Sec. 3. Improvements to Medicare Advantage 5–Star Quality Rating System for plans with predominately Dual Eligible enrollees

587 words·~3 min read·/bill/113/hr/4484/ih/section-3

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

Section 1853(o) of the Social Security Act ( 42 U.S.C. 1395w–23(o) ) is amended by adding at the end the following new paragraph: In implementing this subsection, the Secretary shall take such steps as are necessary to ensure that the quality rating for a plan— does not disadvantage such a plan that enrolls— full-benefit dual eligible individual (as defined in section 1935(c)(6)); qualified Medicare beneficiaries (as defined in section 1905(p)(1)); or individuals with complex health care needs, such as individuals with multiple conditions or individuals who require chronic care or institutional care; and accounts for differences in socioeconomic and demographic characteristics of enrollees of such a plan that result in significant variation in health outcomes.

The steps described in subparagraph

(A)shall include at least the following: Comparing specialized MA plans for special needs individuals (as defined in section 1859(b)(6)) for special needs individuals who are described in subparagraph (B)(ii) of such section only against other plans with the same types of enrollment. Developing a methodology specific to specialized MA plans for special needs individuals (as defined in section 1859(b)(6)) for special needs individuals who are described in subparagraph (B)(ii) of such section for determining a quality rating under this subsection for such plans. Developing appropriate case mix adjustment to Healthcare Effectiveness Data and Information Set (HEDIS) and Health Outcomes Survey

(HOS)measures for specialized MA plans for special needs individuals (as defined in section 1859(b)(6)) for special needs individuals who are described in subparagraph (B)(ii) of such section that account for factors beyond the control of the health system, such as the management of conditions. Identifying and implementing those quality measures that are appropriate for evaluating the performance of specialized MA plans for special needs individuals (as defined in section 1859(b)(6)) for special needs individuals who are described in subparagraph (B)(ii) of such section. Eliminating duplicative or substantially similar measures applied under this title or title XIX with respect to specialized MA plans. . Section 1853(o) of the Social Security Act ( 42 U.S.C. 1395w–23(o) ), as amended by subsection (a), is further amended by adding at the end the following new paragraph: In implementing this subsection during the period beginning on the date of the enactment of this paragraph and ending one year after the date on which the Secretary has taken such steps as are required under paragraph (6), the Secretary may increase the quality rating that a specialized MA plans for special needs individuals (as defined in section 1859(b)(6)) for special needs individuals who are described in subparagraph (B)(ii) of such section would otherwise receive under this subsection for a year by 0.5 stars if the plan demonstrates to the satisfaction of the Secretary that the quality rating the plan would have otherwise received is predominately attributable to socio-economic, demographic, or pre-existing complex health care needs of the population enrolled in such plan with respect to such year instead of the performance of the plan with respect to such year. . Not later than one year after the date on which the Secretary of Health and Human Services has taken such steps as are required under paragraph

(6)of section 1853(o) of the Social Security Act ( 42 U.S.C. 1395w–23(o) ), as added by subsection (a), and annually thereafter for the following four years, the Comptroller General of the United States shall submit to Congress a report that includes a comprehensive review of the effectiveness of, and recommendations to improve, such steps so taken for improving health outcomes, cost controls, and beneficiary satisfaction.

Connections1 off-index

1 reference not yet in our index

42 USC 1395w–23(o)

Citation graph

cites case law

Sec. 3

Improvements to Medicare Advantage 5–Star Quality Rating System for plans with predominately Dual Eligible enrollees

Cite42 USC 1395w–23(o)

Cites 1Cited by 0 across 0 sources