I
103D CONGRESS
2D SESSION
H. R. 4810
To amend title XIX of the Social Security Act to prohibit the Secretary
of Health and Human Services from granting a waiver under the medic-
aid program to permit a State to require children enrolled in the program
to receive medical assistance under the program through managed care
plans unless such assistance is provided through an integrated child
health care network, and for other purposes.
IN THE HOUSE OF REPRESENTATIVES
JULY 21, 1994
Ms. SCHENK (for herself and Mr. LEHMAN) 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 prohibit
the Secretary of Health and Human Services from grant-
ing a waiver under the medicaid program to permit a
State to require children enrolled in the program to
receive medical assistance under the program through
managed care plans unless such assistance is provided
through an integrated child health care network, and
for other purposes.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ‘‘Integrated Child
Health Care Network Act of 1994’’.
SEC. 2. LIMITATION ON MANAGED CARE WAIVERS AFFECT-
ING CHILDREN UNDER MEDICAID.
(a) REQUIRING MEDICAL ASSISTANCE FOR CHIL-
DREN FURNISHED THROUGH MANAGED CARE
TO
BE
FURNISHED THROUGH INTEGRATED NETWORKS.—Sec-
tion 1915 of the Social Security Act (42 U.S.C. 1396n)
is amended by adding at the end the following new sub-
section:
‘‘(i)(1) The Secretary may not grant a waiver under
this section, section 1115, or any provision of this Act that
includes a waiver of the requirements of section
1902(a)(23) to permit a State to restrict the medical as-
sistance furnished under the State plan to a child to as-
sistance furnished through a primary care case-manage-
ment plan under subsection (b)(1) or a capitated managed
care plan unless such a plan—
‘‘(A) furnishes such assistance to the individual
through an integrated child health network described
in paragraph (2);
‘‘(B) provides assurances that the capitated
payments made to providers for assistance furnished
to children enrolled in the plan are determined on
the basis of children’s health care needs and utiliza-
tion of services; and
‘‘(C) submits reports (at such intervals as the
Secretary may require) to the Secretary and the
State containing such information as the Secretary
and the State may require to assure that the plan
meets the requirements of subparagraphs (A) and
(B), and makes the reports available to the public.
‘‘(2) In this subsection:
‘‘(A) A ‘capitated managed care plan’ means an
entity which—
‘‘(i) has a contract with the State agency
under which such entity is paid a fixed amount
for providing or arranging for the provision of
health care items or services specified in such
contract to an individual eligible for medical as-
sistance under the State plan and enrolled with
such entity, regardless of whether such items or
services are furnished to such individual; and
‘‘(ii) is liable for all or part of the cost of
furnishing any of such items or services, re-
gardless of whether such cost exceeds such fixed
payment.
‘‘(B) A ‘child’ is an individual under 18 years
of age.
‘‘(C) An ‘integrated child health network’
means a network of providers with expertise in pro-
viding services to children that meets the following
requirements (together with any other requirements
that Secretary may impose):
‘‘(i) The network includes (but is not lim-
ited to)—
‘‘(I) pediatricians and pediatric spe-
cialists, family practice physicians, and
other pediatric health professionals;
‘‘(II) community-based clinics that
provide services of providers described in
subclause (I); and
‘‘(III) hospitals with pediatric units
which are a distinct part of the hospital
(as defined by the Secretary), hospitals
whose inpatients are predominantly chil-
dren, and specialty hospitals whose inpa-
tients are predominantly children (includ-
ing rehabilitation and long-term care hos-
pitals).
‘‘(ii) The network has an explicit mission
of meeting the health care needs of children.
‘‘(iii) The network participates in graduate
medical education programs for primary and
specialty pediatric care services.
‘‘(iv) The network provides for the coordi-
nation of pediatric specialty and subspecialty
care for children with special health care needs,
including (but not limited to)—
‘‘(I) children eligible for supplemental
security income under title XVI;
‘‘(II) children described in section
501(a)(1)(D); and
‘‘(III) children described in section
1902(e)(3).’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply to quarters beginning on or
after the expiration of the 6-month period that begins on
the date of the enactment of this Act.
SEC. 3. GRANTS FOR ESTABLISHMENT OF INTEGRATED
CHILD HEALTH NETWORKS APPLYING SEPA-
RATE CAPITATED PAYMENT RATE FOR CHIL-
DREN.
(a) AVAILABILITY OF GRANTS.—
(1) IN GENERAL.—The Secretary of Health and
Human Services shall make grants to eligible enti-
ties over a 3-year period for the establishment, ini-
tial operation, and the continuing operation of inte-
grated child health networks using different payment
models, including grants to demonstrate the oper-
ation of networks applying a separate capitated pay-
ment rate with respect to children enrolled with the
network. The previous sentence shall apply to dem-
onstrations of such networks initiated by States.
(2) INTEGRATED CHILD HEALTH NETWORK DE-
FINED.—In this section, the term ‘‘integrated child
health network’’ has the meaning given such term in
section 1915(i)(2)(C) of the Social Security Act (as
added by section 2(a)).
(b) ELIGIBILITY OF ENTITIES.—An entity is eligible
to receive a grant under subsection (a) if the entity sub-
mits to the Secretary (at such time and in such form as
the Secretary may require) an application containing—
(1) assurances that the entity has established
or is in the process of establishing an integrated
child health network;
(2) assurances that the entity will submit re-
ports on the activities of the entity that are funded
through the grant; and
(3) such other information and assurances as
the Secretary may require.