,i #aacth ,,congress #b;d ,session ,h4 ,r4 #ddhd ,,in ,,the ,,house ,,of ,,representatives ,april #aj1 #bjad ,ms4 ,sinema 7for herself1 ,mr4 ,gibson1 ,mr4 ,barber1 ,mr4 ,bilirakis1 and ,mr4 ,murphy of ,florida7 introduced the following bill2 which was referred to the ,committee on ,ways and ,means1 and in addition to the ,committee on ,energy and ,commerce1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to amend title ,,xviii of the ,social ,security ,act to provide improvements for ,medicare ,advantage special needs plans1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,strengthening ,healthcare ,options for ,vulnerable ,populations ,act4 #b4 ,reauthorization of certain ,medicare ,advantage ,special ,needs ,plans 7a7 ,permanent extension of ,medicare ,advantage ,dual ,special ,needs ,plans authority ,section #ahei7;f77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7;f77#a77 is amended by inserting 1 in the case of a specialized ,,ma plan for special needs individuals who are not described in section #ahei7;b77#f77;,b77ii71 before for periods before ,january #a1 #bjae4 7b7 ,medicare ,advantage ,dual ,special ,needs ,plans required ,to provide integrated care ,section #ahei7;f77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7;f77#c77 is amended by adding at the end the following new subparagraph3 7,f7 ,not later than ,december #ca1 #bjah1 the plan is fully integrated with capitated contracts with ,states for any ,medicaid benefits1 including long-term care and behavioral health1 to the extent ,state law permits capitation of such services under such plan4 4 7c7 ,clearly defined role of ,state ,medicaid agency ,section #aheb7;a77#a77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;a77#a77;,b77 is amended by adding at the end the following new clause3 7vi7 ,defined role of ,state ,medicaid agencies with respect to fully integrated dual special needs plans ,the ,secretary1 in coordination with ,state ,medicaid ,directors1 shall develop a clearly defined role for ,state ,medicaid agencies in contracting and oversight of plans described in clause 7v77,,ii74 4 #c4 ,improvements to ,medicare ,advantage #e-,star ,quality ,rating ,system for plans with predominately ,dual ,eligible enrollees 7a7 ,treatment of plans with disproportionately high dual eligible enrollees ,section #ahec7o7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7o77 is amended by adding at the end the following new paragraph3 7#f7 ,treatment of plans with disproportionately high dual eligible enrollees 7,a7 ,in general ,in implementing this subsection1 the ,secretary shall take such steps as are necessary to ensure that the quality rating for a plan-- 7i7 does not disadvantage such a plan that enrolls-- 7,i7 full-benefit dual eligible individual 7as defined in section #aice7;c77#f772 7,,ii7 qualified ,medicare beneficiaries 7as defined in section #aije7p77#a772 or 7,,iii7 individuals with complex health care needs1 such as individuals with multiple conditions or individuals who require chronic care or institutional care2 and 7ii7 accounts for differences in socioeconomic and demographic characteristics of enrollees of such a plan that result in significant variation in health outcomes4 7,b7 ,specific steps ,the steps described in subparagraph 7,a7 shall include at least the following3 7i7 ,comparing specialized ,,ma plans for special needs individuals 7as defined in section #ahei7;b77#f77 for special needs individuals who are described in subparagraph 7,b77ii7 of such section only against other plans with the same types of enrollment4 7ii7 ,developing a methodology specific to specialized ,,ma plans for special needs individuals 7as defined in section #ahei7;b77#f77 for special needs individuals who are described in subparagraph 7,b77ii7 of such section for determining a quality rating under this subsection for such plans4 7iii7 ,developing appropriate case mix adjustment to ,healthcare ,effectiveness ,data and ,information ,set 7,,hedis7 and ,health ,outcomes ,survey 7,,hos7 measures for specialized ,,ma plans for special needs individuals 7as defined in section #ahei7;b77#f77 for special needs individuals who are described in subparagraph 7,b77ii7 of such section that account for factors beyond the control of the health system1 such as the management of conditions4 7iv7 ,identifying and implementing those quality measures that are appropriate for evaluating the performance of specialized ,,ma plans for special needs individuals 7as defined in section #ahei7;b77#f77 for special needs individuals who are described in subparagraph 7,b77ii7 of such section4 7v7 ,eliminating duplicative or substantially similar measures applied under this title or title ,,xix with respect to specialized ,,ma plans4 4 7b7 ,temporary treatment of certain dual special needs plans ,section #ahec7o7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7o771 as amended by subsection 7a71 is further amended by adding at the end the following new paragraph3 7#g7 ,temporary treatment of certain dual special needs plans ,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 7#f71 the ,secretary may increase the quality rating that a specialized ,,ma plans for special needs individuals 7as defined in section #ahei7;b77#f77 for special needs individuals who are described in subparagraph 7,b77ii7 of such section would otherwise receive under this subsection for a year by #j4e 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-economic1 demographic1 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 year4 4 7c7 ,,gao report ,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 7#f7 of section #ahec7o7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7o771 as added by subsection 7a71 and annually thereafter for the following four years1 the ,comptroller ,general of the ,united ,states shall submit to ,congress a report that includes a comprehensive review of the effectiveness of1 and recommendations to improve1 such steps so taken for improving health outcomes1 cost controls1 and beneficiary satisfaction4 #d4 ,additional improvements to the oversight and operation of ,medicare ,advantage ,dual ,special ,needs ,plans by the ,federal ,coordinated ,health ,care ,office 7a7 ,dedicated point of contact for assisting ,states with administration ,section #bfjb7;d7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #acae;b7d77 is amended by adding at the end the following new paragraph3 7#f7 ,serving as the dedicated point of contact within the ,centers for ,medicare ,medicaid ,services to assist ,states with ongoing issues related to the administration of specialized ,,ma plans for special needs individuals 7as defined in section #ahei7;b77#f7 of the ,social ,security ,act7 for special needs individuals who are described in subparagraph 7,b77ii7 of such section1 including-- 7,a7 addressing any misalignment between the contracting timelines1 processes1 and deadlines under title ,,xviii of such ,act1 with respect to such plans for such individuals and contracting timelines1 processes1 and deadlines under title ,,xix of such ,act1 with respect to such plans and individuals2 and 7,b7 streamlining the flow of information to dual eligible individuals and establishing a single set of rules for outreach and marketing to such individuals4 4 7b7 ,authority ,to waive certain requirements 7#a7 ,in general ,subject to paragraph 7#b71 the ,secretary of ,health and ,human ,services1 through the ,federal ,coordinated ,health ,care ,office established under section #bfjb of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #acae;b7 and in coordination with the appropriate ,state ,medicaid agency1 may waive the application of requirements under title ,,xviii of the ,social ,security ,act to promote the integration1 alignment1 and delivery of items and services under the ,medicare program under title ,,xviii of such ,act and the ,medicaid program under title ,,xix of such ,act1 with respect to dual eligible individuals 7as defined in section #bfjb7;f7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #acae;b7f771 and to ensure the seamless delivery of patient-centered services across the continuum of care with respect to such individuals4 7#b7 ,public notice requirement ,the ,secretary may not waive the application of a requirement pursuant to paragraph 7#a7 unless the ,secretary makes such waiver publicly available 7whether on the public ,internet website of ,department of ,health and ,human ,services1 or otherwise7 at least #cj days before the effective date of such waiver4 #e4 ,improvements to dispute resolution for claims and appeals under ,medicare ,advantage ,dual ,special ,needs ,plans 7a7 ,medicare ,advantage ,dual ,special ,needs ,plans required ,to provide coverage during appeals process ,section #ahei7;f77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7;f77#c771 as amended by section #b7;b71 is further amended by adding at the end the following new subparagraph3 7,g7 ,for plan years beginning after ,december #ca1 #bjae1 coverage under this title and title ,,xix of an individual enrolled under such respective title shall continue during any determination1 reconsideration1 or appeals proceeding described in section #aheb7;g71 with respect to such individual4 4 7b7 ,streamlined pathway for dispute resolution ,not later than ,december #ca1 #bjae1 the ,secretary of ,health and ,human ,services shall establish a streamlined process for dispute resolution for claims and appeals1 with respect items and services furnished to special needs individuals described in section #ahei7;b77#f77;,b77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7;b77#f77;,b77ii771 to align such process under the ,medicare program under title ,,xviii of the ,social ,security ,act with such process under the ,medicaid program under title ,,xix of such ,act4 ,such streamlined process shall take into account various ,state requirements and promote a pathway that would be the most beneficial for individuals entitled to benefits under part ,a of title ,,xviii of such ,act or enrolled under part ,b of such ,act and to individuals enrolled under a ,state plan under title ,,xix of such ,act4 #f4 ,report on implementation of certain ,medicare and ,medicaid fraud detection and program integrity provisions ,section #aabh;,j7a77#a77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#gk7a77#a77;,a77 is amended by adding at the end the following new clause3 7iii7 ,report on integrated data repository and one program integrity system ,not later than six months after the date of enactment of this clause1 the ,secretary shall submit to the appropriate ,congressional committees a report on the following3 7,i7 ,integrated data repository ,efforts to finalize plans and schedules for fully implementing and expanding the use of the ,integrated ,data ,repository1 including actions taken to finalize1 implement1 and manage plans for incorporating data into the ,integrated ,data ,repository and actions taken to define measurable financial benefits expected from the implementation of the ,integrated ,data ,repository4 7,,ii7 ,one program integrity system ,actions taken to plan1 schedule1 and conduct training on the ,one ,program ,integrity ,system1 a ,web-based portal and suite of software tools used to analyze and extract data from the ,integrated ,data ,repository1 and actions taken to define measurable financial benefits expected from the use of the ,one ,program ,integrity ,system4 4