,,ii #aadth ,,congress #ast ,session ,s4 #bih ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,january #bh1 #bjae,mr4 ,grassley 7for himself1 ,mr4 ,bennet1 ,mr4 ,portman1 ,mr4 ,nelson1 ,mr4 ,blunt1 ,mr4 ,brown1 ,mr4 ,kirk1 and ,mrs4 ,murray7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to amend titles ,,xix and ,,xxi of the ,social ,security ,act to provide ,states with the option of providing services to children with medically complex conditions under the ,medicaid program and ,children's ,health ,insurance ,program through a care coordination program focused on improving health outcomes for children with medically complex conditions and lowering costs1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,advancing ,care for ,exceptional ,kids ,act of #bjae or the ,,ace ,kids ,act of #bjae4 #b4 ,findings ,congress finds the following3 7#a7 ,approximately #c1jjj1jjj children in the ,united ,states suffer from medically complex conditions and approximately #b1jjj1jjj of such children are enrolled in ,state plans under the ,medicaid program under title ,,xix of the ,social ,security ,act4 7#b7 ,such children account for an estimated #f percent of ,medicaid enrollees and approximately #dj percent of children's ,medicaid spending is due to the severity of the illnesses of such children4 7#c7 ,the creation of nationally designated children's hospital networks focused upon better coordination and integration of care for such pediatric population will result in improved health outcomes and savings under the ,medicaid program and the ,children's ,health ,insurance ,program under title ,,xxi of the ,social ,security ,act4 #c4 ,establishment of ,medicaid and ,chip ,care ,coordination program for children with medically complex conditions as ,medicaid ,state option 7a7 ,medicaid ,title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 is amended by adding at the end the following new section3 #aidg4 ,medicaid ,children's ,care ,coordination programs for children with complex medical conditions 7a7 ,in general ,beginning ,january #a1 #bjaf1 a ,state1 at its option as a ,state plan amendment1 may elect to provide medical assistance for items and services furnished to eligible children enrolled in an ,,mccc program that meets the requirements of this section4 ,as a condition on an eligible child's receipt of medical assistance under this title1 the ,state shall require1 under such an amendment1 that the eligible child be enrolled in a ,,mccc program that meets the requirements of this section4 7b7 ,,mccc program requirements ,an ,,mccc program meets the requirements of this section if the ,,mccc program-- 7#a7 coordinates1 integrates1 and provides for the furnishing of the full range of ,,mccc program services to eligible children enrolled in the program2 7#b7 enrolls eligible children in accordance with subsection 7c72 7#c7 is operating under a program agreement that meets the requirements of subsection 7d72 and 7#d7 meets the pediatric network adequacy standards developed under subsection 7e74 7c7 ,eligibility determinations2 assignment 7#a7 ,enrollment ,subject to the assignment requirements of paragraph 7#b71 the enrollment and disenrollment of eligible children in an ,,mccc program shall be carried out in accordance with the requirements of this section and the applicable program agreement4 7#b7 ,network assignment 7,a7 ,in general ,eligible children shall be prospectively enrolled in an ,,mccc program by the ,state by assigning such eligible children to a nationally designated children's hospital network for an initial period of up to #ij days beginning on the date on which the child is assigned to such hospital network1 unless the child opts not to participate in any ,,mccc program in accordance with a process established by the ,state4 7,b7 ,basis for initial assignment ,such an assignment shall be made as follows3 7i7 ,first1 by considering the prevalence of visits by the child to a pediatrician or other specialist who is participating in the nationally designated children's hospital network4 7ii7 ,second1 by considering the selection of the child's family4 7iii7 ,third1 by considering the location of the primary residence of the child4 7iv7 ,fourth1 by considering the proximity of the child to regional referral networks established by the nationally designated children's hospital network4 7,c7 ,limitation on certain assignments ,in the case of the assignment of a child under subparagraph 7,a7 through the consideration of a factor specified in clause 7iii7 or 7iv7 of subparagraph 7,b71 such an assignment may only be made to a nationally designated children's hospital network that ensures access to a medical home that is located not more than #cj miles of the primary residence of the child4 7,d7 ,reassignment ,following the #ij-;day period referred to in subparagraph 7,a71 the child may elect-- 7i7 to be assigned to the nationally designated children's hospital network of their choice that has a program agreement in effect with respect to an ,,mccc program in which the child is eligible to enroll2 or 7ii7 to not participate in any ,,mccc program and receive care through enrollment in the ,state plan under this title or the ,state child health plan under title ,,xxi4 7d7 ,program agreements 7#a7 ,in general ,the ,secretary1 in close cooperation with the ,state administering agencies electing to provide the medical assistance described in subsection 7a71 shall establish procedures for entering into1 extending1 and terminating program agreements under this section4 7#b7 ,terms 7,a7 ,in general ,a program agreement entered into under this section by the ,secretary1 a ,state administering agency1 and a nationally designated children's hospital network shall provide for each of the following terms3 7i7 ,the agreement shall designate the service area of the ,,mccc program that is the subject of the agreement4 7ii7 ,the agreement shall be effective for a contract year1 but may be extended for additional contract years in the absence of a notice by a party to terminate1 and is subject to termination by the ,secretary and the ,state administering agency at any time for cause 7as provided under the agreement74 7iii7 ,the agreement shall require that the nationally designated children's hospital network submit care management network and coverage plans to the ,secretary that are centered around medical home models and that describe the governance of the network4 7iv7 ,the agreement shall require the hospital network to meet all applicable requirements imposed by ,state and local laws4 7v7 ,the agreement shall require such ,state1 in the case of eligible children who are residents of the ,state1 to make payments to the hospital network1 regardless of whether ,,mccc program services are furnished to such eligible children in another ,state4 7vi7 ,the agreement shall require that the standards and measures developed under subsection 7e7 be applied to the hospital network1 including measures requiring1 with respect to network adequacy standards1 that the hospital network establish such provider networks for primary1 secondary1 and tertiary care as are necessary to ensure the adequate furnishing of ,,mccc program services to eligible children enrolled in the ,,mccc program that is the subject of the agreement4 7vii7 ,the agreement shall require the hospital network to comply with the data collection and recordkeeping requirements of subparagraph 7,c74 7viii7 ,the agreement shall require the hospital network to accept as payment any payment made using the risk-based methodology developed under subsection 7g74 7ix7 ,the agreement shall contain such additional terms and conditions as the parties may agree to1 so long as such terms and conditions are consistent with this section4 7,b7 ,service area requirements ,in designating a service area under subparagraph 7,a77i71 the ,secretary 7in consultation with the relevant ,state administering agency7 shall-- 7i7 ensure that such service area provides convenient access for eligible children to ,,mccc program services1 without limiting the size of1 or number of1 nationally designated children's hospital networks providing such services2 and 7ii7 ensure that such hospital networks and the population of eligible children in the proposed service area are sufficient to support the delivery of ,,mccc program services and to avoid the unnecessary duplication of services and the impairment of the financial and service viability of another ,,mccc program4 7,c7 ,data and recordkeeping requirements ,the data collection and recordkeeping requirements under this subparagraph1 with respect to a nationally designated children's hospital network1 are as follows3 7i7 ,the hospital network shall collect claims data on claims submitted with respect to eligible children who are furnished ,,mccc program services under an ,,mccc program4 ,such data shall be reported in a standardized format and made available to the public for purposes of establishing a national database on such claims4 7ii7 ,the hospital network shall maintain1 and provide the ,secretary and the ,state administering agency access to1 the records relating to the ,,mccc program operated by the hospital network1 including pertinent financial1 medical1 and personnel records4 7iii7 ,the hospital network shall submit to the ,secretary and the ,state administering agency such reports as the ,secretary finds 7in consultation with the ,state administering agency7 necessary to monitor the operation1 cost1 and effectiveness of the ,,mccc program operated by the hospital network4 7#c7 ,termination of agreements ,the ,secretary shall issue regulations establishing the circumstances under which-- 7,a7 the ,secretary or a ,state administering agency may terminate a ,,mccc program agreement for cause2 and 7,b7 a nationally designated children's hospital network may terminate such an agreement after appropriate notice to the ,secretary1 the ,state administering agency1 and enrollees4 7e7 ,quality assurance 7#a7 ,development of standards and measures ,the ,secretary shall1 in consultation with nationally designated children's hospital networks and national pediatric policy organizations 7such as the ,children's ,hospital ,association and the ,american ,academy of ,pediatrics7-- 7,a7 establish a national set of quality assurance and improvement protocols and procedures to apply under ,,mccc programs2 7,b7 develop pediatric quality measures2 7,c7 develop pediatric network adequacy standards for access by eligible children to ,,mccc program services2 and 7,d7 develop criteria for national pediatric-focused care coordination for eligible children4 7#b7 ,use of pqmp measures ,in carrying out paragraph 7#a71 the ,secretary shall apply1 to the extent applicable1 child health quality measures and measures for centers of excellence for children with complex needs developed under this title1 title ,,xxi1 and section #aaci;,a and take into account ,,hedis quality measures as required under section #aheb7;e77#c7 and other quality measures4 7f7 ,standard ,medicaid data set 7#a7 ,in general ,the ,secretary1 the ,states1 and the nationally designated children's hospital networks shall collaborate to obtain consistent and verifiable ,medicaid ,analytic ,extract data or a comparable data set and shall establish data-sharing agreements to further support collaborative planning and care coordination for medically complex children4 7#b7 ,claims analysis ,the ,secretary shall-- 7,a7 perform claims analysis on the data set developed under paragraph 7#a7 to determine the utilization of items and services furnished under an ,,mccc program to eligible children2 and 7,b7 for purposes of building a national database1 submit to ,congress1 and make publicly available on the ,internet site of the ,centers for ,medicare and ,medicaid services1 a report on such claims in a standardized format4 7#c7 ,payment for reporting incentives ,the ,state plan may provide for pay-for-reporting incentives during the first two years of any program agreement entered into under this section to ensure participation and analysis of consistent data under this paragraph to enable the development of an appropriate risk-based payment methodology under subsection 7g74 7g7 ,payments to nationally designated children's hospital networks 7#a7 ,in general ,the ,state plan shall provide for payment to nationally designated children's hospital networks pursuant to the terms of a program agreement using a risk-based payment methodology 7or methodologies7 established in accordance with this subsection4 7#b7 ,transition from fee-for-service to risk-based payment model 7,a7 ,in general ,subject to subparagraph 7,b71 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 transition1 over a #e-year period1 to an equitable1 risk-based payment model using a methodology developed under paragraph 7#c74 ,for the first two years of such period1 a nationally designated children's hospital network may receive1 in addition to any fee-for-service payments made to such hospital network1 per capita care coordination payments with respect to expenditures for items and services furnished to eligible children enrolled in the ,,mccc program operated by the hospital network through medical home programs and other care coordination activities for which an all-inclusive payment model is more suitable than fee-for-service reimbursement4 7,b7 ,exception for certain ,states ,subparagraph 7,a7 shall not apply in the case of a ,state that1 as of the date of the enactment of this section1 uses a risk-based payment methodology with respect to payments made for items and services furnished to eligible children under the ,state plan or ,state child health plan4 7,c7 ,data analysis during initial period ,during the first two years of the implementation of an ,,mccc program1 the ,secretary shall analyze data collected under subsection 7f7 for purposes of developing a risk-based payment methodology that would be implemented beginning with the third year of implementation of the ,,mccc program4 7#c7 ,development of risk-based payment methodology ,the relevant ,state administering agency shall develop1 in coordination with the ,medicaid and ,,chip ,payment and ,access ,commission and the pediatric health care provider community1 payment methodologies for payment under the ,state plan in accordance with this subsection that-- 7,a7 take into account the data analyzed under paragraph 7#b77;,c72 7,b7 are actuarially sound1 determined using an actuarial method that ensures that such methodologies reflect historic pediatric claims data2 7,c7 include-- 7i7 a risk adjustment method1 re-insurance system1 or risk-corridor procedure to account for variations in acuity of the eligible children enrolled in ,,mccc programs2 and 7ii7 a shared savings approach1 which may include a form of bundled payment or risk-reward payment model that aligns payment with both cost savings and quality improvement2 and 7,d7 may provide for a model for making payments other than payments made on a per-member1 per-month basis4 7h7 ,waivers of requirements 7#a7 ,in general ,with respect to carrying out an ,,mccc program under this section1 the following provisions of law shall not apply3 7,a7 ,section #aijb7;a77#a71 relating to statewideness4 7,b7 ,section #aijb7;a77#aj71 insofar as such section relates to comparability of services among different population groups4 7,c7 ,sections #aijb7;a77#bc7 and #aiae7;b77#d71 relating to freedom of choice of providers4 7,d7 ,section #aijc7m77#b77;,a71 insofar as such section would prohibit a nationally designated children's hospital network from receiving certain payments4 7,e7 ,such other provisions of this title1 title ,,xviii1 sections #aabh;,a and #aabh;,b1 and any provisions 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 section4 7#b7 ,application in states operating under demonstration projects 7,a7 ,in general ,in the case of any ,state which is providing medical assistance to its residents under a waiver described in subparagraph 7,b71 the ,secretary shall not require that the ,state meet the requirements of this section in the same manner as the ,state would be required to meet such requirements if the ,state had in effect a plan approved under this title4 7,b7 ,waiver described ,a waiver described in this subparagraph is a waiver granted under section #aaae under which a ,state-- 7i7 provides for coverage through a medicaid managed care plan of all or a certain proportion of ,,mccc program services furnished to eligible children in the ,state through a nationally designated children's hospital network2 7ii7 assigns such eligible children to such a network in accordance with subsection 7c72 7iii7 requires that the ,state and such network enter into a program agreement that meets the requirements applicable to program agreements under subsection 7d72 and 7iv7 uses a payment methodology to make payments made for ,,mccc program services furnished to eligible children that is consistent with the requirements of subsection 7g74 7i7 ,preemption of ,state law ,a ,state may not impose any requirement on the nationally qualified children's hospital network's operation of a ,,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 7including the requirements of such program agreement74 7j7 ,definitions ,in this section3 7#a7 ,eligible child ,the term eligible child means1 with respect to an ,,mccc program1 an individual who is under the age of #ah and who-- 7,a7 is eligible for medical assistance under the ,state plan under this title or child health assistance under the ,state child health plan under title ,,xxi2 and 7,b7 has a chronic1 physical1 developmental1 behavioral1 or emotional condition that-- 7i7 affects two or more body systems2 7ii7 requires intensive care coordination to avoid excessive hospitalizations or emergency department visits2 or 7iii7 meets the criteria for medical complexity using risk adjustment methodologies 7such as ,clinical ,risk ,groups or another recognized pediatric population grouping system7 agreed upon by the ,secretary in coordination with a national panel of pediatric experts4 7#b7 ,,mccc program ,the term ,,mccc program 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 7d74 7#c7 ,,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 children1 including pediatric care management services and pediatric-focused care coordination and health promotion1 as specified in the program agreement4 7#d7 ,nationally designated children's hospital network ,the term nationally designated children's hospital network means a network of hospitals and health care providers-- 7,a7 anchored by a qualified children's hospital or hospitals with principal governance responsibility over the hospital network2 7,b7 in which the full complement of health care providers needed to provide the best care for children in the network participate2 and 7,c7 that represents the interests of physicians1 other health care providers1 parents of medically complex children1 and other relatives of such children4 7#e7 ,program agreement ,the term program agreement means an agreement between a nationally designated children's hospital network1 the ,secretary1 and a ,state administering agency for the operation of an ,,mccc program by the hospital network in the ,state that meets the requirements of this section4 7#f7 ,qualified children's hospital ,the term qualified children's hospital means a children's hospital that-- 7,a7 qualifies to receive payment under section #cdj;,e of the ,public ,health ,service ,act 7relating to children's hospitals that operate graduate medical education programs72 or 7,b7 meets #c or more of the following criteria3 7i7 ,minimum pediatric discharges ,the hospital has at least #e1jjj annual pediatric discharges 7including neonates1 but excluding obstetrics and normal newborns7 for the most recent cost reporting period for which data are available4 7ii7 ,minimum number of beds ,the hospital has #ajj licensed pediatric beds1 not including beds in neonatal intensive care units but including beds in pediatric intensive care units and other acute care beds4 7iii7 ,access to pediatric emergency services ,the hospital has access 7through ownership or otherwise7 to pediatric emergency services4 7iv7 ,medicaid reliant ,at least #cj percent of the pediatric discharges or inpatient days 7excluding observation days7 in the hospital for the most recent cost reporting period for which data are available were children eligible for medical assistance under this title or for children's health assistance under title ,,xxi4 7v7 ,affiliation with accredited pediatric residency training program ,the hospital sponsors or is affiliated with a pediatric residency program that is accredited by the ,accreditation ,council for ,graduate ,medical ,education4 7vi7 ,pediatric medical home programs ,the hospital has established and implemented demonstrable pediatric medical home programs dedicated to medically complex children4 7#g7 ,state administering agency ,the term ,state administering agency means1 with respect to the operation of an ,,mccc program in a ,state1 the agency of that ,state 7which may be the single agency responsible for administration of the ,state plan under this title in the ,state7 responsible for administering program agreements under this section4 4 7b7 ,inclusion as medical assistance ,section #aije7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7a77 is amended-- 7#a7 in paragraph 7#bh71 by striking and at the end2 7#b7 by redesignating paragraph 7#bi7 as paragraph 7#cj72 and 7#c7 by inserting after paragraph 7#bh7 the following new paragraph3 7#bi7 items and services furnished under an ,,mccc program under section #aidg to eligible children enrolled in an ,,mccc program under such section2 and 4 7c7 ,application under chip ,section #bajg7;e77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;gg7e77#a77 is amended by adding at the end the following new subparagraph3 7,p7 ,section #aidg 7relating to ,medicaid children's care coordination programs for children with complex medical conditions74 4 7d7 ,regulations ,not later than #abj days after the date of the enactment of this ,act1 the ,secretary of ,health and ,human ,services shall make rules on the record1 after opportunity for an agency hearing to carry out the amendments made by this section in accordance with sections #eef and #eeg of title #e1 ,united ,states ,code4