185
•HR 3080 SC2
tion) of the premiums and cost-sharing of
such a group health plan.
‘‘(ii) NO
FEDERAL
MATCHING
PAY-
MENTS.—For purposes of payment to
States under section 1903(a), no amounts
expended by the State under the program
during a fiscal year on behalf of an indi-
vidual enrolled under subparagraph (A)
may be included in the total amount ex-
pended during the fiscal year as medical
assistance under the State plan.
‘‘(iii) OPTIONAL
USE
OF
STANDARD
COVERAGE.—Notwithstanding 
subsection
(c)(2)(A), with respect to individuals en-
rolled under subparagraph (A), such pro-
gram may provide standard coverage (con-
sistent with section 1102(c) of the Afford-
able Health Care Now Act of 1993) rather
than the benefits of an actuarial value oth-
erwise required under such subsection.
‘‘(5) 
OFFERING
OF
COVERAGE
THROUGH
OTHER PROGRAMS.—Nothing in this section shall be
construed as preventing a State which—
‘‘(A) does not operate a State health allow-
ance program under this section from assuring
186
•HR 3080 SC2
that individuals in the State who are not of-
fered coverage under an employer group health
plan are offered coverage under a health plan,
or
‘‘(B) does operate such a program from as-
suring that individuals in the State who are not
described in paragraph (1), (2), or (3) and who
are not offered coverage under an employer
group health plan are offered coverage under a
health plan other than through such program.’’.
Subtitle H—Medicaid Program
Flexibility
SEC. 1701. MODIFICATION OF FEDERAL REQUIREMENTS TO
ALLOW STATES MORE FLEXIBILITY IN CON-
TRACTING FOR COORDINATED CARE SERV-
ICES UNDER MEDICAID.
(a) IN GENERAL.—Section 1903(m) of the Social Se-
curity Act (42 U.S.C. 1396b(m)) is amended—
(1) by striking all that precedes paragraph (4)
and inserting the following:
‘‘(m) COORDINATED CARE.—
‘‘(1) PAYMENT
CONDITIONED
ON
COMPLI-
ANCE.—
‘‘(A) GENERAL RULE.—No payment shall
be made under this title to a State with respect
187
•HR 3080 SC2
to expenditures incurred by it for payment to a
risk contracting entity or primary care case
management entity (as defined in subparagraph
(B)), or with respect to an undertaking de-
scribed in paragraph (6), unless the State and
the entity or undertaking meet the applicable
requirements of this subsection. For purposes
of determining whether payment may be made
under this section, the Secretary may reject a
State’s determination of compliance with any
provision of this subsection.
‘‘(B) GENERAL
DEFINITIONS.—For pur-
poses of this title—
‘‘(i) RISK
CONTRACTING
ENTITY.—
The term ‘risk contracting entity’ means
an entity that has a contract with the
State agency under which the entity—
‘‘(I) provides or arranges for the
provision of health care items or serv-
ices to individuals eligible for medical
assistance under the State plan under
this title, and
‘‘(II) is at risk (as defined in
clause (iv)) for part or all of the cost
188
•HR 3080 SC2
of such items or services furnished to
such individuals.
‘‘(ii) PRIMARY
CARE
CASE
MANAGE-
MENT PROGRAM.—The term ‘primary care
case management program’ means a State
program under which individuals eligible
for medical assistance under the State plan
under this title are enrolled with primary
care case management entities, and are en-
titled to receive specified health care items
and services covered under such plan only
as arranged for and approved by such enti-
ties.
‘‘(iii) AT RISK.—An entity is ‘at risk’,
for purposes of this subparagraph, if it has
a contract with the State agency under
which it is paid a fixed amount for provid-
ing or arranging for the provision of speci-
fied health care items or services to an in-
dividual eligible for medical assistance and
enrolled with the entity, regardless of
whether such items or services are fur-
nished to such individual, and is liable for
all or part of the cost of furnishing such
items or services, regardless of whether or
189
•HR 3080 SC2
the extent to which such cost exceeds such
fixed payment.
‘‘(iv) PRIMARY CARE CASE MANAGE-
MENT
ENTITY.—The term ‘primary care
case management entity’ means a health
care provider (whether an individual or an
entity) that, under a State primary care
case management program meeting the re-
quirements of paragraph (7), has a con-
tract with the State agency under which
the entity arranges for or authorizes the
provision of health care items and services
to individuals eligible for medical assist-
ance under the State plan under this title,
but is not at risk (as defined in clause (iv))
for the cost of such items or services pro-
vided to such individuals.
‘‘(2) GENERAL REQUIREMENTS FOR RISK CON-
TRACTING ENTITIES.—
‘‘(A) FEDERAL
OR
STATE
QUALIFICA-
TION.—Subject to paragraph (3), a risk con-
tracting entity meets the requirements of this
subsection only if it either—
‘‘(i) is a qualified health maintenance
organization as defined in section 1310(d)
190
•HR 3080 SC2
of the Public Health Service Act, as deter-
mined by the Secretary pursuant to section
1312 of that Act, or
‘‘(ii) is an entity which the State
agency has determined—
‘‘(I) affords, to individuals eligi-
ble for medical assistance under the
State plan and enrolled with the en-
tity, access to health care items and
services furnished by the entity, with-
in the area served by the entity, at
least equivalent to the access such in-
dividuals would have to such health
care items and services in such area if
not enrolled with the entity, and
‘‘(II) has made adequate provi-
sion against the risk of insolvency,
and assures that individuals eligible
for medical assistance under this title
are not held liable for the entity’s
debts in case of the entity’s insol-
vency.
‘‘(B) INTERNAL
QUALITY
ASSURANCE.—
Subject to paragraph (3), a risk contracting en-
tity meets the requirements of this subsection