text: SECTION 1. SHORT TITLE.
  
      This Act may be cited as the ``Strengthening the Health Care Safety 
  Net Act of 2009''.
  
  SEC. 2. APPLICATION OF UNEXPENDED MEDICAID DSH ALLOTMENTS FOR INCREASED 
                ALLOTMENTS FOR LOW DSH STATES AND FOR HEALTH NETWORK 
                ACCESS GRANTS.
  
      (a) Establishment of DSH Redistribution Pool From Unexpended 
  Medicaid DSH Allotments.--Subsection (f) of section 1923 of the Social 
  Security Act (42 U.S.C. 1396r-4) is amended--
              (1) by redesignating paragraph (7) as paragraph (8); and
              (2) by inserting after paragraph (6) the following new 
          paragraph:
              ``(7) DSH redistribution pool from portion of unexpended 
          dsh allotments to fund increase in allotments for low dsh 
          states and health network access grants.--
                      ``(A) Establishment.--There is established a DSH 
                  redistribution pool in the amount provided under this 
                  paragraph. Such amount shall be determined by the 
                  Secretary at the beginning of each fiscal year and the 
                  Secretary may adjust such amount in subsequent fiscal 
                  years to take into account errors in estimates made for 
                  previous fiscal years. The amount in such pool shall be 
                  available for obligation and expenditure without fiscal 
                  year limitation.
                      ``(B) Addition of unexpended dsh allotments.--At 
                  the beginning of each fiscal year (beginning with 
                  fiscal year 2010), there shall be added to the DSH 
                  redistribution pool an amount equal to the amount by 
                  which--
                              ``(i) the total of the DSH allotments for 
                          all States for the third preceding fiscal year; 
                          exceeded
                              ``(ii) the total Federal financial 
                          participation under this title attributable to 
                          such allotments for such fiscal year.
                      ``(C) Reduction for expenditures resulting from 
                  increased allotments for low dsh states and for health 
                  network access grants.--At the beginning of each fiscal 
                  year (beginning with fiscal year 2011), there shall be 
                  subtracted from the DSH redistribution pool an amount 
                  equal to the sum of--
                              ``(i) the aggregate increase in Federal 
                          financial participation under this title 
                          attributable to the amendments made by section 
                          2(b) of the Strengthening the Health Care 
                          Safety Net Act of 2009 for the previous fiscal 
                          year; and
                              ``(ii) the amount obligated on grants under 
                          subsection (k) for such previous fiscal 
                          year.''.
      (b) Increase in DSH Allotments for Low DSH States; Qualification of 
  Low DSH States Based on Fiscal Year 2005 Data.--Subsection (f)(5) of 
  such section is amended--
              (1) in subparagraph (B)--
                      (A) by striking ``and'' at the end of clause (ii);
                      (B) in clause (iii)--
                              (i) by striking ``2009'' and inserting 
                          ``2015'';
                              (ii) by inserting ``, subject to 
                          subparagraph (D),'' after ``shall be''; and
                              (iii) by redesignating such clause as 
                          clause (iv); and
                      (C) by inserting after clause (ii) the following 
                  new clause:
                              ``(iii) each succeeding fiscal year before 
                          fiscal year 2015 shall be, subject to 
                          subparagraph (D), the DSH allotment for the 
                          State for the previous fiscal year increased by 
                          16 percent; and''; and
              (2) by adding at the end the following new subparagraphs:
                      ``(C) Additional states covered for fiscal year 
                  2010 and subsequent years.--In the case of a State not 
                  described in subparagraph (B) in which the total 
                  expenditures under the State plan (including Federal 
                  and State shares) for disproportionate share hospital 
                  adjustments under this section for fiscal year 2005, as 
                  reported to the Administrator of the Centers for 
                  Medicare & Medicaid Services as of August 31, 2008, is 
                  greater than 0 but less than 3 percent of the State's 
                  total amount of expenditures under the State plan for 
                  medical assistance during the fiscal year, the DSH 
                  allotment for the State with respect to--
                              ``(i) fiscal year 2010 and any succeeding 
                          fiscal year before fiscal year 2015 shall be, 
                          subject to subparagraph (D), the DSH allotment 
                          for the State for the previous fiscal year 
                          increased by 16 percent; and
                              ``(ii) any subsequent fiscal year shall be, 
                          subject to subparagraph (D), the DSH allotment 
                          for the State for the previous fiscal year 
                          subject to an increase for inflation as 
                          provided in paragraph (3)(A).
                      ``(D) Limitation on increases to amount available 
                  from dsh redistribution pool.--If the Secretary 
                  estimates for a fiscal year (beginning with fiscal year 
                  2010) that--
                              ``(i) the amount of additional expenditures 
                          in the fiscal year resulting from the 
                          application of an increase in DSH allotments 
                          under subparagraphs (B) and (C) beginning with 
                          fiscal year 2010 of 16 percent (instead of the 
                          application of an increase for inflation as 
                          provided in paragraph (3)(A)), exceeds
                              ``(ii) the amount available for obligation 
                          from the DSH redistribution pool under 
                          paragraph (7) for the fiscal year,
                  the Secretary shall reduce the increase in the DSH 
                  allotments otherwise provided under such subparagraphs 
                  for the fiscal year in a pro-rata manner so that the 
                  amount of additional expenditures in the fiscal year 
                  resulting from the application of such subparagraphs is 
                  equal to the amount described in clause (ii) for the 
                  fiscal year. A reduction in a DSH allotment for a State 
                  under this subparagraph shall not affect the 
                  computation of the DSH allotment for the State under 
                  subparagraph (B) or (C) for the subsequent fiscal 
                  year.''.
      (c) Demonstration Grants to Health Access Networks.--Such section 
  is further amended by adding at the end the following new subsection:
      ``(k) Demonstration Grants to Health Access Networks.--
              ``(1) In general.--From the amount of funds made available 
          under paragraph (6)(A) of this subsection from funds made 
          available under subsection (d)(7) for a fiscal year, the 
          Secretary shall award demonstration grants under this 
          subsection to health access networks for such fiscal year for 
          the purpose of improving access, quality, and continuity of 
          care for uninsured individuals through better coordination of 
          care by the network.
              ``(2) Health access network defined.--
                      ``(A) In general.--In this subsection, the term 
                  `health access network' means an entity representing a 
                  collection of safety net providers, including 
                  hospitals, community health centers, public health 
                  departments, physicians, safety net health plans, 
                  federally qualified health centers, or other recognized 
                  safety net providers, that--
                              ``(i) is organized for the purpose of 
                          restructuring and improving the access, 
                          quality, and continuity of care to the 
                          uninsured and underinsured; and
                              ``(ii) offers patients access to all levels 
                          of care, including primary, outpatient, 
                          specialty, certain ancillary services, and 
                          acute inpatient care, within a community or 
                          across a broad spectrum of providers across a 
                          service region or State.
                      ``(B) Inclusion of section 330 networks and 
                  plans.--Such term includes networks and plans that meet 
                  the requirements for funding under section 330(e)(1)(C) 
                  of the Public Health Service Act (42 U.S.C. 
                  254b(e)(1)(C)).
                      ``(C) Inclusion of integrated health care 
                  systems.--
                              ``(i) In general.--Such term also includes 
                          an integrated health care system (including a 
                          pediatric system).
                              ``(ii) Definition.--For purposes of this 
                          subparagraph, the term `integrated health care 
                          system (including a pediatric system)' means a 
                          health care provider that--
                                      ``(I) is organized to provide care 
                                  in a coordinated fashion; and
                                      ``(II) assures access to a full 
                                  range of primary, specialty, and 
                                  hospital care, to uninsured and under-
                                  insured individuals, as appropriate.
              ``(3) Application and plan requirement.--
                      ``(A) In general.--In order to be eligible for a 
                  grant under this subsection, a health access network 
                  shall--
                              ``(i) submit an application, in such form 
                          and manner as the Secretary shall specify;
                              ``(ii) submit with such application a plan 
                          that meets the requirements of subparagraph 
                          (B);
                              ``(iii) identify in such plan measurable 
                          performance targets for at least 3 of the goals 
                          described in subparagraph (B); and
                              ``(iv) agree that a portion of the payment 
                          of grant funds for patient care services after 
                          the first year for which such payment is made 
                          shall be contingent upon the health access 
                          network demonstrating success in achieving such 
                          targets.
                      ``(B) Plan requirements.--A health access network 
                  that desires a grant under this subsection shall submit 
                  a plan to the Secretary that details how the network 
                  intends through the grant--
                              ``(i) to manage costs associated with the 
                          provision of health care services to uninsured 
                          and underinsured individuals served by the 
                          network;
                              ``(ii) to improve access to, and the 
                          availability of, health care services provided 
                          to uninsured and underinsured individuals 
                          served by the network;
                              ``(iii) to enhance the quality and 
                          coordination of health care services provided 
                          to uninsured and underinsured individuals 
                          served by the network;
                              ``(iv) to improve the health status of 
                          uninsured and underinsured individuals served 
                          by the network; and
                              ``(v) to reduce health disparities in the 
                          population of uninsured and underinsured 
                          individuals served by the network.
                  Nothing in this paragraph shall be construed as 
                  requiring a health access network operating in a State 
                  to operate on a statewide basis or otherwise to serve 
                  all uninsured and underinsured individuals in area 
                  served.
                      ``(C) Authority to limit number of grants.--In 
                  awarding grants under this subsection, the Secretary 
                  may limit the grants in a manner so that each grantee 
                  is able to provide patient care services to the number 
                  of uninsured individuals specified by each network in 
                  its grant application.
              ``(4) Use of funds.--
                      ``(A) In general.--A health access network that 
                  receives funds under a grant under this subsection 
                  shall expend an amount equal to at least 90 percent of 
                  such funds for the provision of (or payment for) direct 
                  patient care services.
                      ``(B) Rule of construction regarding direct patient 
                  care services.--For purposes of subparagraph (A), the 
                  term `direct patient care services' means, with respect 
                  to a health access network, services, such as specialty 
                  medical care and diagnostic services, that are not 
                  available or are insufficiently available through the 
                  network's providers other than under a grant under this 
                  subsection.
                      ``(C) Preference for services through safety net 
                  providers.--In purchasing direct patient care services 
                  for uninsured and underinsured individuals under a 
                  grant under this subsection, health access networks 
                  shall, to the maximum extent feasible, endeavor to 
                  purchase such services from safety net providers.
              ``(5) Supplement, not supplant.--Funds paid to a health 
          access network under a grant under this subsection shall 
          supplement and not supplant, other Federal or State payments 
          that are made to the network to support the provision of health 
          care services to low-income or uninsured patients.
              ``(6) Funding.--
                      ``(A) Availability of funds from dsh redistribution 
                  pool.--To carry out this subsection there is hereby 
                  made available for each fiscal year (beginning with 
                  fiscal year 2010 and ending with fiscal year 2014) and 
                  appropriated from the DSH redistribution pool 
                  established under subsection (d)(7), an amount equal 
                  to--
                              ``(i) the amount available for obligation 
                          from such pool in such fiscal year, reduced by
                              ``(ii) the Secretary's estimate of the 
                          aggregate increase in Federal financial 
                          participation under this title for the fiscal 
                          year that will be attributable to the 
                          amendments made by section 2(b) of the 
                          Strengthening the Health Care Safety Net Act of 
                          2009.
                      ``(B) Treatment of grant funds.--Payments to a 
                  health access network under a grant under this 
                  subsection shall not be treated as a disproportionate 
                  share hospital payment adjustments under this section 
                  and shall not be counted against the DSH allotment for 
                  any State.
                      ``(C) No state matching required.--Nothing in this 
                  subsection shall be construed as requiring a State to 
                  provide for any State matching funds to receive funds 
                  under this subsection.
                      ``(D) Availability.--The amount of any grant to a 
                  health access network under this subsection shall 
                  remain available for expenditure under the grant 
                  through the end of the third fiscal year after the 
                  fiscal year in which the grant is made.''.
      (d) Conforming Date of Application of DSH Hospital Requirement to 
  Availability of Funding for Low DSH States.--Subsection (d)(2)(A)(ii) 
  of such section is amended by inserting before the period at the end 
  the following: ``(or, in the case of a low DSH State described in 
  subparagraph (B) or (C) of subsection (f)(5), the date of the enactment 
  of the Strengthening the Safety Net Act of 2009)''.
      (e) Reporting Using Unified Reporting Document.--Not later than 60 
  days after the date of the enactment of this Act, the Secretary of 
  Health and Human Services shall develop a unified reporting document 
  for all disproportionate share hospital (DSH) allocations and 
  expenditures under section 1923 of the Social Security Act. Beginning 
  in fiscal year 2010 each State receiving a DSH allocation under such 
  section shall be required by the Secretary to report all expenditures 
  against the allocation using such unified reporting document. This 
  requirement shall apply to States regardless of whether the DSH 
  expenditures occur through a waiver.
      (f) Effective Date.--The amendments made by this section shall 
  apply beginning with fiscal year 2010.
target: Strengthening the Health Care Safety Net Act of 2009 - Amends title XIX (Medicaid) of the Social Security Act to establish a disproportionate share hospital (DSH) redistribution pool from unexpended Medicaid DSH allotments to fund an increase in allotments for low DSH states.
  
  Directs the Secretary of Health and Human Services to award demonstration grants to health access networks to improve access, quality, and continuity of care for uninsured individuals through better coordination of care by such networks.
feat_title: To amend title XIX of the Social Security Act to provide for a DSH redistribution pool from unexpended Medicaid DSH allotments in order to increase Medicaid DSH allotments for low DSH States and to provide grants for health access networks serving the uninsured.