,,ii #aagth ,,congress #b;d ,session ,s4 #dfce ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,july #bg1 #bjbb,mr4 ,brown 7for himself and ,mr4 ,portman7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to amend the ,social ,security ,act to establish an optional ,state-administered program to provide fully integrated1 comprehensive1 coordinated care for full-benefit dual eligible individuals under the ,medicare and ,medicaid programs1 and for other purposes4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,comprehensive ,care for ,dual ,eligible ,individuals ,act4 7b7 ,table of contents ,the table of contents for this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4,sec4 #b4 ,establishment of ,all ,inclusive ,medicare-,medicaid ,program for ,full-,benefit ,dual ,eligible ,individuals4,,title ,,xxii--,all ,inclusive ,medicare-,medicaid 7,,aim7 ,program for ,full-,benefit ,dual ,eligible ,individuals,sec4 #bbja4 ,purpose2 ,general requirements4,sec4 #bbjb4 ,eligibility4,sec4 #bbjc4 ,enrollment4,sec4 #bbjd4 ,benefits4,sec4 #bbje4 ,beneficiary protections4,sec4 #bbjf4 ,federal administration4,sec4 #bbjg4 ,selection and role of ,,aim-administering entities4,sec4 #bbjh4 ,program financing4,sec4 #bbji4 ,accountability and oversight4,sec4 #bbaj4 ,definitions2 miscellaneous provisions4,sec4 #c4 ,med,p,a,c study and report4 #b4 ,establishment of ,all ,inclusive ,medicare-,medicaid ,program for ,full-,benefit ,dual ,eligible ,individuals 7a7 ,in general ,the ,social ,security ,act is amended by adding at the end the following new title3 ,,xxii ,all ,inclusive ,medicare-,medicaid 7,,aim7 ,program for ,full-,benefit ,dual ,eligible ,individuals #bbja4 ,purpose2 ,general requirements 7a7 ,purpose ,the purpose of this title is to provide1 at the option of a ,state1 for a program implemented and administered by the ,state of comprehensive1 coordinated care for individuals eligible for benefits under the ,medicare program under title ,,xviii and for full benefits under the ,medicaid program under title ,,xix in order to improve quality1 control costs1 address health disparities1 and support independence1 community participation1 and quality of life4 7b7 ,requirement for approved ,,aim program application ,a ,state may not be approved to implement an ,,aim program under this title unless1 consistent with the process specified for approval of ,,aim programs under subsection 7c7-- 7#a7 the ,state has completed1 in a pre-printed format and manner specified by the ,secretary1 a notice of intent to establish such a program not earlier than #c years after the date on which the ,state submits the notice of intent to the ,secretary1 and which includes a plan for such a program 7or the ,state is working with the ,federal ,coordinated ,health ,care ,office to transition an integrated care program of the ,state into an ,,aim program under this title72 and 7#b7 the ,secretary has received assurances1 satisfactory to the ,secretary1 that the proposed ,state ,,aim program and its plan 7or1 in the case of a ,state working with the ,federal ,coordinated ,health ,care ,office to transition an integrated care program of the ,state into an ,,aim program under this title1 the ,state ,,aim program after such transition is completed7 meet the applicable requirements for such a program under this title1 including the requirements specified in subsection 7c74 7c7 ,general requirements ,the requirements specified in this subsection for an ,,aim program of a ,state are as follows3 7#a7 ,eligibility and enrollment ,the program provides for eligibility and enrollment of ,,aimp-eligible individuals under the program in accordance with sections #bbjb and #bbjc4 7#b7 ,benefits ,the program provides for benefits for ,,aimp enrollees under the program in accordance with section #bbjd4 7#c7 ,beneficiary protections ,the program provides for beneficiary protections for ,,aimp enrollees under the program that are not less than those required under section #bbje4 7#d7 ,coordinating and integration of benefits ,the program provides for the coordination and integration of benefits by ,,aim-administering entities in accordance with section #bbje4 7#e7 ,program accountability ,the program provides for accountability in administration and financing in accordance with section #bbjh4 7#f7 ,other requirements ,the program meets such other requirements as the ,secretary may establish to carry out this title4 7d7 ,program approval process ,the ,secretary shall establish a process for the initial approval of ,,aim programs of ,states based on the process used for approval of waivers under section #aaae with respect to title ,,xix4 ,the process established under this subsection shall include at least the following elements3 7#a7 ,notice of intent 7,a7 ,in general ,subject to subparagraph 7,b71 the ,state submits to the ,secretary a notice of intent to establish the ,,aimp4 7,b7 ,conditions for transparent process ,the ,secretary shall not accept a notice of intent submitted under subparagraph 7,a7 unless1 before the date of such submission1 the ,state-- 7i7 has provided a period of not less than #ij days for notice and public comment on the proposed establishment of the program in the ,state2 7ii7 has held at least #b public meetings regarding the establishment of the program2 and 7iii7 has conducted relevant consultation with any relevant tribal authorities of ,federally recognized ,indian tribes located in the ,state4 7#b7 ,federal readiness review completed ,at least #a year before the identified initial implementation date for an ,,aim program in a ,state1 the ,state has passed a review by the ,secretary of the ,state's readiness to implement the program4 7#c7 ,state readiness review of aim-administering entities ,after a ,state passes the ,federal readiness review under paragraph 7#b71 the ,state shall conduct a review of the proposed ,,aim-administering entities under proposed ,,aimp contracts with the ,state with respect to their readiness to administer the program for benefits for ,,aimp enrollees assigned to such entities4 ,such review-- 7,a7 shall include elements specified by the ,secretary1 including a network adequacy review2 7,b7 may include activities such as a desk review1 separate network validation review1 and site visit2 and 7,c7 must be passed by an ,,aimp-administering entity before any outreach or marketing of or by that entity is permitted under a ,state ,,aim program4 7e7 ,technical assistance planning grants 7#a7 ,eligibility ,a ,state that has provided a notice of intent under subsection 7d77#a7 to implement an ,,aim program is eligible for funding assistance with technical planning necessary to implement the program4 ,such funding shall be provided in amounts of up to #aj1jjj1jjj per ,state1 and under such conditions as the ,secretary shall specify4 7#b7 ,use of funds ,funding made available to a ,state under this subsection may be used to assist the ,state with the staffing1 information technology1 planning and evaluation1 and initial implementation of the ,,aim program in the ,state for expenses incurred during the #c-year period that begins on the date the ,state submits a notice of intent under subsection 7d77#a74 7#c7 ,funding ,for the purpose of providing funding assistance under this subsection1 there is appropriated1 out of any money in the ,treasury not otherwise appropriated1 such sums as may be necessary to carry out this subsection4 #bbjb4 ,eligibility 7a7 ,in general ,in this title1 the term ,,aimp-eligible individual means1 with respect to an ,,aimp-participating ,state1 an individual who-- 7#a7 is #ba years of age or older2 7#b7 is entitled 7or eligible to be enrolled7 under part ,a or part ,b1 or both1 of title ,,xviii2 7#c7 subject to subsection 7c71 is eligible for medical assistance under the ,state plan 7including a waiver thereof7 under title ,,xix as a full-benefit dual eligible individual2 and 7#d7 meets such income and asset standards as the ,state may establish for the ,,aim program in accordance with subsection 7d7 7and which shall be applied in addition to the income and asset standards the individual is required to meet for purposes of eligibility for medical assistance under the ,state plan 7or a waiver7 under title ,,xix74 7b7 ,process for determination of eligibility ,except as otherwise provided in this title1 the determination of whether an individual is an ,,aimp-eligible individual with respect to the ,,aim program of a ,state shall be made in accordance with the processes used to determine the individual's eligibility for medical assistance under the ,state plan 7or waiver thereof7 under title ,,xix of the ,state4 7c7 ,flexibility permitted 7#a7 ,geographic scope 7,a7 ,statewide ,except as provided in subparagraph 7,b71 an ,,aimp-participating ,state shall provide for the implementation of its ,,aim program on a statewide basis4 7,b7 ,phase-in permitted on a time-limited basis ,an ,,aimp-participating ,state may provide for the implementation of its ,,aim program not on a statewide basis so long as the program is phased in geographically in a manner so that it is implemented statewide no later than the #dth year of implementation1 except that the ,secretary may permit a longer phase-in period due to extenuating circumstances4 7#b7 ,new population phase-in permitted 7,a7 ,carve-outs not permitted ,except as provided in subparagraph 7,b71 an ,,aimp-participating ,state may not deny eligibility under its ,,aim program to subpopulations of ,,aimp-eligible individuals and shall enroll all ,,aimp-eligible individuals under the program without the application of any waiting lists4 7,b7 ,time-limited exception permitted ,the ,secretary may allow ,states to phase in the enrollment of certain subpopulations over a specified period1 not to exceed a period of #d years4 7#c7 ,pace continuation permitted ,nothing in this title shall be construed as preventing an ,,aimp-participating ,state from continuing to offer a ,program of ,all-,inclusive ,care for the ,elderly 7,,pace7 under section #ahid or #aicd4 7d7 ,income and asset standards 7#a7 ,income eligibility floor ,in no case shall an ,,aimp-participating ,state have an income eligibility threshold under its ,,aim program that is less than #gc percent of the official poverty line 7as defined by the ,office of ,management and ,budget1 and revised annually in accordance with section #fgc7b7 of the ,omnibus ,budget ,reconciliation ,act of #aiha7 applicable to a family of the size involved or1 if greater1 the income threshold applied during the fiscal year preceding the year in which this title is enacted4 7#b7 ,asset threshold floor ,in no case shall an ,,aimp-participating ,state apply an asset threshold for eligibility for a fiscal year that is less than the following3 7,a7 ,for first fiscal year ,for the #ast fiscal year 7or portion of a fiscal year7 in which the ,,aim program is implemented in the ,state1 the greater of-- 7i7 #b1jjj2 and 7ii7 the asset eligibility standard applied under the ,state plan 7including a waiver thereof7 under title ,,xix for a full-benefit dual eligible individual during the fiscal year preceding the fiscal year in which this title is enacted4 7,b7 ,for subsequent fiscal year ,for a subsequent fiscal year1 the minimum asset threshold applied under this paragraph for the previous fiscal year increased 7and rounded to the nearest #aj7 by the annual increase in the consumer price index for all urban consumers 7,united ,states city average74 7#c7 ,flexibility ,nothing in this subsection shall be construed as limiting the ability of an ,,aimp-participating ,state to increase the income eligibility threshold1 asset eligibility threshold1 or income or asset disregards1 including by allowing buy-ins or spenddowns1 above the minimum levels required under this subsection4 7#d7 ,eligibility threshold ,the income and asset thresholds that a ,state establishes under this subsection shall be applied under the ,state ,,aim program to determine whether an individual is an ,,aimp-eligible individual without regard to whether the individual elects to enroll1 or is enrolled1 in the ,state ,,aim program4 7e7 ,use of streamlined eligibility determination and enrollment processes 7#a7 ,in general ,each ,,aimp-participating ,state shall use streamlined eligibility and enrollment processes in order to promote continuity and incentivize ,states that invest in improving quality and costs1 including those specified in this subsection4 7#b7 ,specific streamlined eligibility required ,each ,,aimp-participating ,state shall utilize the following with respect to streamlining the eligibility determination and enrollment of individuals in the ,state's ,,aim program3 7,a7 #ab-month continuous eligibility4 7,b7 ,use of electronic data matches with trusted third-party sources 7such as the ,social ,security ,administration or the ,supplemental ,nutrition ,assistance ,program7 to verify eligibility under the ,state ,,aim program both for initial eligibility applications and for renewals4 7,c7 ,streamlined eligibility recertification every #ab months1 including-- 7i7 for individuals who have been determined eligible and enrolled1 only requiring submission of information on any changes to their financial or disability status 7instead of submitting an entire renewal application72 7ii7 with respect to verification of eligibility1 initially using of available information to auto-verify eligibility2 7iii7 if additional information is needed for renewal of eligibility1 using pre-populated forms and allowing submission of information online1 in person1 by telephone1 fax1 or mail2 and 7iv7 using a standard reconsideration period of #ij days from the time of termination of coverage4 7#c7 ,use of deeming ,each ,,aimp-participating ,state shall use deemed eligibility for a period of not less than #f months4 7#d7 ,data sharing on enrollment ,under an ,,aimp contract1 an ,,aimp-participating ,state1 the ,secretary1 and ,,aim-administering entities shall routinely and frequently share data among themselves with regard to eligibility and enrollment of individuals under ,,aim programs4 ,such data sharing may include monthly changes in program enrollment and eligibility1 beneficiary opt-out rates1 and other changes specified by the ,secretary4 7f7 ,rule of construction of continuation as a medicare and medicaid beneficiary for purposes other than benefits ,the fact that an individual qualifies as an ,,aimp-eligible individual shall not be construed as removing the individual's status as an individual entitled to benefits under title ,,xviii or ,,xix1 but insofar as the individual becomes an ,,aimp enrollee entitled to benefits under this title1 such entitlement to benefits under titles ,,xviii and ,,xix shall be considered as met through the provision of benefits under this title4 #bbjc4 ,enrollment 7a7 ,beneficiary choice ,in an ,,aimp-participating ,state under its ,,aim program1 an ,,aimp-eligible individual may select 7in a manner specified by the ,state consistent with this section7 to receive benefits through any of the following3 7#a7 ,the ,state ,,aim program4 7#b7 ,a ,,pace program 7if available to the individual in the ,state74 7#c7 ,a combination of ,medicare fee-for-service program 7under parts ,a1 ,b1 and ,d1 as applicable1 of title ,,xviii7 and medical assistance under title ,,xix 7whether delivered through fee-for-service or managed care1 as provided by the ,state under such title74 7b7 ,initial assignment at time of program implementation or initial enrollment ,an ,,aimp-participating ,state may provide that all ,,aimp-eligible individuals in the ,state who are not enrolled in a ,,pace program under section #ahid or #aicd and who do not make an affirmative selection under subsection 7a77#c7 shall be deemed to have elected to enroll in the ,,aim program of the ,state4 7c7 ,coordination of selection and enrollment with medicare enrollment processes ,the process for selection and enrollment of ,,aimp-eligible individuals in ,,aim programs shall be consistent and coordinated with the processes for enrollment in ,medicare ,advantage plans under part ,c of title ,,xviii during open and special enrollment periods4 ,such processes shall1 consistent with section #dbc4ch7;c7 of title #db1 ,code of ,federal ,regulations 7or any successor regulation7 and any other applicable regulations1 provide-- 7#a7 a special enrollment period for individuals who-- 7,a7 are dually eligible individuals enrolled in fee-for-service ,medicare when the ,state ,,aim program is first established to permit such individuals to elect to enroll in the ,state ,,aim program2 or 7,b7 become ,,aimp-eligible individuals2 and 7#b7 for the right of an ,,aimp-enrolled individual to disenroll from the ,,aim program and to otherwise to make changes in the selection in enrollment described in subsection 7a74 7d7 ,assistance in enrollment choice ,an ,,aimp-participating ,state must contract with #a or more independent enrollment brokers1 at least #a of which is a nonprofit1 community-based organization1 and all of which are approved by the ,secretary1 to assist ,,aimp-eligible individuals in understanding the ,,aim program and making enrollment choices under this section in the same manner as such brokers are permitted with respect to enrollment of individuals under its ,state plan under title ,,xix 7or waiver thereof71 except that no individual sales commissions shall be permitted 7including to the extent such commissions may otherwise be permitted by brokers and employed or captive agents under the ,medicare ,advantage program under part ,c of title ,,xviii74 7e7 ,construction regarding continued medicaid use of managed care ,nothing in this subsection shall be construed as affecting the authority of an ,,aimp-participating ,state to require1 in the case of an ,,aimp-eligible individual who makes the election described in subsection 7a77#c7 7or otherwise opts-out of enrollment in the ,,aim program and into benefits under title ,,xix71 to obtain benefits for covered services under title ,,xix through participation in a managed care plan or arrangement4 7f7 ,assignment of enrollees to ,,aimp-,administering entities 7#a7 ,in general ,an ,,aimp-eligible individual enrolled under an ,,aim program shall be provided with a choice of the ,,aimp-administering entity to which the individual is assigned for purposes of obtaining benefits under the program4 7#b7 ,initial assignment at time of program implementation or initial enrollment 7,a7 ,in general ,in the case of an ,,aimp-eligible individual who1 at the time of enrollment under an ,,aim program1 is enrolled in an integrated program for individuals dually eligible for ,medicare and ,medicaid participating in the ,financial ,alignment ,initiative of the ,federal ,coordinated ,health ,care ,office1 or enrolled in a ,medicare ,advantage plan that is a highly integrated dual eligible special needs plan or a fully integrated dual eligible special needs plan1 the ,state ,,aim program may initially assign the individual to the ,,aimp-administering entity for such ,medicare ,advantage plan 7or1 in the case of an ,,aimp-eligible individual who1 at the time of enrollment under an ,,aim program1 is enrolled in an integrated program for individuals dually eligible for ,medicare and ,medicaid participating in the ,financial ,alignment ,initiative of the ,federal ,coordinated ,health ,care ,office1 to the ,,aimp-administering entity designated by the ,state71 or another ,,aimp-administering entity1 if necessary if-- 7i7 the provider network of such entity under the ,,aim program is substantially similar to the network used under the plan offered by the entity that the individual is enrolled in prior to such assignment2 and 7ii7 the individual is provided with-- 7,i7 at least #a written notice of such assignment at least #fj days in advance of the effective date of the assignment2 and 7,,ii7 at least #a phone call notifying the individual of the assignment in advance of the effective date of the assignment4 7,b7 ,continuity of care ,to the extent possible to prevent disruption and promote continuity of care1 a ,state ,,aim program shall seek to ensure that individuals described in subparagraph 7,a7 are assigned to the ,,aimp-administering entity that offers the plan or program in which the individual is enrolled in prior to the individual's transfer to1 and enrollment in1 the ,state ,,aim program4 7,c7 ,conditional initial assignment for other ,,aimp-eligible individuals ,in the case of an ,,aimp-eligible individual who1 at the time of enrollment under a ,state ,,aim program is enrolled in a ,medicare ,advantage plan that is operating as an ,,aimp-administering entity other than a plan described in subparagraph 7,a71 or is enrolled in a ,medicaid managed care plan offered by the same entity that is operating as an ,,aimp-administering entity in the ,state ,,aim ,program1 the ,state ,,aim program may initially assign the individual to that ,,aimp-administering entity if-- 7i7 the provider network of such entity under the ,state ,,aim program is substantially similar to the network used under the ,medicare ,advantage plan or ,medicaid managed care plan offered by the entity that the individual is enrolled in prior to such assignment2 and 7ii7 the individual is provided with-- 7,i7 at least #a written notice of such assignment at least #fj days in advance of the effective date of the assignment2 and 7,,ii7 at least #a phone call notifying the individual of the assignment in advance of the effective date of the assignment4 7#c7 ,rule of construction ,nothing in this subsection shall be construed as-- 7,a7 preventing an individual from choosing to be assigned to a different participating ,,aimp-administering entity2 7,b7 preventing an individual from changing their assignment to an ,,aimp-administering entity or from opting-out of participating in the ,state ,,aim program2 or 7,c7 constraining or changing the authority of a ,state under the ,state plan under title ,,xix or under a waiver of such plan to require a ,medicaid-eligible individual to enroll with a managed care entity if the individual chooses not to participate in the ,,aim ,program4 7#d7 ,choice of enrollment from fee-for-service medicare ,an ,,aimp-eligible individual who1 as of the date on which a ,state first implements the ,state ,,aim program1 is enrolled in the ,medicare fee-for-service program under title ,,xviii1 may elect to enroll in the ,state ,,aim ,program through a special enrollment period established for such individuals1 consistent with the requirements of section #dbc4ch7;c77#d7 of title #db1 ,code of ,federal ,regulations 7or a successor regulation74 7g7 ,effect of enrollment on medicare and medicaid payments to states ,except as provided in this title1 in the case of an individual who is enrolled as an ,,aimp enrollee under a ,state ,,aim program under this title1 during the period of such enrollment payment to the ,state under this title shall be instead of the payment amounts which would otherwise be payable under title ,,xviii or ,,xix for items and services furnished to the enrollee4 7h7 ,outreach and enrollment support 7#a7 ,funding ,for the purpose of providing funding assistance to ,,aimp-participating ,states for outreach to1 and enrollment support of1 ,,aimp-eligible individuals1 there is appropriated1 out of any money in the ,treasury not otherwise appropriated1 such sums as may be necessary for each fiscal year beginning with the first fiscal year that begins on or after the date of enactment of this title4 7#b7 ,use of funds ,an ,,aimp-participating ,state shall use funds provided to the ,state under this subsection for outreach to1 and enrollment support of1 ,,aimp-eligible individuals1 that includes the following3 7,a7 ,distributing outreach and enrollment materials printed in accessible language formats 7including primary languages1 ,braille1 large print1 and alternative texts74 7,b7 ,engaging community-based organizations to conduct outreach to1 and provide enrollment assistance for1 ,,aimp-eligible individuals4 7,c7 ,referring ,,aimp-eligible individuals to the ,state long-term care ombudsman1 the qualified nonprofit ,,aim ,ombudsman selected for the ,,aim program under section #bbje7;c71 and other beneficiary support entities for enrollment assistance and information4 #bbjd4 ,benefits 7a7 ,covered benefits 7#a7 ,in general ,a ,state ,,aim program shall provide a core package of covered benefits to address medical1 behavioral1 long-term care1 and social needs of ,,aimp enrollees in accordance with an individual assessment and plan of care4 ,such core package of available benefits shall include the following3 7,a7 ,medicare benefits ,all benefits available under parts ,a1 ,b1 and ,d of title ,,xviii1 including with respect to benefits available under such part ,d1 coverage of the #f protected classes and #b drugs from each class4 7,b7 ,medicaid mandatory benefits ,all benefits otherwise required to be provided to ,,aimp-eligible individuals under title ,,xix in the ,state if they were not ,,aimp enrollees4 7,c7 ,historic benefits ,all ,medicaid services and benefits offered as of #a year prior to the enactment of this title1 as required by section #bbjd7;d74 7,d7 ,drugs ,all prescription drugs and covered outpatient drugs available under the ,state ,medicaid program1 including any such drugs that are available under a prescription drug plan under part ,d of title ,,xviii4 7,e7 ,additional services ,an ,,aimp-participating ,state may1 with approval from the ,federal ,coordinated ,health ,care ,office1 make available under the ,state ,,aim program additional behavioral health1 social1 and supportive services that enable flexibility to achieve person-centered outcomes in the most cost-effective setting4 7#b7 ,limitation on benefit carve-outs ,the ,secretary may permit a ,state ,,aim program to exclude benefits for some services under paragraph 7#a77;,c7 if the ,secretary determines that such an exclusion is essential for the ,state to implement the ,,aim program but such exclusion may not extend over a period of longer than #d years4 7b7 ,benefit assessment process 7#a7 ,assessment tool and plan of care 7,a7 ,development ,not later than #ah months after the date of the enactment of this title1 the ,secretary1 in consultation with ,state agencies administering ,state plans or waivers under title ,,xix and with input from other stakeholders1 shall develop and publish a robust1 comprehensive standard assessment tool for use by all ,,aim programs in evaluating the condition and needs of ,,aimp enrollees for benefits under the program4 7,b7 ,application to plan of care ,each ,,aim program shall provide for an assessment for each ,,aimp enrollee1 using such standard assessment tool1 to form a basis for the enrollee's plan of care under the program4 ,such an assessment shall be conducted at least annually1 and when a triggering event 7as defined by the ,secretary7 affecting the enrollee's need for care occurs4 7,c7 ,application of grievance and appeals procedures ,disagreements concerning the plan of care for an ,,aim enrollee shall be subject to grievance and appeal rights under section #bbje7;b74 7#b7 ,standard assessment tool ,the standard assessment tool under paragraph 7#a7 shall-- 7,a7 contain a required set of core elements1 to which ,states and ,,aimp-administering entities may add additional requirements so long as the requirements a ,state or ,,aimp administering entity uses contain at a minimum the core set of elements2 7,b7 cover multiple domains1 including medical1 functional1 behavioral1 and social domains2 and 7,c7 be applicable to the full range of ,,aimp enrollees1 including individuals with serious mental illness and with needs for assistance with activities of daily living4 7c7 ,state provision of covered benefits 7#a7 ,use of tiered-benefit model ,an ,,aimp-participating ,state may establish a tiered-benefit design structure for benefits so that specialized benefits may be available to meet the needs of specific subpopulations of ,,aimp enrollees so long as such tiering-- 7,a7 only applies to benefits described in subparagraph 7,e7 of subsection 7a77#a7 and does not limit the coverage of core covered benefits described in subparagraphs 7,a7 and 7,b7 of such subsection2 and 7,b7 is no more restrictive than the benefit structure in place in the ,state under title ,,xix in the year before the date of the enactment of this title4 7#b7 ,in-lieu-thereof alternative services permitted ,an ,,aimp-participating ,state may permit ,,aimp-administering entities to cover benefits for cost-effective alternative services 7known as in lieu of services7 instead of benefits for services otherwise included under the ,,aim program but in no case shall an ,,aimp enrollee be required to use such alternative services4 7#c7 ,continuity of services 7,a7 ,in general ,except as provided in subparagraph 7,b71 during the first #f months of an ,,aim enrollee's enrollment in an ,,aim program 7or for such longer period as the ,,aim program may provide7 an ,,aimp-participating ,state shall continue to provide access to all medically necessary covered items and services and providers 7for continuity of care7 that were being provided at the time of enrollment4 7,b7 ,exception ,subparagraph 7,a7 shall not apply in cases in which it is determined by the ,state1 and agreed to by the ,secretary1 that the ,,aimp enrollee was not eligible for such services at the time of enrollment or was enrolled in the ,,aim program due to error or fraud4 7d7 ,maintenance of effort ,as a condition for approval of an ,,aim program of a ,state1 the ,state shall maintain levels of benefits for ,,aim enrollees under the program that are not less than the level of benefits under its ,state plan 7including under a waiver7 under title ,,xix for full-benefit dual eligible individuals as of fiscal year #bjba1 as of the fiscal year before the fiscal year in which this title is enacted1 or as of the fiscal year before the #ast fiscal year in which the program is implemented in the ,state1 whichever fiscal year has the highest level of benefits4 7e7 ,administration of benefits through ,,aim-,administering entities ,,aimp-participating ,states shall provide for the coordination of1 and the responsibility for the delivery of covered services through ,,aim-administering entities under an ,,aim contract under section #bbjg4 #bbje4 ,beneficiary protections 7a7 ,in general ,except as otherwise provided1 the beneficiary protections applicable to individuals enrolled under plans under parts ,c and ,d of title ,,xviii and under a ,state plan under title ,,xix shall apply in a manner specified by the ,secretary to ,,aimp enrollees under an ,,aim program under this title and are in addition to beneficiary protections provided under this title4 7b7 ,application of grievances and internal and external appeals under ,,aimp contracts ,the rights of individuals with respect to internal and external complaints and appeals processes shall be specified in the contract between the ,,aimp-participating ,state and an ,,aimp-administering entity4 ,such processes shall1 at a minimum1 incorporate relevant rights and processes from the requirements for plans under parts ,c and ,d of title ,,xviii as well as requirements for ,medicaid managed care organizations under title ,,xix4 7c7 ,requirement for qualified ,,aim ombudsman program 7#a7 ,in general ,as a condition for approval of an ,,aim program for a ,state under this title-- 7,a7 the ,state shall have established and have ready for implementation not later than #ah months prior to implementing the ,,aim program1 a qualified nonprofit ,,aim ,ombudsman program run by a community-based organization for such ,,aim program2 and 7,b7 the ,state1 before implementation of its ,,aim program1 shall demonstrate to the satisfaction of the ,secretary 7through an application of certification process specified by the ,secretary7 that its ,,aim ,ombudsman program has the capacity to carry out its functions in the ,state1 including that the program has the independence1 expertise1 and adequate resources in place to serve ,,aimp-eligible individuals and ,,aimp enrollees under the ,state ,,aim program4 7#b7 ,qualifications for qualified aim ombudsman program 7,a7 ,in general ,in order to be a qualified ,,aim ,ombudsman program1 such program must meet the requirements of this subsection for such a program4 7,b7 ,construction ,nothing in this subsection shall be construed as preventing a qualified ,,aim ,ombudsman program from being structured as part of another protection service 7including those specified in paragraph 7#c771 so long as such other protection service meets the requirements of this subsection for a qualified ,,aim ,ombudsman program4 7#c7 ,coordination with other beneficiary protection services ,a qualified ,,aim ,ombudsman program shall coordinate with ,state and ,federal beneficiary protection services1 including the following3 7,a7 ,demonstration ,ombudsman ,programs ,serving ,medicare-,medicaid ,enrollees4 7,b7 ,managed ,care ,beneficiary ,support ,systems4 7,c7 ,long-,term ,care ,ombudsman ,programs4 7,d7 ,disability ,protection and ,advocacy ,programs4 7#d7 ,core services ,a qualified ,,aim ,ombudsman program for an ,,aimp-participating ,state shall have authority to provide the following core services with respect to the ,,aim program in the ,state3 7,a7 ,individual assistance 7including consumer education and empowerment1 assistance with and representation in beneficiary appeals1 fair hearings1 and grievances1 guidance regarding plan and provider selection1 and support during enrollment and disenrollment7 for ,,aimp-eligible individuals considering enrollment in the ,state ,,aim program and for ,,aimp enrollees in such program4 7,b7 ,systemic monitoring and reporting to the ,state regarding compliance with applicable requirements4 7#e7 ,providing reports to consumer advisory boards ,a qualified ,,aim ,ombudsman program for a ,state shall provide1 on a timely basis1 any reports it produces to the consumer advisory boards 7established under subsection 7e77 for the ,state and shall make them publicly available4 7#f7 ,funding and oversight 7,a7 ,in general ,the ,secretary shall oversee and administer ,federal funding directly to qualified ,,aim ,ombudsman programs established by ,states4 7,b7 ,funding level ,for the purpose of providing funding to qualified ,,aimp ,ombudsman programs in each ,state over a period of #c fiscal years1 there is appropriated1 out of any money in the ,treasury not otherwise appropriated1 not less than #a1jjj1jjj1 and not more than #e1jjj1jjj4 ,the ,secretary shall determine the funding for each such program based on the estimated number of ,,aimp-eligible individuals in each ,state4 7,c7 ,supplemental funding ,nothing in this paragraph shall be construed as preventing an ,,aimp-participating ,state from providing supplemental funding for the qualified ,,aim ,ombudsman program for the ,state4 7d7 ,beneficiary advisory council ,each ,,aimp-participating ,state shall have in operation a ,beneficiary ,advisory ,council to advise the ,state regarding the treatment of ,,aimp-eligible individuals and ,,aimp enrollees under this title4 ,the composition and specific functions and authority of such a ,council shall be delineated in readiness review requirements specified by the ,secretary in carrying out paragraphs 7#b7 and 7#c7 of section #bbja7;d74 7e7 ,consumer advisory boards 7#a7 ,in general ,each ,,aimp-participating ,state and each ,,aimp-administering entity in each such ,state shall establish a consumer advisory board that will provide regular feedback to the ,state or governing board of the entity1 respectively1 on issues of care of ,,aimp enrollees under the ,,aim program in that ,state or through that entity1 respectively4 7#b7 ,composition2 functions ,each such consumer advisory board shall-- 7,a7 meet at least quarterly2 7,b7 be comprised of members who-- 7i7 may be subject to approval by the ,secretary and the ,,aimp-participating ,state2 7ii7 are ,,aimp enrollees2 7iii7 are family members and other caregivers for ,,aimp enrollees2 and 7iv7 are chosen in a manner that reflects the demographic diversity of the population of ,,aimp enrollees1 including with respect to race1 ethnicity1 age1 and urban and rural populations1 and which includes individuals with disabilities2 7,c7 meet the requirements for member advisory committees under section #dch4aaj of title #db1 ,code of ,federal ,regulations2 and 7,d7 file and make publicly available an annual report that includes at least information on-- 7i7 the dates for its meetings held within the reporting year2 7ii7 the names of board members invited and of those members in attendance at each such meeting2 and 7iii7 the agenda and minutes for each such meeting4 #bbjf4 ,federal administration 7a7 ,primary administration through the ,federal ,coordinated ,health ,care ,office 7#a7 ,in general ,the ,secretary shall carry out this title through the ,federal ,coordinated ,health ,care ,office1 except that with respect to payments under section #bbjh1 the ,secretary may delegate such authority to the ,administrator of the ,centers for ,medicare ,medicaid ,services4 7#b7 ,appropriations ,there are hereby appropriated to the ,secretary to carry out this title1 out of any funds in the ,treasury not otherwise appropriated-- 7,a7 for each of fiscal years #bjbb1 #bjbc1 and #bjbd1 #ajj1jjj1jjj2 and 7,b7 for each succeeding fiscal year1 #cj1jjj1jjj4 7b7 ,standards and process 7#a7 ,federal standards ,in carrying out this title1 the ,secretary shall specify a minimum set of ,federal standards1 including standards relating to access to care1 quality of care1 beneficiary protections1 marketing and enrollment1 grievances and appeals1 and procurement4 7#b7 ,transparency in rulemaking ,in implementing the provisions of this title1 to the extent practical1 the ,secretary shall utilize notice and comment rulemaking to ensure transparency for stakeholders4 7#c7 ,application of knowledge gained from demonstration projects and contract management teams under the financial alignment initiative ,the ,secretary shall carry out this title taking into account the knowledge gained from the use of contract management teams in demonstration projects under the ,financial ,alignment ,initiative for ,medicare-,medicaid ,enrollees administered by the ,federal ,coordinated ,health ,care ,office4 7c7 ,direct-,hire authority ,in carrying out this title1 the ,secretary 7acting through the ,federal ,coordinated ,health ,care ,office7 shall have direct-hire authority to the extent required to implement and administer this title on a timely basis4 #bbjg4 ,selection and role of ,,aim-administering entities 7a7 ,requirements for ,state selection of ,,aim-,administering entities ,the ,secretary1 in consultation with ,states1 shall develop 7not later than #a year after the date of the enactment of this title7 a set of standardized requirements for the selection of qualified organizations to serve as ,,aimp-administering entities in the ,,aim programs in each ,,aimp-participating ,state4 7b7 ,application of criteria for the qualification and selection of ,,aimp-,administering entities 7#a7 ,in general ,each ,,aim program in an ,,aimp-participating ,state shall be implemented through contracts entered into by the ,,aimp-participating ,state and organizations that qualify as ,,aimp-administering entities under this title4 ,a contract with an ,,aimp-administrating entity shall require the entity to assume #b-sided financial risk in return for payment for the arrangement and delivery of covered benefits to ,,aimp enrollees assigned to the entity under the program4 7#b7 ,specification of criteria ,the ,secretary and ,,aimp-participating ,states shall establish basic national criteria for the qualification and selection of organizations to be ,,aimp-administering entities4 ,such criteria shall take into account the prior experience 7including under both the ,medicare program under title ,,xviii and ,medicaid programs under title ,,xix7 of such an organization in serving the population of ,,aimp-eligible individuals as well as other criteria1 including the following3 7,a7 ,the organization's experience serving ,,aimp-eligible individuals in that ,state 7or another ,state71 including the organization's experience in providing covered services described in section #bbjd7;a77#a7 7including long-term services and supports and behavioral health services7 to such individuals1 and in integrating all of those services and supports for such individuals in that ,state 7or another ,state74 7,b7 ,the organization's performance on key quality measures in providing such services1 such as on measures of key health outcomes and enrollee satisfaction4 7,c7 ,the adequacy of the organization's provider network in ensuring timely access to care4 7,d7 ,the organization's demonstrated experience in implementing models of care for the full range of such services1 including with respect to non-medical services described in section #bbjd7;a77#a74 7#c7 ,additional state-specific criteria ,nothing in this subsection shall be construed as preventing a ,state1 with the approval of the ,secretary1 from applying additional criteria or requirements regarding health care quality1 equity1 or access on ,,aimp-administering entities specific to quality1 equity1 or access1 so long as such requirements and criteria-- 7,a7 can be applied consistently to all ,,aimp-administering entities2 and 7,b7 are made available for public comment prior to being imposed4 7#d7 ,application of medical loss ratio requirements 7,a7 ,in general ,any ,,aimp contract between an ,,aimp-participating ,state and an ,,aimp-administering entity to administer benefits under an ,,aim program shall include a requirement that the medical loss ratio under the ,,aim program shall not be not less than a percentage 7not less than #he percent7 specified by the ,state and that the entity shall return to the ,state payment amounts that result in the medical loss ratio being below such percentage4 7,b7 ,special rules ,if an administering entity who is contracting with a participating ,state to administer a program under this title is an entity bearing #b-sided risk1 the ,state shall establish with the approval of the ,secretary a mechanism comparable to a medical loss ratio target to ensure appropriate spending on services by the entity4 7c7 ,state procurement process for ,,aimp-,administering entities 7#a7 ,in general ,each ,,aimp-participating ,state shall be responsible for establishing and implementing a process for the procurement and selection of ,,aimp-administering entities for the ,state ,,aim program1 subject to the approval of the ,secretary4 ,the ,secretary shall not approve such a process unless the ,state demonstrates to the ,secretary's satisfaction that the process results in the selection of ,,aimp-administering entities that meet the requirements of this title and are qualified to serve the needs of ,,aimp enrollees in the ,state under the ,state's ,,aim program4 ,an ,,aimp-participating ,state may add additional requirements specific to quality1 equity1 or access that further the ,state's overall integrated care strategy and goals1 so long as such requirements are posted for public comment and approved by the ,federal ,coordinated ,health ,care ,office4 7#b7 ,separate procurement process required for initial procurement ,for the initial procurement executed to establish an ,,aim program in an ,,aimp-participating ,state1 the ,state shall not combine its ,,aim administering entity procurement process with a procurement process that is also used for procurement under the ,state plan or waiver under title ,,xix and shall select ,,aim administering entities through a standalone procurement process4 7d7 ,payments to ,,aim-,administering entities ,each ,,aimp-participating ,state shall make payments to ,,aim-administering entities under a risk-adjusted payment model that-- 7#a7 reflects the risk of the population of ,,aimp enrollees served by each entity2 7#b7 ensures that there are appropriate resources to serve the ,,aimp enrollees in the ,state2 and 7#c7 protects against any adverse selection of ,,aimp enrollees by entities4 #bbjh4 ,program financing 7a7 ,payments to ,states with ,,aim programs 7#a7 ,for program benefits 7,a7 ,in general ,from the sums appropriated under paragraph 7#c71 the ,secretary shall pay to each ,,aimp-participating ,state for each quarter in a fiscal year 7beginning with the first fiscal year that begins after the date of enactment of this title71 an amount equal to the ,federal ,,aimp matching percentage 7as defined in subsection 7b77#a77 of the total amount expended during the quarter as ,,aimp assistance 7as defined in subparagraph 7,b74 7,b7 ,,aimp assistance defined ,in this title1 the term ,,aimp assistance has the meaning given the term medical assistance under section #aije7;a71 except that in applying such term under this subparagraph-- 7i7 the services described in section #bbjd7;a77#a7 shall be substituted for the services described in paragraph 7#a7 and the subsequent paragraphs of such section #aije7;a72 7ii7 an ,,aimp enrollee shall be treated as an individual referred to in the matter in section #aije7;a7 before paragraph 7#a7 of such section2 and 7iii7 the exclusion in the subdivision 7,b7 following the last paragraph of the first sentence of section #aije7;a7 shall not apply4 7#b7 ,for administrative expenses ,in addition to the amount paid for each quarter in a fiscal year to an ,,aimp-participating ,state under paragraph 7#a71 the ,secretary shall pay to each such ,state for each quarter in a fiscal year 7beginning with the first fiscal year that begins after the date of enactment of this title71 from the sums appropriated under paragraph 7#c71 not less than #ej percent of the total amount expended during such quarter as found necessary by the ,secretary for the proper and efficient administration of the ,state ,,aim program under this title4 7#c7 ,appropriation ,there is appropriated1 out of any money in the ,treasury not otherwise appropriated1 such amounts as may be required to provide payments to ,states under this section1 reduced by any amounts made available from the ,medicare trust funds under paragraph 7#e74 7#d7 ,relation to other payments ,payment amounts provided under this subsection are in addition to payments provided under other provisions of this title4 7#e7 ,relation to medicare trust funds ,there shall be made available for application under this title from the ,federal ,hospital ,insurance ,trust ,fund 7under section #ahag7 and from the ,federal ,supplementary ,medical ,insurance ,trust ,fund 7under section #ahda7 7and from the ,medicare ,prescription ,drug ,account 7under section #ahfj;,d-#af7 within such ,trust ,fund7 such amounts as the ,secretary determines appropriate1 taking into account the reductions in payments from such ,trust ,funds and ,account that are attributable to the coverage of ,,aimp enrollees under ,,aim programs under this title4 7b7 ,federal ,,aimp matching percentage 7#a7 ,in general ,in this section1 the term ,federal ,,aimp matching percentage means1 for an ,,aimp-participating ,state for a fiscal year1 #ajj percent minus the ,state contribution percentage 7as defined in paragraph 7#b77 for the ,state and fiscal year4 7#b7 ,state contribution percentage formula 7,a7 ,in general ,in this section1 the term ,state contribution percentage means1 subject to adjustment under the subsequent provisions of this paragraph1 with respect to an ,,aimp-participating ,state for-- 7i7 the #ast fiscal year of the ,,aim program in the ,state1 the base ,,aimp ,state percentage computed under subsection 7c72 or 7ii7 a subsequent fiscal year1 the ,state contribution percentage under this paragraph for the previous fiscal year adjusted in accordance with subparagraph 7,b7 or 7,c71 as applicable4 7,b7 ,annual adjustment based on changes in expenditures ,for an ,,aimp-participating ,state for a fiscal year after such #ast fiscal year1 if the expenditures for ,,aimp assistance for which payment is made under subsection 7a77#a7 under the ,state ,,aim program for the second previous fiscal year-- 7i7 are not greater than #aaj percent1 or less than #ij percent1 of the ,,aimp assistance expenditures for the previous fiscal year1 there shall be no adjustment for the fiscal year involved under this subparagraph2 7ii7 is greater than #aaj percent of the ,,aimp assistance expenditures for the previous fiscal year1 the adjustment under this subparagraph for the fiscal year involved shall be an increase in the ,state contribution percentage of #a percentage point for each multiple of #aj percentage points by which such ,,aimp assistance expenditures exceed #aaj percent2 or 7iii7 is less than #ij percent of the ,,aimp assistance expenditures for the previous fiscal year1 the adjustment under this subparagraph for the fiscal year involved shall be a decrease in the ,state contribution percentage of #a percentage point for each multiple of #aj percentage points by which such ,,aimp assistance expenditures is less than #ij percent4 7,c7 ,additional adjustments for exceptions ,the ,secretary shall provide a process by which adjustments may be made to the ,state contribution percentage to take into account increases and decreases in ,,aimp expenditures described in clause 7ii7 or 7iii7 of subparagraph 7,b7 in which the adjustments under such clauses would not apply1 such as in cases of a significant increase or decrease in ,,aimp enrollees1 a declaration of a national emergency that impacts on ,,aimp expenditures under this title1 or a significant cost increase beyond the control of the ,state1 as determined by the ,secretary4 7c7 ,baseline expenditure and percentage computations 7#a7 ,in general ,using the data reported under paragraph 7#b73 7,a7 ,computation of base aimp percentages ,for the base ,federal fiscal year 7as defined in paragraph 7#c771 the ,secretary shall compute and publish for each ,state-- 7i7 the base ,,aimp ,state percentage 7as defined in subparagraph 7,b77 for the ,state and such fiscal year2 and 7ii7 the ,federal ,,aimp matching percentage for the ,state and such fiscal year4 7,b7 ,base ,,aimp state percentage defined ,in this section1 the base ,,aimp ,state percentage means the amount equal to the ratio 7expressed as a percentage7 of-- 7i7 the sum of-- 7,i7 the amount of the ,state share of expenditures under title ,,xix for medical assistance during the base ,federal fiscal year attributable to full-benefit dual eligible individuals2 and 7,,ii7 the amount of the payment made to the ,federal ,government during the base ,federal fiscal year under section #aice7;c7 7commonly referred to as the part ,d clawback7 attributable to such individuals2 to 7ii7 the sum of-- 7,i7 the total expenses paid under title ,,xviii that are attributable to full-benefit dual eligible individuals for services 7or periods of coverage7 occurring the base ,federal fiscal year 7as estimated by the ,secretary72 and 7,,ii7 the total amount expended on items and services described in section #bbjd7;a77#a7 paid under title ,,xix 7including any waivers under title ,,xi7 for full-benefit dual eligible individuals in the base ,federal fiscal year4 7,c7 ,adjustments to base ,,aimp percentages ,with respect to the base ,,aimp ,state percentages and the ,federal ,,aimp matching percentages otherwise computed under this paragraph for the base ,federal fiscal year1 the ,secretary shall adjust such percentages to take into account material changes in the programs under titles ,,xviii and ,,xix between the base ,federal fiscal year and the first fiscal year for which ,,aim programs may be implemented under this title insofar as such material changes have a direct material impact on ,,aimp expenditures relating to ,,aimp-eligible individuals4 7#b7 ,data reporting for baseline computations ,each ,state1 in its application for approval of its ,,aim program1 shall provide the ,secretary 7in such form and manner as the ,secretary may require7 such financial data 7including detailed and aggregate1 historical and projected expenditures data7 on its expenditures under title ,,xix as the ,secretary may require to carry out the computations required under this section4 ,the ,secretary shall share with the ,state1 in a process defined by the ,secretary1 ,medicare expenditure data 7including detailed and aggregate historical and projected expenditures data7 for services and benefits for full-benefit dual eligible individuals in such ,state4 7#c7 ,base federal fiscal year defined ,in this section1 the term base ,federal fiscal year means the ,federal fiscal year that is the second preceding fiscal year to the #ast fiscal year for which ,,aim programs may be implemented under this title4 7d7 ,reinvestment of shared savings 7#a7 ,in general 7,a7 ,in general ,if1 with respect to a fiscal year1 an ,,aimp-participating ,state has expenditures under this title for ,,aimp assistance that for the preceding fiscal year1 are less than #he percent of the expenditures for such assistance under the ,state ,,aim program for the second preceding fiscal year1 the ,secretary shall ensure that for each quarter in the following fiscal year1 the ,state spends at least the shared savings amount determined for the ,state for the fiscal year on #a or more of the core applications described in paragraph 7#c74 ,amounts expended by a ,state to meet the requirement of the preceding sentence shall not be subject to any ,federal matching payments under this title4 7,b7 ,shared savings amount defined ,in this subsection1 the term shared savings amount means1 with respect to an ,,aimp-participating ,state for a fiscal year1 the amount by which the ,,aimp assistance expenditures for the fiscal year is less than #he percent of the expenditures for such assistance under the ,state ,,aim program for the second preceding fiscal year4 7#b7 ,application of shared savings ,the ,secretary shall issue guidance outlining allowable use of the shared savings payments under paragraph 7#a74 ,under such guidance1 the ,secretary shall outline the types of services and benefits for which a ,state has the authority to apply the payments for the benefit of consumers who are ,,aimp-eligible individuals4 ,such guidance shall permit the use of such payments consistent with the core applications described in paragraph 7#c7 and with paragraph 7#d71 and may be used for existing ,state-funded health programs or new health-related initiatives that serve full-benefit dual eligible individuals under this title4 7#c7 ,core applications ,the core applications described in this paragraph for such consumers are as follows3 7,a7 ,consumer power and choice ,to provide such consumers more information and control over their health care and community support options4 7,b7 ,equity and access to care ,to improve access to1 and quality of1 care across populations1 advance health equity for consumers1 and reduce health disparities and eliminate barriers to care4 7,c7 ,prevention and wellness ,to strive to better enable such consumers to receive individualized health care that is outcomes-oriented and focused on prevention1 wellness1 recovery and maintaining independence4 7,d7 ,pay for performance ,to employ purchasing and payment methods that encourage and reward service quality and cost-effectiveness by linking reimbursements for services to such consumers to common1 evidence-based quality performance measures1 including patient satisfaction4 7,e7 ,innovative advancement ,to implement innovative and technological advancements that facilitate such consumers remaining in the community4 7,f7 ,service integration ,to increase integration of services with social needs to improve health outcomes for such consumers4 7,g7 ,state personnel ,to hire additional ,state personnel to carry out this title4 7,h7 ,capacity building ,to expand capacity in providing services to such consumers1 such as in-- 7i7 community-based care2 and 7ii7 caregiver assistance4 7,i7 ,improve enrollment policies and process ,to improve the ability to enroll in the ,state ,,aimp program through streamlining enrollment policies and processes4 7,j7 ,increase education for providers and beneficiaries ,to ensure providers and beneficiaries understand the ,state ,,aimp program and the choices available under such program4 7,k7 ,improve data collection regarding racial disparities and health inequities ,to ensure appropriate data is collected and used to determine program inequities4 7,l7 ,other services and initiatives ,other services and initiatives approved by the ,secretary that serve full-benefit dual eligible individuals under this title4 7#d7 ,limitation on payment to ,,aimp-administering entities ,an ,,aimp-participating ,state may use payments under this subsection for an ,,aimp-administering entity only if the ,state demonstrates1 to the satisfaction of the ,secretary1 that the ,state's ,,aim program provides appropriate maintenance of access to and quality of care based on the requirements imposed by the ,state on the applicable ,,aimp-administering entities4 7e7 ,application of medicaid payment methodologies financing limitations for the non-,federal share of expenditures 7#a7 ,in general ,except as the ,secretary may otherwise provide through notice and comment regulation1 the following provisions of title ,,xix 7and related regulations7 shall apply to ,,aimp-participating ,states' expenditures in the ,,aim program in a manner similar to the manner in which such provisions apply under title ,,xix3 7,a7 ,section #aijc7;d7 7relating to estimated payments1 recovery of overpayments1 disallowance of provisions74 7,b7 ,section #aijc7w7 7relating to provider-related donations1 health care related taxes1 and broad-based health care related taxes74 7,c7 ,section #aijc7w77#f7 7relating to certified public expenditures and intergovernmental transfers74 7,d7 ,other provisions relating to deferral of payments1 preventing fraud and abuse1 and ensuring program integrity4 7#b7 ,processes and forms 7,a7 ,in general ,the ,secretary shall establish appropriate forms and processes 7including expenditure reconciliation processes7 for submission of information on ,state expenditures under this title in a manner similar to the processes used for purposes of payments to ,states under title ,,xix1 but through the use of such alternative forms as may be appropriate in implementing this title4 7,b7 ,reporting of estimated expenditures by quarter ,an ,,aimp-participating ,state shall estimate matchable expenditures 7including both total expenditures as well as the estimated ,federal share of those expenditures7 and separately report these expenditures by quarter for each fiscal year for its ,,aim program4 ,the ,secretary shall make ,federal funds available based upon the ,state's estimate1 as approved by the ,secretary4 7,c7 ,reporting and reconciliation of actual expenditures on a quarterly basis ,not later than #cj days after the end of each quarter1 each ,,aimp-participating ,state shall submit to the ,secretary 7on an appropriate form7 a quarterly expenditure report1 showing expenditures made in the quarter just ended under its ,,aim program4 ,the ,secretary shall reconcile expenditures so reported with ,federal funding previously made available to the ,state under this section and include the reconciling adjustment in the finalization of the grant award to the ,state4 7#c7 ,rule of construction ,nothing in this title shall be construed as constraining or limiting the authority of the ,secretary1 the ,administrator of the ,centers for ,medicare ,medicaid ,services1 the ,inspector ,general of the ,department of ,health and ,human ,services1 or the ,comptroller ,general of the ,united ,states1 to conduct routine and targeted program and financial management audits and other oversight activities of funds expended under this title1 including oversight activities relating to the allowable use of funds4 7f7 ,option for multi-,year investment initiative ,the ,secretary may specify a process by which an ,,aim-participating ,state may elect to participate in a multi-year investment initiative during the first #c-year period in which the ,state participates in the ,,aim program4 ,under such option1 an ,,aim-participating ,state shall be eligible for additional ,federal financial participation 7as determined by the ,secretary7 for expenditures under this title that do not exceed an annual budget target established for the ,state1 based on the expenditures of the ,state used to determined the base ,,aimp ,state percentage under subsection 7c77#a77;,b71 and increased for the #b;d and #crd years of such period1 by #i4ii percent over the budget target established for the preceding year4 #bbji4 ,accountability and oversight 7a7 ,quality assessment ,to ensure that full-benefit dual eligible individuals receive high quality care and to encourage quality improvement under ,,aim programs1 each ,,aim-participating ,state shall establish a quality incentive program that uses financial rewards1 penalties1 or both that are meaningful enough to influence the administering entity's behavior and is approved by the ,federal ,coordinated ,health ,care ,office4 ,each ,,aim program will be expected to tie financial incentives to performance either in the form of quality withholds or incentives1 such as making additional quality payments to an ,,aimp-administering entity that achieves quality or equity goals or the withholding of a portion of a capitation payment to an entity that fails to achieve such goals4 ,each ,,aim-participating ,state shall publicly post and seek comment on its proposed quality incentive program prior to submitting to the ,federal ,coordinated ,health ,care ,office for approval4 7b7 ,monitoring and program evaluation 7#a7 ,consolidated reporting requirements for aim-administering entities ,the ,secretary and each ,,aimp-participating ,state shall define and specify in the contract for each ,,aimp-administering entity under this title a consolidated reporting process that ensures the provision of the necessary data on diagnosis1 ,,hedis measures1 encounter reports1 enrollee satisfaction1 and evidence-based measures and other information as may be useful in order to monitor each ,,aimp-administering entity's performance under the ,,aimp contract4 7#b7 ,evaluation ,the ,secretary and each ,,aimp-participating ,state shall develop processes and protocols for collecting 7or ensuring that ,,aimp-administering entities collect7 and reporting to the ,secretary and the ,state the data needed for an evaluation by the ,secretary to measure the impact of ,,aimp-administering entities1 the effectiveness of the process in enrolling ,,aimp-eligible individuals under the ,,aim program1 and the effectiveness of the ,,aim program in reducing disparities1 improving quality of care1 and advancing health equity4 7#c7 ,collaborative evaluation ,the ,secretary and ,,aimp-participating ,states shall collaborate on and coordinate during any evaluation activity conducted under this subsection4 7c7 ,administrative oversight responsibilities 7#a7 ,state role ,each ,,aimp-participating ,state shall be responsible for day-to-day oversight of the ,,aimp-administering entities providing services with respect to ,,aimp enrollees under the ,,aimp contract with the ,state under its ,,aim program4 ,such oversight shall include the following activities3 7,a7 ,conducting a comprehensive readiness review of each entity 7as required under section #bbja7;d774 7,b7 ,monitoring compliance of the entity with the terms of its ,,aimp contract under the ,,aim program1 including-- 7i7 ensuring adherence to and protection of enrollee rights as provided under this title2 7ii7 monitoring the entity to ensure it authorizes1 arranges1 coordinates1 and provides all covered and medically necessary services 7as required under this title7 to ,,aimp enrollees receiving benefits administered by the entity1 in accordance with the requirements of the ,,aimp contract2 and 7iii7 ensuring compliance with applicable reporting requirements under this title4 7,c7 ,reviewing1 approving1 and monitoring-- 7i7 the entity's network adequacy2 7ii7 the outreach and orientation materials and procedures of the entity2 7iii7 the complaint and appeals procedures carried out by the entity2 7iv7 the utilization management functions of the entity2 7v7 the entity's adherence to required continuity of care provisions under section #bbjd7;c77#c72 7vi7 the entity's use of required standard assessment tool under section #bbjd7;b72 7vii7 the entity's informational materials1 particularly for those individuals who will be assigned to the entity under section #bbjc7;f72 and 7viii7 the entity's use of streamlined eligibility processes under this title4 7,d7 ,conducting monthly 7or more frequent7 performance review meetings with the entity4 7,e7 ,conducting periodic audits of the entity1 including at least an annual independent external review and an annual site visit4 7,f7 ,receiving and responding to complaints about the entity4 7,g7 ,conducting annual surveys of ,,aimp enrollees and providing the entity with written results of such surveys4 7,h7 ,applying #a or more sanctions 7such as those provided under title ,,xix71 which may include termination of the contract1 if the ,state or the ,secretary determines that the entity is in material violation of any of the terms of the ,,aimp contract4 7#b7 ,federal oversight role 7,a7 ,in general ,the ,secretary shall be responsible for the oversight of ,,aimp-participating ,states4 ,such oversight shall include activities developed through engagement with stakeholders1 including consumer advocates1 and shall include at the least the following activities3 7i7 ,monitoring the process to select organizations to serve as ,,aimp-administering entities under the ,,aim program4 7ii7 ,conducting a thorough readiness review of the ,state 7before readiness reviews for such organizations7 under section #bbja7;d77#b74 7iii7 ,ensuring1 including through complaint tracking and secret shopping1 the ,state creates and maintains a highly functional1 dedicated ,,aimp ,ombudsman program under section #bbje7;c74 7iv7 ,ensuring1 through direct monitoring1 ,state oversight of compliance of ,,aimp-administering entities with the terms of their ,,aimp contracts under the ,,aim program4 7v7 ,reviewing eligibility and enrollment processes and procedures4 7vi7 ,monitoring ,state data systems to ensure they are sufficient for providing timely data on program performance4 7vii7 ,ensuring payment rates to ,,aimp-administering entities under the ,,aimp contract are actuarially sound1 including by establishing a rate setting process established through rulemaking whereby1 at a minimum-- 7,i7 ,states and the ,secretary provide ,,aimp-administering entities with comprehensive and timely data as part of the rate setting process and procurement1 including historical ,medicaid and ,medicare cost and utilization data for full-benefit dual eligible individuals by region and including detailed categories of service2 7,,ii7 ,states may elect to share the final rate certification package provided to the ,secretary with ,,aimp-administering entities2 and 7,,iii7 an opportunity for public input is established for annual rate setting or when rates are significantly modified whereby stakeholders1 including patient advocacy groups1 health care providers1 and ,,aimp-administering entities1 can provide feedback to the ,secretary prior to rate approval4 7viii7 ,coordinating periodic audits of the ,state with respect o its ,,aim program4 7ix7 ,conducting regular meetings with the ,state4 7x7 ,applying discretionary action1 if warranted4 7xi7 ,ensuring regular engagement with dually eligible individuals and their caregivers4 7,b7 ,compliance authority ,if the ,secretary finds with respect to a ,state ,,aim program that the ,state failed to achieve the appropriate performance levels or compliance with the activities required under subparagraph 7,a71 the ,secretary shall take such action as is necessary to address and correct the ,state failures1 which may include1 to the extent the ,secretary determines appropriate1 #a or more of the following3 7i7 ,developing in consultation with the ,state1 a corrective compliance plan for achieving appropriate performance levels or compliance4 7ii7 ,remedial education and supervised training4 7iii7 ,imposition of penalties or sanctions4 7iv7 ,removal of the ,state from the ,,aim program4 7#c7 ,state-federal partnership role through joint contract management teams 7cmt7 7,a7 ,establishment ,the ,secretary shall1 jointly with each ,,aimp-participating ,state1 establish a ,joint ,contract ,management ,team 7in this paragraph referred to as a ,,cmt7 following the model used in the demonstration projects conducted under the ,financial ,alignment ,initiative for ,medicare-,medicaid ,enrollees administered by the ,federal ,coordinated ,health ,care ,office4 7,b7 ,composition and structure 7i7 ,in general ,each ,,cmt shall include at least #a contract officer from the ,centers for ,medicare ,medicaid ,services and at least #a contract officer from the ,,aimp-participating ,state1 each of whom is authorized and empowered to represent the ,secretary and the ,state1 respectively1 about all aspects of the ,,aimp contract with an ,,aimp-administering entity under the ,,aim program of the ,state4 7ii7 ,lead ,the representation from the ,federal ,government shall be led by the individual from the ,federal ,coordinated ,health ,care ,office who is assigned to work with the ,state1 who will bring in additional individuals1 as appropriate4 7iii7 ,state lead ,the representation from the ,,aimp-participating ,state shall be led by the ,director of the ,state ,medicaid program under title ,,xix 7or such ,director's designee7 who will bring in additional individual to represent the ,state1 as appropriate4 7,c7 ,responsibilities of cmt ,each ,,cmt for a ,state shall act as a liaison among the ,,aimp-administering entity1 the ,secretary1 and the ,state for the duration of the ,,aimp contract with such entity and shall serve to facilitate communications and operations among the #c parties4 ,each ,,cmt shall1 among other functions-- 7i7 receive and respond to complaints2 7ii7 conduct quarterly meetings among the parties2 7iii7 establish a mechanism for ongoing consumer engagement2 7iv7 coordinate requests for assistance from the entity and assign ,federal and ,state staff with appropriate expertise to provide technical assistance to the entity2 7v7 make best efforts to resolve any issues applicable to the parties2 and 7vi7 monitor any discretionary action by the ,state or the ,secretary under the provisions of the ,,aimp contract4 #bbaj4 ,definitions2 miscellaneous provisions 7a7 ,definitions ,in this title3 7#a7 ,terms relating to ,,aimp 7,a7 ,,aimp-administering entity ,the term ,,aimp-administering entity means an organization that has been determined to meet the requirements for such an entity under this title and has an ,,aimp contract with an ,,aimp-participating ,state under this title4 7,b7 ,,aimp assistance ,the term ,,aimp assistance has the meaning given such term in section #bbjh7;a77#a77;,b74 7,c7 ,,aimp contract ,the term ,,aimp contract is a contract described in section #bbjg7;b77#a74 7,d7 ,,aimp-eligible individual ,the term ,,aimp-eligible individual has the meaning given such term in section #bbjb7;a74 7,e7 ,,aimp enrollee ,the term ,,aimp enrollee means an individual who is enrolled in an ,,aim program under this title4 7,f7 ,,aimp-participating ,state ,the term ,,aimp-participating ,state means a ,state administering an ,,aim program under this title4 7,g7 ,,aim program2 ,,aimp ,the terms ,,aim program and ,,aimp mean1 with respect to a ,state1 the program established by the ,state under this title4 7#b7 ,other definitions 7,a7 ,full-benefit dual eligible individual ,the term full-benefit dual eligible individual has the meaning given such term in section #aice7;c77#f7 but without the application of subparagraph 7,a77i7 of such section4 7,b7 ,federal ,coordinated ,health ,care ,office ,the term ,federal ,coordinated ,health ,care ,office means the office established under section #bfjb of the ,patient ,protection and ,affordable ,care ,act4 7,c7 ,medicaid managed care organization ,the term medicaid managed care organization has the meaning given that term in section #aijc7m77#a77;,a7 and includes a prepaid inpatient health plan1 as defined in section #dch4b of title #db1 ,code of ,federal ,regulations 7or any successor regulation7 and a prepaid ambulatory health plan1 as defined in such section 7or any successor regulation74 7b7 ,miscellaneous provisions 7#a7 ,relation to other requirements ,except as otherwise provided under this title or by regulation1 the requirements of title ,,xix shall apply under an ,,aim program in relation to ,,aimp-eligible individuals1 ,,aimp enrollees1 and the provision of benefits under an ,,aim program1 in the same manner as such requirements apply with respect to individuals eligible for medical assistance who are enrolled in under a medicaid managed care organization4 7#b7 ,limitation on waiver authority ,except as provided in this title1 the ,secretary is not authorized 7under section #aaae1 #aaae;,a1 or otherwise7 to waive the requirements specified in this title4 4 7b7 ,conforming amendments to medicare 7#a7 ,enrollment ,section #ahea7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba7;a77 is amended by adding at the end the following new paragraph3 7#d7 ,additional enrollment option for certain full-benefit dual eligible individuals ,full-benefit dual eligible individuals may also be eligible to enroll under a ,state ,,aim program under title ,,xxii4 4 7#b7 ,prohibition ,during the period in which an ,,aim program is fully implemented in an ,,aimp-participating ,state under title ,,xxii1 ,,aimp-eligible individuals in the ,state may not enroll in a managed ,medicare and other integrated duals product 7other than a ,,pace program74 7c7 ,conforming amendments to medicaid 7#a7 ,preventing duplicate payments ,section #aijc7;i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif7;i77 is amended-- 7,a7 by striking or at the end of paragraph 7#bf72 7,b7 by striking the period at the end of paragraph 7#bg7 and inserting 2 or2 and 7,c7 by inserting after paragraph 7#bg7 the following new paragraph3 7#bh7 with respect to any amount expended for medical assistance for an individual who is an ,,aimp enrollee under a ,state ,,aim program under title ,,xxii1 except specifically permitted under such title4 4 7#b7 ,note3 ,additional conforming amendments to be provided4 7d7 ,conforming amendment ,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 following3 7#i7 ,to be primarily responsible for the ,federal administration of title ,,xxii of the ,social ,security ,act4 4 7e7 ,other conforming amendments ,section #aaja7;a77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acja7;a77#a77 is amended-- 7#a7 by striking ,,xix1 and ,,xxi and inserting ,,xix1 ,,xxi1 and ,,xxii2 and 7#b7 by striking ,,xix and ,,xxi and inserting ,,xix1 ,,xxi1 and ,,xxii4 #c4 ,med,p,a,c study and report 7a7 ,study ,the ,medicare ,payment ,advisory ,commission shall conduct a study for purposes of making recommendations regarding how to improve health care and other support needs of individuals who are eligible for and are receiving medical assistance for the payment of medicare cost-sharing under a ,state ,medicaid program pursuant to clause 7i71 7iii71 or 7iv7 of section #aijb7;a77#aj77;,e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77#aj77;,e774 7b7 ,report ,not later than #ah months after the date of enactment of this ,act1 the ,medicare ,payment ,advisory ,commission shall submit to ,congress a report on the study conducted under subsection 7a71 together with recommendations for such legislation and administrative action as the ,commission determines to be appropriate4