HR 722 IHCommentsClose CommentsPermalink

To amend title XIX of the Social Security Act to provide an option of States to cover a children’s program of all-inclusive coordinated care (ChiPACC) under the Medicaid Program.CommentsClose CommentsPermalink

January 27, 2009CommentsClose CommentsPermalink

Mr. MORAN of Virginia (for himself and Mr. YOUNG of Florida) introduced the following bill; which was referred to the Committee on Energy and CommerceCommentsClose CommentsPermalink

To amend title XIX of the Social Security Act to provide an option of States to cover a children’s program of all-inclusive coordinated care (ChiPACC) under the Medicaid Program.CommentsClose CommentsPermalink

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,CommentsClose CommentsPermalink

SECTION 1. SHORT TITLE.

This Act may be cited as the ‘ChiPACC Act of 2009’.CommentsClose CommentsPermalink

SEC. 2. OPTIONAL MEDICAID COVERAGE OF CHILDREN’S PROGRAM OF ALL-INCLUSIVE COORDINATED CARE (CHIPACC).

(a) In General- Section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) is amended--CommentsClose CommentsPermalink





(1) by striking ‘and’ at the end of paragraph (27);CommentsClose CommentsPermalink





(2) by redesignating paragraph (28) as paragraph (29); andCommentsClose CommentsPermalink





(3) by inserting after paragraph (27) the following new paragraph:CommentsClose CommentsPermalink





‘(28) services furnished under a children’s program of all-inclusive coordinated care (ChiPACC) under section 1942; and’.CommentsClose CommentsPermalink





(b) Children’s Program of All-Inclusive Coordinated Care (ChiPACC)- Title XIX of such Act is further amended by adding at the end the following new section:CommentsClose CommentsPermalink

‘CHILDREN’S PROGRAM OF ALL-INCLUSIVE COORDINATED CARE (CHIPACC)

‘Sec. 1942. (a) State Option-CommentsClose CommentsPermalink





‘(1) IN GENERAL- A State may elect to provide medical assistance under this section with respect to a children’s program of all-inclusive coordinated care to ChiPACC eligible individuals who are eligible for medical assistance under the State plan and who are enrolled in the program. In the case of an individual enrolled in such a program pursuant to such an election--CommentsClose CommentsPermalink





‘(A) the individual shall receive benefits under the plan solely through such program; andCommentsClose CommentsPermalink





‘(B) the health care providers furnishing services under such program shall receive payment in accordance with the terms of such program for providing such services.CommentsClose CommentsPermalink





‘(2) NUMERICAL AND GEOGRAPHICAL LIMITATIONS PERMITTED- A State may establish--CommentsClose CommentsPermalink





‘(A) a numerical limit on the number of individuals who may be enrolled in the State’s ChiPACC; andCommentsClose CommentsPermalink





‘(B) geographic limitations on the service areas for a ChiPACC.CommentsClose CommentsPermalink





‘(b) ChiPACC and Other Terms Defined- In this section:CommentsClose CommentsPermalink





‘(1) Children’S PROGRAM OF ALL-INCLUSIVE COORDINATED CARE; CHIPACC- The terms ‘children’s program of all-inclusive coordinated care’ and ‘ChiPACC’ mean a program of coordinated care for ChiPACC eligible children that is established by a State under this section and meets the following requirements:CommentsClose CommentsPermalink





‘(A) OPERATION- The program is administered by a single State agency. Such agency may provide for the operation of the program through arrangements between one or more other entities, such as a ChiPACC coordinator, and such agency.CommentsClose CommentsPermalink





‘(B) COMPREHENSIVE BENEFITS-CommentsClose CommentsPermalink





‘(i) IN GENERAL- The program provides comprehensive health care items and services to ChiPACC eligible individuals in accordance with this section and regulations.CommentsClose CommentsPermalink





‘(ii) SCOPE AND PLAN FOR SERVICES- Such items and services shall--CommentsClose CommentsPermalink





‘(I) include items and services described in subsection (c)(1)(A) to the extent such items and services are appropriate to the individual; andCommentsClose CommentsPermalink





‘(II) be provided consistent with a comprehensive care plan developed by an interdisciplinary health professional team.CommentsClose CommentsPermalink





‘(iii) QUALIFICATIONS OF PROVIDERS- Such items and services are provided through health care providers that--CommentsClose CommentsPermalink





‘(I) meet such certification or other quality requirements as may be necessary to participate in the program of medical assistance under this title or in the program under title XVIII; andCommentsClose CommentsPermalink





‘(II) maintain records on ChiPACC eligible individuals enrolled in the program and to whom the provider furnishes services, reflecting both the specific care and services furnished by the provider and the relationship of those services to the comprehensive plan of care for that individual and to the delivery of other services to the individual through the program.CommentsClose CommentsPermalink





‘(2) CHIPACC ELIGIBLE INDIVIDUAL- The term ‘ChiPACC eligible individual’ means, with respect to a ChiPACC, an individual--CommentsClose CommentsPermalink





‘(A) who, at the time of enrollment in the ChiPACC is a child (as defined under the State plan for this purpose) and who is not older than such age as the State may specify;CommentsClose CommentsPermalink





‘(B) who suffers from a serious illness or health condition that is life threatening;CommentsClose CommentsPermalink





‘(C) for whom there is a reasonable likelihood that the child’s life will be threatened by such illness or condition;CommentsClose CommentsPermalink





‘(D) whose health status is expected to decline because of such illness or condition before attaining full adulthood (as defined under the State plan);CommentsClose CommentsPermalink





‘(E) resides in the service area of the ChiPACC; andCommentsClose CommentsPermalink





‘(F) is eligible for medical assistance under the State plan without regard to this section (or, but for enrollment in a ChiPACC would, based on the individual’s illness or health condition or the projected cost of treatment required for such illness or condition, become so eligible).CommentsClose CommentsPermalink





The Secretary may waive the application of subparagraph (F) with respect to eligibility for medical assistance under the State plan without regard to this section in the case of individuals if the State demonstrates to the satisfaction of the Secretary that the sum of the additional expenditures under this title resulting from such waiver in a fiscal year will not exceed the aggregate savings in expenditures otherwise resulting from the implementation of this section in the fiscal year.CommentsClose CommentsPermalink





‘(3) CHIPACC COORDINATOR- The term ‘ChiPACC coordinator’ means, with respect to a ChiPACC, an entity (which may be the State administering agency or another entity under an arrangement with such an agency) that directs, supervises, and assures the coordination of comprehensive services to ChiPACC eligible individuals enrolled in the ChiPACC consistent with the following:CommentsClose CommentsPermalink





‘(A) The entity must assure the direct and continuous involvement of an interdisciplinary health professional team in managing and coordinating the provision of care and services within the coordinator’s responsibility to each such enrolled individual.CommentsClose CommentsPermalink





‘(B) The entity must include on its staff, or otherwise arrange for the provision of services, through contracts or otherwise, of each of the types of the health care professionals and other service providers required to provide the items and services required under subsection (c)(1)(A), to the extent such items and services are necessary and appropriate to the care of an enrolled individual.CommentsClose CommentsPermalink





‘(C) To the extent consistent with provision of the highest quality of care to enrolled individuals--CommentsClose CommentsPermalink





‘(i) promote the utilization of volunteers in the provision of care and services under the ChiPACC, in accordance with standards set by the Secretary, which standards shall ensure a continuing level of effort to utilize such volunteers; andCommentsClose CommentsPermalink





‘(ii) ensure that records are maintained on the use of such volunteers and the cost savings and expansion of care and services achieved through the use of such volunteers.CommentsClose CommentsPermalink





‘(4) INTERDISCIPLINARY HEALTH PROFESSIONAL TEAM- The term ‘interdisciplinary health professional team’ means, with respect to a ChiPACC, a group of health professionals that--CommentsClose CommentsPermalink





‘(A) includes at least--CommentsClose CommentsPermalink





‘(i) one physician (as defined in section 1861(r)(1));CommentsClose CommentsPermalink





‘(ii) one registered professional nurse; andCommentsClose CommentsPermalink





‘(iii) one social worker, pastoral counselor, or other counselor;CommentsClose CommentsPermalink





‘(B) develops a comprehensive plan of care for ChiPACC eligible individuals enrolled with the ChiPACC and furnishes, or supervises the provision of, care and services described in subsection (c)(1) to an individual enrolled in the ChiPACC; andCommentsClose CommentsPermalink





‘(C) through direct action and communication with health care providers furnishing services under the ChiPACC, on behalf of or under the direction or supervision of a State administering agency or a ChiPACC coordinator, coordinates the care and services furnished to such enrollees in a manner that takes into account the best interests of each such enrollee and the enrollee’s family, as well as considerations of cost and efficient use of available resources.CommentsClose CommentsPermalink





‘(5) STATE ADMINISTERING AGENCY- The term ‘State administering agency’ means, with respect to the operation of a ChiPACC in a State, the agency of that State (which may be the single agency responsible for administration of the State plan under this title in the State) responsible for the implementation, either directly or through arrangements with one or more ChiPACC coordinators, of the ChiPACC under this section in the State.CommentsClose CommentsPermalink





‘(6) REGULATIONS- Except as otherwise provided, the term ‘regulations’ refers to interim final or final regulations promulgated under subsection (g).CommentsClose CommentsPermalink





‘(c) Scope of Benefits; Beneficiary Safeguards-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Under a ChiPACC of a State, the State administering agency shall assure that--CommentsClose CommentsPermalink





‘(A) individuals enrolled in the ChiPACC are furnished, at a minimum--CommentsClose CommentsPermalink





‘(i) all items and services that are necessary and appropriate to their care and that are covered under this title, and all additional items and services specified in regulations, but without any limitation or condition as to amount, duration, or scope;CommentsClose CommentsPermalink





‘(ii) access to covered items and services, as needed, 24 hours per day, every day of the year; andCommentsClose CommentsPermalink





‘(iii) services that include comprehensive, integrated palliative and curative services, expressive therapy and counseling, and counseling and anticipatory bereavement services to immediate family members of the ChiPACC eligible individual, as part of the services to the eligible individual;CommentsClose CommentsPermalink





‘(B) provision of such services to such individuals through a comprehensive, interdisciplinary and multidisciplinary health and social services delivery system which integrates, as appropriate to the individual recipient of services, acute and long-term care services, palliative, respite and curative treatment, counseling and support for family members who are caretakers or otherwise relevant to appropriate care and treatment of the individual, and such other services as may be furnished pursuant to regulations and the provisions of the applicable State plan; andCommentsClose CommentsPermalink





‘(C) the ChiPACC is operated, and the services to enrolled individuals are furnished, in a manner that is consistent with Standards of Care and Practice Guidelines developed by Children’s Hospice International for a Program of All-Inclusive Care for Children (as in effect as of the date of the enactment of this section or such later date as the Secretary may specify).CommentsClose CommentsPermalink





‘(2) QUALITY ASSURANCE; PATIENT SAFEGUARDS- With respect to a ChiPACC, the State administering agency shall assure the following:CommentsClose CommentsPermalink





‘(A) The provision of services under the ChiPACC meets Federal and State guidelines for quality assurance.CommentsClose CommentsPermalink





‘(B) Necessary safeguards have been established to protect the health and welfare of individuals enrolled in the ChiPACC under this section.CommentsClose CommentsPermalink





‘(C) There is financial accountability of funds expended under this title with respect to such services.CommentsClose CommentsPermalink





‘(D) There is a written plan of quality assurance, and procedures implementing such plan, in accordance with regulations.CommentsClose CommentsPermalink





‘(E) Written safeguards of the rights of individuals enrolled in the ChiPACC, including a patient bill of rights and procedures for grievances and appeals, in accordance with regulations and with other requirements of this title and Federal and State law designed for the protection of patients.CommentsClose CommentsPermalink





‘(F) There are in effect procedures for data collection, record maintenance and retention, and the development of outcome measures, and such other policies, systems, and procedures as are sufficient to afford the Secretary and the State administering agency access to records and data relating to the ChiPACC, including pertinent financial, medical, and personnel records.CommentsClose CommentsPermalink





‘(G) The agency shall submit to the Secretary such reports as the Secretary finds (in consultation with State administering agencies) necessary to monitor the operation, cost, and effectiveness of ChiPACCs.CommentsClose CommentsPermalink





‘(3) COST-SHARING WAIVER- A State administering agency may, in the case of a ChiPACC eligible individual enrolled in the State’s ChiPACC, waive deductibles, copayments, coinsurance, or other cost-sharing that would otherwise apply under the State plan under this title.CommentsClose CommentsPermalink





‘(d) Eligibility Determinations-CommentsClose CommentsPermalink





‘(1) IN GENERAL- In determining whether an individual is a ChiPACC eligible individual, the State administering agency shall conduct an independent evaluation and assessment, which shall include the following:CommentsClose CommentsPermalink





‘(A) Where appropriate, consultation with the individual’s family, guardian, or other responsible individual.CommentsClose CommentsPermalink





‘(B) Consultation with appropriate treating and consulting health and support professionals caring for the individual.CommentsClose CommentsPermalink





‘(C) An examination of the individual’s relevant history, medical records, and care and support needs, guided by best practices and research on effective strategies that result in improved health and quality of life outcomes.CommentsClose CommentsPermalink





‘(2) CERTIFICATION- Upon completion of the evaluation and assessment described in paragraph (1), an individual meeting the criteria of a ChiPACC eligible individual shall be certified as such, pursuant to procedures specified in regulations and the applicable State plan.CommentsClose CommentsPermalink





‘(3) CONTINUATION OF ELIGIBILITY- An individual who is a ChiPACC eligible individual may be deemed to continue to be such an individual notwithstanding a determination that the individual no longer meets the requirement of subsection (b)(2)(B) if, in accordance with regulations, it is reasonably foreseeable that, if the individual is not furnished services under this section, the severity or impact of the individual’s illness or condition would increase to a degree that the individual would again meet such requirement before the individual attains adulthood or within the succeeding 12-month period.CommentsClose CommentsPermalink





‘(4) ANNUAL REEVALUATIONS- Subject to such limitations as the Secretary may by regulation prescribe, the eligibility determination made under this subsection shall be reevaluated annually, except that such an annual evaluation may be waived, in accordance with regulations, in a case where the administering State agency determines that there is no reasonable expectation of improvement or significant change in the individual’s illness or condition during a period to which the reevaluation requirement would otherwise be applicable.CommentsClose CommentsPermalink





‘(5) ENROLLMENT AND DISENROLLMENT-CommentsClose CommentsPermalink





‘(A) VOLUNTARY DISENROLLMENT AT ANY TIME- The enrollment and disenrollment of ChiPACC eligible individuals in a ChiPACC shall be pursuant to procedures specified in regulations and the State plan, but shall permit an enrollee, or an enrollee’s guardian or other legal representative, acting on behalf of an enrollee, to voluntarily disenroll for any reason at any time.CommentsClose CommentsPermalink





‘(B) LIMITATIONS ON DISENROLLMENT-CommentsClose CommentsPermalink





‘(i) IN GENERAL- Regulations, and the applicable State plan, shall provide that a ChiPACC may not involuntarily disenroll a ChiPACC eligible individual enrolled in the ChiPACC except--CommentsClose CommentsPermalink





‘(I) for disruptive or threatening behavior by the enrollee, or by a family member with whom a health care provider providing services under the ChiPACC necessarily has contact in the provision of services, as defined in provisions of regulations (developed in close consultation with State administering agencies); andCommentsClose CommentsPermalink





‘(II) if there is a change in the individual’s medical condition, residency or geographic location, or financial situation such that the individual no longer is a ChiPACC eligible individual and paragraph (3) does not apply to warrant continuation of enrollment.CommentsClose CommentsPermalink





‘(ii) NO DISENROLLMENT FOR NONCOMPLIANT BEHAVIOR- Except as allowed under regulations, a ChiPACC may not disenroll a ChiPACC eligible individual on the ground that the individual has engaged in noncompliant behavior if such behavior is related to a mental or physical condition of the individual. For purposes of the preceding sentence, the term ‘noncompliant behavior’ includes repeated noncompliance with medical advice and repeated failure to appear for appointments.CommentsClose CommentsPermalink





‘(iii) TIMELY REVIEW OF PROPOSED NONVOLUNTARY DISENROLLMENT- A proposed involuntary disenrollment under this subparagraph shall be subject to timely review and final determination by the Secretary or by the State administering agency (as applicable), prior to the proposed disenrollment becoming effective, pursuant to procedures prescribed in regulations.CommentsClose CommentsPermalink





‘(C) APPEALS- If an individual is determined not to be a ChiPACC eligible individual upon application, any time after such services begin, or is disenrolled from a ChiPACC for reasons described in subparagraph (B)(i)(I), the State plan under this title shall allow for an appeal of such determination. During the course of the appeals process, an individual previously enrolled in a ChiPACC shall continue to be so enrolled and to receive benefits through the ChiPACC.CommentsClose CommentsPermalink





‘(6) CONSTRUCTION- The fact that a ChiPACC eligible individual is enrolled under a ChiPACC shall not be construed as adversely affecting the eligibility of the individual’s parents or caretaker relatives for medical assistance under this title.CommentsClose CommentsPermalink





‘(e) Payments to Health Care Providers Under ChiPACC-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Payments to health care providers furnishing items and services under a ChiPACC shall be paid on a capitated or fee-for-service basis, according to regulations and as specified in the applicable State plan consistent with this subsection.CommentsClose CommentsPermalink





‘(2) USE OF INTEGRATED, BUDGET-NEUTRAL FINANCING- Payments under this subsection shall be made--CommentsClose CommentsPermalink





‘(A) on a basis that permits provision for integrated financing methodologies that allow providers to pool payments received from public and private programs and individuals; andCommentsClose CommentsPermalink





‘(B) in amounts that are designed, according to regulations, to ensure that aggregate payments under this section for individuals enrolled in a ChiPACC, whether made on a capitated basis or fee-for-service basis, do not exceed on average the aggregate payments that would have been paid under the State plan for such individuals if they were not so enrolled, taking into account the comparative case-mix of ChiPACC enrollees and such other factors as the Secretary determines to be appropriate.CommentsClose CommentsPermalink





‘(f) Termination Procedures-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Under regulations--CommentsClose CommentsPermalink





‘(A) the Secretary may require a State administering agency to terminate the participation of a ChiPACC coordinator for cause; andCommentsClose CommentsPermalink





‘(B) a State administering agency may terminate operation of a ChiPACC after appropriate notice to the Secretary and enrollees.CommentsClose CommentsPermalink





‘(2) CAUSES FOR COORDINATOR TERMINATION- In accordance with regulations establishing procedures for termination of participation of ChiPACC coordinators, the Secretary may require a State administering agency to terminate participation of a ChiPACC coordinator for, among other reasons, the fact that--CommentsClose CommentsPermalink





‘(A) the Secretary determines that the ChiPACC coordinator has failed to comply substantially with requirements for a ChiPACC coordinator under this section; andCommentsClose CommentsPermalink





‘(B) the State administering agency has failed to develop and successfully initiate, within 30 days of the date of the receipt of written notice of such a determination for the ChiPACC coordinator, a plan to correct the coordinator’s deficiencies, or has failed to continue implementation of such a plan of correction.CommentsClose CommentsPermalink





‘(g) Regulations-CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall issue interim final or final regulations to carry out this section.CommentsClose CommentsPermalink





‘(2) USE OF EXISTING STANDARDS-CommentsClose CommentsPermalink





‘(A) IN GENERAL- In issuing such regulations, the Secretary shall, to the extent appropriate and consistent with the provisions of this section, incorporate the standards and requirements applied to Programs of All-Inclusive Care for Children demonstration waiver programs that have been implemented before (or as of) the date of the enactment of this section, including standards of care and practice guidelines applied under such programs.CommentsClose CommentsPermalink





‘(B) FLEXIBILITY- In order to provide for reasonable flexibility in adapting the service delivery model described in subparagraph (A) to the needs of particular organizations (such as those in rural areas or those that may determine it appropriate to use nonstaff physicians according to State licensing law requirements) under this section, the Secretary (in close consultation with State administering agencies) may modify or waive provisions described in subparagraph (A) so long as any such modification or waiver is not inconsistent with and would not impair the essential elements, objectives, and requirements of this section, but may not modify or waive any of the following provisions:CommentsClose CommentsPermalink





‘(i) The requirement of delivery of comprehensive, integrated palliative, respite and curative services, therapy, counseling and other medical and psycho-social services for ChiPACC eligible individual, to the extent such services would benefit the individual.CommentsClose CommentsPermalink





‘(ii) The requirement of delivery of counseling and bereavement services to immediate family members of the ChiPACC enrollees as part of the services to the enrollee.CommentsClose CommentsPermalink





‘(iii) The requirement of an interdisciplinary health professional team approach to care management and service delivery to ChiPACC eligible individuals.CommentsClose CommentsPermalink





‘(iv) The provision of integrated financing methodologies that allow for the pooling of payments received from public and private programs and individuals.CommentsClose CommentsPermalink





‘(v) The limitation on average aggregate payment under subsection (e)(2).CommentsClose CommentsPermalink





‘(C) CONTINUATION OF MODIFICATIONS OR WAIVERS OPERATIONAL REQUIREMENTS- If a State agency administering a program of all-inclusive coordinated care for seriously ill children approved pursuant to waiver authority under section 1115 or 1915(c) has contractual or other operating arrangements relating to such program which are not otherwise recognized in regulation and which were in effect as of the date of the enactment of this section, the Secretary shall permit the agency to continue such arrangements so long as such arrangements are found by the Secretary to be reasonably consistent with the objectives of a ChiPACC.CommentsClose CommentsPermalink





‘(3) CONSTRUCTION- Nothing in this subsection shall be construed as preventing the Secretary from including in regulations provisions to ensure the health and safety of individuals enrolled in a ChiPACC under this section that are in addition to those otherwise provided under this section.CommentsClose CommentsPermalink





‘(h) Waivers of Requirements- With respect to carrying out a ChiPACC under this section, the following requirements of this title (and regulations relating to such requirements) shall not apply:CommentsClose CommentsPermalink





‘(1) Section 1902(a)(1), relating to any requirement that ChiPACCs or ChiPACC services be provided in all areas of a State.CommentsClose CommentsPermalink





‘(2) Section 1902(a)(10), insofar as such section relates to comparability of services among different population groups.CommentsClose CommentsPermalink





‘(3) Sections 1902(a)(23) and 1915(b)(4), relating to freedom of choice of providers under a ChiPACC.CommentsClose CommentsPermalink





‘(4) Section 1903(m)(2)(A), insofar as it restricts a ChiPACC provider from receiving prepaid capitation payments.CommentsClose CommentsPermalink





‘(5) Such other provisions of this title that the Secretary determines are inapplicable to carrying out a ChiPACC under this section.CommentsClose CommentsPermalink





‘(i) Continued Demonstration Project Authority- Nothing in this section shall be construed as preventing a State from developing, or the Secretary from approving, a project similar to or related to ChiPACCs as described in this section, under existing authorities, including demonstration project and waiver authorities under this title or other provisions of this Act.’.CommentsClose CommentsPermalink





(c) Other Conforming Amendments- Section 1905(r)(5) of such Act (42 U.S.C. 1396d(r)(5)) is amended by inserting before the period at the end the following: ‘, other than items and services to the extent such items and services are included under subsection (a) because of the application of paragraph (28)’.CommentsClose CommentsPermalink





(d) Timely Issuance of Regulations; Effective Date- The Secretary of Health and Human Services shall promulgate regulations to carry out the amendments made by this section in a timely manner, so as to assure that it will be feasible for State agencies and entities to establish and operate ChiPACCs for periods beginning not later than 1 year after the date of the enactment of this Act.CommentsClose CommentsPermalink





(e) Funds for Technical Assistance - The Secretary is authorized to expend funds appropriated to carry out title XIX of the Social Security Act to make grants to, or enter into contracts with, private entities or organizations that are qualified to provide technical or other assistance in developing and establishing ChiPACCs within the States, except that--CommentsClose CommentsPermalink





(1) such funds may be expended solely for the purposes of implementing this section; andCommentsClose CommentsPermalink





(2) a private entity or organization in receipt of such funds must have demonstrated expertise and a minimum of 5 years of experience in working with or assisting in the establishment of programs for comprehensive care of children meeting the description of ChiPACC eligible individuals under section 1942(b) of the Social Security Act, as added by subsection (b).CommentsClose CommentsPermalink