,,ib ,union ,calendar ,no4 #cec #aaeth ,,congress #ast ,session ,h4 ,r4 #cafh ,report ,no4 #aae-dgh1 ,part ,i ,,in ,,the ,,house ,,of ,,representatives ,july #f1 #bjag ,mr4 ,tiberi 7for himself and ,mr4 ,levin7 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 ,december #ba1 #bjag ,reported from the ,committee on ,ways and ,means with an amendment ,strike out all after the enacting clause and insert the part printed in italic ,december #ba1 #bjag,the ,committee on ,energy and ,commerce discharged2 committed to the ,committee of the ,whole ,house on the ,state of the ,union and ordered to be printed,for text of introduced bill1 see copy of bill as introduced on ,july #f1 #bjag ,a ,,bill ,to amend title ,,xviii of the ,social ,security ,act to provide continued access to specialized ,medicare ,advantage plans for special needs individuals1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,special ,needs ,plans ,reauthorization ,act of #bjag or the ,,snp ,reauthorization ,act of #bjag4 #b4 ,specialized ,medicare ,advantage plans for special needs individuals 7a7 ,extension ,section #ahei7;f77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7;f77#a77 is amended-- 7#a7 by striking and for periods before ,january #a1 #bjai2 and 7#b7 by adding at the end the following new sentence3 ,in the case of a specialized ,,ma plan for special needs individuals described in clause 7ii7 or 7iii7 of subsection 7b77#f77;,b71 the previous sentence shall apply for periods before ,january #a1 #bjbd44 7b7 ,increased integration of dual ,s,n,ps 7#a7 ,in general ,section #ahei7;f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7;f77 is amended-- 7,a7 in paragraph 7#c71 by adding at the end the following new subparagraph3 7,f7 ,the plan meets the requirements applicable under paragraph 7#h74 2 and 7,b7 by adding at the end the following new paragraph3 7#h7 ,increased integration of dual ,s,n,ps 7,a7 ,designated contact ,the ,secretary1 acting through the ,federal ,coordinated ,health ,care ,office established under section #bfjb of ,public ,law #aaa-adh1 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 7b77#f77;,b77ii7 under this paragraph and1 consistent with such role1 shall-- 7i7 establish a uniform process for disseminating to ,state ,medicaid agencies information under this title impacting contracts between such agencies and such plans under this subsection2 and 7ii7 establish basic resources for ,states interested in exploring such plans as a platform for integration1 such as a model contract or other tools to achieve those goals4 7,b7 ,unified grievances and appeals process 7i7 ,in general ,not later than ,april #a1 #bjbj1 the ,secretary shall establish procedures1 to the extent feasible as determined by the ,secretary1 unifying grievances and appeals procedures under sections #aheb7;f71 #aheb7;g71 #aijb7;a77#c71 #aijb7;a77#e71 and #aicb7;b77#d7 for items and services provided by specialized ,,ma plans for special needs individuals described in subsection 7b77#f77;,b77ii7 under this title and title ,,xix4 ,the ,secretary shall solicit comment in developing such procedures from ,states1 plans1 beneficiaries and their representatives1 and other relevant stakeholders4 ,with respect to items and services described in the previous sentence1 appeals procedures established under this clause shall apply in place of otherwise applicable appeals procedures4 7ii7 ,procedures ,the procedures established under clause 7i7 shall be included in the plan contract under paragraph 7#c77;,d7 and shall-- 7,i7 adopt the provisions for the enrollee that are most protective for the enrollee and1 to the extent feasible as determined by the ,secretary1 are compatible with unified timeframes and consolidated access to external review under an integrated process2 7,,ii7 take into account differences in ,state plans under title ,,xix to the extent necessary2 7,,iii7 be easily navigable by an enrollee2 and 7,,iv7 include the elements described in clause 7iii71 as applicable4 7iii7 ,elements described ,both unified appeals and unified grievance procedures shall include1 as applicable1 the following elements described in this clause3 7,i7 ,single written notification of all applicable grievances and appeal rights under this title and title ,,xix4 ,for purposes of this subparagraph1 the ,secretary may waive the requirements under section #aheb7;g77#a77;,b7 when the specialized ,,ma plan covers items or services under this part or under title ,,xix4 7,,ii7 ,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 7b77#f77;,b77ii7 under this title and title ,,xix4 7,,iii7 ,notices written in plain language and available in a language and format that is accessible to the enrollee1 including in non-,english languages that are prevalent in the service area of the specialized ,,ma plan4 7,,iv7 ,unified timeframes for grievances and appeals processes1 such as an individual's filing of a grievance or appeal1 a plan's acknowledgment and resolution of a grievance or appeal1 and notification of decisions with respect to a grievance or appeal4 7,v7 ,requirements for how the plan must process1 track1 and resolve grievances and appeals1 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 appeal4 7iv7 ,continuation of benefits pending appeal ,the unified procedures under clause 7i7 shall1 with respect to all benefits under parts ,a and ,b and title ,,xix subject to appeal under such procedures1 incorporate provisions under current law and implementing regulations that provide continuation of benefits pending appeal under this title and title ,,xix4 7,c7 ,requirement for unified grievances and appeals ,for #bjbb and subsequent years1 the contract of a specialized ,,ma plan for special needs individuals described in subsection 7b77#f77;,b77ii7 with a ,state ,medicaid agency under paragraph 7#c77;,d7 shall require the use of unified grievances and appeals procedures as described in subparagraph 7,b74 7,d7 ,requirements for full integration for certain dual ,s,n,ps 7i7 ,requirement ,for #bjba and subsequent years1 a specialized ,,ma plan for special needs individuals described in subsection 7b77#f77;,b77ii7 shall meet one or more of the following requirements for integration of benefits under this title and title ,,xix3 7,i7 ,meet the requirements of a fully integrated plan described in section #ahec7;a77#a77;,b77iv77,,ii7 7other than the requirement that the plan have similar average levels of frailty1 as determined by the ,secretary1 as the ,,pace program74 7,,ii7 ,enter into a capitated contract with the ,state ,medicaid agency to provide long-term services and supports or behavioral health services1 or both4 7,,iii7 ,to the extent the ,state does not allow for or require such a specialized ,,ma plan to enter into a capitated contract described in subclause 7,,ii71 enter into another type of integration arrangement1 as determined appropriate by the ,secretary after consultation with stakeholders1 such as by-- 7aa7 entering into a contract with the ,state that requires notifying the ,state in a timely manner of hospitalizations1 emergency room visits1 and hospital or nursing home discharges of enrollees or otherwise requires sharing data that would benefit the coordination of items and services under this title and the ,state plan under title ,,xix2 or 7bb7 offering1 by a parent organization1 a ,medicaid managed care plan that provides long term services and supports or behavioral health services to the same enrollees as under such specialized ,,ma plan4 7ii7 ,sanctions ,for #bjba and subsequent years1 if the ,secretary determines that a specialized ,,ma plan fails to comply with clause 7i71 the ,secretary may provide for the application against the ,medicare ,advantage organization offering the plan any of the remedies described in section #aheg7;g77#b74 4 7#b7 ,conforming amendment to responsibilities of ,federal ,coordinated ,health ,care ,office ,section #bfjb7;d7 of ,public ,law #aaa-adh 7#db ,u4,s4,c4 #acae;b7d77 is amended by adding at the end the following new paragraphs3 7#f7 ,to act as a designated contact for ,states under subsection 7f77#h77;,a7 of section #ahei of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7 with respect to the integration of specialized ,,ma plans for special needs individuals described in subsection 7b77#f77;,b77ii7 of such section4 7#g7 ,to be responsible for developing regulations and guidance related to the implementation of a unified grievance and appeals process as described in subparagraphs 7,b7 and 7,c7 of section #ahei7;f77#h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7;f77#h774 7#h7 ,to be responsible 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 ,medicaid program under title ,,xix of such ,act regarding specialized ,,ma plans for special needs individuals described in subsection 7b77#f77;,b77ii7 of such section #ahei4 4 7c7 ,improvements to severe or disabling chronic condition ,s,n,ps 7#a7 ,care management requirements ,section #ahei7;f77#e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7;f77#e77 is amended-- 7,a7 by redesignating subparagraphs 7,a7 and 7,b7 as clauses 7i7 and 7ii71 respectively1 and indenting appropriately2 7,b7 in clause 7ii71 as redesignated by subparagraph 7,a71 by redesignating clauses 7i7 through 7iii7 as subclauses 7,i7 through 7,,iii71 respectively1 and indenting appropriately2 7,c7 by striking all ,s,n,ps4--,the requirements and inserting 8all ,s,n,ps4-- 7,a7 ,in general ,subject to subparagraph 7,b71 the requirements 2 and 7,d7 by adding at the end the following new subparagraph3 7,b7 ,improvements to care management requirements for severe or disabling chronic condition ,s,n,ps ,for #bjbj and subsequent years1 in the case of a specialized ,,ma plan for special needs individuals described in subsection 7b77#f77;,b77iii71 the requirements described in this paragraph include the following3 7i7 ,the interdisciplinary team under subparagraph 7,a77ii77,,iii7 includes a team of providers with demonstrated expertise1 including training in an applicable specialty1 in treating individuals similar to the targeted population of the plan4 7ii7 ,requirements developed by the ,secretary to provide face-to-face encounters with individuals enrolled in the plan not less frequently than on an annual basis4 7iii7 ,as part of the model of care under clause 7i7 of subparagraph 7,a71 the results of the initial assessment and annual reassessment under clause 7ii77,i7 of such subparagraph of each individual enrolled in the plan are addressed in the individual's individualized care plan under clause 7ii77,,ii7 of such subparagraph4 7iv7 ,as part of the annual evaluation and approval of such model of care1 the ,secretary shall take into account whether the plan fulfilled the previous year's goals 7as required under the model of care74 7v7 ,the ,secretary shall establish a minimum benchmark for each element of the model of care of a plan4 ,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 sentence4 4 7#b7 ,revisions to the definition of a severe or disabling chronic conditions specialized needs individual 7,a7 ,in general ,section #ahei7;b77#f77;,b77iii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7;b77#f77;,b77iii77 is amended-- 7i7 by striking who have and inserting 8who-- 7,i7 before ,january #a1 #bjbb1 have 2 7ii7 in subclause 7,i71 as added by clause 7i71 by striking the period at the end and inserting 2 and2 and 7iii7 by adding at the end the following new subclause3 7,,ii7 on or after ,january #a1 #bjbb1 have one or more comorbid and medically complex chronic conditions that is life threatening or significantly limits overall health or function1 have a high risk of hospitalization or other adverse health outcomes1 and require intensive care coordination and that is listed under subsection 7f77#i77;,a74 4 7,b7 ,panel of clinical advisors ,section #ahei7;f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7;f771 as amended by subsection 7b71 is amended by adding at the end the following new paragraph3 7#i7 ,list of conditions for clarification of the definition of a severe or disabling chronic conditions specialized needs individual 7,a7 ,in general ,not later than ,december #ca1 #bjbj1 and every #e years thereafter1 the ,secretary shall convene a panel of clinical advisors to establish and update a list of conditions that meet each of the following criteria3 7i7 ,conditions that meet the definition of a severe or disabling chronic condition under subsection 7b77#f77;,b77iii7 on or after ,january #a1 #bjbb4 7ii7 ,conditions that require prescription drugs1 providers1 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-- 7,i7 as a result of such special needs individuals with such a condition having access to and being enrolled in such a plan1 as compared to access to and enrollment in other ,medicare ,advantage plans under this part1 it is projected that such individuals would improve health outcomes with respect to such condition1 that such individuals would have reduced overall costs under this title1 and that there would not be any increase in expenditures under this title for such individuals2 or 7,,ii7 have a low prevalence in the general population of beneficiaries under this title or a disproportionally high per-beneficiary cost under this title4 7,b7 ,,gao ,study on ,health ,outcomes of ,individuals ,enrolled in ,specialized ,,ma plans ,not later than the date that is #c years after the date of the enactment of this paragraph1 the ,comptroller ,general of the ,united ,states shall conduct a study and submit to ,congress a report on the extent to which health outcomes can be compared across specialized ,,ma plans for special needs individuals 7as defined in section #ahei7;b77#f77 and other ,medicare ,advantage plans under this part across similar populations1 using existing measures and that identifies any potential limitations where new measures may need to be developed for such population4 4 7d7 ,quality measurement at the plan level for ,s,n,ps and determination of feasability of quality measurement at the plan level for all ,,ma plans ,section #ahec7o7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7o77 is amended by adding at the end the following new paragraphs3 7#f7 ,quality measurement at the plan level for ,s,n,ps 7,a7 ,in general ,subject to subparagraph 7,b71 the ,secretary may require reporting of data under section #aheb7;e7 for1 and apply under this subsection1 quality measures at the plan level for specialized ,,ma plans for special needs individuals instead of at the contract level4 7,b7 ,considerations ,prior to applying quality measurement at the plan level under this paragraph1 the ,secretary shall-- 7i7 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 paragraph2 7ii7 if quality measures are reported at the plan level1 ensure that ,,ma plans are not required to provide duplicative information2 and 7iii7 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 data4 7,c7 ,application ,if the ,secretary applies quality measurement at the plan level under this paragraph-- 7i7 such quality measurement may include ,medicare ,health ,outcomes ,survey 7,,hos71 ,healthcare ,effectiveness ,data and ,information ,set 7,,hedis71 ,consumer ,assessment of ,healthcare ,providers and ,systems 7,,cahps7 measures and quality measures under part ,d2 and 7ii7 the ,secretary shall consider applying administrative actions1 such as remedies described in section #aheg7;g77#b71 to the plan level4 7#g7 ,determination of feasibility of quality measurement at the plan level for all ,,ma plans 7,a7 ,determination of feasibility ,the ,secretary shall determine the feasibility of requiring reporting of data under section #aheb7;e7 for1 and applying under this subsection1 quality measures at the plan level for all ,,ma plans under this part4 7,b7 ,consideration of change ,after making a determination under subparagraph 7,a71 the ,secretary shall consider requiring such reporting and applying such quality measures at the plan level as described in such subparagraph4 4 7e7 ,,gao study and report on ,state-,level integration between dual ,s,n,ps and ,medicaid 7#a7 ,study ,the ,comptroller ,general of the ,united ,states 7in this paragraph referred to as the ,comptroller ,general7 shall conduct a study on ,state-level integration between specialized ,,ma plans for special needs individuals described in subsection 7b77#f77;,b77ii7 of section #ahei of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7 and the ,medicaid program under title ,,xix of such ,act 7#db ,u4,s4,c4 #acif et seq474 ,such study shall include an analysis of the following3 7,a7 ,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 program1 including the requirements under such ,state plan with respect to long term services and supports4 7,b7 ,the types of such specialized ,,ma plans1 which may include the following3 7i7 ,a plan described in section #ahec7;a77#a77;,b77iv77,,ii7 of such ,act 7#db ,u4,s4,c4 #aciew-#bc7;a77#a77;,b77iv77,,ii774 7ii7 ,a plan that meets the requirements described in subsection 7f77#c77;,d7 of such section #ahei4 7iii7 ,a plan described in clause 7ii7 that also meets additional requirements established by the ,state4 7,c7 ,the characteristics of individuals enrolled in such specialized ,,ma plans4 7,d7 ,as practicable1 the following with respect to ,state programs for the delivery of long term services and supports under such title ,,xix through a managed care program3 7i7 ,which populations of individuals are eligible to receive such services and supports4 7ii7 ,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-service4 7,e7 ,as1 practicable1 how the availability and variation of integration arrangements of such specialized ,,ma plans offered in ,states affects spending1 service delivery options1 access to community-based care1 and utilization of care4 7,f7 ,barriers and opportunities for making further progress on dual integration1 as well as recommend legislation to expedite or refine pathways toward fully integrated care4 7#b7 ,report ,not later than #b years after the date of the enactment of this ,act1 the ,comptroller ,general shall submit to ,congress a report containing the results of the study conducted under paragraph 7#a71 together with recommendations for such legislation and administrative action as the ,comptroller ,general determines appropriate4 #c4 ,expanding supplemental benefits to meet the needs of chronically ill medicare advantage enrollees 7a7 ,in general ,section #aheb7;a77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;a77#c77 is amended-- 7#a7 in subparagraph 7,a71 by striking ,each and inserting ,subject to subparagraph 7,d71 each2 and 7#b7 by adding at the end the following new subparagraph3 7,d7 ,expanding supplemental benefits to meet the needs of chronically ill enrollees 7i7 ,in general ,for plan year #bjbj and subsequent plan years1 in addition to any supplemental health care benefits otherwise provided under this paragraph1 an ,,ma plan1 including a specialized ,,ma plan for special needs individuals described in subsection 7b77#f7 of section #ahei1 may provide supplemental benefits described in clause 7ii7 to a chronically ill enrollee 7as defined in clause 7iii774 7ii7 ,supplemental benefits described 7,i7 ,in general ,supplemental benefits described in this clause are supplemental benefits that1 with respect to a chronically ill enrollee1 have a reasonable expectation of improving or maintaining the health or overall function of the chronically ill enrollee and may not be limited to being primarily health related benefits4 7,,ii7 ,authority to waive uniformity requirements ,the ,secretary may1 with respect to supplemental benefits provided to a chronically ill enrollee under this subparagraph1 waive the uniformity requirement1 as determined appropriate by the ,secretary4 7iii7 ,chronically ill enrollee defined ,in this subparagraph1 the term chronically ill enrollee means an enrollee in an ,,ma plan that the ,secretary determines-- 7,i7 has one or more comorbid and medically complex chronic conditions that is life threatening or significantly limits the overall health or function of the enrollee2 7,,ii7 has a high risk of hospitalization or other adverse health outcomes2 or 7,,iii7 requires intensive care coordination4 4 7b7 ,,gao ,study ,and ,report 7#a7 ,study ,the ,comptroller ,general of the ,united ,states 7in this subsection referred to as the ,comptroller ,general7 shall conduct a study on supplemental benefits provided to enrollees in ,medicare ,advantage plans under part ,c of title ,,xviii of the ,social ,security ,act1 including specialized ,,ma plans for special needs individuals described in section #ahei7;b77#f7 of such ,act 7#db ,u4,s4,c4 #aciew-#bh7;b77#f774 ,such study shall be conducted in consultation with the ,centers for ,medicare ,medicaid ,services and ,medicare ,advantage plans as necessary and1 to the extent data is available1 shall include an analysis of the following3 7,a7 ,the type of supplemental benefits provided to such enrollees1 the total number of enrollees receiving each supplemental benefit1 and whether the supplemental benefit is covered by the standard benchmark cost of the benefit or with an additional premium4 7,b7 ,the frequency in which supplemental benefits are utilized by such enrollees4 7,c7 ,the impact supplemental benefits have on-- 7i7 indicators of the quality of care received by such enrollees1 including overall health and function of the enrollees2 7ii7 the utilization of items and services for which benefits are available under the original ,medicare fee-for-service program option under parts ,a and ,b of such title ,,xviii by such enrollees2 and 7iii7 the amount of the bids submitted by ,medicare ,advantage ,organizations for ,medicare ,advantage plans under such part ,c4 7#b7 ,report ,not later than #e years after the date of the enactment of this ,act1 the ,comptroller ,general shall submit to ,congress a report containing the results of the study conducted under paragraph 7#a71 together with recommendations for such legislation and administrative action as the ,comptroller ,general determines appropriate4 ,december #ba1 #bjag ,reported from the ,committee on ,ways and ,means with an amendment,december #ba1 #bjag,the ,committee on ,energy and ,commerce discharged2 committed to the ,committee of the ,whole ,house on the ,state of the ,union and ordered to be printed