 

15 outcomes data, quality data, and such other data as 

16 the Secretary shall require, as a condition of such 

17 grantee receiving payment for Medicaid covered 

18 services under this subsection.’’. 

19 (b) EFFECTIVE DATE.— 

20 (1) Except as provided in paragraph (2), the 

21 amendments made by subsection (a) shall apply to 

22 services furnished on or after January 1, 2016, 

23 without regard to whether or not final regulations to 

24 carry out such amendment have been promulgated 

25 by such date. 


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1 (2) In the case of a State plan for medical as2 sistance under title XIX of the Social Security Act 

3 which the Secretary of Health and Human Services 

4 determines requires State legislation (other than leg5 islation appropriating funds) in order for the plan to 

6 meet the additional requirement imposed by the 

7 amendments made by subsection (a), the State plan 

8 shall not be regarded as failing to comply with the 

9 requirements of such title solely on the basis of its 

10 failure to meet this additional requirement before 

11 the first day of the first calendar quarter beginning 

12 after the close of the first regular session of the 

13 State legislature that begins after the date of the en14 actment of this Act. For purposes of the previous 

15 sentence, in the case of a State that has a 2-year 

16 legislative session, each year of such session shall be 

17 deemed to be a separate regular session of the State 

18 legislature. 

Æ 


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