Sec. 206. Specialized Medicare Advantage plans for special needs individuals
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Section 1859(f)(1) of the Social Security Act ( 42 U.S.C. 1395w–28(f)(1) ) is amended— by striking and inserting “ enrollment .—In the case enrollment .— Subject to subparagraphs
(B)and (C), in the case ; in subparagraph (A), as added by paragraph (1), by striking and for periods before January 1, 2016 ; and by adding at the end the following new subparagraphs: Subparagraph
(A)shall only apply to a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(ii) for periods before January 1, 2021. Subparagraph
(A)shall only apply to a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(iii) for periods before January 1, 2018. . Section 1859(f) of the Social Security Act ( 42 U.S.C. 1395w–28(f) ) is amended— in paragraph (3), by adding at the end the following new subparagraph: The plan meets the requirements applicable under paragraph (8). ; and by adding at the end the following new paragraph: The Secretary, acting through the Federal Coordinated Health Care Office (Medicare-Medicaid Coordination Office) established under section 2602 of the Patient Protection and Affordable Care Act (in this paragraph referred to as the MMCO ), shall serve as a dedicated point of contact for States to address misalignments that arise with the integration of specialized MA plans for special needs individuals described in subsection (b)(6)(B)(ii) under this paragraph. Consistent with such role, the MMCO shall— establish a uniform process for disseminating to State Medicaid agencies information under this title impacting contracts between such agencies and such plans under this subsection; and establish basic resources for States interested in exploring such plans as a platform for integration. Not later than April 1, 2015, the Secretary shall establish procedures unifying the grievances and appeals procedures under sections 1852(f), 1852(g), 1902(a)(3), and 1902(a)(5) for items and services provided by specialized MA plans for special needs individuals described in subsection (b)(6)(B)(ii) under this title and title XIX. The Secretary shall solicit comment in developing such procedures from States, plans, beneficiary representatives, and other relevant stakeholders. The procedures established under clause
(i)shall— adopt the most protective provisions for the enrollee under current law, including continuation of benefits under title XIX pending appeal if an appeal is filed in a timely manner; take into account differences in State plans under title XIX; be easily navigable by an enrollee; and include the elements described in clause (iii). The following elements are described in this clause: Single notification of all applicable grievances and appeal rights under this title and title XIX. Notices written in plain language and available in a language and format that is accessible to the enrollee. Unified timeframes for internal and external grievances and appeals processes, such as an individual's filing of a grievance or appeal, a plan’s acknowledgment and resolution of a grievance or appeal, and notification of decisions with respect to a grievance or appeal. Guidelines to allow the plan to process, track, and resolve grievances and appeals, to ensure beneficiaries are notified on a timely basis of decisions that are made throughout the grievance or appeals process and are able to easily determine the status of a grievance or appeal. For 2016 and subsequent years, the contract of a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(ii) with a State Medicaid agency under this subsection shall require the use of unified grievances and appeals procedures as described in subparagraph (B). The Secretary shall consider applying the unified grievances and appeals process described in subparagraph
(B)to specialized MA plans for special needs individuals described in subsection (b)(6)(B)(i) and subsection (b)(6)(B)(iii) that have a substantial portion of enrollees who are dually eligible for benefits under this title and title XIX and are at risk for full benefits under title XIX. Subject to the succeeding provisions of this subparagraph, for 2018 and subsequent years, a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(ii) shall— integrate all benefits under this title and title XIX; and meet the requirements of a fully integrated plan described in section 1853(a)(1)(B)(iv)(II) (other than the requirement that the plan have similar average levels of frailty, as determined by the Secretary, as the PACE program), including with respect to long-term care services or behavioral health services to the extent State law permits capitation of those services under such plan. For each of 2018 and 2019, if the Secretary determines that a plan has failed to meet the requirement described in clause (i), the Secretary shall impose one of the following on the plan: A reduction in payment to the plan under this part in an amount at least equal to the portion of the monthly rebate computed under section 1854(b)(1)(C)(i) for the plan and year that would otherwise be kept by the plan after application of the beneficiary rebate rule under section 1854(b)(1)(C). Closing enrollment in the plan. Sanctioning the plan in accordance with section 1857(g). Other reasonable action (other than the sanction described in clause (iii)) the Secretary determines appropriate. For 2020 and subsequent years, if the Secretary determines that a plan has failed to meet the requirement described in clause (i), the plan shall be deemed to no longer meet the definition of a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(ii). This subparagraph shall not apply to a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(ii) that only enrolls individuals for whom the only medical assistance to which the individuals are entitled under the State plan is medicare cost sharing described in section 1905(p)(3)(A)(ii). . Section 2602(d) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 1315b(d) ) is amended by adding at the end the following new paragraph: To act as a designated contact for States under subsection (f)(8)(A) of section 1859 of the Social Security Act ( 42 U.S.C. 1395w–28 ) with respect to the integration of specialized MA plans for special needs individuals described in subsection (b)(6)(B)(ii) of such section. . Section 1859(f)(5) of the Social Security Act ( 42 U.S.C. 1395w–28(f)(5) ) is amended— by striking and inserting “ all SNPs .—The requirements all SNPs .— Subject to subparagraph (B), the requirements ; by redesignating subparagraphs
(A)and
(B)as clauses
(i)and (ii), respectively, and indenting appropriately; in clause (ii), as redesignated by paragraph (2), by redesignating clauses
(i)through
(iii)as subclauses
(I)through (III), respectively, and indenting appropriately; and by adding at the end the following new subparagraph: For 2016 and subsequent years, in the case of a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(iii), the requirements described in this paragraph include the following: The interdisciplinary team under subparagraph (A)(ii)(III) includes a team of providers with demonstrated expertise, including training in an applicable specialty, in treating individuals similar to the targeted population of the plan. Requirements developed by the Secretary to provide face-to-face encounters with individuals enrolled in the plan not less frequently than on an annual basis. As part of the model of care under clause
(i)of subparagraph (A), the results of the initial assessment and annual reassessment under clause (ii)(I) of such subparagraph of each individual enrolled in the plan are addressed in the individual’s individualized care plan under clause (ii)(II) of such subparagraph. As part of the annual evaluation and approval of such model of care, the Secretary shall take into account whether the plan fulfilled the previous year’s goals (as required under the model of care). The Secretary shall establish a minimum benchmark for each element of the model of care of a plan. The Secretary shall only approve a plan's model of care under this paragraph if each element of the model of care meets the minimum benchmark applicable under the preceding sentence. . The Comptroller General of the United States shall conduct a study on how the Secretary of Health and Human Services could change the quality measurement system under the Medicare Advantage program under part C of title XVIII of the Social Security Act ( 42 U.S.C. 1395w–21 et seq. ) to allow an accurate comparison of the quality of care provided by specialized MA plans for special needs individuals (as defined in section 1859(b)(6) of such Act (42 U.S.C. 1395w–28(b)(6)), both for individual plans and such plans overall, compared to the quality of care delivered by the original Medicare fee-for-service program under parts A and B of such title and other Medicare Advantage plans under such part C across similar populations. Not later than July 1, 2016, the Comptroller General shall submit to Congress a report containing the results of the study under paragraph (1), together with recommendations for such legislation and administrative action as the Comptroller General determines appropriate. 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 paragraphs: Subject to subparagraph (B), beginning in plan year 2016, in the case of a specialized MA plan for special needs individuals, the Secretary shall increase the emphasis on the plan’s improvement or decline in performance when determining the star rating of the plan under this subsection for the year as follows: For plan year 2016, at least 10 percent, but not more than 12 percent, of the total star rating of the plan shall be based on improvement or decline in performance. For plan year 2017 and subsequent plan years, at least 12 percent, but not more than 15 percent, of the total star rating of the plan shall be based on improvement or decline in performance. Improvement or decline in performance under this subparagraph shall be measured based on net change in the individual star rating measures of the plan, with appropriate weight given to specific individual star ratings measures, such as readmission rates, as determined by the Secretary. The Secretary shall make an appropriate adjustment to the improvement rating of a plan under this subparagraph if the plan has achieved a 4.5-star rating or the highest rating possible overall or for an individual measure in order to ensure that the plan is not punished in cases where it is not possible to improve. Subparagraph
(A)shall not apply, with respect to a year, to a specialized MA plan for special needs individuals that has a rating that is less than two-and-one-half stars. The Secretary may require reporting for and apply under this subsection quality measures at the plan level for specialized MA plan for special needs individuals instead of at the contract level. The Secretary shall take into consideration the minimum number of enrollees in a specialized MA plan for special needs individuals in order to determine if a statistically significant or valid measurement of quality at the plan level is possible under clause (i). If the Secretary applies quality measurement at the plan level under this subparagraph— such quality measurement shall include Medicare Health Outcomes Survey (HOS), Healthcare Effectiveness Data and Information Set (HEDIS), and Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures; and payment and other administrative actions linked to quality measurement (including the 5-star rating system under this subsection) shall be applied at the plan level in accordance with this subparagraph. The Secretary shall determine the feasibility of requiring reporting for and applying under this subsection quality measures at the plan level for all MA plans under this part. After making a determination under subparagraph (A), the Secretary shall consider requiring such reporting and applying such quality measures at the plan level as described in such subparagraph. .
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- 42 USC 1395w–28(f)(1)
- 42 USC 1395w–28(f)
- 42 USC 1395w–28
- 42 USC 1395w–28(f)(5)
- 42 USC 1395w–21
- 42 USC 1395w–28(b)(6)
- 42 USC 1395w–23(o)
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Sec. 206
Specialized Medicare Advantage plans for special needs individuals
Cite42 USC 1395w–28(f)(1)
Cite42 USC 1395w–28(f)
Cite42 USC 1395w–28
Cite42 USC 1395w–28(f)(5)
Cite42 USC 1395w–21
Cites 8 · showing 6Cited by 0 across 0 sources