Index for HR3962: Affordable Health Care for America Act

To provide affordable, quality health care for all Americans and reduce the growth in health care spending, and for other purposes.

Mr. Dingell (for himself, Mr. Rangel, Mr. Waxman, Mr. George Miller of California, Mr. Stark, Mr. Pallone, and Mr. Andrews) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Education and Labor, Oversight and Government Reform, and the Budget, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

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

(a) Purpose.—The purpose of this subtitle is to establish and provide assistance to community-based collaborative care networks—

(1) to develop or strengthen coordination of services to allow all individuals, including the uninsured and low-income, to receive efficient and higher quality care and to gain entry into and receive services from a comprehensive system of care;

(2) to develop efficient and sustainable infrastructure for a health care delivery system characterized by effective collaboration, information sharing, and clinical and financial coordination among providers of care in the community;

(3) to develop or strengthen activities related to providing coordinated care for individuals with chronic conditions; and

(4) to reduce the use of emergency departments, inpatient and other expensive resources of hospitals and other providers.

(b) Creation of the Community-Based Collaborative Care Network Program.—Part D of title III (42 U.S.C. 254b et seq.), as amended, is further amended by inserting after subpart XII the following new subpart:

“(a) In general.—The Secretary may award grants to eligible entities for the purpose of establishing model projects to accomplish the following goals:

“(1) To reduce unnecessary use of items and services furnished in emergency departments of hospitals (especially to ensure that individuals without health insurance coverage or with inadequate health insurance coverage do not use the services of such department instead of the services of a primary care provider) through methods such as—

“(A) screening individuals who seek emergency department services for possible eligibility under relevant governmental health programs or for subsidies under such programs; and

“(B) providing such individuals referrals for followup care and chronic condition care.

“(2) To manage chronic conditions to reduce their severity, negative health outcomes, and expense.

“(3) To encourage health care providers to coordinate their efforts so that the most vulnerable patient populations seek and obtain primary care.

“(4) To provide more comprehensive and coordinated care to vulnerable low-income individuals and individuals without health insurance coverage or with inadequate coverage.

“(5) To provide mechanisms for improving both quality and efficiency of care for low-income individuals and families, with an emphasis on those most likely to remain uninsured despite the existence of government programs to make health insurance more affordable.

“(6) To increase preventive services, including screening and counseling, to those who would otherwise not receive such screening, in order to improve health status and reduce long-term complications and costs.

“(7) To ensure the availability of community-wide safety net services, including emergency and trauma care.

“(b) Eligibility and grantee selection.—

“(1) APPLICATION.—A community-based collaborative care network described in subsection (d) shall submit to the Secretary an application in such form and manner and containing such information as specified by the Secretary. Such information shall at least—

“(A) identify the health care providers participating in the community-based collaborative care network proposed by the applicant and, if a provider designated in paragraph (d)(1)(B) is not included, the reason such provider is not so included;

“(B) include a description of how the providers plan to collaborate to provide comprehensive and integrated care for low-income individuals, including uninsured and underinsured individuals;

“(C) include a description of the organizational and joint governance structure of the community-based collaborative care network in a manner so that it is clear how decisions will be made, and how the decisionmaking process of the network will include appropriate representation of the participating entities;

“(D) define the geographic areas and populations that the network intends to serve;

“(E) define the scope of services that the network intends to provide and identify any reasons why such services would not include a suggested core service identified by the Secretary under paragraph (3);

“(F) demonstrate the network’s ability to meet the requirements of this section; and

“(G) provide assurances that grant funds received shall be used to support the entire community-based collaborative care network.

“(2) SELECTION OF GRANTEES.—

“(A) IN GENERAL.—The Secretary shall select community-based collaborative care networks to receive grants from applications submitted under paragraph (1) on the basis of quality of the proposal involved, geographic diversity (including different States and regions served and urban and rural diversity), and the number of low-income and uninsured individuals that the proposal intends to serve.

“(B) PRIORITY.—The Secretary shall give priority to proposals from community-based collaborative care networks that—

“(i) include the capability to provide the broadest range of services to low-income individuals; and

“(ii) include providers that currently serve a high volume of low-income individuals.

“(C) RENEWAL.—In subsequent years, based on the performance of grantees, the Secretary may provide renewal grants to prior year grant recipients.

“(3) SUGGESTED CORE SERVICES.—For purposes of paragraph (1)(E), the Secretary shall develop a list of suggested core patient and core network services to be provided by a community-based collaborative care network. The Secretary may select a community-based collaborative care network under paragraph (2), the application of which does not include all such services, if such application provides a reasonable explanation why such services are not proposed to be included, and the Secretary determines that the application is otherwise high quality.

“(4) TERMINATION AUTHORITY.—The Secretary may terminate selection of a community-based collaborative care network under this section for good cause. Such good cause shall include a determination that the network—

“(A) has failed to provide a comprehensive range of coordinated and integrated health care services as required under subsection (d)(2);

“(B) has failed to meet reasonable quality standards;

“(C) has misappropriated funds provided under this section; or

“(D) has failed to make progress toward accomplishing goals set out in subsection (a).

“(c) Use of funds.—

“(1) USE BY GRANTEES.—Grant funds are provided to community-based collaborative care networks to carry out the following activities:

“(A) Assist low-income individuals without adequate health care coverage to—

“(i) access and appropriately use health services;

“(ii) enroll in applicable public or private health insurance programs;

“(iii) obtain referrals to and see a primary care provider in case such an individual does not have a primary care provider; and

“(iv) obtain appropriate care for chronic conditions.

“(B) Improve heath care by providing case management, application assistance, and appropriate referrals such as through methods to—

“(i) create and meaningfully use a health information technology network to track patients across collaborative providers;

“(ii) perform health outreach, such as by using neighborhood health workers who may inform individuals about the availability of safety net and primary care providers available through the community-based collaborative care network;

“(iii) provide for followup outreach to remind patients of appointments or follow-up care instructions;

“(iv) provide transportation to individuals to and from the site of care;

“(v) expand the capacity to provide care at any provider participating in the community-based collaborative care network, including telehealth, hiring new clinical or administrative staff, providing access to services after-hours, on weekends, or otherwise providing an urgent care alternative to an emergency department; and

“(vi) provide a primary care provider or medical home for each network patient.

“(C) Provide direct patient care services as described in their application and approved by the Secretary.

“(2) GRANT FUNDS TO HRSA GRANTEES.—The Secretary may limit the percent of grant funding that may be spent on direct care services provided by grantees of programs administered by the Health Resources and Services Administration (in this section referred to as ‘HRSA’) or impose other requirements on HRSA grantees participating in a community-based collaborative care network as may be necessary for consistency with the requirements of such programs.

“(3) RESERVATION OF FUNDS FOR NATIONAL PROGRAM PURPOSES.—The Secretary may use not more than 7 percent of funds appropriated to carry out this section for providing technical assistance to grantees, obtaining assistance of experts and consultants, holding meetings, developing of tools, disseminating of information, and evaluation.

“(d) Community-Based collaborative care networks.—

“(1) IN GENERAL.—

“(A) DESCRIPTION.—A community-based collaborative care network described in this subsection is a consortium of health care providers with a joint governance structure that provides a comprehensive range of coordinated and integrated health care services for low-income patient populations or medically underserved communities (whether or not such individuals receive benefits under title XVIII, XIX, or XXI of the Social Security Act, private or other health insurance or are uninsured or underinsured) and that complies with any applicable minimum eligibility requirements that the Secretary may determine appropriate.

“(B) REQUIRED INCLUSION.—Each such network shall include the following providers that serve the community (unless such provider does not exist within the community, declines or refuses to participate, or places unreasonable conditions on their participation)—

“(i) A safety net hospital that provides services to a high volume of low-income patients, as demonstrated by meeting the criteria in section 1923(b)(1) of the Social Security Act, or other similar criteria determined by the Secretary; and

“(ii) All Federally qualified health centers (as defined in section 1861(aa) of the Social Security Act (42 U.S.C. 1395x(aa))) located in the geographic area served by the Coordinated Care Network;

“(C) ADDITIONAL INCLUSIONS.—Each such network may include any of the following additional providers:

“(i) A hospital, including a critical access hospital (as defined in section 1820(c)(2) of the Social Security Act (42 U.S.C. 1395i–4(c)(2))).

“(ii) A county or municipal department of health.

“(iii) A rural health clinic or a rural health network (as defined in sections 1861(aa) and 1820(d) of the Social Security Act, respectively (42 U.S.C. 1395x(aa), 1395i–4(d))).

“(iv) A community clinic, including a mental health clinic, substance abuse clinic, or a reproductive health clinic.

“(v) A health center controlled network as defined by section 330(e)(1)(C) of the Public Health Service Act

“(vi) A private practice physician or group practice.

“(vii) A nurse or physician assistant or group practice.

“(viii) An adult day care center.

“(ix) A home health provider.

“(x) Any other type of provider specified by the Secretary, which has a desire to serve low-income and uninsured patients.

“(D) CONSTRUCTION.—

“(i) Nothing in this section shall prohibit a single entity from qualifying as community-based collaborative care network so long as such single entity meets the criteria of a community-based collaborative care network. If the network does not include the providers referenced in clauses (i) and (ii) of subparagraph (B) of this paragraph, the application must explain the reason pursuant to subsection (b)(1)(A).

“(ii) Participation in a community-based collaborative care network shall not affect Federally qualified health centers’ obligation to comply with the governance requirements under section 330 of the Public Health Service Act (42 U.S.C. 254b).

“(iii) Federally qualified health centers participating in a community-based collaborative care network may not be required to provide services beyond their Federal Health Center scope of project approved by HRSA.

“(iv) Nothing in this section shall be construed to expand medical malpractice liability protection under the Federal Tort Claims Act for Section 330-funded Federally qualified health centers.

“(2) COMPREHENSIVE RANGE OF COORDINATED AND INTEGRATED HEALTH CARE SERVICES.—The Secretary shall define criteria for evaluating whether the services offered by a community-based collaborative care network qualify as a comprehensive range of coordinated and integrated health care services. Such criteria may vary based on the needs of the geographic areas and populations to be served by the network and may include the following:

“(A) Requiring community-based collaborative care networks to include at least the suggested core services identified under subsection (b)(3), or whichever subset of the suggested core services is applicable to a particular network.

“(B) Requiring such networks to assign each patient of the network to a primary care provider responsible for managing that patient’s care.

“(C) Requiring the services provided by a community-based collaborative care network to include support services appropriate to meet the health needs of low-income populations in the network’s community, which may include chronic care management, nutritional counseling, transportation, language services, enrollment counselors, social services and other services as proposed by the network.

“(D) Providing that the services provided by a community-based collaborative care network may also include long-term care services and other services not specified in this subsection.

“(E) Providing for the approval by the Secretary of a scope of community-based collaborative care network services for each network that addresses an appropriate minimum scope of work consistent with the setting of the network and the health professionals available in the community the network serves.

“(3) CLARIFICATION.—Participation in a community-based collaborative care network shall not disqualify a health care provider from reimbursement under title XVIII, XIX, or XXI of the Social Security Act with respect to services otherwise reimbursable under such title. Nothing in this section shall prevent a community-based collaborative care network that is otherwise eligible to contract with Medicare, a private health insurer, or any other appropriate entity to provide care under Medicare, under health insurance coverage offered by the insurer, or otherwise.

“(e) Evaluations.—

“(1) GRANTEE REPORTS.—Beginning in the third year following an initial grant, each community-based collaborative care network shall submit to the Secretary, with respect to each year the grantee has received a grant, an evaluation on the activities carried out by the community-based collaborative care network under the community-based collaborative care network program and shall include—

“(A) the number of people served;

“(B) the most common health problems treated;

“(C) any reductions in emergency department use;

“(D) any improvements in access to primary care;

“(E) an accounting of how amounts received were used, including identification of amounts used for patient care services as may be required for HRSA grantees; and

“(F) to the extent requested by the Secretary, any quality measures or any other measures specified by the Secretary.

“(2) PROGRAM REPORTS.—The Secretary shall submit to Congress an annual evaluation (beginning not later than 6 months after the first reports under paragraph (1) are submitted) on the extent to which emergency department use was reduced as a result of the activities carried out by the community-based collaborative care network under the program. Each such evaluation shall also include information on—

“(A) the prevalence of certain chronic conditions in various populations, including a comparison of such prevalence in the general population versus in the population of individuals with inadequate health insurance coverage;

“(B) demographic characteristics of the population of uninsured and underinsured individuals served by the community-based collaborative care network involved; and

“(C) the conditions of such individuals for whom services were requested at such emergency departments of participating hospitals.

“(3) AUDIT AUTHORITY.—The Secretary may conduct periodic audits and request periodic spending reports of community-based collaborative care networks under the community-based collaborative care network program.

“(f) Clarification.—Nothing in this section requires a provider to report individually identifiable information of an individual to government agencies, unless the individual consents, consistent with HIPAA privacy and security law, as defined in section 3009(a)(2).

“(g) Authorization of appropriations.—There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2011 through 2015.”.