Sec. 3205. EXTENSION FOR SPECIALIZED MA PLANS FOR SPECIAL NEEDS INDIVIDUALS

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## SEC. 3205 EXTENSION FOR SPECIALIZED MA PLANS FOR SPECIAL NEEDS INDIVIDUALS ###

(a)Extension of SNP Authority Section 1859(f)(1) of the Social Security Act (42 U.S.C. 1395w–28(f)(1)), as amended by section 164(a) of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110–275), is amended by striking “2011” and inserting “2014”. ###

(b)Authority To Apply Frailty Adjustment Under PACE Payment Rules Section 1853(a)(1)(B) of the Social Security Act (42 U.S.C. 1395w–23(a)(1)(B)) is amended by adding at the end the following new clause: > > ###### “(iv) Authority To apply frailty adjustment under PACE payment rules for certain specialized MA plans for special needs individuals > > > ###### “(I) In general > > Notwithstanding the preceding provisions of this paragraph, for plan year 2011 and subsequent plan years, in the case of a plan described in subclause (II), the Secretary may apply the payment rules under section 1894(d) (other than paragraph

(3)of such section) rather than the payment rules that would otherwise apply under this part, but only to the extent necessary to reflect the costs of treating high concentrations of frail individuals. > > > ###### “(II) Plan described > > A plan described in this subclause is a specialized MA plan for special needs individuals described in section 1859(b)(6)(B)(ii) that is fully integrated with capitated contracts with States for Medicaid benefits, including long-term care, and that have similar average levels of frailty (as determined by the Secretary) as the PACE program.” > . ###

(c)Transition and Exception Regarding Restriction on Enrollment Section 1859(f) of the Social Security Act (42 U.S.C. 1395w–28(f)) is amended by adding at the end the following new paragraph: > > #### “(6) Transition and exception regarding restriction on enrollment > > > ##### “(A) In general > > Subject to subparagraph (C), the Secretary shall establish procedures for the transition of applicable individuals to— > > > ###### “(i) > > a Medicare Advantage plan that is not a specialized MA plan for special needs individuals (as defined in subsection (b)(6)); or > > > ###### “(ii) > > the original medicare fee-for-service program under parts A and B. > > > ##### “(B) Applicable individuals > > For purposes of clause (i), the term ‘**applicable individual**’ means an individual who— > > > ###### “(i) > > is enrolled under a specialized MA plan for special needs individuals (as defined in subsection (b)(6)); and > > > ###### “(ii) > > is not within the 1 or more of the classes of special needs individuals to which enrollment under the plan is restricted to. > > > ##### “(C) Exception > > The Secretary shall provide for an exception to the transition described in subparagraph

(A)for a limited period of time for individuals enrolled under a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(ii) who are no longer eligible for medical assistance under title XIX. > > > ##### “(D) Timeline for initial transition > > The Secretary shall ensure that applicable individuals enrolled in a specialized MA plan for special needs individuals (as defined in subsection (b)(6)) prior to January 1, 2010, are transitioned to a plan or the program described in subparagraph

(A)by not later than January 1, 2013.” > . ###

(d)Temporary Extension of Authority To Operate But No Service Area Expansion for Dual Special Needs Plans that Do Not Meet Certain Requirements **[**[42 U.S.C. 1395w–28 note](/us/usc/t42/s1395w–28)**]** Section 164(c)(2) of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110–275) is amended by striking “December 31, 2010” and inserting “December 31, 2012”. ###

(e)Authority To Require Special Needs Plans be NCQA Approved Section 1859(f) of the Social Security Act (42 U.S.C. 1395w–28(f)), as amended by subsections

(a)and (c), is amended— ####

(1)in paragraph (2), by adding at the end the following new subparagraph: > > ##### “(C) > > If applicable, the plan meets the requirement described in paragraph (7).” > ; ####

(2)in paragraph (3), by adding at the end the following new subparagraph: > > ##### “(E) > > If applicable, the plan meets the requirement described in paragraph (7).” > ; ####

(3)in paragraph (4), by adding at the end the following new subparagraph: > > ##### “(C) > > If applicable, the plan meets the requirement described in paragraph (7).” > ; and ####

(4)by adding at the end the following new paragraph: > > #### “(7) Authority to require special needs plans be NCQA approved > > For 2012 and subsequent years, the Secretary shall require that a Medicare Advantage organization offering a specialized MA plan for special needs individuals be approved by the National Committee for Quality Assurance (based on standards established by the Secretary).” > . ###

(f)Risk Adjustment Section 1853(a)(1)(C) of the Social Security Act (42 U.S.C. 1395i–23(a)(1)(C)) is amended by adding at the end the following new clause: > > ###### “(iii) Improvements to risk adjustment for special needs individuals with chronic health conditions > > > ###### “(I) In general > > For 2011 and subsequent years, for purposes of the adjustment under clause

(i)with respect to individuals described in subclause (II), the Secretary shall use a risk score that reflects the known underlying risk profile and chronic health status of similar individuals. Such risk score shall be used instead of the default risk score for new enrollees in Medicare Advantage plans that are not specialized MA plans for special needs individuals (as defined in section 1859(b)(6)). > > > ###### “(II) Individuals described > > An individual described in this subclause is a special needs individual described in subsection (b)(6)(B)(iii) who enrolls in a specialized MA plan for special needs individuals on or after January 1, 2011. > > > ###### “(III) Evaluation > > For 2011 and periodically thereafter, the Secretary shall evaluate and revise the risk adjustment system under this subparagraph in order to, as accurately as possible, account for higher medical and care coordination costs associated with frailty, individuals with multiple, comorbid chronic conditions, and individuals with a diagnosis of mental illness, and also to account for costs that may be associated with higher concentrations of beneficiaries with those conditions. > > > ###### “(IV) Publication of evaluation and revisions > > The Secretary shall publish, as part of an announcement under subsection (b), a description of any evaluation conducted under subclause

(III)during the preceding year and any revisions made under such subclause as a result of such evaluation.” > . ###

(g)Technical Correction Section 1859(f)(5) of the Social Security Act (42 U.S.C. 1395w–28(f)(5)) is amended, in the matter preceding subparagraph (A), by striking “described in subsection (b)(6)(B)(i)”.

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42 USC 1395w–28(f)(1)
Pub. L. 110-275
42 USC 1395w–23(a)(1)(B)
42 USC 1395w–28(f)
42 USC 1395w–28
42 USC 1395i–23(a)(1)(C)
42 USC 1395w–28(f)(5)

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Sec. 3205

EXTENSION FOR SPECIALIZED MA PLANS FOR SPECIAL NEEDS INDIVIDUALS

Cite42 USC 1395w–28(f)(1)

Pub. L.Pub. L. 110-275

Cite42 USC 1395w–23(a)(1)(B)

Cite42 USC 1395w–28(f)

Cite42 USC 1395w–28

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