Section 1 Short title
This Act may be cited as the “Medicaid and CHIP Continuous Quality Act of 2014”.
Medicaid and CHIP Continuous Quality Act of 2014
A BILL
To amend titles XIX and XXI of the Social Security Act to provide for 12-month continuous enrollment under the Medicaid program and Children’s Health Insurance Program and to promote quality care.
Sec. 2 Findings
Congress finds the following:
Every year millions of people are enrolled in Medicaid and the Children’s Health Insurance Program (in this section referred to as “CHIP”), but subsequently lose their coverage, despite still being eligible, because of inefficient and cumbersome paperwork and logistical requirements.
Data show that the typical enrollee receives Medicaid coverage for about three-quarters of the year. Coverage periods are lower for non-elderly, non-disabled adults than for those with disabilities, seniors, and children.
Medicaid enrollees with coverage disruption are more likely to be hospitalized for illnesses like asthma, diabetes, or cardiovascular disease that can be effectively managed through ongoing primary medical care and medication, are less likely to be screened for breast cancer, and may have poorer cancer outcomes.
Children enrolled in CHIP also experience disruptions in health coverage and care. For example, during just a one-year period, over one-third of CHIP enrollees were also enrolled in a State’s Medicaid program. Transitions between Medicaid and CHIP can cause disruptions in care because the health care coverage and participating providers vary between the two programs.
Interruptions in coverage can impair the receipt of effective primary care and lead to expensive hospitalizations or emergency room visits.
Unnecessary enrollment, disenrollment and reenrollment in Medicaid and CHIP result in higher administrative expenses for reenrollment and result in more people uninsured at any given time.
Stable coverage under Medicaid and CHIP lowers average monthly medical costs. Continuous enrollment also permits better prevention and disease management, leading to fewer serious illnesses and hospitalizations.
Children with stable coverage are less likely to have unmet medical needs, allowing children to receive the preventive care that is necessary to help them grow into healthy adults.
For the majority of Medicaid enrollees who are served by Primary Care Case Management (PCCM) or fee-for-service arrangements, there are no Federal requirements for comparable quality monitoring or improvement. No structured oversight exists for Medicaid enrollees when they move between fee-for-service and capitated managed care plans. Thus, there currently is no ability to make fair assessments across all modes of care for Medicaid enrollees.
Sec. 3 12-month continuous enrollment
Requirement of 12-Month continuous enrollment under Medicaid—
In general— Section 1902(e)(12) of the Social Security Act (42 U.S.C. 1396a(e)), is amended to read as follows:
“(12) 12-month continuous enrollment
“(A) In general—Notwithstanding any other provision of this title, a State plan approved under this title (or under any waiver of such plan approved pursuant to section 1115 or section 1915), shall provide that an individual who is determined to be eligible for benefits under such plan (or waiver) shall remain eligible and enrolled for such benefits through the end of the month in which the 12-month period (beginning on the date of determination of eligibility) ends.
“(B) Promoting retention of eligible and enrolled persons beyond 12 months—The Secretary shall—
“(i) identify methods that promote the retention of individuals who are enrolled under the State plan and who remain eligible for medical assistance beyond the 12-month period described in subparagraph (A); and
“(ii) actively promote the adoption of such enrollment retention methods by States, which should include but not be limited to issuing guidance and developing resources on State best practices.
“(C) Enrollment and retention reporting
“(i) In general—Not later than September 30, 2014, the Secretary shall publish the procedures that States are expected to use to provide annual enrollment and retention reports beginning September 30, 2015.
“(ii) State reporting requirements—At a minimum, such reporting procedures shall include a description of State eligibility criteria and enrollment procedures under this title, and data regarding enrollment and retention using standardized reporting formats determined by the Secretary.
“(iii) Secretary report and publication—The Secretary shall annually publish enrollment and retention performance results for all States beginning not later than June 30, 2016.
“(iv) Each such annual report shall include estimates of Medicaid enrollment continuity ratios for each State. In this clause, the term enrollment continuity ratio means, for a given group, the ratio of the average monthly enrollment of that group in the fiscal year divided by the total unduplicated enrollment for that group in the fiscal year, expressed as a percentage.
“(v) For purposes of such reports, the Secretary shall develop both overall ratios for all enrollees and separate ratios for the following categories:
“(I) Children.
“(II) Individuals whose eligibility category is related to being equal to or over the age of 65.
“(III) Individuals whose eligibility category is related to disability or blindness.
“(IV) Individuals whose eligibility category is related to their status as parents and caretaker relatives of children under 19 or who are otherwise not elderly, blind or disabled adults.”
Requirement of 12-Month continuous enrollment under CHIP—
In general— Section 2102(b) of the Social Security Act (42 U.S.C. 1397bb(b)) is amended by adding at the end the following new paragraph:
“(6) Requirement for 12-month continuous enrollment—Notwithstanding any other provision of this title, a State child health plan that provides child health assistance under this title through a means other than described in section 2101(a)(2), shall provide that an individual who is determined to be eligible for benefits under such plan shall remain eligible and enrolled for such benefits through the end of the month in which the 12-month period (beginning on the date of determination of eligibility) ends.”
Conforming amendment— Section 2105(a)(4)(A) of the Social Security Act (42 U.S.C. 1397ee(a)(4)(A)) is amended—
by striking “has elected the option of” and inserting “is in compliance with the requirement for”; and
by striking “applying such policy under its State child health plan under this title” and inserting “in compliance with section 2102(b)”.
Effective date—
In general— Except as provided in paragraph (2) or (3), the amendments made by subsections (a) and (b) shall apply to determinations (and redeterminations) of eligibility made on or after the date that is 18 months after the date of the enactment of this Act.
Extension of effective date for state law amendment— In the case of a State plan under title XIX or State child health plan under title XXI of the Social Security Act (42 U.S.C. 1396 et seq., 42 U.S.C. 1397aa et seq.) which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the respective plan to meet the additional requirement imposed by the amendment made by subsection (a) or (b), respectively, the respective plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet such applicable additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of enactment of this Act. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of the session is considered to be a separate regular session of the State legislature.
Option to implement 12-month continuous eligibility prior to effective date— A State may elect through a State plan amendment under title XIX or XXI of the Social Security Act (42 U.S.C. 1396 et seq., 42 U.S.C. 1397aa et seq.) to apply the amendment made by subsection (a) or (b), respectively, on any date prior to the 18-month date specified in paragraph (1), but not sooner than the date of the enactment of this Act.
Sec. 4 Preventing the application under CHIP of coverage waiting periods
In general— Section 2102(b)(1)(B) of the Social Security Act (42 U.S.C. 1397bb(b)(1)(B)) is amended—
in clause (iii)—
by striking “in the case of” and inserting “in the case of a targeted low-income child (including a child provided dental-only supplemental coverage under section 2110(b)(5)) or in the case of”; and
by adding “and” after the semicolon;
by striking clause (iv); and
by redesignating clause (v) as clause (iv).
Conforming amendments— Section 2105(c)(10) of the Social Security Act (42 U.S.C. 1397ee(c)(10)) is amended by striking subparagraph (F) and redesignating subparagraphs (G) through (M) as subparagraphs (F) through (L), respectively.
Effective date— The amendments made by this section shall take effect on the date of enactment of this Act.
Sec. 5 Performance bonuses for enrollment and retention improvements for certain individuals
Medicaid— Section 1903 of the Social Security Act (42 U.S.C. 1396b) is amended by adding at the end the following new subsection:
“(aa) Performance bonuses for enrollment and retention of low-Income individuals
“(1) In general—In addition to performance bonuses for enrollment and retention described in section 2105(a) (related to children), a State may qualify for 1 or more performance bonuses related to the enrollment and retention of individuals described in section 1902(e)(12)(C)(iii)(III). For purposes of this paragraph, a State meets the condition of this paragraph for such individuals if, for each category of individuals specified in section 1902(e)(12)(C)(iii)(III) and selected by the State for additional enrollment and retention provisions, the State is implementing at least 3 of the following enrollment and retention provisions (treating each subparagraph as a separate enrollment and retention provision) throughout the entire fiscal year:
“(A) Aligning treatment of income under medicaid with that of other insurance affordability programs—The State implements policies, including prorating income over annual periods, so as to align its treatment of income for purposes of a determination of eligibility for medical assistance with that of other affordability insurance programs with the goal of eliminating inconsistent determinations among these programs.
“(B) Maintaining coverage for individuals during periods of transition
“(i) In general—Upon determination that an individual is no longer eligible for medical assistance, the State implements policies to maintain eligibility for medical assistance, including enrollment in the managed care organization in which the individual was enrolled at the time of the determination of ineligibility, during the period of time in which—
“(I) eligibility-related information is transmitted to the other insurance affordability programs;
“(II) a determination is made as to for which other insurance affordability program the individual is eligible; and
“(III) coverage in such program and any related managed care organization becomes effective.
“(ii) Managed care organization continuity—The State shall also implement policies to enroll the individual in the managed care organization in which the individual was a member prior to the loss of medical assistance eligibility, if such managed care organization participates in the other insurance affordability program, unless the individual voluntarily selects a separate managed care organization.
“(C) Enhanced data-sharing between agencies—The State utilizes findings from an American Health Benefit Exchange, an Express Lane Agency (as identified by the State and as described in section 1902(e)(13)(F)) or the Social Security Administration or other agencies administering employment, educational, or social services programs as identified by the State, to document income, assets, residency, age or other relevant information in determining or renewing eligibility.
“(D) Eligibility based on pending status—The State maintains eligibility for enrollees whose renewal status has not yet been determined and for whom eligibility based on alternative eligibility criteria has not yet been ruled out.
“(E) Default reenrollment in managed care organization—In the case of individuals who are determined to be eligible for medical assistance under this title after the loss of eligibility for fewer than 6 months, and who previously had been members of a managed care organization, the State re-enrolls the individual in the managed care organization in which the individual was a member prior to the loss of eligibility, unless the individual voluntarily selects a separate managed care organization.
“(2) Performance bonus payment to offset costs resulting from 12-month continuous enrollment for medicaid enrollees
“(A) Authority to make bonus payments
“(i) In general—In addition to the payments provided under section 2105(a) of the Social Security Act, subject to subparagraph (C) the Secretary shall make payments to a State (beginning with fiscal year 2016) that satisfies the requirements of subparagraph (B).
“(ii) Regulations—Payments to States shall be allocated annually among States in accordance with regulations promulgated by the Secretary not later than July 1, 2015.
“(iii) Timing—The payment under this paragraph shall be made, to a State for a fiscal year, as a single payment not later than the last day of the first calendar quarter of the following fiscal year to which the performance payment applies.
“(B) State eligibility for bonus payments—A State shall be eligible for bonus payments under this subsection if—
“(i) the State has adopted at least 3 of the 5 policies described in subparagraphs (A) through (E) of paragraph (1); and
“(ii) the State is able to demonstrate improvement in the continuity of enrollment by aged, blind, and disabled and adult populations, compared to its baseline performance in fiscal year 2013.
“(C) Amounts available for payments
“(i) In general—The total amount of payments under paragraphs (1) and (2) of this section shall be equal to $500,000,000 for fiscal year 2016 for making payments under this paragraph, to be available until expended.
“(ii) Budget authority—This subsection constitutes budget authority in advance of appropriations Acts and represents the obligation of the Secretary to provide for the payment of amounts provided under this subsection.
“(D) Uses of enrollment and retention performance bonuses—Nothing in this section shall prohibit a State from establishing criteria which would permit the State to distribute a portion of the proceeds of any performance bonuses received pursuant to this section to financially support providers who have contributed to improved enrollment and retention activities. For purposes of allocation of Enrollment and Retention Performance Bonuses the definition of provider shall have the meaning given to it in a State Plan.”
Extension of CHIP Performance Bonus To align with reauthorization of State allotments— Section 2105(a)(3) of the Social Security Act (42 U.S.C. 1397ee(a)(3)) is amended—
in subparagraph (A), by striking “2013” and inserting “2015”;
in subparagraph (E)(ii)—
in the heading for subclause (I)(aa), by striking “2012” and inserting “2014”;
in subclause (I)(aa)—
by striking “2012” and inserting “2014”;
by striking “subsection (a)” and inserting “section 2104(a)”; and
by striking “subsection (m)” and inserting “section 2104(m)”;
in the heading for subclause (I)(bb), by striking “2013” and inserting “2015”;
in subclause (I)(bb)—
by striking “fiscal year 2013” and inserting “fiscal year 2015”;
by striking “subsection (a)(16)(A)” and inserting “section 2104(a)(18)(A)”;
by striking “October 1, 2012, and ending on March 31, 2013” and inserting “October 1, 2014, and ending on March 31, 2015”;
by striking “subsection (m)” and inserting “section 2104(m)”; and
by striking “or set aside under subsection (b)(2) of section 2111 for such fiscal year”;
in the heading for subclause (I)(cc), by striking “2013” and inserting “2015”;
in subclause (I)(cc)—
by striking “2013” each place it appears and inserting “2015”;
by striking “subsection (a)(16)(B)” and inserting “section 2104(a)(18)(B)”;
by striking “subsection (m)” and inserting “section 2104(m)”; and
by striking “or set aside under subsection (b)(2) of section 2111 for such fiscal year”;
in subclause (II), by striking “2013” and inserting “2015”; and
in subclause (III), by striking “2013” and inserting “2015”; and
in subparagraph (F)(iii), by striking “2013” and inserting “2015”.
Sec. 6 Measuring and reporting on comparable health care quality measures for all persons enrolled in Medicaid
Quality assurance standards— Section 1932(c)(1) of the Social Security Act (42 U.S.C. 1396u–2(c)(1)) is amended in subparagraph (A), by inserting after “1903(m)” the following: “or comparable primary care case management services providers described in section 1905(t) as well as health care services furnished in fee-for-service settings”.
Adult health quality measures— Title XI of the Social Security Act (42 U.S.C. 1301 et seq.), as amended by section 2701 of the Patient Protection and Affordable Care Act (Public Law 111–148), is amended at section 1139B (42 U.S.C. 1320b–9b)—
by adding after (b)(3) the following:
“(4) Quality reporting for medicaid eligible adults—Beginning January 1, 2016, the Secretary shall require States to use the measures and approaches identified in paragraph (3) of this subsection to report on the initial core set of quality measures for Medicaid eligible adults identified in paragraph (2), subject to revisions made by (5)(B) of this subsection.”
by redesignating subsection (b)(4) as (b)(5) and (b)(5) as (b)(6);
in subsection (d)(1)(B) inserting after “Section 1937 of this title” the following: “or comparable primary care case management services providers described in section 1905(t) as well as health care services furnished in fee-for-service settings”; and
in subsection (d)(2) by inserting after “(1)” the following: “including analysis of comparable quality measures for Medicaid eligible adults who receive their health services through managed care, primary care case management, and fee-for-service settings”.
Pediatric health care measures—
In general— Title XI of the Social Security Act, is amended at section 1139A(a) (42 U.S.C. 1320b–9a(a)) by—
inserting after paragraph (4) as if it were included upon enactment:
“(5) Reporting of pediatric health care measures—Not later than five years after the date of enactment of the Medicaid Continuous Quality Act of 2012, States shall use the procedures and approaches identified in paragraph (4) to report information on the initial core measurement set regarding the quality of pediatric health care under titles XIX and XXI.”
redesignating paragraphs (5), (6), (7) and (8) as (6), (7), (8) and (9), respectively; and
in subsection (c)(1)(B), inserting after “section 2103 of such Act” the following: “or comparable primary care case management services providers described in section 1905(t) as well as health care services furnished in fee-for-service settings”.
Sec. 7 Performance bonuses for significant achievement in Medicaid quality performance
Section 1932(c)(1) of the Social Security Act (42 U.S.C. 1396u–2(c)(1)) is amended by adding at the end the following new subparagraph:
“(F) Performance bonus for quality performance achievement
“(i) In general—The Secretary shall establish a Medicaid Quality Performance Bonus fund for awarding performance bonuses to States for high attainment and improvement on a core set of quality measures related to the goals and purposes of the Medicaid program.
“(ii) Quality performance bonus methodology—Not later than three years after the date of enactment of this Act, the Secretary shall establish a methodology for awarding Medicaid Quality Performance bonuses to States not less than annually which will be based on the annual State reports required under section 1138B of title XI of the Social Security Act, in accordance with regulations promulgated by the Secretary.
“(iii) Quality performance measurement bonuses—Medicaid Quality Performance Bonus funds will be awarded to up to 10 States that meet thresholds established by the Secretary for—
“(I) the top five States achieving the designation of superior quality performing State; or
“(II) five States demonstrating the greatest relative level of annual improvement in quality performance.
“(iv) Initial appropriation—The total amount of payments under this subparagraph shall be equal to $500,000,000 for making payments under this subparagraph, to be available until expended.
“(v) Uses of quality performance bonus funds
“(I) Designation for quality improvement activities—As a condition of receiving a bonus fund award under clause (iii), a State shall agree to designate at least 75 percent of the performance bonus funds for the development and operation of quality-related initiatives that will directly benefit providers, including—
“(aa) provider pay-for-performance programs;
“(bb) provider collaboration initiatives that have been demonstrated to improve performance on quality;
“(cc) provider quality improvement initiatives, including those aimed at improving care for special and hard-to-reach populations; and
“(dd) Secretary-approved activities and initiatives that a State may pursue to encourage quality improvement and patient-focused high value care.
“(II) Remaining bonus funds—States may designate up to 25 percent of the quality performance bonus award for activities related to the goals and purposes of the program.
“(vi) Definition of providers—For purposes of allocation of Medicaid Quality Performance Bonuses the definition of provider shall have the meaning given to it in a State Plan. Nothing in this section shall prohibit a State from investing bonus funds into quality improvement activities for managed care entities.”