Sec. 101. State implementation
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/bill/118/s/3950/is/section-101·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
The Social Security Act is amended by adding at the end the following new title: In this title: The term Director means the Director of the Federal Coordinated Health Care Office of the Centers for Medicare & Medicaid Services. The term dual eligible individual means an individual who is entitled to, or enrolled for, benefits under part A of title XVIII, or enrolled for benefits under part B of title XVIII, and is eligible for medical assistance for full benefits under title XIX under section 1902(a)(10)(A) or 1902(a)(10)(C), by reason of section 1902(f), or under any other category of eligibility for medical assistance for full benefits under such title, as determined by the Secretary.
The term integrated care plan means an entity or organization that is selected by a State under section 2202(a) to provide fully integrated care for a dual eligible individual in accordance with the requirements of this title and related Federal and State regulations. Such term shall not include a PACE program (as defined in sections 1894(a)(2) and 1934(a)(2)). Not later than 1 year after the date on which the Director first publishes the range of program models for providing integrated care for dual eligible individuals required by section 2208(b)(1), each State shall select from such published models, and shall work with the Director to implement such models in the State in accordance with the requirements of this title a program model to provide comprehensive, fully integrated care for dual eligible individuals.
Each State shall work with the Director to implement the models selected by the State under subsection
(a)so that, to the extent practicable, the State may begin to enroll dual eligible individuals in the program models selected during the 4th year that occurs after the year in which the State makes such selection and, by the end of such 4th year, the models are fully implemented and operated in accordance with the requirements of this title and related Federal and State regulations. Nothing in this subsection shall prohibit a State from enrolling dual eligible individuals in such program models earlier than the end of such 4th year if the models are fully implemented and operated in accordance with the requirements of this title and related Federal and State regulations. The Director may modify the timing required by subsections
(a)and
(b)as appropriate to account for the particular needs or circumstances of a State. A State shall establish an implementation council in accordance with such requirements as the Secretary shall establish. The members of the council shall include representatives of a wide range of stakeholders relevant to the provision of integrated care for dual eligible individuals. The implementation council shall provide advice and counsel to the State with respect to the implementation of the models selected by the State under subsection (a). A State shall automatically enroll a dual eligible individual with an integrated care plan under a contract with the State provided that the State notifies the individual that the individual will be enrolled with such plan at least 60 days (90 days, in the case of the first time the individual is provided such notice) prior to the effective date of such enrollment. Notice provided to a dual eligible individual under this paragraph shall include the following: The name and contact information for the integrated care plan. The date on which the enrollment takes effect and, if applicable, whether the State has elected the option for a 12-month continuous eligibility period under paragraph (4). A summary of the benefits to be provided by the plan. Information regarding the provider network of the plan. Information regarding how the dual eligible individual may elect to opt-out of enrollment with the plan within 60 days (90 days, in the case of the first time the individual is provided such notice). A State shall not passively enroll a dual eligible individual in an integrated care plan unless the individual's primary care physician is an in-network, participating provider for the plan. A State shall offer a dual eligible individual the option to enroll in an integrated care plan without regard to meeting the requirement of paragraph (2). A State may elect for a dual eligible individual who is determined to be eligible for medical assistance under the State plan under title XIX or under a waiver of such plan and who is enrolled with an integrated care plan under a contract with the State to remain eligible for medical assistance and enrolled with such plan until the earlier of— the end of the 12-month period beginning on the date of such determination; or the date that such individual ceases to be a resident of such State. A State shall permit a dual eligible individual to change enrollment in an integrated care plan— on a monthly basis if the individual is electing to enroll in another integrated care plan; during the general enrollment period applicable under section 1837, if the individual is electing to disenroll from an integrated care plan and not enroll in another integrated care plan; and during the 60-day period beginning on the date the individual receives notice from the State that the individual has been determined to no longer be eligible for treatment as a dual eligible individual, if the individual is no longer eligible to enroll in an integrated care plan. A care coordinator for an integrated care plan may contact a dual eligible individual who has been passively enrolled in the plan prior to the effective date of the enrollment. A contract between a State, an offeror of an integrated care plan, and the Director shall not be considered to meet the requirements of this title unless— in the case of a dual eligible individual enrolled with the plan who changes enrollment to another integrated care plan for which the individual's primary care provider is not a participating, in-network provider, or who disenrolls from the plan and does not enroll in another integrated care plan, the offeror of the plan will, during the 30-day period that begins on the date on which the individual's disenrollment from the plan takes effect— allow the individual to continue to be treated by the individual's primary care provider; and cover any treatment provided to the individual by such provider as if the individual were still enrolled with the plan; the offeror of the plan administers a health risk assessment to each dual eligible individual enrolled with the plan within 90 days of the effective date of the individual's enrollment in accordance with the requirements of subsection
(c)and shall affirm that there are no changes in the information provided at least every 12 months thereafter; the offeror of the plan provides benefits for a dual eligible individual under a comprehensive care plan in accordance with the requirements of subsections
(d)and (f); the offeror of the plan assigns a care coordinator to each dual eligible individual enrolled with the plan in accordance with the requirements of subsection
(e)and notifies such individual in a timely and accessible manner when a new care coordinator is assigned; and the contract provides for payment to the offeror for benefits provided to dual eligible individuals enrolled with the plan using a financing structure that satisfies the requirements of section 2208(c). The disenrollment of a dual eligible individual from an integrated care plan who was passively enrolled in the plan under section 2203 shall be disregarded for purposes of any data used for rating of the plan for such plan year. An offeror of an integrated care plan shall administer a health risk assessment to each dual eligible individual enrolled with the plan using the standardized health risk assessment questionnaire developed by the Director under section 2208(b)(3) and in accordance with such additional requirements as the State may establish. An integrated care plan may rely on the results of a previously administered health risk assessment of a dual eligible individual if such results are accessible to the plan and the dual eligible individual affirms that there are no changes in the information previously provided. An integrated care plan shall provide benefits under the plan in accordance with requirements established by the Director and the State, and which shall include the following: Clinical health services. Behavioral health services. Long-term services and supports. The Director may permit a State and integrated care plan to separately contract for the provision of services or supports required under paragraph
(1)but only if the State demonstrates to the Director that— the level of care provided for a dual eligible individual under the separate contract with respect to such services or supports is not less than the level of care that would be provided without the exception; and the dual eligible individual will not be subject to any unreasonable administrative requirements to access the services or supports, as determined by the Secretary. An integrated care plan may provide customized, supplemental benefits to a dual eligible individual enrolled with the plan, including supplemental health care benefits described in section 1852(a)(3), other primarily health-related benefits offered by Medicare Advantage plans and benefits permitted by the Secretary to be offered as Special Supplemental Benefits for the Chronically Ill (SSBCI), without regard to whether the dual eligible individual has a requisite condition or diagnosis, so long as the plan demonstrates to the Director and the State that the offering of such benefits has a positive impact on patient health. A care coordinator assigned to a dual eligible individual enrolled in an integrated care plan shall— serve as the single point of contact between the individual and the plan; be responsible for helping the individual and the individual's caregivers and family make benefit and service decisions; design a beneficiary-focused comprehensive care plan for the individual that meets the requirements of subsection (f); and connect and coordinate acute, subacute, social, primary, and specialty care for the individual and the provision of long-term services and supports for the individual. The comprehensive care plan for a dual eligible individual enrolled in an integrated care plan shall be— designed to address the totality of the individual's medical, functional, behavioral, social, and caregiving needs and goals, and to the extent practicable, to apply to multiple years; be based on the health risk assessment of the individual required by subsection (c); be implemented by an interdisciplinary care team that includes relevant specialists to ensure access to all aspects of care that are required for the individual; be approved by the individual (or by an authorized caregiver or guardian) prior to implementation; and be reviewed at least annually and within 30 days of a major health event, such as hospitalization or an emergency room visit. An integrated care plan shall provide a dual eligible individual enrolled in the plan with a minimum 90-day transition period for any active course of treatment when the individual has enrolled in an integrated care plan after starting a course of treatment, even if the service is furnished by an out-of-network provider. This includes enrollees new to a plan and enrollees new to Medicare. The integrated care plan must not disrupt or require reauthorization for an active course of treatment for new plan enrollees for a period of at least 90 days. An integrated care plan may provide for a longer transition period than 90 days at the option of the plan. For purposes of this subsection the following definitions apply: The term course of treatment means as a prescribed order or ordered course of treatment for a specific individual with a specific condition is outlined and decided upon ahead of time with the patient and provider. A course of treatment may but is not required to be part of a treatment plan. The term active course of treatment means a course of treatment in which a patient is actively seeing the provider and following the course of treatment. A contract between a State, an integrated care plan, and the Director under this title may apply a frailty adjustment factor with respect to dual eligible individuals enrolled in the plan in the same manner as is permitted under section 1853(a)(1)(B)(iv), but without regard to requiring the plan to demonstrate enrollment of a high concentration of frail individuals. Each State, and each integrated care plan with a contract with a State under this title, annually shall collect and report information and data to the Director in accordance with the requirements of this section and guidance and regulations issued under section 2208(b)(7) that includes data collected by such States and plans with respect to a plan year regarding age, gender, disability (including specific disability statuses required to be reported by the Director), smoking status, mobility, employment status, education, race and ethnicity, and ZIP Code, of dual eligible individuals enrolled in the plan. A State may require an integrated care plan with a contract with the State under this title to collect and report to the State additional data and information. Each State shall establish and operate an Office of the Ombudsman for Integrated Care Plans for Dual Eligible Individuals (in this section referred to as the Office ). The Office may operate independently of, or in connection with, the State agency responsible for administering the Medicaid program under title XIX. The Office shall be headed by an individual, to be known as the State Integrated Care for Dual Eligible Individuals Ombudsman, who shall be selected from among individuals with expertise in and experience with integrated care models for dual eligible individuals, the Medicare program under title XVIII, and the Medicaid program under title XIX. The Ombudsman shall be responsible for the management, including the fiscal management, of the Office. The primary responsibility of the Office shall be to provide support and feedback for dual eligible individuals enrolled in integrated care plans under this title and caregivers or family members of such individuals who need assistance. The Office shall have a minimum staffing ratio of 1 employee for every 2,000 dual eligible individuals in the State. During the first 2 years in which a State operates the Office, the Secretary shall pay to the State for each such year for expenditures necessary to establish and operate the Office, from amounts appropriated under section 2207(c), an amount equal to $50,000,000 multiplied by the ratio of— the number of dual eligible individuals in the State; to the number of dual eligible individuals in all States. Beginning with the 3rd year of the Office's operation, expenditures necessary to operate the Office shall be considered, for purposes of section 1903(a)(7), to be necessary for the proper and efficient administration of the State plan under title XIX and reimbursed to a State in accordance with that section. Amounts expended by a State for payments to an integrated care plan for the Medicaid component of the capitation payment described in section 2208(c) shall be treated as medical assistance for which payment is made under section 1903(a). Nothing in this title shall prevent a State from providing medical assistance under title XIX to a dual eligible individual for services for which coverage is not provided under the integrated care plan with which the individual is enrolled or from receiving payment under section 1903(a) with respect to expenditures attributable to providing such medical assistance. From the sums appropriated under subsection (c), the Secretary shall pay to each State for each calendar year (beginning January 1 of the first full calendar year in which this title is implemented in the State), an amount equal to the sum of the following: The shared savings payment applicable to the State and the year, as determined in accordance with section 2208(b)(6)(D). For administrative expenses to carry out this title, other than section 2205, an amount that bears the same proportion to $50,000,000 as the number of dual eligible individuals in the State bears to the number of dual eligible individuals in all States, as determined by the Secretary. For data collection and reporting expenses under section 2205, an amount that bears the same proportion to $50,000,000 as the number of dual eligible individuals in the State bears to the number of dual eligible individuals in all States, as determined by the Secretary. There is appropriated, out of any money in the Treasury not otherwise appropriated, such amounts as may be required to provide payments to States under this section, for each calendar year (beginning January 1 of the first full calendar year in which this title is implemented in any State), reduced by any amounts made available from the Medicare trust funds under subsection (d). There shall be made available for carrying out this title, and the Secretary shall provide for the transfer from the Federal Hospital Insurance Trust Fund (under section 1817) and from the Federal Supplementary Medical Insurance Trust Fund (under section 1841) (and from the Medicare Prescription Drug Account (under section 1860D–16) within such Trust Fund) such amounts as the Secretary determines appropriate, taking into account the reductions in payments from such Trust Funds and Account that are attributable to the enrollment of dual eligible individuals in integrated care plans under this title, for each calendar year (beginning January 1 of the first full calendar year in which this title is implemented in any State). Payments provided under this section to a State are in addition to payments provided under section 2208. The Director shall have primary authority for implementing and carrying out responsibilities of the Federal Government under this title. In carrying out this title, the Director shall have the following responsibilities: Subject to subsection (c), to develop and, not later than 180 days after the date of enactment of this paragraph, publish, a range of program models (including but not limited to Medicare-Medicaid plans, accountable care organizations, and dual eligible special needs plans) for providing integrated care for dual eligible individuals from which States shall select to develop and administer integrated care programs for dual eligible individuals in accordance with this title. To develop and, not later than 1 year after the date of enactment of this paragraph, publish a unified administrative appeals process for State integrated care programs for dual eligible individuals under this title to use in lieu of other administrative appeals processes involving Medicare and Medicaid. To develop a standardized health risk assessment questionnaire for dual eligible individuals that collects standard demographic data and information relating to food insecurity, access to transportation, internet access, utility difficulty, interpersonal safety, and housing instability. To establish standards for reporting by States and integrated care plans under title XXII information relating to the offering and provision of supplemental benefits under section 2204(d)(3), including data relating to enrollment, utilization, and outcomes, to annually publish a report regarding the offering and utilization of such benefits, and to study and report to the Secretary on whether to cap the actuarial dollar value allowed for such benefits under titles XVIII, XIX, and XXII. To— establish a formula based on patient chronic conditions, activities of daily living standards, geographic, and such other factors as the Director determines are necessary for States and integrated care plans to use to determine the maximum staffing ratio for assigning care coordinators to dual eligible individuals enrolled with integrated care plans under this title; and develop online training and professional development materials relating to the statutory and administrative requirements for providing integrated care for care coordinators for dual eligible individuals enrolled with integrated care plans under this title. To— develop and issue guidance and regulations related to the alignment of policy and operational process under the Medicare program under title XVIII and the Medicaid program under title XIX, necessary for implementation, administration, and oversight of integrated care plans for dual eligible individuals under this title; and administer and provide oversight of integrated care plans for dual eligible individuals under this title, including with respect to— the development and application of an integrated medical loss ratio for such plans, in lieu of compliance with separate medical loss ratio requirements under titles XVIII and XIX; the establishment and application of network adequacy standards for such plans that— apply only with respect to such plans; allow the Director to waive compliance with such standards for integrated care plans that cannot meet the requirements in certain areas, but must operate statewide to meet a State's selective contracting requirements; and allow the Director to consider flexibilities to support innovative models that do not rely on traditional time and distance standards, such as the use of telehealth; and the establishment and application of targeted, streamlined model-of-care requirements for such plans that include an integrated audit process, with shared responsibilities between the Director and States, and that requires the Director to share the results of such audits with State Medicaid programs. To the extent practicable, such requirements also shall be designed to be integrated with model of care requirements applicable to Medicaid managed care organizations; develop contract management teams, consisting of representatives from integrated care plans with contracts with States under this title, State agencies responsible for administering the State plan under title XIX or a waiver of such plan, and the Federal Coordinated Health Care Office, to oversee compliance and performance of integrated care plans under this title; develop and implement a shared savings payment for States to receive a share of savings to Federal spending in the Medicaid program under title XIX as a result of the implementation and operation of integrated care plans for dual eligible individuals under this title; and develop a new star rating system for integrated care plans for dual eligible individuals under this title that rates the performance of each plan type separately, with State-specific measures and tied to single contracts, instead of the collective performance of all of the offeror’s plans under contract with the State under that title, that include measures which directly reflect enrollee satisfaction, and that awards higher star ratings to plans based on their ability to retain enrollees. To establish data and information collection and reporting requirements for States and integrated care plans under section 2205, including required reporting of specific disability statuses and safeguards to protect patient privacy, and to annually publish not later than April 30 of any year, the data and information collected and reported to the Director under such section for the preceding year. To develop quality measures for the population of dual eligible individuals that are designed to be uniformly implemented across all platforms and health benefits plans that provide integrated care for such individuals under this title. Such measures shall include measures relating to patient satisfaction, quality of life, rates of emergency room use, institutionalization for long-term care, hospital admission and readmission rates, and medication errors. The Director shall regularly review and update such measures as necessary and may develop outcome-based quality measures for determining payments to health benefits plans that provide integrated care for dual eligible individuals under this title. To not less than annually publish best practices under this title for States and integrated care plans, including with respect to improving outreach to beneficiaries, improving comprehensive care plans and health risk assessments for dual eligible individuals, and developing a workforce that provides culturally intelligent and respectful care. To develop training programs related to integrated care plans under this title for— providers of care, services, and supports under such plans with respect to issues such as coordination of benefits, data sharing barriers, quality ratings, and provider incentives; State employees to increase Medicare expertise at State agencies responsible for administering Medicaid plans and waivers and contracting with integrated care plans under this title; and insurance brokers and local counselors who help enroll individuals in Medicare, Medicaid, and integrated care plans under this title. Each program model that is designed by the Director under subsection (b)(1) shall provide that payments shall be made to an integrated care plan for benefits provided under a contract under this title using a capitated payment structure under which, for each month that the integrated care plan provides such benefits— the State shall pay the integrated care plan an amount equal to the Medicaid component payment determined for the month; and the Secretary shall pay the integrated care plan an amount equal to the Medicare component payment determined for the month. For purposes of paragraph (1), the Medicaid component payment payable to an integrated care plan for a month shall be an amount equal to the sum of the products of— for each category of beneficiary, the Medicaid capitation rate applicable to the category of beneficiary (as determined by the Secretary and specified in the contract between the State, the Secretary, and the offeror of the plan); and the number of beneficiaries in such category enrolled with the plan for the month. For purposes of paragraph (1), the Medicare component payment payable to an integrated care plan for a month shall be an amount equal to the sum of the products of— for each category of beneficiary, the Medicare capitation rate applicable to the category of beneficiary (as determined by the Secretary and specified in the contract between the State, the Secretary, and the offeror of the plan); and the number of beneficiaries in such category enrolled with the plan for the month. The Medicaid and Medicare capitation rates for each category of beneficiary specified in a contract between a State, the Secretary, and the offeror of an integrated care plan shall be determined using the risk adjustment payment model developed under subsection (d). Not later than 1 year after the date of enactment of this subsection, the Director shall enter into a contract or other agreement with an independent entity to develop a risk adjustment payment model for dual eligible individuals that— is designed to be uniformly implemented across all platforms and health benefits plans that provide integrated care for such individuals under title XXII of the Social Security Act; includes factors based on the health status of such individuals; and allows plan payments to be made and updated on a monthly basis. Not later than 180 days after the date of enactment of this subsection, the Director, in consultation with State Medicaid programs, shall develop outreach plans for such programs to use to contact providers of health benefits, services, or supports for dual eligible individuals and provide information and education regarding the State Integrated Care Programs for Dual Eligible Individuals established under this title, how such program will operate in the State where such providers offer health benefits, services or supports for such individuals, and the impact of such program on such providers. Not later than 180 days after the date of enactment of this subsection, the Director, in consultation with the Administrator of the Centers for Medicare & Medicaid Services and State Medicaid programs, shall establish a plan for collecting data on quality measures from health benefits plans that provide integrated care for dual eligible individuals under Medicare or Medicaid. Such data shall include, at a minimum, data relating to provider network availability in both Medicare and Medicaid, providers in-network who are accepting new Medicare and Medicaid patients, spending on supplemental benefits, and claims denials. The Director may— collect additional data and information relating to the quality of care provided for dual eligible individuals by health benefits plans that provide integrated care for such individuals under Medicare or Medicaid; and make the data and information collected in accordance with this paragraph publicly available. Not later than 180 days after the date of enactment of this subsection, the Director, in consultation with the Administrator of the Centers for Medicare & Medicaid Services and State Medicaid programs, shall develop an aligned program for offering Institutional Special Needs Plans under Medicaid that has 1 entity financially responsible for providing health benefits, services, and supports for dual eligible individuals. Not later than 180 days after the date of enactment of this subsection, the Director, in consultation with the Administrator of the Centers for Medicare & Medicaid Services, shall assess the adequacy of regulations and oversight of Institutional Special Needs Plan to determine whether new, or additional requirements should be established to improve the utilization, performance, and oversight of such plans and how such plans may be offered under State Integrated Care Programs for Dual Eligible Individuals established under this title. There are hereby appropriated, out of any funds in the Treasury not otherwise appropriated, for the first fiscal year that begins after the date of enactment of this title, and for each fiscal year thereafter, such sums as are necessary to carry out this title. In carrying out this title, the Director shall have direct-hire authority to the extent required to implement and administer this title on a timely basis. .