,,ii  #aag? ,,congress  #b;d ,session   
,s4 #dfce  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,july #bg1 #bjbb,mr4   
,br[n 7= himself & ,mr4 ,portman7       
introduc$ ! foll[+ bill2 :i* 0 read     
twice & ref]r$ to ! ,committee on       
,f9ance  ,a ,,bill  ,to am5d ! ,social  
,security ,act to e/abli% an optional   
,/ate-adm9i/]$ program to provide fully 
integrat$1 compreh5sive1 coord9at$ c>e =
 full-b5efit dual eligible individuals  
"u ! ,m$ic>e & ,m$icaid programs1 & =   
o!r purposes4  #a4 ,%ort title2 table ( 
cont5ts  7a7 ,%ort title ,?is ,act may  
be cit$ z ! ,compreh5sive ,c>e = ,dual  
,eligible ,individuals ,act4  7b7 ,table
 ( cont5ts ,! table ( cont5ts = ?is ,act
 is z foll[s3 ,sec4 #a4 ,%ort title2    
table ( cont5ts4,sec4 #b4 ,e/abli%m5t ( 
,all ,inclusive ,m$ic>e-,m$icaid        
,program = ,full-,b5efit ,dual ,eligible
 ,individuals4,,title ,,xxii--,all      
,inclusive ,m$ic>e-,m$icaid 7,,aim7     
,program = ,full-,b5efit ,dual ,eligible
 ,individuals,sec4 #bbja4 ,purpose2     

,g5]al requirem5ts4,sec4 #bbjb4         
,eligibility4,sec4 #bbjc4               
,enrollm5t4,sec4 #bbjd4 ,b5efits4,sec4  
#bbje4 ,b5efici>y protections4,sec4     
#bbjf4 ,f$]al adm9i/ration4,sec4 #bbjg4 
,selection & role ( ,,aim-adm9i/]+      
entities4,sec4 #bbjh4 ,program          
f9anc+4,sec4 #bbji4 ,acc\ntability &    
ov]sight4,sec4 #bbaj4 ,def9itions2      
miscellane\s provisions4,sec4 #c4       
,med,p,a,c /udy & report4  #b4          
,e/abli%m5t ( ,all ,inclusive           
,m$ic>e-,m$icaid ,program =             
,full-,b5efit ,dual ,eligible           
,individuals  7a7 ,9 g5]al ,! ,social   
,security ,act is am5d$ by add+ at ! end
 ! foll[+ new title3  ,,xxii ,all       
,inclusive ,m$ic>e-,m$icaid 7,,aim7     
,program = ,full-,b5efit ,dual ,eligible
 ,individuals  #bbja4 ,purpose2 ,g5]al  
requirem5ts  7a7 ,purpose ,! purpose (  
?is title is to provide1 at ! option ( a
 ,/ate1 = a program implem5t$ & adm9i/]$
 by ! ,/ate ( compreh5sive1 coord9at$   
c>e = individuals eligible = b5efits "u 

! ,m$ic>e program "u title ,,xviii & =  
full b5efits "u ! ,m$icaid program "u   
title ,,xix 9 ord] to improve quality1  
control co/s1 address heal? disp>ities1 
& support indep5d5ce1 community         
p>ticipation1 & quality ( life4  7b7    
,requirem5t = approv$ ,,aim program     
application ,a ,/ate may n be approv$ to
 implem5t an ,,aim program "u ?is title 
unless1 consi/5t ) ! process specifi$ = 
approval ( ,,aim programs "u subsection 
7c7-- 7#a7 ! ,/ate has complet$1 9 a    
pre-pr9t$ =mat & mann] specifi$ by !    
,secret>y1 a notice ( int5t to e/abli%  
su* a program n e>li] ?an #c ye>s aft] !
 date on :i* ! ,/ate submits ! notice ( 
int5t to ! ,secret>y1 & :i* includes a  
plan = su* a program 7or ! ,/ate is     
work+ ) ! ,f$]al ,coord9at$ ,heal? ,c>e 
,(fice to transition an integrat$ c>e   
program ( ! ,/ate into an ,,aim program 
"u ?is title72 &  7#b7 ! ,secret>y has  
receiv$ assurances1 satisfactory to !   
,secret>y1 t ! propos$ ,/ate ,,aim      
program & its plan 7or1 9 ! case ( a    

,/ate work+ ) ! ,f$]al ,coord9at$ ,heal?
 ,c>e ,(fice to transition an integrat$ 
c>e program ( ! ,/ate into an ,,aim     
program "u ?is title1 ! ,/ate ,,aim     
program aft] su* transition is complet$7
 meet ! applicable requirem5ts = su* a  
program "u ?is title1 includ+ !         
requirem5ts specifi$ 9 subsection 7c74  
7c7 ,g5]al requirem5ts ,! requirem5ts   
specifi$ 9 ?is subsection = an ,,aim    
program ( a ,/ate are z foll[s3 7#a7    
,eligibility & enrollm5t ,! program     
provides = eligibility & enrollm5t (    
,,aimp-eligible individuals "u ! program
 9 accordance ) sections #bbjb & #bbjc4 
7#b7 ,b5efits ,! program provides =     
b5efits = ,,aimp enrollees "u ! program 
9 accordance ) section #bbjd4  7#c7     
,b5efici>y protections ,! program       
provides = b5efici>y protections =      
,,aimp enrollees "u ! program t are n   
less ?an ^? requir$ "u section #bbje4   
7#d7 ,coord9at+ & integration ( b5efits 
,! program provides = ! coord9ation &   
integration ( b5efits by ,,aim-adm9i/]+ 

entities 9 accordance ) section #bbje4  
7#e7 ,program acc\ntability ,! program  
provides = acc\ntability 9 adm9i/ration 
& f9anc+ 9 accordance ) section #bbjh4  
7#f7 ,o!r requirem5ts ,! program meets  
su* o!r requirem5ts z ! ,secret>y may   
e/abli% to c>ry out ?is title4  7d7     
,program approval process ,! ,secret>y  
%all e/abli% a process = ! initial      
approval ( ,,aim programs ( ,/ates bas$ 
on ! process us$ = approval ( waiv]s "u 
section #aaae ) respect to title ,,xix4 
,! process e/abli%$ "u ?is subsection   
%all include at lea/ ! foll[+ elem5ts3  
7#a7 ,notice ( int5t  7,a7 ,9 g5]al     
,subject to subp>agraph 7,b71 ! ,/ate   
submits to ! ,secret>y a notice ( int5t 
to e/abli% ! ,,aimp4  7,b7 ,conditions =
 transp>5t process ,! ,secret>y %all n  
accept a notice ( int5t submitt$ "u     
subp>agraph 7,a7 unless1 be=e ! date (  
su* submission1 ! ,/ate-- 7i7 has       
provid$ a p]iod ( n less ?an #ij days = 
notice & public comm5t on ! propos$     
e/abli%m5t ( ! program 9 ! ,/ate2  7ii7 

has held at lea/ #b public meet+s reg>d+
 ! e/abli%m5t ( ! program2 &  7iii7 has 
conduct$ relevant consultation ) any    
relevant tribal au?orities ( ,f$]ally   
recogniz$ ,indian tribes locat$ 9 !     
,/ate4  7#b7 ,f$]al read9ess review     
complet$ ,at lea/ #a ye> be=e ! id5tifi$
 initial implem5tation date = an ,,aim  
program 9 a ,/ate1 ! ,/ate has pass$ a  
review by ! ,secret>y ( ! ,/ate's       
read9ess to implem5t ! program4  7#c7   
,/ate read9ess review ( aim-adm9i/]+    
entities ,aft] a ,/ate passes ! ,f$]al  
read9ess review "u p>agraph 7#b71 !     
,/ate %all conduct a review ( ! propos$ 
,,aim-adm9i/]+ entities "u propos$      
,,aimp contracts ) ! ,/ate ) respect to 
_! read9ess to adm9i/] ! program =      
b5efits = ,,aimp enrollees assign$ to   
su* entities4 ,su* review-- 7,a7 %all   
include elem5ts specifi$ by ! ,secret>y1
 includ+ a network adequacy review2     
7,b7 may include activities su* z a desk
 review1 sep>ate network validation     
review1 & site visit2 &  7,c7 mu/ be    

pass$ by an ,,aimp-adm9i/]+ entity be=e 
any outrea* or m>ket+ ( or by t entity  
is p]mitt$ "u a ,/ate ,,aim program4    
7e7 ,te*nical assi/ance plann+ grants   
7#a7 ,eligibility ,a ,/ate t has provid$
 a notice ( int5t "u subsection 7d77#a7 
to implem5t an ,,aim program is eligible
 = fund+ assi/ance ) te*nical plann+    
necess>y to implem5t ! program4 ,su*    
fund+ %all be provid$ 9 am\nts ( up to  
#aj1jjj1jjj p] ,/ate1 & "u su*          
conditions z ! ,secret>y %all specify4  
7#b7 ,use ( funds ,fund+ made available 
to a ,/ate "u ?is subsection may be us$ 
to assi/ ! ,/ate ) ! /aff+1 in=mation   
te*nology1 plann+ & evaluation1 &       
initial implem5tation ( ! ,,aim program 
9 ! ,/ate = exp5ses incurr$ dur+ !      
#c-ye> p]iod t beg9s on ! date ! ,/ate  
submits a notice ( int5t "u subsection  
7d77#a74  7#c7 ,fund+ ,= ! purpose (    
provid+ fund+ assi/ance "u ?is          
subsection1 !re is appropriat$1 out (   
any money 9 ! ,treasury n o!rwise       
appropriat$1 su* sums z may be necess>y 

to c>ry out ?is subsection4  #bbjb4     
,eligibility  7a7 ,9 g5]al ,9 ?is title1
 ! t]m ,,aimp-eligible individual means1
 ) respect to an ,,aimp-p>ticipat+      
,/ate1 an individual :o-- 7#a7 is #ba   
ye>s ( age or old]2  7#b7 is entitl$ 7or
 eligible to be enroll$7 "u "p ,a or "p 
,b1 or bo?1 ( title ,,xviii2  7#c7      
subject to subsection 7c71 is eligible =
 m$ical assi/ance "u ! ,/ate plan       
7includ+ a waiv] !re(7 "u title ,,xix z 
a full-b5efit dual eligible individual2 
&  7#d7 meets su* income & asset /&>ds z
 ! ,/ate may e/abli% = ! ,,aim program 9
 accordance ) subsection 7d7 7& :i* %all
 be appli$ 9 addition to ! income &     
asset /&>ds ! individual is requir$ to  
meet = purposes ( eligibility = m$ical  
assi/ance "u ! ,/ate plan 7or a waiv]7  
"u title ,,xix74  7b7 ,process =        
det]m9ation ( eligibility ,except z     
o!rwise provid$ 9 ?is title1 !          
det]m9ation ( :e!r an individual is an  
,,aimp-eligible individual ) respect to 
! ,,aim program ( a ,/ate %all be made 9

 accordance ) ! processes us$ to det]m9e
 ! individual's eligibility = m$ical    
assi/ance "u ! ,/ate plan 7or waiv]     
!re(7 "u title ,,xix ( ! ,/ate4  7c7    
,flexibility p]mitt$  7#a7 ,geographic  
scope  7,a7 ,/atewide ,except z provid$ 
9 subp>agraph 7,b71 an ,,aimp-p>ticipat+
 ,/ate %all provide = ! implem5tation ( 
its ,,aim program on a /atewide basis4  
7,b7 ,phase-9 p]mitt$ on a "t-limit$    
basis ,an ,,aimp-p>ticipat+ ,/ate may   
provide = ! implem5tation ( its ,,aim   
program n on a /atewide basis s long z !
 program is phas$ 9 geographically 9 a  
mann] s t x is implem5t$ /atewide no    
lat] ?an ! #d? ye> ( implem5tation1     
except t ! ,secret>y may p]mit a long]  
phase-9 p]iod due to ext5uat+           
circum/ances4  7#b7 ,new population     
phase-9 p]mitt$  7,a7 ,c>ve-outs n      
p]mitt$ ,except z provid$ 9 subp>agraph 
7,b71 an ,,aimp-p>ticipat+ ,/ate may n  
d5y eligibility "u its ,,aim program to 
subpopulations ( ,,aimp-eligible        
individuals & %all enroll all           

,,aimp-eligible individuals "u ! program
 )\t ! application ( any wait+ li/s4    
7,b7 ,"t-limit$ exception p]mitt$ ,!    
,secret>y may all[ ,/ates to phase 9 !  
enrollm5t ( c]ta9 subpopulations ov] a  
specifi$ p]iod1 n to exce$ a p]iod ( #d 
ye>s4  7#c7 ,pace cont9uation p]mitt$   
,no?+ 9 ?is title %all be con/ru$ z     
prev5t+ an ,,aimp-p>ticipat+ ,/ate f    
cont9u+ to (f] a ,program (             
,all-,inclusive ,c>e = ! ,eld]ly        
7,,pace7 "u section #ahid or #aicd4  7d7
 ,income & asset /&>ds  7#a7 ,income    
eligibility floor ,9 no case %all an    
,,aimp-p>ticipat+ ,/ate h an income     
eligibility ?re%old "u its ,,aim program
 t is less ?an #gc p]c5t ( ! (ficial    
pov]ty l9e 7z def9$ by ! ,(fice (       
,managem5t & ,budget1 & revis$ annually 
9 accordance ) section #fgc7b7 ( !      
,omnibus ,budget ,reconciliation ,act ( 
#aiha7 applicable to a family ( ! size  
involv$ or1 if great]1 ! income ?re%old 
appli$ dur+ ! fiscal ye> prec$+ ! ye> 9 
:i* ?is title is enact$4  7#b7 ,asset   

?re%old floor ,9 no case %all an        
,,aimp-p>ticipat+ ,/ate apply an asset  
?re%old = eligibility = a fiscal ye> t  
is less ?an ! foll[+3 7,a7 ,= fir/      
fiscal ye> ,= ! #a/ fiscal ye> 7or      
portion ( a fiscal ye>7 9 :i* ! ,,aim   
program is implem5t$ 9 ! ,/ate1 ! great]
 (-- 7i7 #b1jjj2 &  7ii7 ! asset        
eligibility /&>d appli$ "u ! ,/ate plan 
7includ+ a waiv] !re(7 "u title ,,xix = 
a full-b5efit dual eligible individual  
dur+ ! fiscal ye> prec$+ ! fiscal ye> 9 
:i* ?is title is enact$4  7,b7 ,=       
subsequ5t fiscal ye> ,= a subsequ5t     
fiscal ye>1 ! m9imum asset ?re%old      
appli$ "u ?is p>agraph = ! previ\s      
fiscal ye> increas$ 7& r\nd$ to ! ne>e/ 
#aj7 by ! annual increase 9 ! consum]   
price index = all urban consum]s 7,unit$
 ,/ates city av]age74  7#c7 ,flexibility
 ,no?+ 9 ?is subsection %all be con/ru$ 
z limit+ ! ability ( an                 
,,aimp-p>ticipat+ ,/ate to increase !   
income eligibility ?re%old1 asset       
eligibility ?re%old1 or income or asset 

disreg>ds1 includ+ by all[+ buy-ins or  
sp5dd[ns1 above ! m9imum levels requir$ 
"u ?is subsection4  7#d7 ,eligibility   
?re%old ,! income & asset ?re%olds t a  
,/ate e/abli%es "u ?is subsection %all  
be appli$ "u ! ,/ate ,,aim program to   
det]m9e :e!r an individual is an        
,,aimp-eligible individual )\t reg>d to 
:e!r ! individual elects to enroll1 or  
is enroll$1 9 ! ,/ate ,,aim program4    
7e7 ,use ( /reaml9$ eligibility         
det]m9ation & enrollm5t processes  7#a7 
,9 g5]al ,ea* ,,aimp-p>ticipat+ ,/ate   
%all use /reaml9$ eligibility &         
enrollm5t processes 9 ord] to promote   
cont9uity & inc5tivize ,/ates t inve/ 9 
improv+ quality & co/s1 includ+ ^?      
specifi$ 9 ?is subsection4  7#b7        
,specific /reaml9$ eligibility requir$  
,ea* ,,aimp-p>ticipat+ ,/ate %all       
utilize ! foll[+ ) respect to /reaml9+ !
 eligibility det]m9ation & enrollm5t (  
individuals 9 ! ,/ate's ,,aim program3  
7,a7 #ab-mon? cont9u\s eligibility4     
7,b7 ,use ( electronic data mat*es )    

tru/$ ?ird-p>ty s\rces 7su* z ! ,social 
,security ,adm9i/ration or !            
,supplem5tal ,nutrition ,assi/ance      
,program7 to v]ify eligibility "u !     
,/ate ,,aim program bo? = initial       
eligibility applications & = r5ewals4   
7,c7 ,/reaml9$ eligibility              
rec]tification e #ab mon?s1 includ+--   
7i7 = individuals :o h be5 det]m9$      
eligible & enroll$1 only requir+        
submission ( in=mation on any *anges to 
_! f9ancial or disability /atus 7in/ead 
( submitt+ an entire r5ewal             
application72  7ii7 ) respect to        
v]ification ( eligibility1 initially us+
 ( available in=mation to auto-v]ify    
eligibility2  7iii7 if additional       
in=mation is ne$$ = r5ewal (            
eligibility1 us+ pre-populat$ =ms &     
all[+ submission ( in=mation onl9e1 9   
p]son1 by telephone1 fax1 or mail2 &    
7iv7 us+ a /&>d reconsid]ation p]iod (  
#ij days f ! "t ( t]m9ation ( cov]age4  
7#c7 ,use ( deem+ ,ea* ,,aimp-p>ticipat+
 ,/ate %all use deem$ eligibility = a   

p]iod ( n less ?an #f mon?s4  7#d7 ,data
 %>+ on enrollm5t ,"u an ,,aimp         
contract1 an ,,aimp-p>ticipat+ ,/ate1 ! 
,secret>y1 & ,,aim-adm9i/]+ entities    
%all r\t9ely & frequ5tly %>e data among 
!mselves ) reg>d to eligibility &       
enrollm5t ( individuals "u ,,aim        
programs4 ,su* data %>+ may include     
mon?ly *anges 9 program enrollm5t &     
eligibility1 b5efici>y opt-out rates1 & 
o!r *anges specifi$ by ! ,secret>y4  7f7
 ,rule ( con/ruction ( cont9uation z a  
m$ic>e & m$icaid b5efici>y = purposes   
o!r ?an b5efits ,! fact t an individual 
qualifies z an ,,aimp-eligible          
individual %all n be con/ru$ z remov+ ! 
individual's /atus z an individual      
entitl$ to b5efits "u title ,,xviii or  
,,xix1 b ins(> z ! individual becomes an
 ,,aimp enrollee entitl$ to b5efits "u  
?is title1 su* entitlem5t to b5efits "u 
titles ,,xviii & ,,xix %all be consid]$ 
z met ?r\gh ! provision ( b5efits "u ?is
 title4  #bbjc4 ,enrollm5t  7a7         
,b5efici>y *oice ,9 an ,,aimp-p>ticipat+

 ,/ate "u its ,,aim program1 an         
,,aimp-eligible individual may select 79
 a mann] specifi$ by ! ,/ate consi/5t ) 
?is section7 to receive b5efits ?r\gh   
any ( ! foll[+3 7#a7 ,! ,/ate ,,aim     
program4  7#b7 ,a ,,pace program 7if    
available to ! individual 9 ! ,/ate74   
7#c7 ,a comb9ation ( ,m$ic>e            
fee-=-s]vice program 7"u p>ts ,a1 ,b1 & 
,d1 z applicable1 ( title ,,xviii7 &    
m$ical assi/ance "u title ,,xix 7:e!r   
deliv]$ ?r\gh fee-=-s]vice or manag$    
c>e1 z provid$ by ! ,/ate "u su* title74
  7b7 ,initial assignm5t at "t ( program
 implem5tation or initial enrollm5t ,an 
,,aimp-p>ticipat+ ,/ate may provide t   
all ,,aimp-eligible individuals 9 !     
,/ate :o are n enroll$ 9 a ,,pace       
program "u section #ahid or #aicd & :o d
 n make an affirmative selection "u     
subsection 7a77#c7 %all be deem$ to h   
elect$ to enroll 9 ! ,,aim program ( !  
,/ate4  7c7 ,coord9ation ( selection &  
enrollm5t ) m$ic>e enrollm5t processes  
,! process = selection & enrollm5t (    

,,aimp-eligible individuals 9 ,,aim     
programs %all be consi/5t & coord9at$ ) 
! processes = enrollm5t 9 ,m$ic>e       
,advantage plans "u "p ,c ( title       
,,xviii dur+ op5 & special enrollm5t    
p]iods4 ,su* processes %all1 consi/5t ) 
section #dbc4ch7;c7 ( title #db1 ,code (
 ,f$]al ,regulations 7or any successor  
regulation7 & any o!r applicable        
regulations1 provide-- 7#a7 a special   
enrollm5t p]iod = individuals :o-- 7,a7 
are dually eligible individuals enroll$ 
9 fee-=-s]vice ,m$ic>e :5 ! ,/ate ,,aim 
program is fir/ e/abli%$ to p]mit su*   
individuals to elect to enroll 9 ! ,/ate
 ,,aim program2 or  7,b7 become         
,,aimp-eligible individuals2 &  7#b7 = !
 "r ( an ,,aimp-enroll$ individual to   
dis5roll f ! ,,aim program & to o!rwise 
to make *anges 9 ! selection 9 enrollm5t
 describ$ 9 subsection 7a74  7d7        
,assi/ance 9 enrollm5t *oice ,an        
,,aimp-p>ticipat+ ,/ate mu/ contract )  
#a or m indep5d5t enrollm5t brok]s1 at  
lea/ #a ( :i* is a nonpr(it1            

community-bas$ organization1 & all ( :i*
 are approv$ by ! ,secret>y1 to assi/   
,,aimp-eligible individuals 9 und]/&+ ! 
,,aim program & mak+ enrollm5t *oices "u
 ?is section 9 ! same mann] z su* brok]s
 are p]mitt$ ) respect to enrollm5t (   
individuals "u its ,/ate plan "u title  
,,xix 7or waiv] !re(71 except t no      
individual sales commissions %all be    
p]mitt$ 7includ+ to ! ext5t su*         
commissions may o!rwise be p]mitt$ by   
brok]s & employ$ or captive ag5ts "u !  
,m$ic>e ,advantage program "u "p ,c (   
title ,,xviii74  7e7 ,con/ruction reg>d+
 cont9u$ m$icaid use ( manag$ c>e ,no?+ 
9 ?is subsection %all be con/ru$ z      
affect+ ! au?ority ( an                 
,,aimp-p>ticipat+ ,/ate to require1 9 ! 
case ( an ,,aimp-eligible individual :o 
makes ! election describ$ 9 subsection  
7a77#c7 7or o!rwise opts-out ( enrollm5t
 9 ! ,,aim program & into b5efits "u    
title ,,xix71 to obta9 b5efits = cov]$  
s]vices "u title ,,xix ?r\gh            
p>ticipation 9 a manag$ c>e plan or     

arrangem5t4  7f7 ,assignm5t ( enrollees 
to ,,aimp-,adm9i/]+ entities  7#a7 ,9   
g5]al ,an ,,aimp-eligible individual    
enroll$ "u an ,,aim program %all be     
provid$ ) a *oice ( ! ,,aimp-adm9i/]+   
entity to :i* ! individual is assign$ = 
purposes ( obta9+ b5efits "u ! program4 
7#b7 ,initial assignm5t at "t ( program 
implem5tation or initial enrollm5t  7,a7
 ,9 g5]al ,9 ! case ( an ,,aimp-eligible
 individual :o1 at ! "t ( enrollm5t "u  
an ,,aim program1 is enroll$ 9 an       
integrat$ program = individuals dually  
eligible = ,m$ic>e & ,m$icaid p>ticipat+
 9 ! ,f9ancial ,alignm5t ,initiative ( !
 ,f$]al ,coord9at$ ,heal? ,c>e ,(fice1  
or enroll$ 9 a ,m$ic>e ,advantage plan t
 is a highly integrat$ dual eligible    
special ne$s plan or a fully integrat$  
dual eligible special ne$s plan1 ! ,/ate
 ,,aim program may initially assign !   
individual to ! ,,aimp-adm9i/]+ entity =
 su* ,m$ic>e ,advantage plan 7or1 9 !   
case ( an ,,aimp-eligible individual :o1
 at ! "t ( enrollm5t "u an ,,aim        

program1 is enroll$ 9 an integrat$      
program = individuals dually eligible = 
,m$ic>e & ,m$icaid p>ticipat+ 9 !       
,f9ancial ,alignm5t ,initiative ( !     
,f$]al ,coord9at$ ,heal? ,c>e ,(fice1 to
 ! ,,aimp-adm9i/]+ entity designat$ by !
 ,/ate71 or ano!r ,,aimp-adm9i/]+       
entity1 if necess>y if-- 7i7 ! provid]  
network ( su* entity "u ! ,,aim program 
is sub/antially simil> to ! network us$ 
"u ! plan (f]$ by ! entity t !          
individual is enroll$ 9 prior to su*    
assignm5t2 &  7ii7 ! individual is      
provid$ )-- 7,i7 at lea/ #a writt5      
notice ( su* assignm5t at lea/ #fj days 
9 advance ( ! effective date ( !        
assignm5t2 &  7,,ii7 at lea/ #a phone   
call notify+ ! individual ( ! assignm5t 
9 advance ( ! effective date ( !        
assignm5t4  7,b7 ,cont9uity ( c>e ,to ! 
ext5t possible to prev5t disruption &   
promote cont9uity ( c>e1 a ,/ate ,,aim  
program %all seek to ensure t           
individuals describ$ 9 subp>agraph 7,a7 
are assign$ to ! ,,aimp-adm9i/]+ entity 

t (f]s ! plan or program 9 :i* !        
individual is enroll$ 9 prior to !      
individual's transf] to1 & enrollm5t 91 
! ,/ate ,,aim program4  7,c7            
,conditional initial assignm5t = o!r    
,,aimp-eligible individuals ,9 ! case ( 
an ,,aimp-eligible individual :o1 at !  
"t ( enrollm5t "u a ,/ate ,,aim program 
is enroll$ 9 a ,m$ic>e ,advantage plan t
 is op]at+ z an ,,aimp-adm9i/]+ entity  
o!r ?an a plan describ$ 9 subp>agraph   
7,a71 or is enroll$ 9 a ,m$icaid manag$ 
c>e plan (f]$ by ! same entity t is     
op]at+ z an ,,aimp-adm9i/]+ entity 9 !  
,/ate ,,aim ,program1 ! ,/ate ,,aim     
program may initially assign !          
individual to t ,,aimp-adm9i/]+ entity  
if-- 7i7 ! provid] network ( su* entity 
"u ! ,/ate ,,aim program is sub/antially
 simil> to ! network us$ "u ! ,m$ic>e   
,advantage plan or ,m$icaid manag$ c>e  
plan (f]$ by ! entity t ! individual is 
enroll$ 9 prior to su* assignm5t2 &     
7ii7 ! individual is provid$ )-- 7,i7 at
 lea/ #a writt5 notice ( su* assignm5t  

at lea/ #fj days 9 advance ( ! effective
 date ( ! assignm5t2 &  7,,ii7 at lea/  
#a phone call notify+ ! individual ( !  
assignm5t 9 advance ( ! effective date (
 ! assignm5t4  7#c7 ,rule ( con/ruction 
,no?+ 9 ?is subsection %all be con/ru$  
z-- 7,a7 prev5t+ an individual f *oos+  
to be assign$ to a diff]5t p>ticipat+   
,,aimp-adm9i/]+ entity2  7,b7 prev5t+ an
 individual f *ang+ _! assignm5t to an  
,,aimp-adm9i/]+ entity or f opt+-out (  
p>ticipat+ 9 ! ,/ate ,,aim program2 or  
7,c7 con/ra9+ or *ang+ ! au?ority ( a   
,/ate "u ! ,/ate plan "u title ,,xix or 
"u a waiv] ( su* plan to require a      
,m$icaid-eligible individual to enroll )
 a manag$ c>e entity if ! individual    
*ooses n to p>ticipate 9 ! ,,aim        
,program4  7#d7 ,*oice ( enrollm5t f    
fee-=-s]vice m$ic>e ,an ,,aimp-eligible 
individual :o1 z ( ! date on :i* a ,/ate
 fir/ implem5ts ! ,/ate ,,aim program1  
is enroll$ 9 ! ,m$ic>e fee-=-s]vice     
program "u title ,,xviii1 may elect to  
enroll 9 ! ,/ate ,,aim ,program ?r\gh a 

special enrollm5t p]iod e/abli%$ = su*  
individuals1 consi/5t ) ! requirem5ts ( 
section #dbc4ch7;c77#d7 ( title #db1    
,code ( ,f$]al ,regulations 7or a       
successor regulation74  7g7 ,effect (   
enrollm5t on m$ic>e & m$icaid paym5ts to
 /ates ,except z provid$ 9 ?is title1 9 
! case ( an individual :o is enroll$ z  
an ,,aimp enrollee "u a ,/ate ,,aim     
program "u ?is title1 dur+ ! p]iod ( su*
 enrollm5t paym5t to ! ,/ate "u ?is     
title %all be in/ead ( ! paym5t am\nts  
:i* w\ld o!rwise be payable "u title    
,,xviii or ,,xix = items & s]vices      
furni%$ to ! enrollee4  7h7 ,outrea* &  
enrollm5t support  7#a7 ,fund+ ,= !     
purpose ( provid+ fund+ assi/ance to    
,,aimp-p>ticipat+ ,/ates = outrea* to1 &
 enrollm5t support (1 ,,aimp-eligible   
individuals1 !re is appropriat$1 out (  
any money 9 ! ,treasury n o!rwise       
appropriat$1 su* sums z may be necess>y 
= ea* fiscal ye> beg9n+ ) ! fir/ fiscal 
ye> t beg9s on or aft] ! date ( enactm5t
 ( ?is title4  7#b7 ,use ( funds ,an    

,,aimp-p>ticipat+ ,/ate %all use funds  
provid$ to ! ,/ate "u ?is subsection =  
outrea* to1 & enrollm5t support (1      
,,aimp-eligible individuals1 t includes 
! foll[+3 7,a7 ,di/ribut+ outrea* &     
enrollm5t mat]ials pr9t$ 9 accessible   
language =mats 7includ+ prim>y          
languages1 ,braille1 l>ge pr9t1 &       
alt]native texts74  7,b7 ,engag+        
community-bas$ organizations to conduct 
outrea* to1 & provide enrollm5t         
assi/ance =1 ,,aimp-eligible            
individuals4  7,c7 ,ref]r+              
,,aimp-eligible individuals to ! ,/ate  
long-t]m c>e ombudsman1 ! qualifi$      
nonpr(it ,,aim ,ombudsman select$ = !   
,,aim program "u section #bbje7;c71 &   
o!r b5efici>y support entities =        
enrollm5t assi/ance & in=mation4  #bbjd4
 ,b5efits  7a7 ,cov]$ b5efits  7#a7 ,9  
g5]al ,a ,/ate ,,aim program %all       
provide a core package ( cov]$ b5efits  
to address m$ical1 behavioral1 long-t]m 
c>e1 & social ne$s ( ,,aimp enrollees 9 
accordance ) an individual assessm5t &  

plan ( c>e4 ,su* core package (         
available b5efits %all include ! foll[+3
 7,a7 ,m$ic>e b5efits ,all b5efits      
available "u p>ts ,a1 ,b1 & ,d ( title  
,,xviii1 includ+ ) respect to b5efits   
available "u su* "p ,d1 cov]age ( ! #f  
protect$ classes & #b drugs f ea* class4
  7,b7 ,m$icaid m&atory b5efits ,all    
b5efits o!rwise requir$ to be provid$ to
 ,,aimp-eligible individuals "u title   
,,xix 9 ! ,/ate if !y 7 n ,,aimp        
enrollees4  7,c7 ,hi/oric b5efits ,all  
,m$icaid s]vices & b5efits (f]$ z ( #a  
ye> prior to ! enactm5t ( ?is title1 z  
requir$ by section #bbjd7;d74  7,d7     
,drugs ,all prescription drugs & cov]$  
outpati5t drugs available "u ! ,/ate    
,m$icaid program1 includ+ any su* drugs 
t are available "u a prescription drug  
plan "u "p ,d ( title ,,xviii4  7,e7    
,additional s]vices ,an                 
,,aimp-p>ticipat+ ,/ate may1 ) approval 
f ! ,f$]al ,coord9at$ ,heal? ,c>e       
,(fice1 make available "u ! ,/ate ,,aim 
program additional behavioral heal?1    

social1 & supportive s]vices t enable   
flexibility to a*ieve p]son-c5t]$       
outcomes 9 ! mo/ co/-effective sett+4   
7#b7 ,limitation on b5efit c>ve-outs ,! 
,secret>y may p]mit a ,/ate ,,aim       
program to exclude b5efits = "s s]vices 
"u p>agraph 7#a77;,c7 if ! ,secret>y    
det]m9es t su* an exclusion is ess5tial 
= ! ,/ate to implem5t ! ,,aim program b 
su* exclusion may n ext5d ov] a p]iod ( 
long] ?an #d ye>s4  7b7 ,b5efit         
assessm5t process  7#a7 ,assessm5t tool 
& plan ( c>e  7,a7 ,developm5t ,n lat]  
?an #ah mon?s aft] ! date ( ! enactm5t (
 ?is title1 ! ,secret>y1 9 consultation 
) ,/ate ag5cies adm9i/]+ ,/ate plans or 
waiv]s "u title ,,xix & ) input f o!r   
/akehold]s1 %all develop & publi% a     
robu/1 compreh5sive /&>d assessm5t tool 
= use by all ,,aim programs 9 evaluat+ !
 condition & ne$s ( ,,aimp enrollees =  
b5efits "u ! program4  7,b7 ,application
 to plan ( c>e ,ea* ,,aim program %all  
provide = an assessm5t = ea* ,,aimp     
enrollee1 us+ su* /&>d assessm5t tool1  

to =m a basis = ! enrollee's plan ( c>e 
"u ! program4 ,su* an assessm5t %all be 
conduct$ at lea/ annually1 & :5 a       
trigg]+ ev5t 7z def9$ by ! ,secret>y7   
affect+ ! enrollee's ne$ = c>e occurs4  
7,c7 ,application ( grievance & appeals 
proc$ures ,disagreem5ts conc]n+ ! plan (
 c>e = an ,,aim enrollee %all be subject
 to grievance & appeal rights "u section
 #bbje7;b74  7#b7 ,/&>d assessm5t tool  
,! /&>d assessm5t tool "u p>agraph 7#a7 
%all-- 7,a7 conta9 a requir$ set ( core 
elem5ts1 to :i* ,/ates & ,,aimp-adm9i/]+
 entities may add additional requirem5ts
 s long z ! requirem5ts a ,/ate or      
,,aimp adm9i/]+ entity uses conta9 at a 
m9imum ! core set ( elem5ts2  7,b7 cov] 
multiple doma9s1 includ+ m$ical1        
functional1 behavioral1 & social doma9s2
 &  7,c7 be applicable to ! full range (
 ,,aimp enrollees1 includ+ individuals )
 s]i\s m5tal illness & ) ne$s =         
assi/ance ) activities ( daily liv+4    
7c7 ,/ate provision ( cov]$ b5efits     
7#a7 ,use ( ti]$-b5efit model ,an       

,,aimp-p>ticipat+ ,/ate may e/abli% a   
ti]$-b5efit design /ructure = b5efits s 
t specializ$ b5efits may be available to
 meet ! ne$s ( specific subpopulations (
 ,,aimp enrollees s long z su* ti]+--   
7,a7 only applies to b5efits describ$ 9 
subp>agraph 7,e7 ( subsection 7a77#a7 & 
does n limit ! cov]age ( core cov]$     
b5efits describ$ 9 subp>agraphs 7,a7 &  
7,b7 ( su* subsection2 &  7,b7 is no m  
re/rictive ?an ! b5efit /ructure 9 place
 9 ! ,/ate "u title ,,xix 9 ! ye> be=e !
 date ( ! enactm5t ( ?is title4  7#b7   
,9-lieu-!re( alt]native s]vices p]mitt$ 
,an ,,aimp-p>ticipat+ ,/ate may p]mit   
,,aimp-adm9i/]+ entities to cov] b5efits
 = co/-effective alt]native s]vices     
7kn[n z 9 lieu ( s]vices7 in/ead (      
b5efits = s]vices o!rwise includ$ "u !  
,,aim program b 9 no case %all an ,,aimp
 enrollee be requir$ to use su*         
alt]native s]vices4  7#c7 ,cont9uity (  
s]vices  7,a7 ,9 g5]al ,except z provid$
 9 subp>agraph 7,b71 dur+ ! fir/ #f     
mon?s ( an ,,aim enrollee's enrollm5t 9 

an ,,aim program 7or = su* long] p]iod z
 ! ,,aim program may provide7 an        
,,aimp-p>ticipat+ ,/ate %all cont9ue to 
provide access to all m$ically necess>y 
cov]$ items & s]vices & provid]s 7=     
cont9uity ( c>e7 t 7 be+ provid$ at ! "t
 ( enrollm5t4  7,b7 ,exception          
,subp>agraph 7,a7 %all n apply 9 cases 9
 :i* x is det]m9$ by ! ,/ate1 & agre$ to
 by ! ,secret>y1 t ! ,,aimp enrollee 0 n
 eligible = su* s]vices at ! "t (       
enrollm5t or 0 enroll$ 9 ! ,,aim program
 due to error or fraud4  7d7 ,ma9t5ance 
( ef=t ,z a condition = approval ( an   
,,aim program ( a ,/ate1 ! ,/ate %all   
ma9ta9 levels ( b5efits = ,,aim         
enrollees "u ! program t are n less ?an 
! level ( b5efits "u its ,/ate plan     
7includ+ "u a waiv]7 "u title ,,xix =   
full-b5efit dual eligible individuals z 
( fiscal ye> #bjba1 z ( ! fiscal ye>    
be=e ! fiscal ye> 9 :i* ?is title is    
enact$1 or z ( ! fiscal ye> be=e ! #a/  
fiscal ye> 9 :i* ! program is implem5t$ 
9 ! ,/ate1 :i*ev] fiscal ye> has !      

highe/ level ( b5efits4  7e7            
,adm9i/ration ( b5efits ?r\gh           
,,aim-,adm9i/]+ entities                
,,aimp-p>ticipat+ ,/ates %all provide = 
! coord9ation (1 & ! responsibility = ! 
deliv]y ( cov]$ s]vices ?r\gh           
,,aim-adm9i/]+ entities "u an ,,aim     
contract "u section #bbjg4  #bbje4      
,b5efici>y protections  7a7 ,9 g5]al    
,except z o!rwise provid$1 ! b5efici>y  
protections applicable to individuals   
enroll$ "u plans "u p>ts ,c & ,d ( title
 ,,xviii & "u a ,/ate plan "u title     
,,xix %all apply 9 a mann] specifi$ by !
 ,secret>y to ,,aimp enrollees "u an    
,,aim program "u ?is title & are 9      
addition to b5efici>y protections       
provid$ "u ?is title4  7b7 ,application 
( grievances & int]nal & ext]nal appeals
 "u ,,aimp contracts ,! rights (        
individuals ) respect to int]nal &      
ext]nal compla9ts & appeals processes   
%all be specifi$ 9 ! contract betwe5 !  
,,aimp-p>ticipat+ ,/ate & an            
,,aimp-adm9i/]+ entity4 ,su* processes  

%all1 at a m9imum1 incorporate relevant 
rights & processes f ! requirem5ts =    
plans "u p>ts ,c & ,d ( title ,,xviii z 
well z requirem5ts = ,m$icaid manag$ c>e
 organizations "u title ,,xix4  7c7     
,requirem5t = qualifi$ ,,aim ombudsman  
program  7#a7 ,9 g5]al ,z a condition = 
approval ( an ,,aim program = a ,/ate "u
 ?is title-- 7,a7 ! ,/ate %all h        
e/abli%$ & h ready = implem5tation n    
lat] ?an #ah mon?s prior to implem5t+ ! 
,,aim program1 a qualifi$ nonpr(it ,,aim
 ,ombudsman program run by a            
community-bas$ organization = su* ,,aim 
program2 &  7,b7 ! ,/ate1 be=e          
implem5tation ( its ,,aim program1 %all 
demon/rate to ! satisfaction ( !        
,secret>y 7?r\gh an application (       
c]tification process specifi$ by !      
,secret>y7 t its ,,aim ,ombudsman       
program has ! capacity to c>ry out its  
functions 9 ! ,/ate1 includ+ t ! program
 has ! indep5d5ce1 exp]tise1 & adequate 
res\rces 9 place to s]ve ,,aimp-eligible
 individuals & ,,aimp enrollees "u !    

,/ate ,,aim program4  7#b7              
,qualifications = qualifi$ aim ombudsman
 program  7,a7 ,9 g5]al ,9 ord] to be a 
qualifi$ ,,aim ,ombudsman program1 su*  
program mu/ meet ! requirem5ts ( ?is    
subsection = su* a program4  7,b7       
,con/ruction ,no?+ 9 ?is subsection %all
 be con/ru$ z prev5t+ a qualifi$ ,,aim  
,ombudsman program f be+ /ructur$ z "p (
 ano!r protection s]vice 7includ+ ^?    
specifi$ 9 p>agraph 7#c771 s long z su* 
o!r protection s]vice meets !           
requirem5ts ( ?is subsection = a        
qualifi$ ,,aim ,ombudsman program4  7#c7
 ,coord9ation ) o!r b5efici>y protection
 s]vices ,a qualifi$ ,,aim ,ombudsman   
program %all coord9ate ) ,/ate & ,f$]al 
b5efici>y protection s]vices1 includ+ ! 
foll[+3 7,a7 ,demon/ration ,ombudsman   
,programs ,s]v+ ,m$ic>e-,m$icaid        
,enrollees4  7,b7 ,manag$ ,c>e          
,b5efici>y ,support ,sy/ems4  7,c7      
,long-,t]m ,c>e ,ombudsman ,programs4   
7,d7 ,disability ,protection & ,advocacy
 ,programs4  7#d7 ,core s]vices ,a      

qualifi$ ,,aim ,ombudsman program = an  
,,aimp-p>ticipat+ ,/ate %all h au?ority 
to provide ! foll[+ core s]vices )      
respect to ! ,,aim program 9 ! ,/ate3   
7,a7 ,individual assi/ance 7includ+     
consum] education & emp[]m5t1 assi/ance 
) & repres5tation 9 b5efici>y appeals1  
fair he>+s1 & grievances1 guidance      
reg>d+ plan & provid] selection1 &      
support dur+ enrollm5t & dis5rollm5t7 = 
,,aimp-eligible individuals consid]+    
enrollm5t 9 ! ,/ate ,,aim program & =   
,,aimp enrollees 9 su* program4  7,b7   
,sy/emic monitor+ & report+ to ! ,/ate  
reg>d+ compliance ) applicable          
requirem5ts4  7#e7 ,provid+ reports to  
consum] advisory bo>ds ,a qualifi$ ,,aim
 ,ombudsman program = a ,/ate %all      
provide1 on a timely basis1 any reports 
x produces to ! consum] advisory bo>ds  
7e/abli%$ "u subsection 7e77 = ! ,/ate &
 %all make !m publicly available4  7#f7 
,fund+ & ov]sight  7,a7 ,9 g5]al ,!     
,secret>y %all ov]see & adm9i/] ,f$]al  
fund+ directly to qualifi$ ,,aim        

,ombudsman programs e/abli%$ by ,/ates4 
7,b7 ,fund+ level ,= ! purpose ( provid+
 fund+ to qualifi$ ,,aimp ,ombudsman    
programs 9 ea* ,/ate ov] a p]iod ( #c   
fiscal ye>s1 !re is appropriat$1 out (  
any money 9 ! ,treasury n o!rwise       
appropriat$1 n less ?an #a1jjj1jjj1 & n 
m ?an #e1jjj1jjj4 ,! ,secret>y %all     
det]m9e ! fund+ = ea* su* program bas$  
on ! e/imat$ numb] ( ,,aimp-eligible    
individuals 9 ea* ,/ate4  7,c7          
,supplem5tal fund+ ,no?+ 9 ?is p>agraph 
%all be con/ru$ z prev5t+ an            
,,aimp-p>ticipat+ ,/ate f provid+       
supplem5tal fund+ = ! qualifi$ ,,aim    
,ombudsman program = ! ,/ate4  7d7      
,b5efici>y advisory c\ncil ,ea*         
,,aimp-p>ticipat+ ,/ate %all h 9        
op]ation a ,b5efici>y ,advisory ,c\ncil 
to advise ! ,/ate reg>d+ ! treatm5t (   
,,aimp-eligible individuals & ,,aimp    
enrollees "u ?is title4 ,! composition &
 specific functions & au?ority ( su* a  
,c\ncil %all be del9eat$ 9 read9ess     
review requirem5ts specifi$ by !        

,secret>y 9 c>ry+ out p>agraphs 7#b7 &  
7#c7 ( section #bbja7;d74  7e7 ,consum] 
advisory bo>ds  7#a7 ,9 g5]al ,ea*      
,,aimp-p>ticipat+ ,/ate & ea*           
,,aimp-adm9i/]+ entity 9 ea* su* ,/ate  
%all e/abli% a consum] advisory bo>d t w
 provide regul> fe$back to ! ,/ate or   
gov]n+ bo>d ( ! entity1 respectively1 on
 issues ( c>e ( ,,aimp enrollees "u !   
,,aim program 9 t ,/ate or ?r\gh t      
entity1 respectively4  7#b7             
,composition2 functions ,ea* su* consum]
 advisory bo>d %all-- 7,a7 meet at lea/ 
qu>t]ly2  7,b7 be compris$ ( memb]s :o--
 7i7 may be subject to approval by !    
,secret>y & ! ,,aimp-p>ticipat+ ,/ate2  
7ii7 are ,,aimp enrollees2  7iii7 are   
family memb]s & o!r c>egiv]s = ,,aimp   
enrollees2 &  7iv7 are *os5 9 a mann] t 
reflects ! demographic div]sity ( !     
population ( ,,aimp enrollees1 includ+ )
 respect to race1 e?nicity1 age1 & urban
 & rural populations1 & :i* includes    
individuals ) disabilities2  7,c7 meet !
 requirem5ts = memb] advisory committees

 "u section #dch4aaj ( title #db1 ,code 
( ,f$]al ,regulations2 &  7,d7 file &   
make publicly available an annual report
 t includes at lea/ in=mation on-- 7i7 !
 dates = its meet+s held )9 ! report+   
ye>2  7ii7 ! names ( bo>d memb]s invit$ 
& ( ^? memb]s 9 att5dance at ea* su*    
meet+2 &  7iii7 ! ag5da & m9utes = ea*  
su* meet+4  #bbjf4 ,f$]al adm9i/ration  
7a7 ,prim>y adm9i/ration ?r\gh ! ,f$]al 
,coord9at$ ,heal? ,c>e ,(fice  7#a7 ,9  
g5]al ,! ,secret>y %all c>ry out ?is    
title ?r\gh ! ,f$]al ,coord9at$ ,heal?  
,c>e ,(fice1 except t ) respect to      
paym5ts "u section #bbjh1 ! ,secret>y   
may delegate su* au?ority to !          
,adm9i/rator ( ! ,c5t]s = ,m$ic>e       
,m$icaid ,s]vices4  7#b7 ,appropriations
 ,!re are h]eby appropriat$ to !        
,secret>y to c>ry out ?is title1 out (  
any funds 9 ! ,treasury n o!rwise       
appropriat$-- 7,a7 = ea* ( fiscal ye>s  
#bjbb1 #bjbc1 & #bjbd1 #ajj1jjj1jjj2 &  
7,b7 = ea* succe$+ fiscal ye>1          
#cj1jjj1jjj4  7b7 ,/&>ds & process  7#a7

 ,f$]al /&>ds ,9 c>ry+ out ?is title1 ! 
,secret>y %all specify a m9imum set (   
,f$]al /&>ds1 includ+ /&>ds relat+ to   
access to c>e1 quality ( c>e1 b5efici>y 
protections1 m>ket+ & enrollm5t1        
grievances & appeals1 & procurem5t4     
7#b7 ,transp>5cy 9 rulemak+ ,9 implem5t+
 ! provisions ( ?is title1 to ! ext5t   
practical1 ! ,secret>y %all utilize     
notice & comm5t rulemak+ to ensure      
transp>5cy = /akehold]s4  7#c7          
,application ( k ga9$ f demon/ration    
projects & contract managem5t teams "u !
 f9ancial alignm5t initiative ,!        
,secret>y %all c>ry out ?is title tak+  
into acc\nt ! k ga9$ f ! use ( contract 
managem5t teams 9 demon/ration projects 
"u ! ,f9ancial ,alignm5t ,initiative =  
,m$ic>e-,m$icaid ,enrollees adm9i/]$ by 
! ,f$]al ,coord9at$ ,heal? ,c>e ,(fice4 
7c7 ,direct-,hire au?ority ,9 c>ry+ out 
?is title1 ! ,secret>y 7act+ ?r\gh !    
,f$]al ,coord9at$ ,heal? ,c>e ,(fice7   
%all h direct-hire au?ority to ! ext5t  
requir$ to implem5t & adm9i/] ?is title 

on a timely basis4  #bbjg4 ,selection & 
role ( ,,aim-adm9i/]+ entities  7a7     
,requirem5ts = ,/ate selection (        
,,aim-,adm9i/]+ entities ,! ,secret>y1 9
 consultation ) ,/ates1 %all develop 7n 
lat] ?an #a ye> aft] ! date ( ! enactm5t
 ( ?is title7 a set ( /&>diz$           
requirem5ts = ! selection ( qualifi$    
organizations to s]ve z ,,aimp-adm9i/]+ 
entities 9 ! ,,aim programs 9 ea*       
,,aimp-p>ticipat+ ,/ate4  7b7           
,application ( crit]ia = ! qualification
 & selection ( ,,aimp-,adm9i/]+ entities
  7#a7 ,9 g5]al ,ea* ,,aim program 9 an 
,,aimp-p>ticipat+ ,/ate %all be         
implem5t$ ?r\gh contracts ent]$ into by 
! ,,aimp-p>ticipat+ ,/ate &             
organizations t qualify z               
,,aimp-adm9i/]+ entities "u ?is title4  
,a contract ) an ,,aimp-adm9i/rat+      
entity %all require ! entity to assume  
#b-sid$ f9ancial risk 9 return = paym5t 
= ! arrangem5t & deliv]y ( cov]$ b5efits
 to ,,aimp enrollees assign$ to ! entity
 "u ! program4  7#b7 ,specification (   

crit]ia ,! ,secret>y & ,,aimp-p>ticipat+
 ,/ates %all e/abli% basic national     
crit]ia = ! qualification & selection ( 
organizations to be ,,aimp-adm9i/]+     
entities4 ,su* crit]ia %all take into   
acc\nt ! prior exp]i5ce 7includ+ "u bo? 
! ,m$ic>e program "u title ,,xviii &    
,m$icaid programs "u title ,,xix7 ( su* 
an organization 9 s]v+ ! population (   
,,aimp-eligible individuals z well z o!r
 crit]ia1 includ+ ! foll[+3 7,a7 ,!     
organization's exp]i5ce s]v+            
,,aimp-eligible individuals 9 t ,/ate   
7or ano!r ,/ate71 includ+ !             
organization's exp]i5ce 9 provid+ cov]$ 
s]vices describ$ 9 section #bbjd7;a77#a7
 7includ+ long-t]m s]vices & supports & 
behavioral heal? s]vices7 to su*        
individuals1 & 9 integrat+ all ( ^?     
s]vices & supports = su* individuals 9 t
 ,/ate 7or ano!r ,/ate74  7,b7 ,!       
organization's p]=mance on key quality  
measures 9 provid+ su* s]vices1 su* z on
 measures ( key heal? outcomes &        
enrollee satisfaction4  7,c7 ,! adequacy

 ( ! organization's provid] network 9   
ensur+ timely access to c>e4  7,d7 ,!   
organization's demon/rat$ exp]i5ce 9    
implem5t+ models ( c>e = ! full range ( 
su* s]vices1 includ+ ) respect to       
non-m$ical s]vices describ$ 9 section   
#bbjd7;a77#a74  7#c7 ,additional        
/ate-specific crit]ia ,no?+ 9 ?is       
subsection %all be con/ru$ z prev5t+ a  
,/ate1 ) ! approval ( ! ,secret>y1 f    
apply+ additional crit]ia or requirem5ts
 reg>d+ heal? c>e quality1 equity1 or   
access on ,,aimp-adm9i/]+ entities      
specific to quality1 equity1 or access1 
s long z su* requirem5ts & crit]ia--    
7,a7 c be appli$ consi/5tly to all      
,,aimp-adm9i/]+ entities2 &  7,b7 are   
made available = public comm5t prior to 
be+ impos$4  7#d7 ,application ( m$ical 
loss ratio requirem5ts  7,a7 ,9 g5]al   
,any ,,aimp contract betwe5 an          
,,aimp-p>ticipat+ ,/ate & an            
,,aimp-adm9i/]+ entity to adm9i/]       
b5efits "u an ,,aim program %all include
 a requirem5t t ! m$ical loss ratio "u !

 ,,aim program %all n be n less ?an a   
p]c5tage 7n less ?an #he p]c5t7 specifi$
 by ! ,/ate & t ! entity %all return to 
! ,/ate paym5t am\nts t result 9 !      
m$ical loss ratio be+ bel[ su* p]c5tage4
  7,b7 ,special rules ,if an adm9i/]+   
entity :o is contract+ ) a p>ticipat+   
,/ate to adm9i/] a program "u ?is title 
is an entity be>+ #b-sid$ risk1 ! ,/ate 
%all e/abli% ) ! approval ( ! ,secret>y 
a me*anism comp>able to a m$ical loss   
ratio t>get to ensure appropriate sp5d+ 
on s]vices by ! entity4  7c7 ,/ate      
procurem5t process = ,,aimp-,adm9i/]+   
entities  7#a7 ,9 g5]al ,ea*            
,,aimp-p>ticipat+ ,/ate %all be         
responsible = e/abli%+ & implem5t+ a    
process = ! procurem5t & selection (    
,,aimp-adm9i/]+ entities = ! ,/ate ,,aim
 program1 subject to ! approval ( !     
,secret>y4 ,! ,secret>y %all n approve  
su* a process unless ! ,/ate demon/rates
 to ! ,secret>y's satisfaction t !      
process results 9 ! selection (         
,,aimp-adm9i/]+ entities t meet !       

requirem5ts ( ?is title & are qualifi$  
to s]ve ! ne$s ( ,,aimp enrollees 9 !   
,/ate "u ! ,/ate's ,,aim program4 ,an   
,,aimp-p>ticipat+ ,/ate may add         
additional requirem5ts specific to      
quality1 equity1 or access t fur!r !    
,/ate's ov]all integrat$ c>e /rategy &  
goals1 s long z su* requirem5ts are po/$
 = public comm5t & approv$ by ! ,f$]al  
,coord9at$ ,heal? ,c>e ,(fice4  7#b7    
,sep>ate procurem5t process requir$ =   
initial procurem5t ,= ! initial         
procurem5t execut$ to e/abli% an ,,aim  
program 9 an ,,aimp-p>ticipat+ ,/ate1 ! 
,/ate %all n comb9e its ,,aim adm9i/]+  
entity procurem5t process ) a procurem5t
 process t is also us$ = procurem5t "u !
 ,/ate plan or waiv] "u title ,,xix &   
%all select ,,aim adm9i/]+ entities     
?r\gh a /&alone procurem5t process4  7d7
 ,paym5ts to ,,aim-,adm9i/]+ entities   
,ea* ,,aimp-p>ticipat+ ,/ate %all make  
paym5ts to ,,aim-adm9i/]+ entities "u a 
risk-adju/$ paym5t model t-- 7#a7       
reflects ! risk ( ! population ( ,,aimp 

enrollees s]v$ by ea* entity2  7#b7     
ensures t !re are appropriate res\rces  
to s]ve ! ,,aimp enrollees 9 ! ,/ate2 & 
7#c7 protects aga9/ any adv]se selection
 ( ,,aimp enrollees by entities4  #bbjh4
 ,program f9anc+  7a7 ,paym5ts to ,/ates
 ) ,,aim programs  7#a7 ,= program      
b5efits  7,a7 ,9 g5]al ,f ! sums        
appropriat$ "u p>agraph 7#c71 !         
,secret>y %all pay to ea*               
,,aimp-p>ticipat+ ,/ate = ea* qu>t] 9 a 
fiscal ye> 7beg9n+ ) ! fir/ fiscal ye> t
 beg9s aft] ! date ( enactm5t ( ?is     
title71 an am\nt equal to ! ,f$]al      
,,aimp mat*+ p]c5tage 7z def9$ 9        
subsection 7b77#a77 ( ! total am\nt     
exp5d$ dur+ ! qu>t] z ,,aimp assi/ance  
7z def9$ 9 subp>agraph 7,b74  7,b7      
,,aimp assi/ance def9$ ,9 ?is title1 !  
t]m ,,aimp assi/ance has ! mean+ giv5 ! 
t]m m$ical assi/ance "u section         
#aije7;a71 except t 9 apply+ su* t]m "u 
?is subp>agraph-- 7i7 ! s]vices describ$
 9 section #bbjd7;a77#a7 %all be        
sub/itut$ = ! s]vices describ$ 9        

p>agraph 7#a7 & ! subsequ5t p>agraphs ( 
su* section #aije7;a72  7ii7 an ,,aimp  
enrollee %all be treat$ z an individual 
ref]r$ to 9 ! matt] 9 section #aije7;a7 
be=e p>agraph 7#a7 ( su* section2 &     
7iii7 ! exclusion 9 ! subdivision 7,b7  
foll[+ ! la/ p>agraph ( ! fir/ s5t5ce ( 
section #aije7;a7 %all n apply4  7#b7 ,=
 adm9i/rative exp5ses ,9 addition to !  
am\nt paid = ea* qu>t] 9 a fiscal ye> to
 an ,,aimp-p>ticipat+ ,/ate "u p>agraph 
7#a71 ! ,secret>y %all pay to ea* su*   
,/ate = ea* qu>t] 9 a fiscal ye> 7beg9n+
 ) ! fir/ fiscal ye> t beg9s aft] ! date
 ( enactm5t ( ?is title71 f ! sums      
appropriat$ "u p>agraph 7#c71 n less ?an
 #ej p]c5t ( ! total am\nt exp5d$ dur+  
su* qu>t] z f\nd necess>y by ! ,secret>y
 = ! prop] & effici5t adm9i/ration ( !  
,/ate ,,aim program "u ?is title4  7#c7 
,appropriation ,!re is appropriat$1 out 
( any money 9 ! ,treasury n o!rwise     
appropriat$1 su* am\nts z may be requir$
 to provide paym5ts to ,/ates "u ?is    
section1 r$uc$ by any am\nts made       

available f ! ,m$ic>e tru/ funds "u     
p>agraph 7#e74  7#d7 ,relation to o!r   
paym5ts ,paym5t am\nts provid$ "u ?is   
subsection are 9 addition to paym5ts    
provid$ "u o!r provisions ( ?is title4  
7#e7 ,relation to m$ic>e tru/ funds ,!re
 %all be made available = application "u
 ?is title f ! ,f$]al ,hospital         
,insurance ,tru/ ,fund 7"u section      
#ahag7 & f ! ,f$]al ,supplem5t>y ,m$ical
 ,insurance ,tru/ ,fund 7"u section     
#ahda7 7& f ! ,m$ic>e ,prescription     
,drug ,acc\nt 7"u section #ahfj;,d-#af7 
)9 su* ,tru/ ,fund7 su* am\nts z !      
,secret>y det]m9es appropriate1 tak+    
into acc\nt ! r$uctions 9 paym5ts f su* 
,tru/ ,funds & ,acc\nt t are            
attributable to ! cov]age ( ,,aimp      
enrollees "u ,,aim programs "u ?is      
title4  7b7 ,f$]al ,,aimp mat*+ p]c5tage
  7#a7 ,9 g5]al ,9 ?is section1 ! t]m   
,f$]al ,,aimp mat*+ p]c5tage means1 = an
 ,,aimp-p>ticipat+ ,/ate = a fiscal ye>1
 #ajj p]c5t m9us ! ,/ate contribution   
p]c5tage 7z def9$ 9 p>agraph 7#b77 = !  

,/ate & fiscal ye>4  7#b7 ,/ate         
contribution p]c5tage =mula  7,a7 ,9    
g5]al ,9 ?is section1 ! t]m ,/ate       
contribution p]c5tage means1 subject to 
adju/m5t "u ! subsequ5t provisions ( ?is
 p>agraph1 ) respect to an              
,,aimp-p>ticipat+ ,/ate =-- 7i7 ! #a/   
fiscal ye> ( ! ,,aim program 9 ! ,/ate1 
! base ,,aimp ,/ate p]c5tage comput$ "u 
subsection 7c72 or  7ii7 a subsequ5t    
fiscal ye>1 ! ,/ate contribution        
p]c5tage "u ?is p>agraph = ! previ\s    
fiscal ye> adju/$ 9 accordance )        
subp>agraph 7,b7 or 7,c71 z applicable4 
7,b7 ,annual adju/m5t bas$ on *anges 9  
exp5ditures ,= an ,,aimp-p>ticipat+     
,/ate = a fiscal ye> aft] su* #a/ fiscal
 ye>1 if ! exp5ditures = ,,aimp         
assi/ance = :i* paym5t is made "u       
subsection 7a77#a7 "u ! ,/ate ,,aim     
program = ! second previ\s fiscal ye>-- 
7i7 are n great] ?an #aaj p]c5t1 or less
 ?an #ij p]c5t1 ( ! ,,aimp assi/ance    
exp5ditures = ! previ\s fiscal ye>1 !re 
%all be no adju/m5t = ! fiscal ye>      

involv$ "u ?is subp>agraph2  7ii7 is    
great] ?an #aaj p]c5t ( ! ,,aimp        
assi/ance exp5ditures = ! previ\s fiscal
 ye>1 ! adju/m5t "u ?is subp>agraph = ! 
fiscal ye> involv$ %all be an increase 9
 ! ,/ate contribution p]c5tage ( #a     
p]c5tage po9t = ea* multiple ( #aj      
p]c5tage po9ts by :i* su* ,,aimp        
assi/ance exp5ditures exce$ #aaj p]c5t2 
or  7iii7 is less ?an #ij p]c5t ( !     
,,aimp assi/ance exp5ditures = ! previ\s
 fiscal ye>1 ! adju/m5t "u ?is          
subp>agraph = ! fiscal ye> involv$ %all 
be a decrease 9 ! ,/ate contribution    
p]c5tage ( #a p]c5tage po9t = ea*       
multiple ( #aj p]c5tage po9ts by :i* su*
 ,,aimp assi/ance exp5ditures is less   
?an #ij p]c5t4  7,c7 ,additional        
adju/m5ts = exceptions ,! ,secret>y %all
 provide a process by :i* adju/m5ts may 
be made to ! ,/ate contribution p]c5tage
 to take into acc\nt increases &        
decreases 9 ,,aimp exp5ditures describ$ 
9 clause 7ii7 or 7iii7 ( subp>agraph    
7,b7 9 :i* ! adju/m5ts "u su* clauses   

w\ld n apply1 su* z 9 cases ( a         
significant increase or decrease 9      
,,aimp enrollees1 a decl>ation ( a      
national em]g5cy t impacts on ,,aimp    
exp5ditures "u ?is title1 or a          
significant co/ increase beyond !       
control ( ! ,/ate1 z det]m9$ by !       
,secret>y4  7c7 ,basel9e exp5diture &   
p]c5tage computations  7#a7 ,9 g5]al    
,us+ ! data report$ "u p>agraph 7#b73   
7,a7 ,computation ( base aimp p]c5tages 
,= ! base ,f$]al fiscal ye> 7z def9$ 9  
p>agraph 7#c771 ! ,secret>y %all compute
 & publi% = ea* ,/ate-- 7i7 ! base      
,,aimp ,/ate p]c5tage 7z def9$ 9        
subp>agraph 7,b77 = ! ,/ate & su* fiscal
 ye>2 &  7ii7 ! ,f$]al ,,aimp mat*+     
p]c5tage = ! ,/ate & su* fiscal ye>4    
7,b7 ,base ,,aimp /ate p]c5tage def9$ ,9
 ?is section1 ! base ,,aimp ,/ate       
p]c5tage means ! am\nt equal to ! ratio 
7express$ z a p]c5tage7 (-- 7i7 ! sum   
(-- 7,i7 ! am\nt ( ! ,/ate %>e (        
exp5ditures "u title ,,xix = m$ical     
assi/ance dur+ ! base ,f$]al fiscal ye> 

attributable to full-b5efit dual        
eligible individuals2 &  7,,ii7 ! am\nt 
( ! paym5t made to ! ,f$]al ,gov]nm5t   
dur+ ! base ,f$]al fiscal ye> "u section
 #aice7;c7 7commonly ref]r$ to z ! "p ,d
 clawback7 attributable to su*          
individuals2 to  7ii7 ! sum (-- 7,i7 !  
total exp5ses paid "u title ,,xviii t   
are attributable to full-b5efit dual    
eligible individuals = s]vices 7or      
p]iods ( cov]age7 occurr+ ! base ,f$]al 
fiscal ye> 7z e/imat$ by ! ,secret>y72 &
  7,,ii7 ! total am\nt exp5d$ on items &
 s]vices describ$ 9 section             
#bbjd7;a77#a7 paid "u title ,,xix       
7includ+ any waiv]s "u title ,,xi7 =    
full-b5efit dual eligible individuals 9 
! base ,f$]al fiscal ye>4  7,c7         
,adju/m5ts to base ,,aimp p]c5tages ,)  
respect to ! base ,,aimp ,/ate p]c5tages
 & ! ,f$]al ,,aimp mat*+ p]c5tages      
o!rwise comput$ "u ?is p>agraph = ! base
 ,f$]al fiscal ye>1 ! ,secret>y %all    
adju/ su* p]c5tages to take into acc\nt 
mat]ial *anges 9 ! programs "u titles   

,,xviii & ,,xix betwe5 ! base ,f$]al    
fiscal ye> & ! fir/ fiscal ye> = :i*    
,,aim programs may be implem5t$ "u ?is  
title ins(> z su* mat]ial *anges h a    
direct mat]ial impact on ,,aimp         
exp5ditures relat+ to ,,aimp-eligible   
individuals4  7#b7 ,data report+ =      
basel9e computations ,ea* ,/ate1 9 its  
application = approval ( its ,,aim      
program1 %all provide ! ,secret>y 79 su*
 =m & mann] z ! ,secret>y may require7  
su* f9ancial data 7includ+ detail$ &    
aggregate1 hi/orical & project$         
exp5ditures data7 on its exp5ditures "u 
title ,,xix z ! ,secret>y may require to
 c>ry out ! computations requir$ "u ?is 
section4 ,! ,secret>y %all %>e ) !      
,/ate1 9 a process def9$ by ! ,secret>y1
 ,m$ic>e exp5diture data 7includ+       
detail$ & aggregate hi/orical & project$
 exp5ditures data7 = s]vices & b5efits =
 full-b5efit dual eligible individuals 9
 su* ,/ate4  7#c7 ,base f$]al fiscal ye>
 def9$ ,9 ?is section1 ! t]m base ,f$]al
 fiscal ye> means ! ,f$]al fiscal ye> t 

is ! second prec$+ fiscal ye> to ! #a/  
fiscal ye> = :i* ,,aim programs may be  
implem5t$ "u ?is title4  7d7 ,re9ve/m5t 
( %>$ sav+s  7#a7 ,9 g5]al  7,a7 ,9     
g5]al ,if1 ) respect to a fiscal ye>1 an
 ,,aimp-p>ticipat+ ,/ate has exp5ditures
 "u ?is title = ,,aimp assi/ance t = !  
prec$+ fiscal ye>1 are less ?an #he     
p]c5t ( ! exp5ditures = su* assi/ance "u
 ! ,/ate ,,aim program = ! second prec$+
 fiscal ye>1 ! ,secret>y %all ensure t =
 ea* qu>t] 9 ! foll[+ fiscal ye>1 !     
,/ate sp5ds at lea/ ! %>$ sav+s am\nt   
det]m9$ = ! ,/ate = ! fiscal ye> on #a  
or m ( ! core applications describ$ 9   
p>agraph 7#c74 ,am\nts exp5d$ by a ,/ate
 to meet ! requirem5t ( ! prec$+ s5t5ce 
%all n be subject to any ,f$]al mat*+   
paym5ts "u ?is title4  7,b7 ,%>$ sav+s  
am\nt def9$ ,9 ?is subsection1 ! t]m %>$
 sav+s am\nt means1 ) respect to an     
,,aimp-p>ticipat+ ,/ate = a fiscal ye>1 
! am\nt by :i* ! ,,aimp assi/ance       
exp5ditures = ! fiscal ye> is less ?an  
#he p]c5t ( ! exp5ditures = su*         

assi/ance "u ! ,/ate ,,aim program = !  
second prec$+ fiscal ye>4  7#b7         
,application ( %>$ sav+s ,! ,secret>y   
%all issue guidance outl9+ all[able use 
( ! %>$ sav+s paym5ts "u p>agraph 7#a74 
,"u su* guidance1 ! ,secret>y %all      
outl9e ! types ( s]vices & b5efits = :i*
 a ,/ate has ! au?ority to apply !      
paym5ts = ! b5efit ( consum]s :o are    
,,aimp-eligible individuals4 ,su*       
guidance %all p]mit ! use ( su* paym5ts 
consi/5t ) ! core applications describ$ 
9 p>agraph 7#c7 & ) p>agraph 7#d71 & may
 be us$ = exi/+ ,/ate-fund$ heal?       
programs or new heal?-relat$ initiatives
 t s]ve full-b5efit dual eligible       
individuals "u ?is title4  7#c7 ,core   
applications ,! core applications       
describ$ 9 ?is p>agraph = su* consum]s  
are z foll[s3 7,a7 ,consum] p[] & *oice 
,to provide su* consum]s m in=mation &  
control ov] _! heal? c>e & community    
support options4  7,b7 ,equity & access 
to c>e ,to improve access to1 & quality 
(1 c>e across populations1 advance heal?

 equity = consum]s1 & r$uce heal?       
disp>ities & elim9ate b>ri]s to c>e4    
7,c7 ,prev5tion & wellness ,to /rive to 
bett] enable su* consum]s to receive    
individualiz$ heal? c>e t is            
outcomes-ori5t$ & focus$ on prev5tion1  
wellness1 recov]y & ma9ta9+ indep5d5ce4 
7,d7 ,pay = p]=mance ,to employ pur*as+ 
& paym5t me?ods t enc\rage & rew>d      
s]vice quality & co/-effectiv5ess by    
l9k+ reimbursem5ts = s]vices to su*     
consum]s to common1 evid5ce-bas$ quality
 p]=mance measures1 includ+ pati5t      
satisfaction4  7,e7 ,innovative         
advancem5t ,to implem5t innovative &    
te*nological advancem5ts t facilitate   
su* consum]s rema9+ 9 ! community4  7,f7
 ,s]vice integration ,to increase       
integration ( s]vices ) social ne$s to  
improve heal? outcomes = su* consum]s4  
7,g7 ,/ate p]sonnel ,to hire additional 
,/ate p]sonnel to c>ry out ?is title4   
7,h7 ,capacity build+ ,to exp& capacity 
9 provid+ s]vices to su* consum]s1 su* z
 9-- 7i7 community-bas$ c>e2 &  7ii7    

c>egiv] assi/ance4  7,i7 ,improve       
enrollm5t policies & process ,to improve
 ! ability to enroll 9 ! ,/ate ,,aimp   
program ?r\gh /reaml9+ enrollm5t        
policies & processes4  7,j7 ,increase   
education = provid]s & b5efici>ies ,to  
ensure provid]s & b5efici>ies und]/& !  
,/ate ,,aimp program & ! *oices         
available "u su* program4  7,k7 ,improve
 data collection reg>d+ racial          
disp>ities & heal? inequities ,to ensure
 appropriate data is collect$ & us$ to  
det]m9e program inequities4  7,l7 ,o!r  
s]vices & initiatives ,o!r s]vices &    
initiatives approv$ by ! ,secret>y t    
s]ve full-b5efit dual eligible          
individuals "u ?is title4  7#d7         
,limitation on paym5t to ,,aimp-adm9i/]+
 entities ,an ,,aimp-p>ticipat+ ,/ate   
may use paym5ts "u ?is subsection = an  
,,aimp-adm9i/]+ entity only if ! ,/ate  
demon/rates1 to ! satisfaction ( !      
,secret>y1 t ! ,/ate's ,,aim program    
provides appropriate ma9t5ance ( access 
to & quality ( c>e bas$ on ! requirem5ts

 impos$ by ! ,/ate on ! applicable      
,,aimp-adm9i/]+ entities4  7e7          
,application ( m$icaid paym5t           
me?odologies f9anc+ limitations = !     
non-,f$]al %>e ( exp5ditures  7#a7 ,9   
g5]al ,except z ! ,secret>y may o!rwise 
provide ?r\gh notice & comm5t           
regulation1 ! foll[+ provisions ( title 
,,xix 7& relat$ regulations7 %all apply 
to ,,aimp-p>ticipat+ ,/ates' exp5ditures
 9 ! ,,aim program 9 a mann] simil> to !
 mann] 9 :i* su* provisions apply "u    
title ,,xix3 7,a7 ,section #aijc7;d7    
7relat+ to e/imat$ paym5ts1 recov]y (   
ov]paym5ts1 disall[ance ( provisions74  
7,b7 ,section #aijc7w7 7relat+ to       
provid]-relat$ donations1 heal? c>e     
relat$ taxes1 & broad-bas$ heal? c>e    
relat$ taxes74  7,c7 ,section           
#aijc7w77#f7 7relat+ to c]tifi$ public  
exp5ditures & int]gov]nm5tal transf]s74 
7,d7 ,o!r provisions relat+ to def]ral (
 paym5ts1 prev5t+ fraud & abuse1 &      
ensur+ program integrity4  7#b7         
,processes & =ms  7,a7 ,9 g5]al ,!      

,secret>y %all e/abli% appropriate =ms &
 processes 7includ+ exp5diture          
reconciliation processes7 = submission (
 in=mation on ,/ate exp5ditures "u ?is  
title 9 a mann] simil> to ! processes   
us$ = purposes ( paym5ts to ,/ates "u   
title ,,xix1 b ?r\gh ! use ( su*        
alt]native =ms z may be appropriate 9   
implem5t+ ?is title4  7,b7 ,report+ (   
e/imat$ exp5ditures by qu>t] ,an        
,,aimp-p>ticipat+ ,/ate %all e/imate    
mat*able exp5ditures 7includ+ bo? total 
exp5ditures z well z ! e/imat$ ,f$]al   
%>e ( ^? exp5ditures7 & sep>ately report
 ^! exp5ditures by qu>t] = ea* fiscal   
ye> = its ,,aim program4 ,! ,secret>y   
%all make ,f$]al funds available bas$ ^u
 ! ,/ate's e/imate1 z approv$ by !      
,secret>y4  7,c7 ,report+ &             
reconciliation ( actual exp5ditures on a
 qu>t]ly basis ,n lat] ?an #cj days aft]
 ! end ( ea* qu>t]1 ea*                 
,,aimp-p>ticipat+ ,/ate %all submit to !
 ,secret>y 7on an appropriate =m7 a     
qu>t]ly exp5diture report1 %[+          

exp5ditures made 9 ! qu>t] j end$ "u its
 ,,aim program4 ,! ,secret>y %all       
reconcile exp5ditures s report$ ) ,f$]al
 fund+ previ\sly made available to !    
,/ate "u ?is section & include !        
reconcil+ adju/m5t 9 ! f9alization ( !  
grant aw>d to ! ,/ate4  7#c7 ,rule (    
con/ruction ,no?+ 9 ?is title %all be   
con/ru$ z con/ra9+ or limit+ ! au?ority 
( ! ,secret>y1 ! ,adm9i/rator ( ! ,c5t]s
 = ,m$ic>e  ,m$icaid ,s]vices1 !        
,inspector ,g5]al ( ! ,dep>tm5t ( ,heal?
 & ,human ,s]vices1 or ! ,comptroll]    
,g5]al ( ! ,unit$ ,/ates1 to conduct    
r\t9e & t>get$ program & f9ancial       
managem5t audits & o!r ov]sight         
activities ( funds exp5d$ "u ?is title1 
includ+ ov]sight activities relat+ to ! 
all[able use ( funds4  7f7 ,option =    
multi-,ye> inve/m5t initiative ,!       
,secret>y may specify a process by :i*  
an ,,aim-p>ticipat+ ,/ate may elect to  
p>ticipate 9 a multi-ye> inve/m5t       
initiative dur+ ! fir/ #c-ye> p]iod 9   
:i* ! ,/ate p>ticipates 9 ! ,,aim       

program4 ,"u su* option1 an             
,,aim-p>ticipat+ ,/ate %all be eligible 
= additional ,f$]al f9ancial            
p>ticipation 7z det]m9$ by ! ,secret>y7 
= exp5ditures "u ?is title t d n exce$  
an annual budget t>get e/abli%$ = !     
,/ate1 bas$ on ! exp5ditures ( ! ,/ate  
us$ to det]m9$ ! base ,,aimp ,/ate      
p]c5tage "u subsection 7c77#a77;,b71 &  
increas$ = ! #b;d & #crd ye>s ( su*     
p]iod1 by #i4ii p]c5t ov] ! budget t>get
 e/abli%$ = ! prec$+ ye>4  #bbji4       
,acc\ntability & ov]sight  7a7 ,quality 
assessm5t ,to ensure t full-b5efit dual 
eligible individuals receive high       
quality c>e & to enc\rage quality       
improvem5t "u ,,aim programs1 ea*       
,,aim-p>ticipat+ ,/ate %all e/abli% a   
quality inc5tive program t uses f9ancial
 rew>ds1 p5alties1 or bo? t are mean+ful
 en\gh to influ5ce ! adm9i/]+ entity's  
behavior & is approv$ by ! ,f$]al       
,coord9at$ ,heal? ,c>e ,(fice4 ,ea*     
,,aim program w be expect$ to tie       
f9ancial inc5tives to p]=mance ei!r 9 ! 

=m ( quality )holds or inc5tives1 su* z 
mak+ additional quality paym5ts to an   
,,aimp-adm9i/]+ entity t a*ieves quality
 or equity goals or ! )hold+ ( a portion
 ( a capitation paym5t to an entity t   
fails to a*ieve su* goals4 ,ea*         
,,aim-p>ticipat+ ,/ate %all publicly po/
 & seek comm5t on its propos$ quality   
inc5tive program prior to submitt+ to ! 
,f$]al ,coord9at$ ,heal? ,c>e ,(fice =  
approval4  7b7 ,monitor+ & program      
evaluation  7#a7 ,consolidat$ report+   
requirem5ts = aim-adm9i/]+ entities ,!  
,secret>y & ea* ,,aimp-p>ticipat+ ,/ate 
%all def9e & specify 9 ! contract = ea* 
,,aimp-adm9i/]+ entity "u ?is title a   
consolidat$ report+ process t ensures ! 
provision ( ! necess>y data on          
diagnosis1 ,,h$is measures1 enc\nt]     
reports1 enrollee satisfaction1 &       
evid5ce-bas$ measures & o!r in=mation z 
may be useful 9 ord] to monitor ea*     
,,aimp-adm9i/]+ entity's p]=mance "u !  
,,aimp contract4  7#b7 ,evaluation ,!   
,secret>y & ea* ,,aimp-p>ticipat+ ,/ate 

%all develop processes & protocols =    
collect+ 7or ensur+ t ,,aimp-adm9i/]+   
entities collect7 & report+ to !        
,secret>y & ! ,/ate ! data ne$$ = an    
evaluation by ! ,secret>y to measure !  
impact ( ,,aimp-adm9i/]+ entities1 !    
effectiv5ess ( ! process 9 enroll+      
,,aimp-eligible individuals "u ! ,,aim  
program1 & ! effectiv5ess ( ! ,,aim     
program 9 r$uc+ disp>ities1 improv+     
quality ( c>e1 & advanc+ heal? equity4  
7#c7 ,collaborative evaluation ,!       
,secret>y & ,,aimp-p>ticipat+ ,/ates    
%all collaborate on & coord9ate dur+ any
 evaluation activity conduct$ "u ?is    
subsection4  7c7 ,adm9i/rative ov]sight 
responsibilities  7#a7 ,/ate role ,ea*  
,,aimp-p>ticipat+ ,/ate %all be         
responsible = day-to-day ov]sight ( !   
,,aimp-adm9i/]+ entities provid+ s]vices
 ) respect to ,,aimp enrollees "u !     
,,aimp contract ) ! ,/ate "u its ,,aim  
program4 ,su* ov]sight %all include !   
foll[+ activities3 7,a7 ,conduct+ a     
compreh5sive read9ess review ( ea*      

entity 7z requir$ "u section #bbja7;d774
  7,b7 ,monitor+ compliance ( ! entity )
 ! t]ms ( its ,,aimp contract "u ! ,,aim
 program1 includ+-- 7i7 ensur+ adh]5ce  
to & protection ( enrollee rights z     
provid$ "u ?is title2  7ii7 monitor+ !  
entity to ensure x au?orizes1 arranges1 
coord9ates1 & provides all cov]$ &      
m$ically necess>y s]vices 7z requir$ "u 
?is title7 to ,,aimp enrollees receiv+  
b5efits adm9i/]$ by ! entity1 9         
accordance ) ! requirem5ts ( ! ,,aimp   
contract2 &  7iii7 ensur+ compliance )  
applicable report+ requirem5ts "u ?is   
title4  7,c7 ,review+1 approv+1 &       
monitor+-- 7i7 ! entity's network       
adequacy2  7ii7 ! outrea* & ori5tation  
mat]ials & proc$ures ( ! entity2  7iii7 
! compla9t & appeals proc$ures c>ri$ out
 by ! entity2  7iv7 ! utilization       
managem5t functions ( ! entity2  7v7 !  
entity's adh]5ce to requir$ cont9uity ( 
c>e provisions "u section #bbjd7;c77#c72
  7vi7 ! entity's use ( requir$ /&>d    
assessm5t tool "u section #bbjd7;b72    

7vii7 ! entity's in=mational mat]ials1  
p>ticul>ly = ^? individuals :o w be     
assign$ to ! entity "u section          
#bbjc7;f72 &  7viii7 ! entity's use (   
/reaml9$ eligibility processes "u ?is   
title4  7,d7 ,conduct+ mon?ly 7or m     
frequ5t7 p]=mance review meet+s ) !     
entity4  7,e7 ,conduct+ p]iodic audits (
 ! entity1 includ+ at lea/ an annual    
indep5d5t ext]nal review & an annual    
site visit4  7,f7 ,receiv+ & respond+ to
 compla9ts ab\t ! entity4  7,g7         
,conduct+ annual surveys ( ,,aimp       
enrollees & provid+ ! entity ) writt5   
results ( su* surveys4  7,h7 ,apply+ #a 
or m sanctions 7su* z ^? provid$ "u     
title ,,xix71 :i* may include t]m9ation 
( ! contract1 if ! ,/ate or ! ,secret>y 
det]m9es t ! entity is 9 mat]ial        
violation ( any ( ! t]ms ( ! ,,aimp     
contract4  7#b7 ,f$]al ov]sight role    
7,a7 ,9 g5]al ,! ,secret>y %all be      
responsible = ! ov]sight (              
,,aimp-p>ticipat+ ,/ates4 ,su* ov]sight 
%all include activities develop$ ?r\gh  

engagem5t ) /akehold]s1 includ+ consum] 
advocates1 & %all include at ! lea/ !   
foll[+ activities3 7i7 ,monitor+ !      
process to select organizations to s]ve 
z ,,aimp-adm9i/]+ entities "u ! ,,aim   
program4  7ii7 ,conduct+ a ?or\gh       
read9ess review ( ! ,/ate 7be=e read9ess
 reviews = su* organizations7 "u section
 #bbja7;d77#b74  7iii7 ,ensur+1 includ+ 
?r\gh compla9t track+ & secret %opp+1 ! 
,/ate creates & ma9ta9s a highly        
functional1 d$icat$ ,,aimp ,ombudsman   
program "u section #bbje7;c74  7iv7     
,ensur+1 ?r\gh direct monitor+1 ,/ate   
ov]sight ( compliance ( ,,aimp-adm9i/]+ 
entities ) ! t]ms ( _! ,,aimp contracts 
"u ! ,,aim program4  7v7 ,review+       
eligibility & enrollm5t processes &     
proc$ures4  7vi7 ,monitor+ ,/ate data   
sy/ems to ensure !y are suffici5t =     
provid+ timely data on program p]=mance4
  7vii7 ,ensur+ paym5t rates to         
,,aimp-adm9i/]+ entities "u ! ,,aimp    
contract are actu>ially s\nd1 includ+ by
 e/abli%+ a rate sett+ process e/abli%$ 

?r\gh rulemak+ :]eby1 at a m9imum-- 7,i7
 ,/ates & ! ,secret>y provide           
,,aimp-adm9i/]+ entities ) compreh5sive 
& timely data z "p ( ! rate sett+       
process & procurem5t1 includ+ hi/orical 
,m$icaid & ,m$ic>e co/ & utilization    
data = full-b5efit dual eligible        
individuals by region & includ+ detail$ 
categories ( s]vice2  7,,ii7 ,/ates may 
elect to %>e ! f9al rate c]tification   
package provid$ to ! ,secret>y )        
,,aimp-adm9i/]+ entities2 &  7,,iii7 an 
opportunity = public input is e/abli%$ =
 annual rate sett+ or :5 rates are      
significantly modifi$ :]eby /akehold]s1 
includ+ pati5t advocacy gr\ps1 heal? c>e
 provid]s1 & ,,aimp-adm9i/]+ entities1 c
 provide fe$back to ! ,secret>y prior to
 rate approval4  7viii7 ,coord9at+      
p]iodic audits ( ! ,/ate ) respect o its
 ,,aim program4  7ix7 ,conduct+ regul>  
meet+s ) ! ,/ate4  7x7 ,apply+          
discretion>y action1 if w>rant$4  7xi7  
,ensur+ regul> engagem5t ) dually       
eligible individuals & _! c>egiv]s4     

7,b7 ,compliance au?ority ,if !         
,secret>y f9ds ) respect to a ,/ate     
,,aim program t ! ,/ate fail$ to a*ieve 
! appropriate p]=mance levels or        
compliance ) ! activities requir$ "u    
subp>agraph 7,a71 ! ,secret>y %all take 
su* action z is necess>y to address &   
correct ! ,/ate failures1 :i* may       
include1 to ! ext5t ! ,secret>y det]m9es
 appropriate1 #a or m ( ! foll[+3 7i7   
,develop+ 9 consultation ) ! ,/ate1 a   
corrective compliance plan = a*iev+     
appropriate p]=mance levels or          
compliance4  7ii7 ,rem$ial education &  
sup]vis$ tra9+4  7iii7 ,imposition (    
p5alties or sanctions4  7iv7 ,removal ( 
! ,/ate f ! ,,aim program4  7#c7        
,/ate-f$]al p>tn]%ip role ?r\gh jo9t    
contract managem5t teams 7cmt7  7,a7    
,e/abli%m5t ,! ,secret>y %all1 jo9tly ) 
ea* ,,aimp-p>ticipat+ ,/ate1 e/abli% a  
,jo9t ,contract ,managem5t ,team 79 ?is 
p>agraph ref]r$ to z a ,,cmt7 foll[+ !  
model us$ 9 ! demon/ration projects     
conduct$ "u ! ,f9ancial ,alignm5t       

,initiative = ,m$ic>e-,m$icaid          
,enrollees adm9i/]$ by ! ,f$]al         
,coord9at$ ,heal? ,c>e ,(fice4  7,b7    
,composition & /ructure  7i7 ,9 g5]al   
,ea* ,,cmt %all include at lea/ #a      
contract (fic] f ! ,c5t]s = ,m$ic>e     
,m$icaid ,s]vices & at lea/ #a contract 
(fic] f ! ,,aimp-p>ticipat+ ,/ate1 ea* (
 :om is au?oriz$ & emp[]$ to repres5t ! 
,secret>y & ! ,/ate1 respectively1 ab\t 
all aspects ( ! ,,aimp contract ) an    
,,aimp-adm9i/]+ entity "u ! ,,aim       
program ( ! ,/ate4  7ii7 ,lead ,!       
repres5tation f ! ,f$]al ,gov]nm5t %all 
be l$ by ! individual f ! ,f$]al        
,coord9at$ ,heal? ,c>e ,(fice :o is     
assign$ to "w ) ! ,/ate1 :o w br+ 9     
additional individuals1 z appropriate4  
7iii7 ,/ate lead ,! repres5tation f !   
,,aimp-p>ticipat+ ,/ate %all be l$ by ! 
,director ( ! ,/ate ,m$icaid program "u 
title ,,xix 7or su* ,director's         
designee7 :o w br+ 9 additional         
individual to repres5t ! ,/ate1 z       
appropriate4  7,c7 ,responsibilities (  

cmt ,ea* ,,cmt = a ,/ate %all act z a   
liaison among ! ,,aimp-adm9i/]+ entity1 
! ,secret>y1 & ! ,/ate = ! duration ( ! 
,,aimp contract ) su* entity & %all s]ve
 to facilitate communications &         
op]ations among ! #c p>ties4 ,ea* ,,cmt 
%all1 among o!r functions-- 7i7 receive 
& respond to compla9ts2  7ii7 conduct   
qu>t]ly meet+s among ! p>ties2  7iii7   
e/abli% a me*anism = ongo+ consum]      
engagem5t2  7iv7 coord9ate reque/s =    
assi/ance f ! entity & assign ,f$]al &  
,/ate /aff ) appropriate exp]tise to    
provide te*nical assi/ance to ! entity2 
7v7 make be/ ef=ts to resolve any issues
 applicable to ! p>ties2 &  7vi7 monitor
 any discretion>y action by ! ,/ate or !
 ,secret>y "u ! provisions ( ! ,,aimp   
contract4  #bbaj4 ,def9itions2          
miscellane\s provisions  7a7 ,def9itions
 ,9 ?is title3 7#a7 ,t]ms relat+ to     
,,aimp  7,a7 ,,aimp-adm9i/]+ entity ,!  
t]m ,,aimp-adm9i/]+ entity means an     
organization t has be5 det]m9$ to meet !
 requirem5ts = su* an entity "u ?is     

title & has an ,,aimp contract ) an     
,,aimp-p>ticipat+ ,/ate "u ?is title4   
7,b7 ,,aimp assi/ance ,! t]m ,,aimp     
assi/ance has ! mean+ giv5 su* t]m 9    
section #bbjh7;a77#a77;,b74  7,c7 ,,aimp
 contract ,! t]m ,,aimp contract is a   
contract describ$ 9 section             
#bbjg7;b77#a74  7,d7 ,,aimp-eligible    
individual ,! t]m ,,aimp-eligible       
individual has ! mean+ giv5 su* t]m 9   
section #bbjb7;a74  7,e7 ,,aimp enrollee
 ,! t]m ,,aimp enrollee means an        
individual :o is enroll$ 9 an ,,aim     
program "u ?is title4  7,f7             
,,aimp-p>ticipat+ ,/ate ,! t]m          
,,aimp-p>ticipat+ ,/ate means a ,/ate   
adm9i/]+ an ,,aim program "u ?is title4 
7,g7 ,,aim program2 ,,aimp ,! t]ms ,,aim
 program & ,,aimp mean1 ) respect to a  
,/ate1 ! program e/abli%$ by ! ,/ate "u 
?is title4  7#b7 ,o!r def9itions  7,a7  
,full-b5efit dual eligible individual ,!
 t]m full-b5efit dual eligible          
individual has ! mean+ giv5 su* t]m 9   
section #aice7;c77#f7 b )\t !           

application ( subp>agraph 7,a77i7 ( su* 
section4  7,b7 ,f$]al ,coord9at$ ,heal? 
,c>e ,(fice ,! t]m ,f$]al ,coord9at$    
,heal? ,c>e ,(fice means ! (fice        
e/abli%$ "u section #bfjb ( ! ,pati5t   
,protection & ,af=dable ,c>e ,act4  7,c7
 ,m$icaid manag$ c>e organization ,! t]m
 m$icaid manag$ c>e organization has !  
mean+ giv5 t t]m 9 section              
#aijc7m77#a77;,a7 & includes a prepaid  
inpati5t heal? plan1 z def9$ 9 section  
#dch4b ( title #db1 ,code ( ,f$]al      
,regulations 7or any successor          
regulation7 & a prepaid ambulatory heal?
 plan1 z def9$ 9 su* section 7or any    
successor regulation74  7b7             
,miscellane\s provisions  7#a7 ,relation
 to o!r requirem5ts ,except z o!rwise   
provid$ "u ?is title or by regulation1 !
 requirem5ts ( title ,,xix %all apply "u
 an ,,aim program 9 relation to         
,,aimp-eligible individuals1 ,,aimp     
enrollees1 & ! provision ( b5efits "u an
 ,,aim program1 9 ! same mann] z su*    
requirem5ts apply ) respect to          

individuals eligible = m$ical assi/ance 
:o are enroll$ 9 "u a m$icaid manag$ c>e
 organization4  7#b7 ,limitation on     
waiv] au?ority ,except z provid$ 9 ?is  
title1 ! ,secret>y is n au?oriz$ 7"u    
section #aaae1 #aaae;,a1 or o!rwise7 to 
waive ! requirem5ts specifi$ 9 ?is      
title4  4  7b7 ,con=m+ am5dm5ts to      
m$ic>e  7#a7 ,enrollm5t ,section        
#ahea7;a7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #aciew-#ba7;a77 is am5d$ 
by add+ at ! end ! foll[+ new p>agraph3 
7#d7 ,additional enrollm5t option =     
c]ta9 full-b5efit dual eligible         
individuals ,full-b5efit dual eligible  
individuals may also be eligible to     
enroll "u a ,/ate ,,aim program "u title
 ,,xxii4  4  7#b7 ,prohibition ,dur+ !  
p]iod 9 :i* an ,,aim program is fully   
implem5t$ 9 an ,,aimp-p>ticipat+ ,/ate  
"u title ,,xxii1 ,,aimp-eligible        
individuals 9 ! ,/ate may n enroll 9 a  
manag$ ,m$ic>e & o!r integrat$ duals    
product 7o!r ?an a ,,pace program74  7c7
 ,con=m+ am5dm5ts to m$icaid  7#a7      

,prev5t+ duplicate paym5ts ,section     
#aijc7;i7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #acif7;i77 is am5d$--    
7,a7 by /rik+ or at ! end ( p>agraph    
7#bf72  7,b7 by /rik+ ! p]iod at ! end (
 p>agraph 7#bg7 & ins]t+ 2 or2 &  7,c7  
by ins]t+ aft] p>agraph 7#bg7 ! foll[+  
new p>agraph3  7#bh7 ) respect to any   
am\nt exp5d$ = m$ical assi/ance = an    
individual :o is an ,,aimp enrollee "u a
 ,/ate ,,aim program "u title ,,xxii1   
except specifically p]mitt$ "u su*      
title4  4  7#b7 ,note3 ,additional      
con=m+ am5dm5ts to be provid$4  7d7     
,con=m+ am5dm5t ,section #bfjb7;d7 ( !  
,pati5t ,protection & ,af=dable ,c>e    
,act 7#db ,u4,s4,c4 #acae;b7d77 is am5d$
 by add+ at ! end ! foll[+3  7#i7 ,to be
 prim>ily responsible = ! ,f$]al        
adm9i/ration ( title ,,xxii ( ! ,social 
,security ,act4  4  7e7 ,o!r con=m+     
am5dm5ts ,section #aaja7;a77#a7 ( !     
,social ,security ,act 7#db ,u4,s4,c4   
#acja7;a77#a77 is am5d$-- 7#a7 by /rik+ 
,,xix1 & ,,xxi & ins]t+ ,,xix1 ,,xxi1 & 

,,xxii2 &  7#b7 by /rik+ ,,xix & ,,xxi &
 ins]t+ ,,xix1 ,,xxi1 & ,,xxii4  #c4    
,med,p,a,c /udy & report  7a7 ,/udy ,!  
,m$ic>e ,paym5t ,advisory ,commission   
%all conduct a /udy = purposes ( mak+   
recomm5dations reg>d+ h[ to improve     
heal? c>e & o!r support ne$s (          
individuals :o are eligible = & are     
receiv+ m$ical assi/ance = ! paym5t (   
m$ic>e co/-%>+ "u a ,/ate ,m$icaid      
program pursuant to clause 7i71 7iii71  
or 7iv7 ( section #aijb7;a77#aj77;,e7 ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#acif;a7a77#aj77;,e774  7b7 ,report ,n  
lat] ?an #ah mon?s aft] ! date (        
enactm5t ( ?is ,act1 ! ,m$ic>e ,paym5t  
,advisory ,commission %all submit to    
,congress a report on ! /udy conduct$ "u
 subsection 7a71 toge!r ) recomm5dations
 = su* legislation & adm9i/rative action
 z ! ,commission det]m9es to be         
appropriate4