Sec. 50311. PROVIDING CONTINUED ACCESS TO MEDICARE ADVANTAGE SPECIAL NEEDS PLANS FOR VULNERABLE POPULATIONS
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## SEC. 50311 PROVIDING CONTINUED ACCESS TO MEDICARE ADVANTAGE SPECIAL NEEDS PLANS FOR VULNERABLE POPULATIONS ###
(a)Extension Section 1859(f)(1) of the Social Security Act (42 U.S.C. 1395w–28(f)(1)) is amended by striking “and for periods before January 1, 2019”. ###
(b)Increased Integration of Dual SNPs ####
(1)In general Section 1859(f) of the Social Security Act (42 U.S.C. 1395w–28(f)) is amended— #####
(A)in paragraph (3), by adding at the end the following new subparagraph: > > ##### “(F) > > The plan meets the requirements applicable under paragraph (8).” > ; and #####
(B)by adding at the end the following new paragraph: > > #### “(8) Increased integration of dual snps > > > ##### “(A) Designated contact > > The Secretary, acting through the Federal Coordinated Health Care Office established under section 2602 of Public Law 111–148, 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 and, consistent with such role, shall establish— > > > ###### “(i) > > 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 > > > ###### “(ii) > > basic resources for States interested in exploring such plans as a platform for integration, such as a model contract or other tools to achieve those goals. > > > ##### “(B) Unified grievances and appeals process > > > ###### “(i) In general > > Not later than April 1, 2020, the Secretary shall establish procedures, to the extent feasible as determined by the Secretary, unifying grievances and appeals procedures under sections 1852(f), 1852(g), 1902(a)(3), 1902(a)(5), and 1932(b)(4) 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. With respect to items and services described in the preceding sentence, procedures established under this clause shall apply in place of otherwise applicable grievances and appeals procedures. The Secretary shall solicit comment in developing such procedures from States, plans, beneficiaries and their representatives, and other relevant stakeholders. > > > ###### “(ii) Procedures > > The procedures established under clause
(i)shall be included in the plan contract under paragraph (3)(D) and shall— > > > ###### “(I) > > adopt the provisions for the enrollee that are most protective for the enrollee and, to the extent feasible as determined by the Secretary, are compatible with unified timeframes and consolidated access to external review under an integrated process; > > > ###### “(II) > > take into account differences in State plans under title XIX to the extent necessary; > > > ###### “(III) > > be easily navigable by an enrollee; and > > > ###### “(IV) > > include the elements described in clause (iii), as applicable. > > > ###### “(iii) Elements described > > Both unified appeals and unified grievance procedures shall include, as applicable, the following elements described in this clause: > > > ###### “(I) > > Single written notification of all applicable grievances and appeal rights under this title and title XIX. For purposes of this subparagraph, the Secretary may waive the requirements under section 1852(g)(1)(B) when the specialized MA plan covers items or services under this part or under title XIX. > > > ###### “(II) > > Single pathways for resolution of any grievance or appeal related to a particular item or service provided by specialized MA plans for special needs individuals described in subsection (b)(6)(B)(ii) under this title and title XIX. > > > ###### “(III) > > Notices written in plain language and available in a language and format that is accessible to the enrollee, including in non-English languages that are prevalent in the service area of the specialized MA plan. > > > ###### “(IV) > > Unified timeframes for 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. > > > ###### “(V) > > Requirements for how the plan must 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. > > > ###### “(iv) Continuation of benefits pending appeal > > The unified procedures under clause
(i)shall, with respect to all benefits under parts A and B and title XIX subject to appeal under such procedures, incorporate provisions under current law and implementing regulations that provide continuation of benefits pending appeal under this title and title XIX. > > > ##### “(C) Requirement for unified grievances and appeals > > For 2021 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 paragraph (3)(D) shall require the use of unified grievances and appeals procedures as described in subparagraph (B). > > > ##### “(D) Requirements for integration > > > ###### “(i) In general > > For 2021 and subsequent years, a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(ii) shall meet one or more of the following requirements, to the extent permitted under State law, for integration of benefits under this title and title XIX: > > > ###### “(I) > > The specialized MA plan must meet the requirements of contracting with the State Medicaid agency described in paragraph (3)(D) in addition to coordinating long-term services and supports or behavioral health services, or both, by meeting an additional minimum set of requirements determined by the Secretary through the Federal Coordinated Health Care Office established under section 2602 of the Patient Protection and Affordable Care Act based on input from stakeholders, such as notifying the State in a timely manner of hospitalizations, emergency room visits, and hospital or nursing home discharges of enrollees, assigning one primary care provider for each enrollee, or sharing data that would benefit the coordination of items and services under this title and the State plan under title XIX. Such minimum set of requirements must be included in the contract of the specialized MA plan with the State Medicaid agency under such paragraph. > > > ###### “(II) > > The specialized MA plan must 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), or enter into a capitated contract with the State Medicaid agency to provide long-term services and supports or behavioral health services, or both. > > > ###### “(III) > > In the case of a specialized MA plan that is offered by a parent organization that is also the parent organization of a Medicaid managed care organization providing long term services and supports or behavioral services under a contract under section 1903(m), the parent organization must assume clinical and financial responsibility for benefits provided under this title and title XIX with respect to any individual who is enrolled in both the specialized MA plan and the Medicaid managed care organization. > > > ###### “(ii) Suspension of enrollment for failure to meet requirements during initial period > > During the period of plan years 2021 through 2025, if the Secretary determines that a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(ii) has failed to comply with clause (i), the Secretary may provide for the application against the Medicare Advantage organization offering the plan of the remedy described in section 1857(g)(2)(B) in the same manner as the Secretary may apply such remedy, and in accordance with the same procedures as would apply, in the case of an MA organization determined by the Secretary to have engaged in conduct described in section 1857(g)(1). If the Secretary applies such remedy to a Medicare Advantage organization under the preceding sentence, the organization shall submit to the Secretary (at a time, and in a form and manner, specified by the Secretary) information describing how the plan will come into compliance with clause (i). > > > ##### “(E) Study and report to congress > > > ###### “(i) In general > > Not later than March 15, 2022, and, subject to clause (iii), biennially thereafter through 2032, the Medicare Payment Advisory Commission established under section 1805, in consultation with the Medicaid and CHIP Payment and Access Commission established under section 1900, shall conduct (and submit to the Secretary and the Committees on Ways and Means and Energy and Commerce of the House of Representatives and the Committee on Finance of the Senate a report on) a study to determine how specialized MA plans for special needs individuals described in subsection (b)(6)(B)(ii) perform among each other based on data from Healthcare Effectiveness Data and Information Set (HEDIS) quality measures, reported on the plan level, as required under section 1852(e)(3) (or such other measures or data sources that are available and appropriate, such as encounter data and Consumer Assessment of Healthcare Providers and Systems data, as specified by such Commissions as enabling an accurate evaluation under this subparagraph). Such study shall include, as feasible, the following comparison groups of specialized MA plans for special needs individuals described in subsection (b)(6)(B)(ii): > > > ###### “(I) > > A comparison group of such plans that are described in subparagraph (D)(i)(I). > > > ###### “(II) > > A comparison group of such plans that are described in subparagraph (D)(i)(II). > > > ###### “(III) > > A comparison group of such plans operating within the Financial Alignment Initiative demonstration for the period for which such plan is so operating and the demonstration is in effect, and, in the case that an integration option that is not with respect to specialized MA plans for special needs individuals is established after the conclusion of the demonstration involved. > > > ###### “(IV) > > A comparison group of such plans that are described in subparagraph (D)(i)(III). > > > ###### “(V) > > A comparison group of MA plans, as feasible, not described in a previous subclause of this clause, with respect to the performance of such plans for enrollees who are special needs individuals described in subsection (b)(6)(B)(ii). > > > ###### “(ii) Additional reports > > Beginning with 2033 and every five years thereafter, the Medicare Payment Advisory Commission, in consultation with the Medicaid and CHIP Payment and Access Commission, shall conduct a study described in clause (i).” > . ####
(2)Conforming amendment to responsibilities of federal coordinated health care office Section 2602(d) of Public Law 111–148 (42 U.S.C. 1315b(d)) is amended by adding at the end the following new paragraphs: > > #### “(6) > > 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. > > > #### “(7) > > To be responsible, subject to the final approval of the Secretary, for developing regulations and guidance related to the implementation of a unified grievance and appeals process as described in subparagraphs
(B)and
(C)of section 1859(f)(8) of the Social Security Act (42 U.S.C. 1395w–28(f)(8)). > > > #### “(8) > > To be responsible, subject to the final approval of the Secretary, for developing regulations and guidance related to the integration or alignment of policy and oversight under the Medicare program under title XVIII of such Act and the Medicaid program under title XIX of such Act regarding specialized MA plans for special needs individuals described in subsection (b)(6)(B)(ii) of such section 1859.” > . ###
(c)Improvements to Severe or Disabling Chronic Condition SNPs ####
(1)Care management requirements Section 1859(f)(5) of the Social Security Act (42 U.S.C. 1395w–28(f)(5)) is amended— #####
(A)by striking “ all snps.—The requirements ” and inserting > “all snps.— > > > ##### “(A) In general > > Subject to subparagraph (B), the requirements” > ; #####
(B)by redesignating subparagraphs
(A)and
(B)as clauses
(i)and (ii), respectively, and indenting appropriately; and #####
(C)in clause (ii), as redesignated by subparagraph (B), by redesignating clauses
(i)through
(iii)as subclauses
(I)through (III), respectively, and indenting appropriately; and #####
(D)by adding at the end the following new subparagraph: > > ##### “(B) Improvements to care management requirements for severe or disabling chronic condition snps > > For 2020 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: > > > ###### “(i) > > 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. > > > ###### “(ii) > > 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. > > > ###### “(iii) > > 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. > > > ###### “(iv) > > 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). > > > ###### “(v) > > 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.” > . ####
(2)Revisions to the definition of a severe or disabling chronic conditions specialized needs individual #####
(A)In general Section 1859(b)(6)(B)(iii) of the Social Security Act (42 U.S.C. 1395w–28(b)(6)(B)(iii)) is amended— ######
(i)by striking “ who have ” and inserting > “who— > > > ###### “(I) > > before January 1, 2022, have” > ; ######
(ii)in subclause (I), as added by clause (i), by striking the period at the end and inserting “; and”; and ######
(iii)by adding at the end the following new subclause: > > ##### “(II) > > on or after January 1, 2022, have one or more comorbid and medically complex chronic conditions that is life threatening or significantly limits overall health or function, have a high risk of hospitalization or other adverse health outcomes, and require intensive care coordination and that is listed under subsection (f)(9)(A).” > . #####
(B)Panel of clinical advisors Section 1859(f) of the Social Security Act (42 U.S.C. 1395w–28(f)), as amended by subsection (b), is amended by adding at the end the following new paragraph: > > #### “(9) List of conditions for clarification of the definition of a severe or disabling chronic conditions specialized needs individual > > > ##### “(A) In general > > Not later than December 31, 2020, and every 5 years thereafter, subject to subparagraphs
(B)and (C), the Secretary shall convene a panel of clinical advisors to establish and update a list of conditions that meet each of the following criteria: > > > ###### “(i) > > Conditions that meet the definition of a severe or disabling chronic condition under subsection (b)(6)(B)(iii) on or after January 1, 2022. > > > ###### “(ii) > > Conditions that require prescription drugs, providers, and models of care that are unique to the specific population of enrollees in a specialized MA plan for special needs individuals described in such subsection on or after such date and— > > > ###### “(I) > > as a result of access to, and enrollment in, such a specialized MA plan for special needs individuals, individuals with such condition would have a reasonable expectation of slowing or halting the progression of the disease, improving health outcomes and decreasing overall costs for individuals diagnosed with such condition compared to available options of care other than through such a specialized MA plan for special needs individuals; or > > > ###### “(II) > > have a low prevalence in the general population of beneficiaries under this title or a disproportionally high per-beneficiary cost under this title. > > > ##### “(B) Inclusion of certain conditions > > The conditions listed under subparagraph
(A)shall include HIV/AIDS, end stage renal disease, and chronic and disabling mental illness. > > > ##### “(C) Requirement > > In establishing and updating the list under subparagraph (A), the panel shall take into account the availability of varied benefits, cost-sharing, and supplemental benefits under the model described in paragraph
(2)of section 1859(h), including the expansion under paragraph
(1)of such section.” > . ###
(d)Quality Measurement at the Plan Level for SNPs and Determination of Feasability of Quality Measurement at the Plan Level for All MA Plans 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: > > #### “(6) Quality measurement at the plan level for snps > > > ##### “(A) In general > > Subject to subparagraph (B), the Secretary may require reporting of data under section 1852(e) for, and apply under this subsection, quality measures at the plan level for specialized MA plans for special needs individuals instead of at the contract level. > > > ##### “(B) Considerations > > Prior to applying quality measurement at the plan level under this paragraph, the Secretary shall— > > > ###### “(i) > > 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 this paragraph; > > > ###### “(ii) > > take into consideration the impact of such application on plans that serve a disproportionate number of individuals dually eligible for benefits under this title and under title XIX; > > > ###### “(iii) > > if quality measures are reported at the plan level, ensure that MA plans are not required to provide duplicative information; and > > > ###### “(iv) > > ensure that such reporting does not interfere with the collection of encounter data submitted by MA organizations or the administration of any changes to the program under this part as a result of the collection of such data. > > > ##### “(C) Application > > If the Secretary applies quality measurement at the plan level under this paragraph— > > > ###### “(i) > > such quality measurement may include Medicare Health Outcomes Survey (HOS), Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures and quality measures under part D; and > > > ###### “(ii) > > the Secretary shall consider applying administrative actions, such as remedies described in section 1857(g)(2), at the plan level. > > > #### “(7) Determination of feasibility of quality measurement at the plan level for all ma plans > > > ##### “(A) Determination of feasibility > > The Secretary shall determine the feasibility of requiring reporting of data under section 1852(e) for, and applying under this subsection, quality measures at the plan level for all MA plans under this part. > > > ##### “(B) Consideration of change > > 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” > . ###
(e)GAO Study and Report on State-Level Integration Between Dual SNPs and Medicaid ####
(1)Study The Comptroller General of the United States (in this subsection referred to as the “Comptroller General”) shall conduct a study on State-level integration between specialized MA plans for special needs individuals described in subsection (b)(6) (B)(ii) of section 1859 of the Social Security Act (42 U.S.C. 1395w–28) and the Medicaid program under title XIX of such Act (42 U.S.C. 1396 et seq.). Such study shall include an analysis of the following: #####
(A)The characteristics of States in which the State agency responsible for administering the State plan under such title XIX has a contract with such a specialized MA plan and that delivers long-term services and supports under the State plan under such title XIX through a managed care program, including the requirements under such State plan with respect to long-term services and supports. #####
(B)The types of such specialized MA plans, which may include the following: ######
(i)A plan described in section 1853(a)(1)(B)(iv)(II) of such Act (42 U.S.C. 1395w–23(a)(1)(B)(iv)(II)). ######
(ii)A plan that meets the requirements described in subsection (f)(3)(D) of such section 1859. ######
(iii)A plan described in clause
(ii)that also meets additional requirements established by the State. #####
(C)The characteristics of individuals enrolled in such specialized MA plans. #####
(D)As practicable, the following with respect to State programs for the delivery of long-term services and supports under such title XIX through a managed care program: ######
(i)Which populations of individuals are eligible to receive such services and supports. ######
(ii)Whether all such services and supports are provided on a capitated basis or if any of such services and supports are carved out and provided through fee-for service. #####
(E)As practicable, how the availability and variation of integration arrangements of such specialized MA plans offered in States affects spending, service delivery options, access to community-based care, and utilization of care. #####
(F)The efforts of State Medicaid programs to transition dually-eligible beneficiaries receiving long-term services and supports
(LTSS)from institutional settings to home and community-based settings and related financial impacts of such transitions. #####
(G)Barriers and opportunities for making further progress on dual integration, as well as recommendations for legislation or administrative action to expedite or refine pathways toward fully integrated care. ####
(2)Report Not later than 2 years after the date of the enactment of this Act, the Comptroller General shall submit to Congress a report containing the results of the study conducted under paragraph (1), together with recommendations for such legislation and administrative action as the Comptroller General determines appropriate. ## Subtitle C Expanding Innovation and Technology
Connectionstraces to 2
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- 42 USC 1395w–28(f)(1)
- 42 USC 1395w–28(f)
- Pub. L. 111-148
- 42 USC 1395w–28
- 42 USC 1395w–28(f)(8)
- 42 USC 1395w–28(f)(5)
- 42 USC 1395w–28(b)(6)(B)(iii)
- 42 USC 1395w–23(o)
- 42 USC 1395w–23(a)(1)(B)(iv)(II)
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cites case law
Sec. 50311
PROVIDING CONTINUED ACCESS TO MEDICARE ADVANTAGE SPECIAL NEEDS PLANS FOR VULNERABLE POPULATIONS
Cite42 USC 1395w–28(f)(1)
Cite42 USC 1395w–28(f)
Pub. L.Pub. L. 111-148
Cite42 USC 1395w–28
Cite42 USC 1395w–28(f)(8)
Cites 11 · showing 7Cited by 0 across 0 sources