I 

111TH CONGRESS 

1ST SESSION H. R. 3430 

To establish a Medicare DSH pilot program under which participants shall 

establish collaborative care networks to reduce the use of emergency 

departments, inpatient and other expensive resources of hospitals and 

other providers and provide more comprehensive and coordinated care 

to low-income individuals, including those without health insurance coverage, and to establish a Collaborative Care Network Center. 

IN THE HOUSE OF REPRESENTATIVES 

JULY 30, 2009 

Ms. LINDA T. SA ́NCHEZ of California (for herself, Mr. LEWIS of Georgia, and 

Mr. RUSH) introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy 

and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To establish a Medicare DSH pilot program under which 

participants shall establish collaborative care networks 

to reduce the use of emergency departments, inpatient 

and other expensive resources of hospitals and other 

providers and provide more comprehensive and coordinated care to low-income individuals, including those 

without health insurance coverage, and to establish a 

Collaborative Care Network Center. 

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


tjames on DSKG8SOYB1PROD with BILLS
2 

•HR 3430 IH

1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘DSH Collaborative 

3 Care Network Pilot Program Act of 2009’’. 

4 SEC. 2. MEDICARE DSH PILOT PROGRAM. 

5 (a) ESTABLISHMENT.— 

6 (1) IN GENERAL.—The Secretary of Health and 

7 Human Services (in this Act referred to as the ‘‘Sec8 retary’’) shall carry out a Medicare DSH pilot pro9 gram (in this Act referred to as the ‘‘Pilot Pro10 gram’’) under which, for purposes of establishing 

11 model projects described in paragraph (2), eligible 

12 DSH Program participants shall, for discharges oc13 curring during a cost reporting period for which the 

14 participant is participating in the Pilot Program, re15 ceive an amount in accordance with paragraph (3) 

16 in addition to the amount the participant would oth17 erwise receive under section 1886(d)(5)(F) of the 

18 Social Security Act (42 U.S.C. 1395ww(d)(5)(F)). 

19 (2) MODEL PROJECTS.—Model projects de20 scribed in this paragraph are projects to accomplish 

21 the following goals: 

22 (A) To reduce unnecessary use of items 

23 and services furnished in emergency depart24 ments of hospitals (especially to ensure that in25 dividuals without health insurance coverage or 

26 with inadequate health insurance coverage do 


tjames on DSKG8SOYB1PROD with BILLS
3 

•HR 3430 IH

1 not use the services of such department instead 

2 of the services of a primary care physician) 

3 through methods such as— 

4 (i) screening individuals who seek 

5 emergency department services for possible 

6 eligibility under relevant governmental 

7 health programs or for subsidies under 

8 such programs; and 

9 (ii) providing such individuals refer10 rals for follow-up care and chronic condi11 tion care. 

12 (B) To manage chronic conditions to re13 duce their severity, negative health outcomes, 

14 and expense. 

15 (C) To encourage health care providers to 

16 coordinate their efforts so that the most vulner17 able patient populations seek and obtain pri18 mary care. 

19 (D) To provide more comprehensive and 

20 coordinated care to low-income vulnerable indi21 viduals and individuals without health insurance 

22 coverage or with inadequate coverage. 

23 (E) To provide mechanisms for improving 

24 both quality and efficiency of care for low-in25 come individuals and families, with an emphasis 


tjames on DSKG8SOYB1PROD with BILLS
4 

•HR 3430 IH

1 on those most likely to remain uninsured de2 spite the existence of government programs to 

3 make health insurance more affordable. 

4 (F) To increase preventive services, includ5 ing screening and counseling, to those who 

6 would otherwise not receive such screening, in 

7 order to improve health status and reduce long 

8 term complications and costs. 

9 (G) To ensure the availability of commu10 nity-wide safety net services, including emer11 gency and trauma care. 

12 (3) ADDITIONAL AMOUNT.— 

13 (A) IN GENERAL.—The Secretary shall 

14 specify the additional amount each eligible 

15 DSH Program participant shall receive for a 

16 cost reporting period from the pool established 

17 under subparagraph (B) for the period involved. 

18 Such amount shall be established, to the max19 imum extent practicable, to retain or increase 

20 the level of funding for such a participant from 

21 year to year. The total of such payments for a 

22 period shall not exceed the total amount of 

23 funds available under subparagraph (B) for 

24 such period. 

25 (B) SPENDING POOL.— 


tjames on DSKG8SOYB1PROD with BILLS
5 

•HR 3430 IH

1 (i) IN GENERAL.—Subject to clause 

2 (ii), the amount described in this subpara3 graph for a fiscal year is equal to 2 per4 cent of the total of all Medicare DSH pay5 ments for the fiscal year 2008 cost report6 ing period, the rate of increase (if any), for 

7 each succeeding fiscal year through the fis8 cal year involved, in Medicare DSH pay9 ments for the fiscal year, as estimated by 

10 the Secretary. 

11 (ii) TREATMENT OF DECREASES.—If 

12 because of a change in law or regulation 

13 there is a decrease total Medicare DSH 

14 payments for a fiscal year, 5 percent of the 

15 amount of such decreased payments shall 

16 be added to the amount otherwise com17 puted under clause (i). 

18 (b) ELIGIBILITY AND PARTICIPANT SELECTION.— 

19 (1) ELIGIBLE DSH PROGRAM PARTICIPANT.— 

20 For purposes of this section, the term ‘‘eligible DSH 

21 Program participant’’ means a hospital described in 

22 section 1886(d)(5)(F)(i) of the Social Security Act 

23 that is to be a member of a collaborative care net24 work described in subsection (d) and selected by the 

25 Secretary under paragraph (3). 


tjames on DSKG8SOYB1PROD with BILLS
6 

•HR 3430 IH

1 (2) APPLICATION.—An applicant representing a 

2 collaborative care network described in subsection 

3 (d) shall submit to the Secretary an application in 

4 such form and manner and containing such informa5 tion as specified by the Secretary. Such information 

6 shall at least— 

7 (A) identify the health care providers par8 ticipating in the collaborative care network pro9 posed by the applicant and in the case a Feder10 ally-qualified health center is not included as 

11 such a participant, the reason such a center is 

12 not so included; 

13 (B) include a description of how the pro14 viders plan to collaborate to provide comprehen15 sive and integrated care for low-income individ16 uals, including uninsured and underinsured in17 dividuals; 

18 (C) include a description of the organiza19 tional and joint governance structure of the col20 laborative care network in a manner so that it 

21 is clear how decisions will be made; 

22 (D) define the geographic areas and popu23 lations that the network intends to serve; 

24 (E) define the scope of services that the 

25 network intends to provide and identify any 


tjames on DSKG8SOYB1PROD with BILLS
7 

•HR 3430 IH

1 reasons why such services would not include a 

2 suggested core service identified by the Sec3 retary under paragraph (4); 

4 (F) demonstrate the network’s ability to 

5 meet the requirements of this section; and 

6 (G) provide assurances that (and include a 

7 plan demonstrating how) funds received by an 

8 eligible DSH Program participant under section 

9 1886(d)(5)(F) of the Social Security Act pursu10 ant to the Pilot Program shall be appropriately 

11 distributed among all health care providers par12 ticipating in the collaborative care network. 

13 (3) SELECTION OF PARTICIPANTS.—The Sec14 retary shall select eligible DSH Program partici15 pants from applications submitted under paragraph 

16 (2) on the basis of quality of the proposal involved, 

17 geographic diversity (including different States and 

18 regions served and urban and rural diversity), and 

19 the number of low-income and uninsured individuals 

20 that the proposal intends to serve. The Secretary 

21 shall give priority to proposals from eligible DSH 

22 Program participants that serve a high volume a 

23 low-income individuals, and in applying this criteria, 

24 may consider whether the eligible DSH Program 

25 participant meets the criteria set out under section 


tjames on DSKG8SOYB1PROD with BILLS
8 

•HR 3430 IH

1 1923(b)(1)(B) of the Social Security Act. Subject to 

2 receiving enough high quality applications under 

3 paragraph (2), the Secretary shall select at least 5 

4 such participants initially. 

5 (4) SUGGESTED CORE SERVICES.—For pur6 poses of paragraph (2)(E), the Secretary shall de7 velop a list of suggested core services to be provided 

8 by a collaborative care network. The Secretary may 

9 select an eligible DSH Program participant under 

10 paragraph (3), the application of which does not in11 clude all such services, if such application provides 

12 a reasonable explanation why such services are not 

13 proposed to be included, and the Secretary deter14 mines that the application is otherwise high quality. 

15 Unless the Secretary determines otherwise, such list 

16 of suggested core services should include primary 

17 care, maternity care, and well-baby care. 

18 (5) TERMINATION AUTHORITY.—The Secretary 

19 may terminate selection of a collaborative care net20 work under this section for good cause. Such good 

21 cause shall include a determination that the net22 work— 

23 (A) has failed to provide a comprehensive 

24 range of coordinated and integrated health care 

25 services as required under subsection (d)(3); 


tjames on DSKG8SOYB1PROD with BILLS
9 

•HR 3430 IH

1 (B) had failed to meet reasonable quality 

2 standards; 

3 (C) has misappropriated funds provided 

4 under this section; or 

5 (D) has failed to make progress toward ac6 complishing goals set out in subsection (a)(2). 

7 (c) USE OF FUNDS.—Funds provided under the Pilot 

8 Program shall be available to an eligible DSH Program 

9 participant (or consortium of participants) to create and 

10 support collaborative care networks (described in sub11 section (d)) that would carry out the following activities: 

12 (1) Assist low-income individuals without ade13 quate health care coverage to— 

14 (A) access and appropriately use health 

15 services; 

16 (B) enroll in applicable public or private 

17 health insurance programs; 

18 (C) obtain referrals to and see a primary 

19 care provider in the case such an individual 

20 does not have a primary care provider; and 

21 (D) obtain appropriate care for chronic 

22 conditions. 

23 (2) Improve heath care by providing case man24 agement, application assistance, and appropriate re25 ferrals such as through methods to— 


tjames on DSKG8SOYB1PROD with BILLS
10 

•HR 3430 IH

1 (A) create and meaningfully use a health 

2 information network to track patients across 

3 collaborative providers; 

4 (B) perform health outreach, such as by 

5 using ‘‘promotoras’’—neighborhood health 

6 workers who may inform individuals about the 

7 availability of safety net and primary care avail8 able through the collaborative care network; 

9 (C) provide for follow-up outreach to re10 mind patients of appointments or follow-up care 

11 instructions; 

12 (D) provide transportation to individuals 

13 to and from the site of care; 

14 (E) expand the capacity to provide care at 

15 any provider participating in the collaborative 

16 care network, including through hiring new 

17 staff, opening new clinics or other provider sites 

18 after-hours, on weekends, or otherwise pro19 viding an urgent care alternative to an emer20 gency department; and 

21 (F) provide a primary care provider or 

22 medical home for each network patient. 

23 Nothing in this section shall be construed as requiring a 

24 collaborative care network to carry out all such activities. 

25 (d) COLLABORATIVE CARE NETWORKS.— 


tjames on DSKG8SOYB1PROD with BILLS
11 

•HR 3430 IH

1 (1) IN GENERAL.— 

2 (A) DESCRIPTION.—A collaborative care 

3 network described in this subsection is a con4 sortium of health care providers with a joint 

5 governance structure that provides a com6 prehensive range of coordinated and integrated 

7 health care services for low-income patient pop8 ulations or medically underserved communities 

9 (whether or not such individuals receive benefits 

10 under title XVIII, XIX, or XXI of the Social 

11 Security Act, private or other health insurance 

12 or are uninsured or underinsured) that complies 

13 with any applicable minimum eligibility require14 ments that the Secretary may determine appro15 priate. 

16 (B) REQUIRED INCLUSION.—Each such 

17 network shall include— 

18 (i) at least one eligible DSH program 

19 participant; and 

20 (ii) at least one Federally-qualified 

21 health center (as defined in section 

22 1905(l)(2)(B) of such Act) unless no such 

23 a center serves the geographic area pro24 posed to be served by the network; a center 

25 exists but refuses to participate; or a cenVerDate Nov 24 2008 04:54 Aug 01, 2009 Jkt 079200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H3430.IH H3430

tjames on DSKG8SOYB1PROD with BILLS
12 

•HR 3430 IH

1 ter places unreasonable conditions on such 

2 participation. 

3 (C) ADDITIONAL INCLUSIONS.—Each such 

4 network may include any of the following addi5 tional providers: 

6 (i) Another hospital. 

7 (ii) A county or municipal department 

8 of health. 

9 (iii) A rural health clinic. 

10 (iv) A community clinic, including a 

11 mental health clinic, substance abuse clin12 ic, or a reproductive health clinic. 

13 (v) A private practice physician or 

14 group practice. 

15 (vi) A nurse or physician assistant or 

16 group practice. 

17 (vii) An adult day care center. 

18 (viii) A home health provider. 

19 (ix) Any other type of provider speci20 fied by the Secretary, which has a desire to 

21 serve low-income and uninsured patients. 

22 (D) CONSTRUCTION.—Nothing in this sec23 tion shall prohibit a single entity from quali24 fying as collaborative care network so long as 

25 such single entity meets the criteria of a colVerDate Nov 24 2008 04:54 Aug 01, 2009 Jkt 079200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\H3430.IH H3430

tjames on DSKG8SOYB1PROD with BILLS
13 

•HR 3430 IH

1 laborative care network. If the network does not 

2 include at least one Federally-qualified health 

3 center (as defined in section 1905(l)(2)(B) of 

4 the Social Security Act), the application must 

5 explain the reason pursuant to subparagraph 

6 (A)(ii). 

7 (2) COLLABORATIVE CARE NETWORK PAYMENT

8 METHODOLOGIES.—The Secretary shall test alter9 native payment methodologies (which the Secretary 

10 may apply under the Pilot Program in lieu of or in 

11 addition to the increased payments under subsection 

12 (a)) to provide reimbursements to members of col13 laborative care networks for services that are pro14 vided by such members under the Pilot Program and 

15 may adopt alternative payment methodologies pro16 posed by the members of the collaborative care net17 work in the Application submitted under Section 

18 (b)(2). Such alternative methodologies may be paid 

19 to the eligible DSH Program participant, to another 

20 member of the network, or to the network itself, pro21 vided that the initial recipient is able to adequately 

22 distribute the funds pursuant to assurances in sub23 section (b)(2)(G). Such alternative payment meth24 odologies may include— 


tjames on DSKG8SOYB1PROD with BILLS
14 

•HR 3430 IH

1 (A) bundled, capitated, or flat rate pay2 ments to the collaborative care network or a 

3 member of the network; 

4 (B) shared savings programs; 

5 (C) a transition from traditional cost-based 

6 payments to alternative payment methodologies 

7 described in this section after an initial period; 

8 and 

9 (D) other payment methodologies designed 

10 to create incentives for the collaborative care 

11 networks to provide integrated and collaborative 

12 care and to reward high quality, cost-efficient 

13 care. 

14 (3) COMPREHENSIVE RANGE OF COORDINATED

15 AND INTEGRATED HEALTH CARE SERVICES.—The 

16 Secretary may define criteria for evaluating the serv17 ices offered by a collaborative care network. Such 

18 criteria may include the following: 

19 (A) Requiring collaborative care networks 

20 to include at least the suggested core services 

21 identified under subsection (b)(4), or whichever 

22 subset of the suggested core services is applica23 ble to a particular network. 

24 (B) Requiring such networks to assign 

25 each patient of the network to a primary care 


tjames on DSKG8SOYB1PROD with BILLS
15 

•HR 3430 IH

1 provider responsible for managing that patient’s 

2 care. 

3 (C) Requiring the services provided by a 

4 collaborative care network to include support 

5 services appropriate to meet the health needs of 

6 low-income populations in the network’s com7 munity, which may include chronic care man8 agement, nutritional counseling, transportation, 

9 language services, enrollment counselors, social 

10 services and other services as proposed by the 

11 network. 

12 (D) Providing that the services provided by 

13 a collaborative care network may also include 

14 long term care services and other services not 

15 specified in this subsection. 

16 (E) Providing for the approval by the Sec17 retary of a scope of collaborative care network 

18 services for each network that addresses an ap19 propriate minimum scope of work consistent 

20 with the setting of the network and the health 

21 professionals available in the community the 

22 network serves. 

23 (4) CLARIFICATION.—Participation in a collabo24 rative care network under the Pilot Program shall 

25 not disqualify a health care provider from reimburseVerDate Nov 24 2008 04:54 Aug 01, 2009 Jkt 079200 PO 00000 Frm 00015 Fmt 6652 Sfmt 6201 E:\BILLS\H3430.IH H3430

tjames on DSKG8SOYB1PROD with BILLS
16 

•HR 3430 IH

1 ment under title XVIII, XIX, or XXI of the Social 

2 Security Act with respect to services otherwise reim3 bursable under such title. Nothing in this section 

4 shall prevent a collaborative care network that is 

5 otherwise eligible to contract with Medicare, a pri6 vate health insurer, or any other appropriate entity 

7 to provide care under Medicare, under health insur8 ance coverage offered by the insurer, or otherwise. 

9 (e) EVALUATIONS.— 

10 (1) PARTICIPANT REPORTS.—Each eligible 

11 DSH Program participant shall submit to the Sec12 retary, for each year of the participant’s participa13 tion in the Pilot Program beginning in the third 

14 year following the date of implementation of the 

15 Pilot Program, an evaluation on the activities car16 ried out by the collaborative care network of such 

17 participant under the Pilot Program and shall in18 clude— 

19 (A) the number of people served; 

20 (B) the most common health problems 

21 treated; 

22 (C) any reductions in emergency depart23 ment use; 


tjames on DSKG8SOYB1PROD with BILLS
17 

•HR 3430 IH

1 (D) an accounting of how amounts re2 ceived pursuant to the Pilot Program were 

3 used; and 

4 (E) to the extent requested by the Sec5 retary, any quality measures or any other meas6 ures specified by the Secretary. 

7 (2) PROGRAM REPORTS.—The Secretary shall 

8 submit to Congress an annual evaluation (beginning 

9 not later than 6 months after the first reports under 

10 paragraph (1) are submitted) on the extent to which 

11 emergency department use was reduced as a result 

12 of the activities carried out by the participant under 

13 the Pilot Program. Each such evaluation shall also 

14 include information on— 

15 (A) the prevalence of certain chronic condi16 tions in various populations, including a com17 parison of such prevalence in the general popu18 lation versus in the population of individuals 

19 with inadequate health insurance coverage; 

20 (B) demographic characteristics of the 

21 population of uninsured and underinsured indi22 viduals served by the collaborative care network 

23 involved; and 


tjames on DSKG8SOYB1PROD with BILLS
18 

•HR 3430 IH

1 (C) the conditions of such individuals for 

2 whom services were requested at such emer3 gency departments of participating hospitals. 

4 (3) AUDIT AUTHORITY.—The Secretary may 

5 conduct periodic audits and request periodic spend6 ing reports of participants under the Pilot Program. 

7 (4) MEDPAC EVALUATION.—In its annual re8 ports to Congress, the Medicare Payment Advisory 

9 Commission shall include its evaluation of the Pilot 

10 Program. 

11 (f) CLARIFICATION.—Nothing in this section or sec12 tion 3 requires a provider to report individually identifi13 able information of an individual to government agencies, 

14 unless the individual consents, consistent with HIPAA pri15 vacy and security law, as defined in section 3009(a)(2) 

16 of the Public Health Service Act. 

17 SEC. 3. CREATION OF A COLLABORATIVE CARE NETWORK 

18 CENTER WITHIN HHS. 

19 (a) IN GENERAL.—The Secretary shall create within 

20 the Department of Health and Human Services a Collabo21 rative Care Network Center (in this section referred to 

22 as the ‘‘Center’’). 

23 (b) DUTIES.—The Center shall carry out the fol24 lowing duties: 


tjames on DSKG8SOYB1PROD with BILLS
19 

•HR 3430 IH

1 (1) Provide technical assistance and other im2 plementation support to collaborative care networks. 

3 (2) Develop and disseminate collaborative care 

4 network best practice models and facilitate net5 working and information sharing among collabo6 rative care networks. 

7 (3) Develop and assist in the development of 

8 pilot programs under title XVIII, XIX, or XXI of 

9 the Social Security Act to test new payment models 

10 and delivery system innovations, such as bundling, 

11 shared savings models, capitated payments, and in12 centive payment structures. 

13 (4) Evaluate the effectiveness of such pilots 

14 programs. 

15 (5) Evaluate the performance of collaborative 

16 care networks based on an aggregation of the quality 

17 measures the network’s providers are to report 

18 under section 2(e)(1)(E). 

19 (6) Advise Congress, the Secretary, and other 

20 relevant agencies regarding proposed changes to 

21 statutory or regulatory barriers to collaborative care 

22 network success. 

23 (7) Carry out other activities as determined by 

24 the Secretary to be necessary for the development or 

25 improvement of collaborative care networks. 


tjames on DSKG8SOYB1PROD with BILLS
20 

•HR 3430 IH

1 (c) AUTHORIZATION OF APPROPRIATIONS.—There 

2 are authorized to be appropriated such sums as are nec3 essary to carry out this section. 

Æ 


tjames on DSKG8SOYB1PROD with BILLS