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[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[H.R. 722 Introduced in House (IH)]

111th CONGRESS
  1st Session
                                H. R. 722

 To amend title XIX of the Social Security Act to provide an option of 
States to cover a children's program of all-inclusive coordinated care 
                 (ChiPACC) under the Medicaid Program.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                            January 27, 2009

Mr. Moran of Virginia (for himself and Mr. Young of Florida) 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 provide an option of 
States to cover a children's program of all-inclusive coordinated care 
                 (ChiPACC) under the Medicaid Program.

    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 ``ChiPACC Act of 2009''.

SEC. 2. OPTIONAL MEDICAID COVERAGE OF CHILDREN'S PROGRAM OF ALL-
              INCLUSIVE COORDINATED CARE (CHIPACC).

    (a) In General.--Section 1905(a) of the Social Security Act (42 
U.S.C. 1396d(a)) is amended--
            (1) by striking ``and'' at the end of paragraph (27);
            (2) by redesignating paragraph (28) as paragraph (29); and
            (3) by inserting after paragraph (27) the following new 
        paragraph:
            ``(28) services furnished under a children's program of 
        all-inclusive coordinated care (ChiPACC) under section 1942; 
        and''.
    (b) Children's Program of All-Inclusive Coordinated Care 
(ChiPACC).--Title XIX of such Act is further amended by adding at the 
end the following new section:

    ``children's program of all-inclusive coordinated care (chipacc)

    ``Sec. 1942.  (a) State Option.--
            ``(1) In general.--A State may elect to provide medical 
        assistance under this section with respect to a children's 
        program of all-inclusive coordinated care to ChiPACC eligible 
        individuals who are eligible for medical assistance under the 
        State plan and who are enrolled in the program. In the case of 
        an individual enrolled in such a program pursuant to such an 
        election--
                    ``(A) the individual shall receive benefits under 
                the plan solely through such program; and
                    ``(B) the health care providers furnishing services 
                under such program shall receive payment in accordance 
                with the terms of such program for providing such 
                services.
            ``(2) Numerical and geographical limitations permitted.--A 
        State may establish--
                    ``(A) a numerical limit on the number of 
                individuals who may be enrolled in the State's ChiPACC; 
                and
                    ``(B) geographic limitations on the service areas 
                for a ChiPACC.
    ``(b) ChiPACC and Other Terms Defined.--In this section:
            ``(1) Children's program of all-inclusive coordinated care; 
        chipacc.--The terms `children's program of all-inclusive 
        coordinated care' and `ChiPACC' mean a program of coordinated 
        care for ChiPACC eligible children that is established by a 
        State under this section and meets the following requirements:
                    ``(A) Operation.--The program is administered by a 
                single State agency. Such agency may provide for the 
                operation of the program through arrangements between 
                one or more other entities, such as a ChiPACC 
                coordinator, and such agency.
                    ``(B) Comprehensive benefits.--
                            ``(i) In general.--The program provides 
                        comprehensive health care items and services to 
                        ChiPACC eligible individuals in accordance with 
                        this section and regulations.
                            ``(ii) Scope and plan for services.--Such 
                        items and services shall--
                                    ``(I) include items and services 
                                described in subsection (c)(1)(A) to 
                                the extent such items and services are 
                                appropriate to the individual; and
                                    ``(II) be provided consistent with 
                                a comprehensive care plan developed by 
                                an interdisciplinary health 
                                professional team.
                            ``(iii) Qualifications of providers.--Such 
                        items and services are provided through health 
                        care providers that--
                                    ``(I) meet such certification or 
                                other quality requirements as may be 
                                necessary to participate in the program 
                                of medical assistance under this title 
                                or in the program under title XVIII; 
                                and
                                    ``(II) maintain records on ChiPACC 
                                eligible individuals enrolled in the 
                                program and to whom the provider 
                                furnishes services, reflecting both the 
                                specific care and services furnished by 
                                the provider and the relationship of 
                                those services to the comprehensive 
                                plan of care for that individual and to 
                                the delivery of other services to the 
                                individual through the program.
            ``(2) ChiPACC eligible individual.--The term `ChiPACC 
        eligible individual' means, with respect to a ChiPACC, an 
        individual--
                    ``(A) who, at the time of enrollment in the ChiPACC 
                is a child (as defined under the State plan for this 
                purpose) and who is not older than such age as the 
                State may specify;
                    ``(B) who suffers from a serious illness or health 
                condition that is life threatening;
                    ``(C) for whom there is a reasonable likelihood 
                that the child's life will be threatened by such 
                illness or condition;
                    ``(D) whose health status is expected to decline 
                because of such illness or condition before attaining 
                full adulthood (as defined under the State plan);
                    ``(E) resides in the service area of the ChiPACC; 
                and
                    ``(F) is eligible for medical assistance under the 
                State plan without regard to this section (or, but for 
                enrollment in a ChiPACC would, based on the 
                individual's illness or health condition or the 
                projected cost of treatment required for such illness 
                or condition, become so eligible).
        The Secretary may waive the application of subparagraph (F) 
        with respect to eligibility for medical assistance under the 
        State plan without regard to this section in the case of 
        individuals if the State demonstrates to the satisfaction of 
        the Secretary that the sum of the additional expenditures under 
        this title resulting from such waiver in a fiscal year will not 
        exceed the aggregate savings in expenditures otherwise 
        resulting from the implementation of this section in the fiscal 
        year.
            ``(3) ChiPACC coordinator.--The term `ChiPACC coordinator' 
        means, with respect to a ChiPACC, an entity (which may be the 
        State administering agency or another entity under an 
        arrangement with such an agency) that directs, supervises, and 
        assures the coordination of comprehensive services to ChiPACC 
        eligible individuals enrolled in the ChiPACC consistent with 
        the following:
                    ``(A) The entity must assure the direct and 
                continuous involvement of an interdisciplinary health 
                professional team in managing and coordinating the 
                provision of care and services within the coordinator's 
                responsibility to each such enrolled individual.
                    ``(B) The entity must include on its staff, or 
                otherwise arrange for the provision of services, 
                through contracts or otherwise, of each of the types of 
                the health care professionals and other service 
                providers required to provide the items and services 
                required under subsection (c)(1)(A), to the extent such 
                items and services are necessary and appropriate to the 
                care of an enrolled individual.
                    ``(C) To the extent consistent with provision of 
                the highest quality of care to enrolled individuals--
                            ``(i) promote the utilization of volunteers 
                        in the provision of care and services under the 
                        ChiPACC, in accordance with standards set by 
                        the Secretary, which standards shall ensure a 
                        continuing level of effort to utilize such 
                        volunteers; and
                            ``(ii) ensure that records are maintained 
                        on the use of such volunteers and the cost 
                        savings and expansion of care and services 
                        achieved through the use of such volunteers.
            ``(4) Interdisciplinary health professional team.--The term 
        `interdisciplinary health professional team' means, with 
        respect to a ChiPACC, a group of health professionals that--
                    ``(A) includes at least--
                            ``(i) one physician (as defined in section 
                        1861(r)(1));
                            ``(ii) one registered professional nurse; 
                        and
                            ``(iii) one social worker, pastoral 
                        counselor, or other counselor;
                    ``(B) develops a comprehensive plan of care for 
                ChiPACC eligible individuals enrolled with the ChiPACC 
                and furnishes, or supervises the provision of, care and 
                services described in subsection (c)(1) to an 
                individual enrolled in the ChiPACC; and
                    ``(C) through direct action and communication with 
                health care providers furnishing services under the 
                ChiPACC, on behalf of or under the direction or 
                supervision of a State administering agency or a 
                ChiPACC coordinator, coordinates the care and services 
                furnished to such enrollees in a manner that takes into 
                account the best interests of each such enrollee and 
                the enrollee's family, as well as considerations of 
                cost and efficient use of available resources.
            ``(5) State administering agency.--The term `State 
        administering agency' means, with respect to the operation of a 
        ChiPACC in a State, the agency of that State (which may be the 
        single agency responsible for administration of the State plan 
        under this title in the State) responsible for the 
        implementation, either directly or through arrangements with 
        one or more ChiPACC coordinators, of the ChiPACC under this 
        section in the State.
            ``(6) Regulations.--Except as otherwise provided, the term 
        `regulations' refers to interim final or final regulations 
        promulgated under subsection (g).
    ``(c) Scope of Benefits; Beneficiary Safeguards.--
            ``(1) In general.--Under a ChiPACC of a State, the State 
        administering agency shall assure that--
                    ``(A) individuals enrolled in the ChiPACC are 
                furnished, at a minimum--
                            ``(i) all items and services that are 
                        necessary and appropriate to their care and 
                        that are covered under this title, and all 
                        additional items and services specified in 
                        regulations, but without any limitation or 
                        condition as to amount, duration, or scope;
                            ``(ii) access to covered items and 
                        services, as needed, 24 hours per day, every 
                        day of the year; and
                            ``(iii) services that include 
                        comprehensive, integrated palliative and 
                        curative services, expressive therapy and 
                        counseling, and counseling and anticipatory 
                        bereavement services to immediate family 
                        members of the ChiPACC eligible individual, as 
                        part of the services to the eligible 
                        individual;
                    ``(B) provision of such services to such 
                individuals through a comprehensive, interdisciplinary 
                and multidisciplinary health and social services 
                delivery system which integrates, as appropriate to the 
                individual recipient of services, acute and long-term 
                care services, palliative, respite and curative 
                treatment, counseling and support for family members 
                who are caretakers or otherwise relevant to appropriate 
                care and treatment of the individual, and such other 
                services as may be furnished pursuant to regulations 
                and the provisions of the applicable State plan; and
                    ``(C) the ChiPACC is operated, and the services to 
                enrolled individuals are furnished, in a manner that is 
                consistent with Standards of Care and Practice 
                Guidelines developed by Children's Hospice 
                International for a Program of All-Inclusive Care for 
                Children (as in effect as of the date of the enactment 
                of this section or such later date as the Secretary may 
                specify).
            ``(2) Quality assurance; patient safeguards.--With respect 
        to a ChiPACC, the State administering agency shall assure the 
        following:
                    ``(A) The provision of services under the ChiPACC 
                meets Federal and State guidelines for quality 
                assurance.
                    ``(B) Necessary safeguards have been established to 
                protect the health and welfare of individuals enrolled 
                in the ChiPACC under this section.
                    ``(C) There is financial accountability of funds 
                expended under this title with respect to such 
                services.
                    ``(D) There is a written plan of quality assurance, 
                and procedures implementing such plan, in accordance 
                with regulations.
                    ``(E) Written safeguards of the rights of 
                individuals enrolled in the ChiPACC, including a 
                patient bill of rights and procedures for grievances 
                and appeals, in accordance with regulations and with 
                other requirements of this title and Federal and State 
                law designed for the protection of patients.
                    ``(F) There are in effect procedures for data 
                collection, record maintenance and retention, and the 
                development of outcome measures, and such other 
                policies, systems, and procedures as are sufficient to 
                afford the Secretary and the State administering agency 
                access to records and data relating to the ChiPACC, 
                including pertinent financial, medical, and personnel 
                records.
                    ``(G) The agency shall submit to the Secretary such 
                reports as the Secretary finds (in consultation with 
                State administering agencies) necessary to monitor the 
                operation, cost, and effectiveness of ChiPACCs.
            ``(3) Cost-sharing waiver.--A State administering agency 
        may, in the case of a ChiPACC eligible individual enrolled in 
        the State's ChiPACC, waive deductibles, copayments, 
        coinsurance, or other cost-sharing that would otherwise apply 
        under the State plan under this title.
    ``(d) Eligibility Determinations.--
            ``(1) In general.--In determining whether an individual is 
        a ChiPACC eligible individual, the State administering agency 
        shall conduct an independent evaluation and assessment, which 
        shall include the following:
                    ``(A) Where appropriate, consultation with the 
                individual's family, guardian, or other responsible 
                individual.
                    ``(B) Consultation with appropriate treating and 
                consulting health and support professionals caring for 
                the individual.
                    ``(C) An examination of the individual's relevant 
                history, medical records, and care and support needs, 
                guided by best practices and research on effective 
                strategies that result in improved health and quality 
                of life outcomes.
            ``(2) Certification.--Upon completion of the evaluation and 
        assessment described in paragraph (1), an individual meeting 
        the criteria of a ChiPACC eligible individual shall be 
        certified as such, pursuant to procedures specified in 
        regulations and the applicable State plan.
            ``(3) Continuation of eligibility.--An individual who is a 
        ChiPACC eligible individual may be deemed to continue to be 
        such an individual notwithstanding a determination that the 
        individual no longer meets the requirement of subsection 
        (b)(2)(B) if, in accordance with regulations, it is reasonably 
        foreseeable that, if the individual is not furnished services 
        under this section, the severity or impact of the individual's 
        illness or condition would increase to a degree that the 
        individual would again meet such requirement before the 
        individual attains adulthood or within the succeeding 12-month 
        period.
            ``(4) Annual reevaluations.--Subject to such limitations as 
        the Secretary may by regulation prescribe, the eligibility 
        determination made under this subsection shall be reevaluated 
        annually, except that such an annual evaluation may be waived, 
        in accordance with regulations, in a case where the 
        administering State agency determines that there is no 
        reasonable expectation of improvement or significant change in 
        the individual's illness or condition during a period to which 
        the reevaluation requirement would otherwise be applicable.
            ``(5) Enrollment and disenrollment.--
                    ``(A) Voluntary disenrollment at any time.--The 
                enrollment and disenrollment of ChiPACC eligible 
                individuals in a ChiPACC shall be pursuant to 
                procedures specified in regulations and the State plan, 
                but shall permit an enrollee, or an enrollee's guardian 
                or other legal representative, acting on behalf of an 
                enrollee, to voluntarily disenroll for any reason at 
                any time.
                    ``(B) Limitations on disenrollment.--
                            ``(i) In general.--Regulations, and the 
                        applicable State plan, shall provide that a 
                        ChiPACC may not involuntarily disenroll a 
                        ChiPACC eligible individual enrolled in the 
                        ChiPACC except--
                                    ``(I) for disruptive or threatening 
                                behavior by the enrollee, or by a 
                                family member with whom a health care 
                                provider providing services under the 
                                ChiPACC necessarily has contact in the 
                                provision of services, as defined in 
                                provisions of regulations (developed in 
                                close consultation with State 
                                administering agencies); and
                                    ``(II) if there is a change in the 
                                individual's medical condition, 
                                residency or geographic location, or 
                                financial situation such that the 
                                individual no longer is a ChiPACC 
                                eligible individual and paragraph (3) 
                                does not apply to warrant continuation 
                                of enrollment.
                            ``(ii) No disenrollment for noncompliant 
                        behavior.--Except as allowed under regulations, 
                        a ChiPACC may not disenroll a ChiPACC eligible 
                        individual on the ground that the individual 
                        has engaged in noncompliant behavior if such 
                        behavior is related to a mental or physical 
                        condition of the individual. For purposes of 
                        the preceding sentence, the term `noncompliant 
                        behavior' includes repeated noncompliance with 
                        medical advice and repeated failure to appear 
                        for appointments.
                            ``(iii) Timely review of proposed 
                        nonvoluntary disenrollment.--A proposed 
                        involuntary disenrollment under this 
                        subparagraph shall be subject to timely review 
                        and final determination by the Secretary or by 
                        the State administering agency (as applicable), 
                        prior to the proposed disenrollment becoming 
                        effective, pursuant to procedures prescribed in 
                        regulations.
                    ``(C) Appeals.--If an individual is determined not 
                to be a ChiPACC eligible individual upon application, 
                any time after such services begin, or is disenrolled 
                from a ChiPACC for reasons described in subparagraph 
                (B)(i)(I), the State plan under this title shall allow 
                for an appeal of such determination. During the course 
                of the appeals process, an individual previously 
                enrolled in a ChiPACC shall continue to be so enrolled 
                and to receive benefits through the ChiPACC.
            ``(6) Construction.--The fact that a ChiPACC eligible 
        individual is enrolled under a ChiPACC shall not be construed 
        as adversely affecting the eligibility of the individual's 
        parents or caretaker relatives for medical assistance under 
        this title.
    ``(e) Payments to Health Care Providers Under ChiPACC.--
            ``(1) In general.--Payments to health care providers 
        furnishing items and services under a ChiPACC shall be paid on 
        a capitated or fee-for-service basis, according to regulations 
        and as specified in the applicable State plan consistent with 
        this subsection.
            ``(2) Use of integrated, budget-neutral financing.--
        Payments under this subsection shall be made--
                    ``(A) on a basis that permits provision for 
                integrated financing methodologies that allow providers 
                to pool payments received from public and private 
                programs and individuals; and
                    ``(B) in amounts that are designed, according to 
                regulations, to ensure that aggregate payments under 
                this section for individuals enrolled in a ChiPACC, 
                whether made on a capitated basis or fee-for-service 
                basis, do not exceed on average the aggregate payments 
                that would have been paid under the State plan for such 
                individuals if they were not so enrolled, taking into 
                account the comparative case-mix of ChiPACC enrollees 
                and such other factors as the Secretary determines to 
                be appropriate.
    ``(f) Termination Procedures.--
            ``(1) In general.--Under regulations--
                    ``(A) the Secretary may require a State 
                administering agency to terminate the participation of 
                a ChiPACC coordinator for cause; and
                    ``(B) a State administering agency may terminate 
                operation of a ChiPACC after appropriate notice to the 
                Secretary and enrollees.
            ``(2) Causes for coordinator termination.--In accordance 
        with regulations establishing procedures for termination of 
        participation of ChiPACC coordinators, the Secretary may 
        require a State administering agency to terminate participation 
        of a ChiPACC coordinator for, among other reasons, the fact 
        that--
                    ``(A) the Secretary determines that the ChiPACC 
                coordinator has failed to comply substantially with 
                requirements for a ChiPACC coordinator under this 
                section; and
                    ``(B) the State administering agency has failed to 
                develop and successfully initiate, within 30 days of 
                the date of the receipt of written notice of such a 
                determination for the ChiPACC coordinator, a plan to 
                correct the coordinator's deficiencies, or has failed 
                to continue implementation of such a plan of 
                correction.
    ``(g) Regulations.--
            ``(1) In general.--The Secretary shall issue interim final 
        or final regulations to carry out this section.
            ``(2) Use of existing standards.--
                    ``(A) In general.--In issuing such regulations, the 
                Secretary shall, to the extent appropriate and 
                consistent with the provisions of this section, 
                incorporate the standards and requirements applied to 
                Programs of All-Inclusive Care for Children 
                demonstration waiver programs that have been 
                implemented before (or as of) the date of the enactment 
                of this section, including standards of care and 
                practice guidelines applied under such programs.
                    ``(B) Flexibility.--In order to provide for 
                reasonable flexibility in adapting the service delivery 
                model described in subparagraph (A) to the needs of 
                particular organizations (such as those in rural areas 
                or those that may determine it appropriate to use 
                nonstaff physicians according to State licensing law 
                requirements) under this section, the Secretary (in 
                close consultation with State administering agencies) 
                may modify or waive provisions described in 
                subparagraph (A) so long as any such modification or 
                waiver is not inconsistent with and would not impair 
                the essential elements, objectives, and requirements of 
                this section, but may not modify or waive any of the 
                following provisions:
                            ``(i) The requirement of delivery of 
                        comprehensive, integrated palliative, respite 
                        and curative services, therapy, counseling and 
                        other medical and psycho-social services for 
                        ChiPACC eligible individual, to the extent such 
                        services would benefit the individual.
                            ``(ii) The requirement of delivery of 
                        counseling and bereavement services to 
                        immediate family members of the ChiPACC 
                        enrollees as part of the services to the 
                        enrollee.
                            ``(iii) The requirement of an 
                        interdisciplinary health professional team 
                        approach to care management and service 
                        delivery to ChiPACC eligible individuals.
                            ``(iv) The provision of integrated 
                        financing methodologies that allow for the 
                        pooling of payments received from public and 
                        private programs and individuals.
                            ``(v) The limitation on average aggregate 
                        payment under subsection (e)(2).
                    ``(C) Continuation of modifications or waivers 
                operational requirements.--If a State agency 
                administering a program of all-inclusive coordinated 
                care for seriously ill children approved pursuant to 
                waiver authority under section 1115 or 1915(c) has 
                contractual or other operating arrangements relating to 
                such program which are not otherwise recognized in 
                regulation and which were in effect as of the date of 
                the enactment of this section, the Secretary shall 
                permit the agency to continue such arrangements so long 
                as such arrangements are found by the Secretary to be 
                reasonably consistent with the objectives of a ChiPACC.
            ``(3) Construction.--Nothing in this subsection shall be 
        construed as preventing the Secretary from including in 
        regulations provisions to ensure the health and safety of 
        individuals enrolled in a ChiPACC under this section that are 
        in addition to those otherwise provided under this section.
    ``(h) Waivers of Requirements.--With respect to carrying out a 
ChiPACC under this section, the following requirements of this title 
(and regulations relating to such requirements) shall not apply:
            ``(1) Section 1902(a)(1), relating to any requirement that 
        ChiPACCs or ChiPACC services be provided in all areas of a 
        State.
            ``(2) Section 1902(a)(10), insofar as such section relates 
        to comparability of services among different population groups.
            ``(3) Sections 1902(a)(23) and 1915(b)(4), relating to 
        freedom of choice of providers under a ChiPACC.
            ``(4) Section 1903(m)(2)(A), insofar as it restricts a 
        ChiPACC provider from receiving prepaid capitation payments.
            ``(5) Such other provisions of this title that the 
        Secretary determines are inapplicable to carrying out a ChiPACC 
        under this section.
    ``(i) Continued Demonstration Project Authority.--Nothing in this 
section shall be construed as preventing a State from developing, or 
the Secretary from approving, a project similar to or related to 
ChiPACCs as described in this section, under existing authorities, 
including demonstration project and waiver authorities under this title 
or other provisions of this Act.''.
    (c) Other Conforming Amendments.--Section 1905(r)(5) of such Act 
(42 U.S.C. 1396d(r)(5)) is amended by inserting before the period at 
the end the following: ``, other than items and services to the extent 
such items and services are included under subsection (a) because of 
the application of paragraph (28)''.
    (d) Timely Issuance of Regulations; Effective Date.--The Secretary 
of Health and Human Services shall promulgate regulations to carry out 
the amendments made by this section in a timely manner, so as to assure 
that it will be feasible for State agencies and entities to establish 
and operate ChiPACCs for periods beginning not later than 1 year after 
the date of the enactment of this Act.
    (e) Funds for Technical Assistance .--The Secretary is authorized 
to expend funds appropriated to carry out title XIX of the Social 
Security Act to make grants to, or enter into contracts with, private 
entities or organizations that are qualified to provide technical or 
other assistance in developing and establishing ChiPACCs within the 
States, except that--
            (1) such funds may be expended solely for the purposes of 
        implementing this section; and
            (2) a private entity or organization in receipt of such 
        funds must have demonstrated expertise and a minimum of 5 years 
        of experience in working with or assisting in the establishment 
        of programs for comprehensive care of children meeting the 
        description of ChiPACC eligible individuals under section 
        1942(b) of the Social Security Act, as added by subsection (b).
                                 <all>
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