‘‘(2) TRANSITION FROM FEE-FOR-SERVICE TO 
RISK-BASED PAYMENT MODEL.— 
‘‘(A) IN GENERAL.—Payment to nationally 
designated children’s hospital networks under 
this subsection shall be based initially on a fee- 
for-service payment model and shall gradually 
transition, over a 5-year period, to an equitable, 
risk-based payment model using a methodology 
developed under paragraph (3). For the first 
two years of such period, a nationally des-
ignated children’s hospital network may receive, 
in addition to any fee-for-service payments 
made to such hospital network, per capita care 
coordination payments with respect to expendi-
tures for items and services furnished to eligible 
children enrolled in the MCCC program oper-
ated by the hospital network through medical 
home programs and other care coordination ac-
tivities for which an all-inclusive payment model 
is more suitable than fee-for-service reimburse-
ment. 
‘‘(B) DATA ANALYSIS DURING INITIAL PE-
RIOD.—During the first two years of the imple-
mentation of an MCCC program, the Secretary 
shall analyze data collected under subsection (f) 
VerDate Mar 15 2010 
03:31 Jun 26, 2014
Jkt 039200
PO 00000
Frm 00014
Fmt 6652
Sfmt 6201
E:\BILLS\H4930.IH
H4930
smartinez on DSK4TPTVN1PROD with BILLS
for purposes of developing a risk-based payment 
methodology that would be implemented begin-
ning with the third year of implementation of 
the MCCC program. 
‘‘(3) DEVELOPMENT OF RISK-BASED PAYMENT 
METHODOLOGY.—The Secretary shall develop pay-
ment methodologies under this subsection in coordi-
nation with the Medicaid and CHIP Payment and 
Access Commission and the pediatric health care 
provider community that— 
‘‘(A) take into account the data analyzed 
under paragraph (2)(B); 
‘‘(B) are actuarially sound, as determined 
by the Secretary and the relevant State admin-
istering agency, in coordination with National 
Association of Insurance Commissioners, using 
an actuarial methodology that is adopted using 
historic pediatric claims data; 
‘‘(C) include— 
‘‘(i) a risk adjustment method, re-in-
surance system, and risk-corridor proce-
dure to account for variations in acuity of 
the eligible children enrolled in MCCC pro-
grams; and 
‘‘(ii) a shared-savings component; and 
VerDate Mar 15 2010 
03:31 Jun 26, 2014
Jkt 039200
PO 00000
Frm 00015
Fmt 6652
Sfmt 6201
E:\BILLS\H4930.IH
H4930
smartinez on DSK4TPTVN1PROD with BILLS
‘‘(D) may provide for an model for making 
payments other than payments made on a per- 
member, per-month basis. 
‘‘(h) WAIVERS OF REQUIREMENTS.—With respect to 
carrying out an MCCC program under this section, the 
following provisions of law shall not apply: 
‘‘(1) 
Section 
1902(a)(1), 
relating 
to 
statewideness. 
‘‘(2) Section 1902(a)(10), insofar as such sec-
tion relates to comparability of services among dif-
ferent population groups. 
‘‘(3) Sections 1902(a)(23) and 1915(b)(4), re-
lating to freedom of choice of providers. 
‘‘(4) Section 1903(m)(2)(A), insofar as such 
section would prohibit a nationally designated chil-
dren’s hospital network from receiving certain pay-
ments. 
‘‘(5) Such other provisions of this title, title 
XVIII, sections 1128A and 1128B, and any provi-
sions of the Federal antitrust laws as the Secretary 
determines are inapplicable or the waiver of which 
are necessary for purposes of carrying out an MCCC 
program under this section. 
‘‘(i) PREEMPTION OF STATE LAW.—A State may not 
impose any requirement on the nationally qualified chil-
VerDate Mar 15 2010 
03:31 Jun 26, 2014
Jkt 039200
PO 00000
Frm 00016
Fmt 6652
Sfmt 6201
E:\BILLS\H4930.IH
H4930
smartinez on DSK4TPTVN1PROD with BILLS
dren’s hospital network’s operation of an MCCC program 
under a program agreement that meets the requirements 
of this section that is inconsistent with or would otherwise 
impede the satisfaction by such hospital network of the 
requirements of this section (including the requirements 
of such program agreement). 
‘‘(j) DEFINITIONS.—In this section: 
‘‘(1) ELIGIBLE
CHILD.—The term ‘eligible 
child’ means, with respect to an MCCC program, an 
individual who is under the age of 18 and who— 
‘‘(A) is eligible for medical assistance 
under the State plan under this title or child 
health assistance under the State child health 
plan under title XXI; and 
‘‘(B) has, or is at a heightened risk of de-
veloping, a chronic, physical, developmental, be-
havioral, or emotional condition that— 
‘‘(i) affects two or more body systems; 
‘‘(ii) requires intensive care coordina-
tion to avoid excessive hospitalizations or 
emergency department visits; or 
‘‘(iii) meets the criteria for medical 
complexity using risk adjustment meth-
odologies (such as Clinical Risk Groups) 
agreed upon by the Secretary in coordina-
VerDate Mar 15 2010 
03:31 Jun 26, 2014
Jkt 039200
PO 00000
Frm 00017
Fmt 6652
Sfmt 6201
E:\BILLS\H4930.IH
H4930
smartinez on DSK4TPTVN1PROD with BILLS
tion with a national panel of pediatric ex-
perts. 
‘‘(2) MCCC PROGRAM.—The term ‘MCCC pro-
gram’ means a Medicaid coordinated care program 
that provides eligible children with MCCC program 
services through a nationally designated children’s 
hospital network in accordance with a program 
agreement that meets the requirements of subsection 
(d). 
‘‘(3) MCCC PROGRAM
SERVICES.—The term 
‘MCCC program services’ means the full range of 
items and services for which medical assistance is 
available under a State plan for children, including 
pediatric care management services and pediatric-fo-
cused care coordination and health promotion, as 
specified in the program agreement. 
‘‘(4) QUALIFIED CHILDREN’S HOSPITAL.—The 
term ‘qualified children’s hospital’ means a chil-
dren’s hospital that— 
‘‘(A) qualifies to receive payment under 
section 340E of the Public Health Service Act 
(relating to children’s hospitals that operate 
graduate medical education programs); or 
‘‘(B) meets 3 or more of the following cri-
teria: 
VerDate Mar 15 2010 
03:31 Jun 26, 2014
Jkt 039200
PO 00000
Frm 00018
Fmt 6652
Sfmt 6201
E:\BILLS\H4930.IH
H4930
smartinez on DSK4TPTVN1PROD with BILLS