I 

114TH CONGRESS 

2D SESSION H. R. 5542 

To amend titles XI and XIX of the Social Security Act to establish a 

comprehensive and nationwide system to evaluate the quality of care 

provided to beneficiaries of Medicaid and the Children’s Health Insurance 

Program and to provide incentives for voluntary quality improvement. 

IN THE HOUSE OF REPRESENTATIVES 

JUNE 21, 2016 

Ms. DEGETTE (for herself and Mr. KENNEDY) introduced the following bill; 

which was referred to the Committee on Energy and Commerce 

A BILL 

To amend titles XI and XIX of the Social Security Act 

to establish a comprehensive and nationwide system to 

evaluate the quality of care provided to beneficiaries of 

Medicaid and the Children’s Health Insurance Program 

and to provide incentives for voluntary quality improvement. 

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 ‘‘Medicaid and CHIP 

5 Quality Improvement Act of 2016’’. 


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1 SEC. 2. FINDINGS. 

2 Congress finds the following: 

3 (1) Despite the fact that Federal and State 

4 governments spend hundreds of billions of dollars 

5 every year on care for Americans through the Med6 icaid and CHIP programs, there is no nationwide, 

7 systematic method of reporting, collecting, evalu8 ating, or improving the quality of care across all 

9 payment and delivery systems (fee-for-service, man10 aged care, primary care case management, or other 

11 mechanisms). 

12 (2) Although the quality of care delivered 

13 through Medicaid health plans is frequently meas14 ured, there is no method or mechanism to systemati15 cally improve the quality of care provided to all Med16 icaid and CHIP beneficiaries. 

17 (3) For the majority of Medicaid and CHIP en18 rollees who are served by primary care case manage19 ment or fee-for-service arrangements, there are no 

20 Federal requirements for comparable quality moni21 toring or improvement. Thus there currently is no 

22 ability to make fair assessments across all modes of 

23 care for Medicaid and CHIP enrollees. 

24 (4) State flexibility and the resulting opportuni25 ties for innovation are hallmarks of the partnership 

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1 icaid and CHIP programs. Without a way to system2 atically measure quality, however, policymakers can3 not know which innovations are the most effective. 

4 SEC. 3. MEASURING AND REPORTING ON COMPARABLE 

5 HEALTH CARE QUALITY MEASURES FOR ALL 

6 PERSONS ENROLLED IN MEDICAID. 

7 (a) QUALITY ASSURANCE STANDARDS.—Section 

8 1932(c)(1)(A) of the Social Security Act (42 U.S.C. 

9 1396u–2(c)(1)(A)) is amended by inserting ‘‘or com10 parable primary care case management services providers 

11 described in section 1905(t) as well as health care services 

12 furnished in fee-for-service settings or other delivery sys13 tems’’ after ‘‘1903(m)’’. 

14 (b) ADULT HEALTH QUALITY MEASURES.—Section 

15 1139B of the Social Security Act (42 U.S.C. 1320b–9b) 

16 is amended— 

17 (1) in subsection (b)— 

18 (A) by redesignating paragraphs (4) and 

19 (5) as paragraphs (5) and (6), respectively; and 

20 (B) by inserting after paragraph (3), the 

21 following: 

22 ‘‘(4) QUALITY REPORTING FOR MEDICAID ELI23 GIBLE ADULTS.—Beginning not later than January 

24 1 of the calendar year that begins on or after the 

25 date that is 2 years after the date of enactment of 


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1 the Medicaid and CHIP Quality Improvement Act of 

2 2016, and annually thereafter, the Secretary shall 

3 require States to use the measures and approaches 

4 identified in paragraph (3) to report on the initial 

5 core set of quality measures for Medicaid eligible 

6 adults identified in paragraph (2), subject to revi7 sions made in accordance with paragraph (6)(B). 

8 Such reporting shall be stratified by delivery system, 

9 including managed care organizations under section 

10 1932, benchmark plans under section 1937, primary 

11 care case management services providers described 

12 in section 1905(t), health care services in fee-for13 service settings, and other delivery systems, except 

14 that the Secretary may determine that reporting on 

15 certain measures should not be stratified by delivery 

16 system because such stratification would not be fea17 sible or the delivery systems are not comparable with 

18 respect to the application of such measures. In addi19 tion to the stratification required under the previous 

20 sentence, the Secretary shall have the discretion to 

21 further stratify reporting on certain measures based 

22 on factors such as eligibility category, income level, 

23 or other differentiating factors that could have an 

24 impact on the comparability of the measure.’’; and 

25 (2) in subsection (d)— 


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1 (A) in paragraph (1)(A), by striking 

2 ‘‘under the such plan’’ and all that follows 

3 through ‘‘subsection (a)(5)’’ and inserting 

4 ‘‘under such plan or waiver, including measures 

5 described in subsection (b)(2), subject to revi6 sions made in accordance with subsection 

7 (b)(6)(B)’’; 

8 (B) in paragraph (1)(B), by inserting ‘‘, or 

9 comparable primary care case management 

10 services providers described in section 1905(t), 

11 as well as health care services furnished in fee12 for-service settings or other delivery systems’’ 

13 after ‘‘section 1937’’; and 

14 (C) in paragraph (2), by inserting before 

15 the period the following: ‘‘, including analysis of 

16 comparable quality measures for Medicaid eligi17 ble adults who receive their health services 

18 through managed care, primary care case man19 agement, and fee-for-service settings or other 

20 delivery systems’’. 

21 (c) PEDIATRIC HEALTH CARE MEASURES.— 

22 (1) IN GENERAL.—Section 1139A of the Social 

23 Security Act (42 U.S.C. 1320b–9a) is amended— 

24 (A) in subsection (a)— 


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1 (i) by redesignating paragraphs (5) 

2 through (8) as paragraphs (6) through (9), 

3 respectively; and 

4 (ii) by inserting after paragraph (4), 

5 the following: 

6 ‘‘(5) REPORTING OF PEDIATRIC HEALTH CARE

7 MEASURES.—Beginning not later than January 1 of 

8 the calendar year that begins on or after the date 

9 that is 2 years after the date of enactment of the 

10 Medicaid and CHIP Quality Improvement Act of 

11 2016, and annually thereafter, the Secretary shall 

12 require States to use the measures and approaches 

13 identified in paragraph (4) to report on the initial 

14 core child health care quality measures established 

15 under this subsection and as such measures subse16 quently are updated under subsection (b)(5). Such 

17 reporting shall be stratified by delivery system, in18 cluding managed care organizations under section 

19 1932, benchmark plans under sections 1937 and 

20 2103, primary care case management services pro21 viders described in section 1905(t), health care serv22 ices in fee-for-service settings, and other delivery 

23 systems, except that the Secretary may determine 

24 that reporting on certain measures should not be 

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1 tion would not be feasible or the delivery systems are 

2 not comparable with respect to the application of 

3 such measures. In addition to the stratification re4 quired under the previous sentence, the Secretary 

5 shall have the discretion to further stratify reporting 

6 on certain measures based on factors such as eligi7 bility category, income level, or other differentiating 

8 factors that could have an impact on the com9 parability of the measure.’’; and 

10 (B) in subsection (c)— 

11 (i) in paragraph (1)(A), by striking 

12 ‘‘measures described in subparagraphs (A) 

13 and (B) of subsection (a)(6)’’ and inserting 

14 ‘‘the core measures described in subsection 

15 (a), as revised in accordance with sub16 section (b)(5)’’; 

17 (ii) in paragraph (1)(B), by inserting 

18 before the period the following: ‘‘, or com19 parable primary care case management 

20 services providers described in section 

21 1905(t), as well as healthcare services fur22 nished in fee-for-service settings or other 

23 delivery systems’’; and 

24 (iii) in paragraph (2), by inserting be25 fore the period the following: ‘‘, including 


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1 analysis of comparable quality measures 

2 for children eligible for medical assistance 

3 under title XIX or child health assistance 

4 under title XXI who receive their health 

5 services through managed care, primary 

6 care case management, and fee-for-service 

7 settings or other delivery systems’’. 

8 (2) EFFECTIVE DATE.—The amendments made 

9 by this subsection shall take effect as if included in 

10 the enactment of section 1139A of the Social Secu11 rity Act, as added by section 401(a) of the Chil12 dren’s Health Insurance Program Reauthorization 

13 Act of 2009 (Public Law 111–3). 

14 SEC. 4. PERFORMANCE BONUSES FOR SIGNIFICANT 

15 ACHIEVEMENT IN MEDICAID AND CHIP QUAL16 ITY PERFORMANCE. 

17 Section 1903 of the Social Security Act (42 U.S.C. 

18 1396b) is amended by adding at the end the following new 

19 subsection: 

20 ‘‘(aa) PERFORMANCE BONUS FOR QUALITY PER21 FORMANCE ACHIEVEMENT.— 

22 ‘‘(1) IN GENERAL.—The Secretary shall estab23 lish a Medicaid Quality Performance Bonus fund for 

24 awarding performance bonuses to States for high at25 tainment and improvement on a core set of quality 


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1 measures related to the goals and purposes of the 

2 Medicaid program under this title. 

3 ‘‘(2) QUALITY PERFORMANCE BONUS METHOD4 OLOGY.—Not later than 3 years after the date of en5 actment of the Medicaid and CHIP Quality Im6 provement Act of 2016, the Secretary shall establish 

7 a methodology for awarding Medicaid quality per8 formance bonuses to States not less than annually in 

9 accordance with paragraph (3) and subject to the 

10 availability of appropriations. Medicaid quality per11 formance bonuses shall be awarded on the basis of 

12 the annual State reports required under sections 

13 1139A and 1139B and in accordance with regula14 tions promulgated by the Secretary. 

15 ‘‘(3) QUALITY PERFORMANCE MEASUREMENT

16 BONUSES.—Medicaid quality performance bonuses 

17 shall be awarded to the following 10 States: 

18 ‘‘(A) The top 5 States achieving the des19 ignation of superior quality performing State 

20 under criteria established by the Secretary. 

21 ‘‘(B) The 5 States that— 

22 ‘‘(i) are not among the States de23 scribed in subparagraph (A); and 

24 ‘‘(ii) demonstrate the greatest relative 

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1 formance under criteria established by the 

2 Secretary. 

3 ‘‘(4) INITIAL APPROPRIATION.— 

4 ‘‘(A) IN GENERAL.—The total amount of 

5 Medicaid quality performance bonuses made 

6 under this subsection for all fiscal years shall be 

7 equal to $500,000,000, to be available until ex8 pended. 

9 ‘‘(B) BUDGET AUTHORITY.—This para10 graph constitutes budget authority in advance 

11 of appropriations Acts and represents the obli12 gation of the Secretary to provide for the pay13 ment of amounts provided under this para14 graph. 

15 ‘‘(5) USE OF QUALITY PERFORMANCE BONUS

16 FUNDS.— 

17 ‘‘(A) DESIGNATION FOR QUALITY IM18 PROVEMENT ACTIVITIES.—As a condition of re19 ceiving a Medicaid quality performance bonus 

20 under this subsection, a State shall agree to 

21 designate at least 75 percent of the bonus funds 

22 paid to the State under this subsection for a 

23 fiscal year for the development and operation of 

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1 pating in the State plan under this title or 

2 under a waiver of such plan, including— 

3 ‘‘(i) pay-for-performance programs; 

4 ‘‘(ii) collaboration initiatives that have 

5 been demonstrated to improve performance 

6 on quality; 

7 ‘‘(iii) quality improvement initiatives, 

8 including those aimed at improving care 

9 for special and hard-to-reach populations, 

10 and those directed to managed care enti11 ties; and 

12 ‘‘(iv) such other Secretary-approved 

13 activities and initiatives that a State may 

14 pursue to encourage quality improvement 

15 and patient-focused high value care. 

16 ‘‘(B) STATE OPTION TO ESTABLISH CRI17 TERIA.—A State may establish criteria for the 

18 State performance program carried out under 

19 subparagraph (A) that limits the award to a 

20 particular provider or entity type, that limits 

21 application to a specific geographic area, or 

22 that directs incentive programs for quality-re23 lated activities for specific populations, includ24 ing individuals eligible under this title and title 

25 XVIII and hard-to-reach populations. 


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1 ‘‘(C) REMAINING BONUS FUNDS.—A State 

2 may designate up to 25 percent of the bonus 

3 funds paid to the State under this subsection 

4 for a fiscal year for activities related to the 

5 goals and purposes of the State program under 

6 this title.’’. 

Æ 


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