II 

110TH CONGRESS 

2D SESSION S. 3631 

To amend title XIX of the Social Security Act to establish a State plan 

option under Medicaid to provide an all-inclusive program of care for 

children who are medically fragile or have one or more chronic conditions 

that impede their ability to function. 

IN THE SENATE OF THE UNITED STATES 

SEPTEMBER 26 (legislative day, SEPTEMBER 17), 2008 

Mrs. CLINTON 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 establish 

a State plan option under Medicaid to provide an allinclusive program of care for children who are medically 

fragile or have one or more chronic conditions that impede their ability to function. 

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 ‘‘Medically Fragile Chil5 dren’s Act of 2008’’. 


wwoods2 on PRODPC68 with BILLS
2 

•S 3631 IS

1 SEC. 2. ESTABLISHMENT OF PROGRAM OF ALL-INCLUSIVE 

2 CARE FOR MEDICALLY FRAGILE CHILDREN 

3 AS A MEDICAID STATE OPTION. 

4 (a) IN GENERAL.—Title XIX of the Social Security 

5 Act is amended— 

6 (1) in section 1902(a)(10)(A)(ii)— 

7 (A) in subclause (XVIII) by striking ‘‘or’’ 

8 at the end; 

9 (B) in subclause (XIX), by adding ‘‘or’’ 

10 after the semicolon; and 

11 (C) by inserting after subclause (XIX) the 

12 following: 

13 ‘‘(XX) who are medically fragile 

14 children described in section 1942;’’; 

15 (2) in section 1905(a), in the matter preceding 

16 paragraph (1)— 

17 (A) in clause (xii), by striking ‘‘or’’ at the 

18 end; 

19 (B) in clause (xiii), by adding ‘‘or’’ after 

20 the comma; and 

21 (C) by inserting after clause (xiii) the fol22 lowing: 

23 ‘‘(xiv) medically fragile children de24 scribed in section 1942;’’; and 

25 (3) by adding at the end the following: 


wwoods2 on PRODPC68 with BILLS
3 

•S 3631 IS

1 ‘‘PROGRAM OF ALL-INCLUSIVE CARE FOR MEDICALLY

2 FRAGILE CHILDREN

3 ‘‘SEC. 1942. (a) STATE OPTION TO ESTABLISH ALL4 INCLUSIVE CARE FOR MEDICALLY FRAGILE CHIL5 DREN.— 

6 ‘‘(1) STATE PLAN AMENDMENT.— 

7 ‘‘(A) IN GENERAL.—A State may elect 

8 through a State plan amendment to provide 

9 medical assistance and other services described 

10 under this section by means of a program of 

11 all-inclusive care described in subsection (b) for 

12 eligible children described in paragraph (2). In 

13 the case of an eligible child enrolled with an all14 inclusive care program pursuant to such an 

15 election— 

16 ‘‘(i) the child shall receive benefits 

17 under the plan, as well as items and serv18 ices described in section 1905(r) solely 

19 through such programs; and 

20 ‘‘(ii) program providers shall receive 

21 an all-inclusive payment in accordance with 

22 a program agreement for the provision of 

23 such care that meets the requirements of 

24 this section. 


wwoods2 on PRODPC68 with BILLS
4 

•S 3631 IS

1 ‘‘(B) OPTION TO LIMIT ENROLLMENT.—A 

2 State may establish a numerical limit on the 

3 number of eligible children who may be enrolled 

4 in an all-inclusive care program under a pro5 gram agreement under this section. 

6 ‘‘(2) DEFINITION OF ELIGIBLE CHILD; PRO7 GRAM PROVIDER.—In this section, 

8 ‘‘(A) ELIGIBLE CHILD.—The term ‘eligible 

9 child’ means an individual who— 

10 ‘‘(i) has not attained age 25; 

11 ‘‘(ii) is— 

12 ‘‘(I) determined by the State to 

13 be medically fragile based on health 

14 status and related indicators (such as 

15 medical diagnoses and measures of ac16 tivities of daily living, instrumental 

17 activities of daily living, and cognitive 

18 impairment); or 

19 ‘‘(II) diagnosed as having 1 or 

20 more chronic conditions; 

21 ‘‘(iii) requires daily monitoring of a 

22 significant medical condition necessitating 

23 overall care planning in order to achieve or 

24 maintain optimum health and develop25 mental status, achieve community integraVerDate Aug 31 2005 01:12 Sep 29, 2008 Jkt 069200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S3631.IS S3631

wwoods2 on PRODPC68 with BILLS
5 

•S 3631 IS

1 tion to the maximum extent possible, and 

2 requires both medical assistance and at 

3 least 2 additional services furnished under 

4 an all-inclusive program as a result of 

5 functional deficits; 

6 ‘‘(iv) resides in the service area of a 

7 program provider with a program agree8 ment under this section; and 

9 ‘‘(v) meets such other eligibility re10 quirements (including eligibility standards 

11 related to family income and resources) as 

12 the State may establish pursuant to sec13 tion 1902(r)(2). 

14 ‘‘(B) PROGRAM PROVIDER.—The term 

15 ‘program provider’ means an organization with 

16 an agreement with the State to provide a pro17 gram of all-inclusive care for eligible children 

18 enrolled with the organization in accordance 

19 with this section and the terms of such agree20 ment. 

21 ‘‘(b) PROGRAM REQUIREMENTS.—In order to satisfy 

22 the requirements of this section, a program of all-inclusive 

23 care for eligible children shall include, subject to sub24 section (d), the following: 


wwoods2 on PRODPC68 with BILLS
6 

•S 3631 IS

1 ‘‘(1) COMPREHENSIVE BENEFITS.—The pro2 gram shall provide items, benefits, and services to el3 igible children enrolled in the program through an 

4 all-inclusive and comprehensive, multi disciplinary 

5 health and social services delivery system. Each par6 ticipating system in a State shall have the dem7 onstrated ability to undertake the following: 

8 ‘‘(A) MEDICAL ASSISTANCE.—Furnish or 

9 arrange for the items and services described in 

10 section 1905(r) (early and periodic screening, 

11 diagnostic, and treatment services), as well as 

12 any other item or service for which Federal fi13 nancial participation may be available under 

14 this Act. 

15 ‘‘(B) ADMINISTRATIVE ACTIVITIES TO AS16 SURE ACCESS TO PREVENTIVE, ACUTE, PRI17 MARY, SPECIALIZED, AND LONG TERM CARE

18 AND MEDICALLY APPROPRIATE UTILIZATION OF

19 CARE.—The administration activities described 

20 in section 1902(a)(43) (related to administra21 tive activities to assure receipt of services de22 scribed in section 1905(r)) and section 

23 1905(a)(19) (related to medical assistance case 

24 management services). 


wwoods2 on PRODPC68 with BILLS
7 

•S 3631 IS

1 ‘‘(C) ADDITIONAL SERVICES.—Social work 

2 services, transportation services, family support 

3 services, care coordination, coordination of pro4 gram services with educational, and social serv5 ices for which the child is eligible, nutrition as6 sessment and counseling, personal care services, 

7 respite care, and home and vehicle modification 

8 services. 

9 ‘‘(2) AVAILABILITY OF SERVICES.—Access to 

10 necessary medical care for acute conditions 24 hours 

11 per day, every day of the year. 

12 ‘‘(3) QUALITY ASSURANCE; PATIENT SAFE13 GUARDS.—At a minimum— 

14 ‘‘(A) for each enrolled child, a written plan 

15 of quality assurance and improvement that is 

16 periodically reviewed and updated, and proce17 dures for implementing such plan and moni18 toring and reviewing the quality of care; 

19 ‘‘(B) coverage of emergency services de20 scribed in section 1932(b)(2); 

21 ‘‘(C) the provision of information to fami22 lies whose children are enrolled in the program 

23 in easily understood form; and 

24 ‘‘(D) written safeguards regarding the 

25 rights of enrolled eligible children (including a 


wwoods2 on PRODPC68 with BILLS
8 

•S 3631 IS

1 patients bill of rights and written procedures 

2 for grievances and appeals, which shall be no 

3 less stringent than procedures applicable to en4 tities participating in a State plan for medical 

5 assistance pursuant to section 1932 of the Act). 

6 ‘‘(4) VOLUNTARY ENROLLMENT AND

7 DISENROLLMENT.—Voluntary enrollment and 

8 disenrollment without cause at any time. 

9 ‘‘(5) TRANSITION ASSISTANCE.—In the case of 

10 a child who is enrolled under the program under this 

11 section and whose enrollment ceases for any reason 

12 (including that the child no longer qualifies as an el13 igible child), assistance to the child in obtaining nec14 essary transitional care through appropriate refer15 rals and making the child’s medical records available 

16 to new providers. 

17 ‘‘(c) PROVIDER AGREEMENTS; USE OF ALL-INCLU18 SIVE PAYMENT METHODOLOGY.— 

19 ‘‘(1) IN GENERAL.— 

20 ‘‘(A) PROVIDER AGREEMENTS.—A State 

21 that elects the option under this section shall 

22 enter into an agreement with a program pro23 vider that has agreed to provide a program of 

24 all-inclusive care in accordance with the provi25 sions of this section for eligible children who reVerDate Aug 31 2005 01:12 Sep 29, 2008 Jkt 069200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S3631.IS S3631

wwoods2 on PRODPC68 with BILLS
9 

•S 3631 IS

1 side in the geographic area served by the pro2 vider (and specified in such agreement) and 

3 elect to enroll with the provider. 

4 ‘‘(B) CHOICE AND COMPETITION.—To the 

5 extent feasible, the State shall enter into agree6 ments with multiple providers in a single geo7 graphic area, and enter into agreements that 

8 provide coverage to as much of the State as is 

9 practicable. 

10 ‘‘(C) REPORTING REQUIREMENT.—An 

11 agreement entered into under subparagraph (A) 

12 shall require that a program provider submit to 

13 the Secretary, in a form and manner specified 

14 by the Secretary and for each eligible child who 

15 is enrolled with the program provider under 

16 such an agreement, the following: 

17 ‘‘(i) Service utilization data. 

18 ‘‘(ii) Expenditures. 

19 ‘‘(iii) Quality and health status meas20 ures (as identified by the Secretary). 

21 ‘‘(2) PAYMENT.— 

22 ‘‘(A) The State may utilize a negotiated, 

23 all-inclusive payment method that reflects the 

24 full range of medical assistance and related ad25 ministrative activities recognized under section 


wwoods2 on PRODPC68 with BILLS
10 

•S 3631 IS

1 1903 of the Act for which the provider will as2 sume responsibility. 

3 ‘‘(B) Such payment method shall provide 

4 for payment in an all-inclusive amount (using 

5 such methods as a per-member-per month or 

6 case payment arrangement) that shall assures 

7 quality, efficiency in relation to an all-inclusive 

8 approach to payment methods, access to nec9 essary care to achieve the purposes of this sec10 tion, and to the greatest degree possible, the in11 tegration of care, services, and activities de12 scribed in this section with other funding re13 lated to the educational, social and other serv14 ices that an enrolled child may receive. 

15 ‘‘(3) AUTHORITY TO CONTRACT.—The State 

16 may enter into an agreement under this section with 

17 a program provider that is not a medicaid managed 

18 care organization (as defined in section 

19 1903(m)(1)(A)) so long as the provider dem20 onstrates the health care expertise and infrastruc21 ture necessary to support the delivery of a program 

22 of all-inclusive care in accordance with the provisions 

23 of this section and satisfies such other criteria as the 

24 State specifies in the State plan amendment filed 

25 under this section. 


wwoods2 on PRODPC68 with BILLS
11 

•S 3631 IS

1 ‘‘(d) RULES OF CONSTRUCTION.—Nothing in this 

2 section shall be construed as— 

3 ‘‘(1) preventing a program provider from enter4 ing into contracts with other governmental or non5 governmental payers for the care of eligible children 

6 enrolled with the provider; or 

7 ‘‘(2) affecting the option of a State to offer 

8 services to medically fragile children under a dem9 onstration or waiver.’’. 

10 (b) CONFORMING AMENDMENT.—Section 1903(f)(4) 

11 of such Act (42 U.S.C. 1936b(f)(4)) is amended in the 

12 matter preceding subparagraph (A) by inserting ‘‘, 1942’’ 

13 after ‘‘1905(p)(1)’’. 

14 (c) STUDY AND REPORT.— 

15 (1) STUDY.—The Secretary of Health and 

16 Human Services, in consultation with State Med17 icaid agencies, annually shall conduct a study of the 

18 quality and cost of providing medical assistance for 

19 a program of all-inclusive care for eligible children 

20 under section 1942 of the Social Security Act (as 

21 added by subsection (a)). Such study shall include 

22 an analysis of— 

23 (A) the information submitted to the Sec24 retary under subsection (c)(1)(C) of such sec25 tion 1942; and 


wwoods2 on PRODPC68 with BILLS
12 

•S 3631 IS

1 (B) the extent to which the provision of 

2 such assistance resulted in improved quality 

3 and health status measures for eligible children. 

4 (2) REPORT.—Not later than 2 years after the 

5 date of the enactment of this Act, and annually 

6 thereafter, the Secretary of Health and Human 

7 Services shall submit a report to Congress on the re8 sults of the study required under paragraph (1) that 

9 includes such recommendations for legislative or ad10 ministrative action as the Secretary determines ap11 propriate. 

Æ 


wwoods2 on PRODPC68 with BILLS