,,ii #aahth ,,congress #b;d ,session ,s4 #ciej ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,march #ad1 #bjbd,mr4 ,cassidy 7for himself1 ,mr4 ,carper1 ,mr4 ,cornyn1 ,mr4 ,warner1 ,mr4 ,scott of ,south ,carolina1 and ,mr4 ,menendez7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to provide ,states with support to establish integrated care programs for individuals who are dually eligible for ,medicare and ,medicaid1 and for other purposes4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,delivering ,unified ,access to ,lifesaving ,services ,act of #bjbd or the ,,duals ,act of #bjbd4 7b7 ,table of contents ,the table of contents for this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4,,title ,i--,state ,integrated ,care ,programs for ,dual ,eligible ,individuals,sec4 #aja4 ,state implementation4,,title ,,xxii--,state ,integrated ,care ,programs for ,dual ,eligible ,individuals,sec4 #bbja4 ,definitions4,sec4 #bbjb4 ,state selection of program models1 development1 and implementation4,sec4 #bbjc4 ,enrollment in integrated care plans4,sec4 #bbjd4 ,plan requirements and payments4,sec4 #bbje4 ,data collection and reporting4,sec4 #bbjf4 ,state ombudsman4,sec4 #bbjg4 ,funding4,sec4 #bbjh4 ,federal administration through the ,federal ,coordinated ,health ,care ,office4,sec4 #ajb4 ,providing ,federal ,coordinated ,health ,care ,office authority over dual snps4,sec4 #ajc4 ,additional conforming amendments4,,title ,,ii--,improving ,eligibility ,determinations1 ,enrollment ,processes1 and ,quality of ,care for ,dual ,eligible ,individuals,sec4 #bja4 ,identifying opportunities for ,state coordination with respect to eligibility determinations4,sec4 #bjb4 ,alignment of bidding1 reporting1 and other dates and deadlines for integrated care plans4,sec4 #bjc4 ,grants to ,state and local community organizations for outreach and enrollment4,sec4 #bjd4 ,application of model standards to information requirements for integrated care plans4,sec4 #bje4 ,enrollment through independent brokers4,sec4 #bjf4 ,reducing threshold for look-alike ,d-,,snp plans under ,medicare ,advantage4,sec4 #bjg4 ,requiring regular update of provider directories4,sec4 #bjh4 ,review of hospital quality star rating system4,sec4 #bji4 ,requirement for ,,fchco and ,state ,medicaid agencies to develop maximum staffing ratios for care coordinators4,sec4 #baj4 ,,cmmi testing of coverage of partial benefit dual eligible individuals through ,state ,integrated ,care ,programs4,,title ,,iii--,administration,sec4 #cja4 ,alignment of billing codes under titles ,,xviii1 ,,xix1 and ,,xxii4,,title ,,iv--,p,a,c,e,sec4 #dja4 ,requiring ,states to offer ,,pace program services to eligible individuals4,sec4 #djb4 ,enrollment of ,,pace beneficiaries at any time4,sec4 #djc4 ,extending eligibility for ,,pace to medicare-eligible individuals under the age of #ee4,sec4 #djd4 ,removal of quarterly restrictions for submission of a new pace organization application1 and removal quarterly restrictions for applications in a new service area4,sec4 #dje4 ,ensuring ,medicare-only ,,pace program enrollees have a choice of prescription drug plans under ,medicare part ,d4 ,i ,state ,integrated ,care ,programs for ,dual ,eligible ,individuals #aja4 ,state implementation ,the ,social ,security ,act is amended by adding at the end the following new title3 ,,xxii ,state ,integrated ,care ,programs for ,dual ,eligible ,individuals #bbja4 ,definitions ,in this title3 7#a7 ,director ,the term ,director means the ,director of the ,federal ,coordinated ,health ,care ,office of the ,centers for ,medicare ,medicaid ,services4 7#b7 ,dual eligible individual ,the term dual eligible individual means an individual who is entitled to1 or enrolled for1 benefits under part ,a of title ,,xviii1 or enrolled for benefits under part ,b of title ,,xviii1 and is eligible for medical assistance for full benefits under title ,,xix under section #aijb7;a77#aj77;,a7 or #aijb7;a77#aj77;,c71 by reason of section #aijb7;f71 or under any other category of eligibility for medical assistance for full benefits under such title1 as determined by the ,secretary4 7#c7 ,integrated care plan ,the term integrated care plan means an entity or organization that is selected by a ,state under section #bbjb7;a7 to provide fully integrated care for a dual eligible individual in accordance with the requirements of this title and related ,federal and ,state regulations4 ,such term shall not include a ,,pace program 7as defined in sections #ahid7;a77#b7 and #aicd7;a77#b774 #bbjb4 ,state selection of program models1 development1 and implementation 7a7 ,state selection of program models ,not later than #a year after the date on which the ,director first publishes the range of program models for providing integrated care for dual eligible individuals required by section #bbjh7;b77#a71 each ,state shall select from such published models1 and shall work with the ,director to implement such models in the ,state in accordance with the requirements of this title a program model to provide comprehensive1 fully integrated care for dual eligible individuals4 7b7 ,timing ,each ,state shall work with the ,director to implement the models selected by the ,state under subsection 7a7 so that1 to the extent practicable1 the ,state may begin to enroll dual eligible individuals in the program models selected during the #dth year that occurs after the year in which the ,state makes such selection and1 by the end of such #dth year1 the models are fully implemented and operated in accordance with the requirements of this title and related ,federal and ,state regulations4 ,nothing in this subsection shall prohibit a ,state from enrolling dual eligible individuals in such program models earlier than the end of such #dth year if the models are fully implemented and operated in accordance with the requirements of this title and related ,federal and ,state regulations4 7c7 ,adjustment authority ,the ,director may modify the timing required by subsections 7a7 and 7b7 as appropriate to account for the particular needs or circumstances of a ,state4 7d7 ,implementation council 7#a7 ,in general ,a ,state shall establish an implementation council in accordance with such requirements as the ,secretary shall establish4 ,the members of the council shall include representatives of a wide range of stakeholders relevant to the provision of integrated care for dual eligible individuals4 7#b7 ,duties ,the implementation council shall provide advice and counsel to the ,state with respect to the implementation of the models selected by the ,state under subsection 7a74 #bbjc4 ,enrollment in integrated care plans 7a7 ,passive enrollment2 opt-,out permitted 7#a7 ,passive enrollment and notice requirements ,a ,state shall automatically enroll a dual eligible individual with an integrated care plan under a contract with the ,state provided that the ,state notifies the individual that the individual will be enrolled with such plan at least #fj days 7#ij days1 in the case of the first time the individual is provided such notice7 prior to the effective date of such enrollment4 ,notice provided to a dual eligible individual under this paragraph shall include the following3 7,a7 ,the name and contact information for the integrated care plan4 7,b7 ,the date on which the enrollment takes effect and1 if applicable1 whether the ,state has elected the option for a #ab-month continuous eligibility period under paragraph 7#d74 7,c7 ,a summary of the benefits to be provided by the plan4 7,d7 ,information regarding the provider network of the plan4 7,e7 ,information regarding how the dual eligible individual may elect to opt-out of enrollment with the plan within #fj days 7#ij days1 in the case of the first time the individual is provided such notice74 7#b7 ,enrollment in plan with in-network1 participating primary care provider required ,a ,state shall not passively enroll a dual eligible individual in an integrated care plan unless the individual's primary care physician is an in-network1 participating provider for the plan4 7#c7 ,voluntary enrollment ,a ,state shall offer a dual eligible individual the option to enroll in an integrated care plan without regard to meeting the requirement of paragraph 7#b74 7#d7 ,state option for continuous eligibility and enrollment ,a ,state may elect for a dual eligible individual who is determined to be eligible for medical assistance under the ,state plan under title ,,xix or under a waiver of such plan and who is enrolled with an integrated care plan under a contract with the ,state to remain eligible for medical assistance and enrolled with such plan until the earlier of-- 7,a7 the end of the #ab-month period beginning on the date of such determination2 or 7,b7 the date that such individual ceases to be a resident of such ,state4 7b7 ,change of enrollment ,a ,state shall permit a dual eligible individual to change enrollment in an integrated care plan-- 7#a7 on a monthly basis if the individual is electing to enroll in another integrated care plan2 7#b7 during the general enrollment period applicable under section #ahcg1 if the individual is electing to disenroll from an integrated care plan and not enroll in another integrated care plan2 and 7#c7 during the #fj-;day period beginning on the date the individual receives notice from the ,state that the individual has been determined to no longer be eligible for treatment as a dual eligible individual1 if the individual is no longer eligible to enroll in an integrated care plan4 7c7 ,contact by plan care coordinator permitted prior to effective date of enrollment ,a care coordinator for an integrated care plan may contact a dual eligible individual who has been passively enrolled in the plan prior to the effective date of the enrollment4 #bbjd4 ,plan requirements and payments 7a7 ,in general ,a contract between a ,state1 an offeror of an integrated care plan1 and the ,director shall not be considered to meet the requirements of this title unless-- 7#a7 in the case of a dual eligible individual enrolled with the plan who changes enrollment to another integrated care plan for which the individual's primary care provider is not a participating1 in-network provider1 or who disenrolls from the plan and does not enroll in another integrated care plan1 the offeror of the plan will1 during the #cj-;day period that begins on the date on which the individual's disenrollment from the plan takes effect-- 7,a7 allow the individual to continue to be treated by the individual's primary care provider2 and 7,b7 cover any treatment provided to the individual by such provider as if the individual were still enrolled with the plan2 7#b7 the offeror of the plan administers a health risk assessment to each dual eligible individual enrolled with the plan within #ij days of the effective date of the individual's enrollment in accordance with the requirements of subsection 7c7 and shall affirm that there are no changes in the information provided at least every #ab months thereafter2 7#c7 the offeror of the plan provides benefits for a dual eligible individual under a comprehensive care plan in accordance with the requirements of subsections 7d7 and 7f72 7#d7 the offeror of the plan assigns a care coordinator to each dual eligible individual enrolled with the plan in accordance with the requirements of subsection 7e7 and notifies such individual in a timely and accessible manner when a new care coordinator is assigned2 and 7#e7 the contract provides for payment to the offeror for benefits provided to dual eligible individuals enrolled with the plan using a financing structure that satisfies the requirements of section #bbjh7;c74 7b7 ,disregard of certain disenrollment data for ratings purposes ,the disenrollment of a dual eligible individual from an integrated care plan who was passively enrolled in the plan under section #bbjc shall be disregarded for purposes of any data used for rating of the plan for such plan year4 7c7 ,health risk assessment ,an offeror of an integrated care plan shall administer a health risk assessment to each dual eligible individual enrolled with the plan using the standardized health risk assessment questionnaire developed by the ,director under section #bbjh7;b77#c7 and in accordance with such additional requirements as the ,state may establish4 ,an integrated care plan may rely on the results of a previously administered health risk assessment of a dual eligible individual if such results are accessible to the plan and the dual eligible individual affirms that there are no changes in the information previously provided4 7d7 ,benefits 7#a7 ,in general ,an integrated care plan shall provide benefits under the plan in accordance with requirements established by the ,director and the ,state1 and which shall include the following3 7,a7 ,clinical health services4 7,b7 ,behavioral health services4 7,c7 ,long-term services and supports4 7#b7 ,carve-out exceptions ,the ,director may permit a ,state and integrated care plan to separately contract for the provision of services or supports required under paragraph 7#a7 but only if the ,state demonstrates to the ,director that-- 7,a7 the level of care provided for a dual eligible individual under the separate contract with respect to such services or supports is not less than the level of care that would be provided without the exception2 and 7,b7 the dual eligible individual will not be subject to any unreasonable administrative requirements to access the services or supports1 as determined by the ,secretary4 7#c7 ,supplemental benefits ,an integrated care plan may provide customized1 supplemental benefits to a dual eligible individual enrolled with the plan1 including supplemental health care benefits described in section #aheb7;a77#c71 other primarily health-related benefits offered by ,medicare ,advantage plans and benefits permitted by the ,secretary to be offered as ,special ,supplemental ,benefits for the ,chronically ,ill 7,,ssbci71 without regard to whether the dual eligible individual has a requisite condition or diagnosis1 so long as the plan demonstrates to the ,director and the ,state that the offering of such benefits has a positive impact on patient health4 7e7 ,care coordinator requirements ,a care coordinator assigned to a dual eligible individual enrolled in an integrated care plan shall-- 7#a7 serve as the single point of contact between the individual and the plan2 7#b7 be responsible for helping the individual and the individual's caregivers and family make benefit and service decisions2 7#c7 design a beneficiary-focused comprehensive care plan for the individual that meets the requirements of subsection 7f72 and 7#d7 connect and coordinate acute1 subacute1 social1 primary1 and specialty care for the individual and the provision of long-term services and supports for the individual4 7f7 ,comprehensive care plan requirements ,the comprehensive care plan for a dual eligible individual enrolled in an integrated care plan shall be-- 7#a7 designed to address the totality of the individual's medical1 functional1 behavioral1 social1 and caregiving needs and goals1 and to the extent practicable1 to apply to multiple years2 7#b7 be based on the health risk assessment of the individual required by subsection 7c72 7#c7 be implemented by an interdisciplinary care team that includes relevant specialists to ensure access to all aspects of care that are required for the individual2 7#d7 be approved by the individual 7or by an authorized caregiver or guardian7 prior to implementation2 and 7#e7 be reviewed at least annually and within #cj days of a major health event1 such as hospitalization or an emergency room visit4 7g7 ,continuity of care requirement ,an integrated care plan shall provide a dual eligible individual enrolled in the plan with a minimum #ij-;day transition period for any active course of treatment when the individual has enrolled in an integrated care plan after starting a course of treatment1 even if the service is furnished by an out-of-network provider4 ,this includes enrollees new to a plan and enrollees new to ,medicare4 ,the integrated care plan must not disrupt or require reauthorization for an active course of treatment for new plan enrollees for a period of at least #ij days4 ,an integrated care plan may provide for a longer transition period than #ij days at the option of the plan4 ,for purposes of this subsection the following definitions apply3 7#a7 ,the term course of treatment means as a prescribed order or ordered course of treatment for a specific individual with a specific condition is outlined and decided upon ahead of time with the patient and provider4 ,a course of treatment may but is not required to be part of a treatment plan4 7#b7 ,the term active course of treatment means a course of treatment in which a patient is actively seeing the provider and following the course of treatment4 7h7 ,authority ,to apply frailty adjustment factor ,to plan payments ,a contract between a ,state1 an integrated care plan1 and the ,director under this title may apply a frailty adjustment factor with respect to dual eligible individuals enrolled in the plan in the same manner as is permitted under section #ahec7;a77#a77;,b77iv71 but without regard to requiring the plan to demonstrate enrollment of a high concentration of frail individuals4 #bbje4 ,data collection and reporting 7a7 ,annual collection and reporting by ,states and integrated care plans ,each ,state1 and each integrated care plan with a contract with a ,state under this title1 annually shall collect and report information and data to the ,director in accordance with the requirements of this section and guidance and regulations issued under section #bbjh7;b77#g7 that includes data collected by such ,states and plans with respect to a plan year regarding age1 gender1 disability 7including specific disability statuses required to be reported by the ,director71 smoking status1 mobility1 employment status1 education1 race and ethnicity1 and ,,zip ,code1 of dual eligible individuals enrolled in the plan4 7b7 ,collection and reporting of additional data and information permitted ,a ,state may require an integrated care plan with a contract with the ,state under this title to collect and report to the ,state additional data and information4 #bbjf4 ,state ombudsman 7a7 ,in general ,each ,state shall establish and operate an ,office of the ,ombudsman for ,integrated ,care ,plans for ,dual ,eligible ,individuals 7in this section referred to as the ,office74 ,the ,office may operate independently of1 or in connection with1 the ,state agency responsible for administering the ,medicaid program under title ,,xix4 7b7 ,ombudsman ,the ,office shall be headed by an individual1 to be known as the ,state ,integrated ,care for ,dual ,eligible ,individuals ,ombudsman1 who shall be selected from among individuals with expertise in and experience with integrated care models for dual eligible individuals1 the ,medicare program under title ,,xviii1 and the ,medicaid program under title ,,xix4 ,the ,ombudsman shall be responsible for the management1 including the fiscal management1 of the ,office4 7c7 ,requirements 7#a7 ,in general ,the primary responsibility of the ,office shall be to provide support and feedback for dual eligible individuals enrolled in integrated care plans under this title and caregivers or family members of such individuals who need assistance4 7#b7 ,minimum staffing ratio ,the ,office shall have a minimum staffing ratio of #a employee for every #b1jjj dual eligible individuals in the ,state4 7d7 ,funding 7#a7 ,initial funding ,during the first #b years in which a ,state operates the ,office1 the ,secretary shall pay to the ,state for each such year for expenditures necessary to establish and operate the ,office1 from amounts appropriated under section #bbjg7;c71 an amount equal to #ej1jjj1jjj multiplied by the ratio of-- 7,a7 the number of dual eligible individuals in the ,state2 to 7,b7 the number of dual eligible individuals in all ,states4 7#b7 ,subsequent funding ,beginning with the #crd year of the ,office's operation1 expenditures necessary to operate the ,office shall be considered1 for purposes of section #aijc7;a77#g71 to be necessary for the proper and efficient administration of the ,state plan under title ,,xix and reimbursed to a ,state in accordance with that section4 #bbjg4 ,funding 7a7 ,treatment of ,state payments to integrated care plans as medical assistance ,amounts expended by a ,state for payments to an integrated care plan for the ,medicaid component of the capitation payment described in section #bbjh7;c7 shall be treated as medical assistance for which payment is made under section #aijc7;a74 ,nothing in this title shall prevent a ,state from providing medical assistance under title ,,xix to a dual eligible individual for services for which coverage is not provided under the integrated care plan with which the individual is enrolled or from receiving payment under section #aijc7;a7 with respect to expenditures attributable to providing such medical assistance4 7b7 ,payments to ,states ,from the sums appropriated under subsection 7c71 the ,secretary shall pay to each ,state for each calendar year 7beginning ,january #a of the first full calendar year in which this title is implemented in the ,state71 an amount equal to the sum of the following3 7#a7 ,shared savings component ,the shared savings payment applicable to the ,state and the year1 as determined in accordance with section #bbjh7;b77#f77;,d74 7#b7 ,general administrative expenses ,for administrative expenses to carry out this title1 other than section #bbje1 an amount that bears the same proportion to #ej1jjj1jjj as the number of dual eligible individuals in the ,state bears to the number of dual eligible individuals in all ,states1 as determined by the ,secretary4 7#c7 ,data collection and reporting ,for data collection and reporting expenses under section #bbje1 an amount that bears the same proportion to #ej1jjj1jjj as the number of dual eligible individuals in the ,state bears to the number of dual eligible individuals in all ,states1 as determined by the ,secretary4 7c7 ,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 for each calendar year 7beginning ,january #a of the first full calendar year in which this title is implemented in any ,state71 reduced by any amounts made available from the ,medicare trust funds under subsection 7d74 7d7 ,relation to medicare trust funds ,there shall be made available for carrying out this title1 and the ,secretary shall provide for the transfer 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 enrollment of dual eligible individuals in integrated care plans under this title1 for each calendar year 7beginning ,january #a of the first full calendar year in which this title is implemented in any ,state74 7e7 ,relation to other payments ,payments provided under this section to a ,state are in addition to payments provided under section #bbjh4 #bbjh4 ,federal administration through the ,federal ,coordinated ,health ,care ,office 7a7 ,in general ,the ,director shall have primary authority for implementing and carrying out responsibilities of the ,federal ,government under this title4 7b7 ,responsibilities of the ,,fchco ,in carrying out this title1 the ,director shall have the following responsibilities3 7#a7 ,development and publication of integrated care program models ,subject to subsection 7c71 to develop and1 not later than #ahj days after the date of enactment of this paragraph1 publish1 a range of program models 7including but not limited to ,medicare-,medicaid plans1 accountable care organizations1 and dual eligible special needs plans7 for providing integrated care for dual eligible individuals from which ,states shall select to develop and administer integrated care programs for dual eligible individuals in accordance with this title4 7#b7 ,unified appeals process ,to develop and1 not later than #a year after the date of enactment of this paragraph1 publish a unified administrative appeals process for ,state integrated care programs for dual eligible individuals under this title to use in lieu of other administrative appeals processes involving ,medicare and ,medicaid4 7#c7 ,health risk assessment ,to develop a standardized health risk assessment questionnaire for dual eligible individuals that collects standard demographic data and information relating to food insecurity1 access to transportation1 internet access1 utility difficulty1 interpersonal safety1 and housing instability4 7#d7 ,supplemental benefits standards and reporting requirements ,to establish standards for reporting by ,states and integrated care plans under title ,,xxii information relating to the offering and provision of supplemental benefits under section #bbjd7;d77#c71 including data relating to enrollment1 utilization1 and outcomes1 to annually publish a report regarding the offering and utilization of such benefits1 and to study and report to the ,secretary on whether to cap the actuarial dollar value allowed for such benefits under titles ,,xviii1 ,,xix1 and ,,xxii4 7#e7 ,care coordinator requirements ,to-- 7,a7 establish a formula based on patient chronic conditions1 activities of daily living standards1 geographic1 and such other factors as the ,director determines are necessary for ,states and integrated care plans to use to determine the maximum staffing ratio for assigning care coordinators to dual eligible individuals enrolled with integrated care plans under this title2 and 7,b7 develop online training and professional development materials relating to the statutory and administrative requirements for providing integrated care for care coordinators for dual eligible individuals enrolled with integrated care plans under this title4 7#f7 ,administration and oversight of integrated care plans for dual eligible individuals ,to-- 7,a7 develop and issue guidance and regulations related to the alignment of policy and operational process under the ,medicare program under title ,,xviii and the ,medicaid program under title ,,xix1 necessary for implementation1 administration1 and oversight of integrated care plans for dual eligible individuals under this title2 and 7,b7 administer and provide oversight of integrated care plans for dual eligible individuals under this title1 including with respect to-- 7i7 the development and application of an integrated medical loss ratio for such plans1 in lieu of compliance with separate medical loss ratio requirements under titles ,,xviii and ,,xix2 7ii7 the establishment and application of network adequacy standards for such plans that-- 7,i7 apply only with respect to such plans2 7,,ii7 allow the ,director to waive compliance with such standards for integrated care plans that cannot meet the requirements in certain areas1 but must operate statewide to meet a ,state's selective contracting requirements2 and 7,,iii7 allow the ,director to consider flexibilities to support innovative models that do not rely on traditional time and distance standards1 such as the use of telehealth2 and 7iii7 the establishment and application of targeted1 streamlined model-of-care requirements for such plans that include an integrated audit process1 with shared responsibilities between the ,director and ,states1 and that requires the ,director to share the results of such audits with ,state ,medicaid programs4 ,to the extent practicable1 such requirements also shall be designed to be integrated with model of care requirements applicable to ,medicaid managed care organizations2 7,c7 develop contract management teams1 consisting of representatives from integrated care plans with contracts with ,states under this title1 ,state agencies responsible for administering the ,state plan under title ,,xix or a waiver of such plan1 and the ,federal ,coordinated ,health ,care ,office1 to oversee compliance and performance of integrated care plans under this title2 7,d7 develop and implement a shared savings payment for ,states to receive a share of savings to ,federal spending in the ,medicaid program under title ,,xix as a result of the implementation and operation of integrated care plans for dual eligible individuals under this title2 and 7,e7 develop a new star rating system for integrated care plans for dual eligible individuals under this title that rates the performance of each plan type separately1 with ,state-specific measures and tied to single contracts1 instead of the collective performance of all of the offeror's plans under contract with the ,state under that title1 that include measures which directly reflect enrollee satisfaction1 and that awards higher star ratings to plans based on their ability to retain enrollees4 7#g7 ,data collection and reporting ,to establish data and information collection and reporting requirements for ,states and integrated care plans under section #bbje1 including required reporting of specific disability statuses and safeguards to protect patient privacy1 and to annually publish not later than ,april #cj of any year1 the data and information collected and reported to the ,director under such section for the preceding year4 7#h7 ,quality measures ,to develop quality measures for the population of dual eligible individuals that are designed to be uniformly implemented across all platforms and health benefits plans that provide integrated care for such individuals under this title4 ,such measures shall include measures relating to patient satisfaction1 quality of life1 rates of emergency room use1 institutionalization for long-term care1 hospital admission and readmission rates1 and medication errors4 ,the ,director shall regularly review and update such measures as necessary and may develop outcome-based quality measures for determining payments to health benefits plans that provide integrated care for dual eligible individuals under this title4 7#i7 ,best practices ,to not less than annually publish best practices under this title for ,states and integrated care plans1 including with respect to improving outreach to beneficiaries1 improving comprehensive care plans and health risk assessments for dual eligible individuals1 and developing a workforce that provides culturally intelligent and respectful care4 7#aj7 ,training programs ,to develop training programs related to integrated care plans under this title for-- 7,a7 providers of care1 services1 and supports under such plans with respect to issues such as coordination of benefits1 data sharing barriers1 quality ratings1 and provider incentives2 7,b7 ,state employees to increase ,medicare expertise at ,state agencies responsible for administering ,medicaid plans and waivers and contracting with integrated care plans under this title2 and 7,c7 insurance brokers and local counselors who help enroll individuals in ,medicare1 ,medicaid1 and integrated care plans under this title4 7c7 ,capitated payment structure for integrated care program models 7#a7 ,in general ,each program model that is designed by the ,director under subsection 7b77#a7 shall provide that payments shall be made to an integrated care plan for benefits provided under a contract under this title using a capitated payment structure under which1 for each month that the integrated care plan provides such benefits-- 7,a7 the ,state shall pay the integrated care plan an amount equal to the ,medicaid component payment determined for the month2 and 7,b7 the ,secretary shall pay the integrated care plan an amount equal to the ,medicare component payment determined for the month4 7#b7 ,determination of ,medicaid component payment ,for purposes of paragraph 7#a71 the ,medicaid component payment payable to an integrated care plan for a month shall be an amount equal to the sum of the products of-- 7,a7 for each category of beneficiary1 the ,medicaid capitation rate applicable to the category of beneficiary 7as determined by the ,secretary and specified in the contract between the ,state1 the ,secretary1 and the offeror of the plan72 and 7,b7 the number of beneficiaries in such category enrolled with the plan for the month4 7#c7 ,determination of ,medicare component payment ,for purposes of paragraph 7#a71 the ,medicare component payment payable to an integrated care plan for a month shall be an amount equal to the sum of the products of-- 7,a7 for each category of beneficiary1 the ,medicare capitation rate applicable to the category of beneficiary 7as determined by the ,secretary and specified in the contract between the ,state1 the ,secretary1 and the offeror of the plan72 and 7,b7 the number of beneficiaries in such category enrolled with the plan for the month4 7#d7 ,application of risk adjustment model to capitation rates ,the ,medicaid and ,medicare capitation rates for each category of beneficiary specified in a contract between a ,state1 the ,secretary1 and the offeror of an integrated care plan shall be determined using the risk adjustment payment model developed under subsection 7d74 7d7 ,risk adjustment payment model for providing health benefits coverage for dual eligible individuals ,not later than #a year after the date of enactment of this subsection1 the ,director shall enter into a contract or other agreement with an independent entity to develop a risk adjustment payment model for dual eligible individuals that-- 7#a7 is designed to be uniformly implemented across all platforms and health benefits plans that provide integrated care for such individuals under title ,,xxii of the ,social ,security ,act2 7#b7 includes factors based on the health status of such individuals2 and 7#c7 allows plan payments to be made and updated on a monthly basis4 7e7 ,additional responsibilities with respect to integrated care plans 7#a7 ,outreach to ,medicaid providers ,not later than #ahj days after the date of enactment of this subsection1 the ,director1 in consultation with ,state ,medicaid programs1 shall develop outreach plans for such programs to use to contact providers of health benefits1 services1 or supports for dual eligible individuals and provide information and education regarding the ,state ,integrated ,care ,programs for ,dual ,eligible ,individuals established under this title1 how such program will operate in the ,state where such providers offer health benefits1 services or supports for such individuals1 and the impact of such program on such providers4 7#b7 ,collection of data on quality measures from integrated care plans under ,medicaid and ,medicare 7,a7 ,in general ,not later than #ahj days after the date of enactment of this subsection1 the ,director1 in consultation with the ,administrator of the ,centers for ,medicare ,medicaid ,services and ,state ,medicaid programs1 shall establish a plan for collecting data on quality measures from health benefits plans that provide integrated care for dual eligible individuals under ,medicare or ,medicaid4 ,such data shall include1 at a minimum1 data relating to provider network availability in both ,medicare and ,medicaid1 providers in-network who are accepting new ,medicare and ,medicaid patients1 spending on supplemental benefits1 and claims denials4 7,b7 ,authority to collect additional data and information2 publication ,the ,director may-- 7i7 collect additional data and information relating to the quality of care provided for dual eligible individuals by health benefits plans that provide integrated care for such individuals under ,medicare or ,medicaid2 and 7ii7 make the data and information collected in accordance with this paragraph publicly available4 7#c7 ,development of an aligned program for ,institutional ,special ,needs ,plans under ,medicaid ,not later than #ahj days after the date of enactment of this subsection1 the ,director1 in consultation with the ,administrator of the ,centers for ,medicare ,medicaid ,services and ,state ,medicaid programs1 shall develop an aligned program for offering ,institutional ,special ,needs ,plans under ,medicaid that has #a entity financially responsible for providing health benefits1 services1 and supports for dual eligible individuals4 7#d7 ,assessment of need for criteria to regulate and expand utilization of ,institutional ,special ,needs ,plans ,not later than #ahj days after the date of enactment of this subsection1 the ,director1 in consultation with the ,administrator of the ,centers for ,medicare ,medicaid ,services1 shall assess the adequacy of regulations and oversight of ,institutional ,special ,needs ,plan to determine whether new1 or additional requirements should be established to improve the utilization1 performance1 and oversight of such plans and how such plans may be offered under ,state ,integrated ,care ,programs for ,dual ,eligible ,individuals established under this title4 7f7 ,appropriations ,there are hereby appropriated1 out of any funds in the ,treasury not otherwise appropriated1 for the first fiscal year that begins after the date of enactment of this title1 and for each fiscal year thereafter1 such sums as are necessary to carry out this title4 7g7 ,direct-,hire authority ,in carrying out this title1 the ,director shall have direct-hire authority to the extent required to implement and administer this title on a timely basis4 4 #ajb4 ,providing ,federal ,coordinated ,health ,care ,office authority over dual snps 7a7 ,in general ,section #ahei7;f77#h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7;f77#h77 is amended by adding at the end the following new subparagraph3 7,f7 ,authority of ,federal ,coordinated ,health ,care ,office ,for plan years beginning on or after ,january #a1 #bjbe1 the ,federal ,coordinated ,health ,care ,office established under section #bfjb of ,public ,law #aaa-adh shall have primary authority for implementing and carrying out responsibilities of the ,secretary with respect to the integration of specialized ,,ma plans for special needs individuals described in subsection 7b77#f77;,b77ii7 under this subsection4 4 7b7 ,conforming amendment ,section #bfjb7;d77#f7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #acae;b7d77#f77 is amended by inserting the following before the period3 and1 for plan years beginning on or after ,january #a1 #bjbe1 to carry out subsection 7f77#h77;,f7 of such section4 #ajc4 ,additional conforming amendments 7a7 ,definition of ,state ,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 7b7 ,medicare 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 dual eligible individuals ,dual eligible individuals 7as defined in section #bbja7 may also be eligible to enroll in an integrated care plan under title ,,xxii4 4 7c7 ,preventing duplicate payments under ,medicaid ,section #aijc7;i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7i77 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 7#c7 by inserting after paragraph 7#bg7 the following new paragraph3 7#bh7 with respect to any amount expended for medical assistance for a dual eligible individual 7as defined in section #bbja7 enrolled in an integrated care plan under title ,,xxii1 except as specifically permitted under such title4 2 and 7#d7 in the third sentence1 by striking 1 and 7#ah7 and inserting 1 7#ah71 and 7#bh74 ,,ii ,improving ,eligibility ,determinations1 ,enrollment ,processes1 and ,quality of ,care for ,dual ,eligible ,individuals #bja4 ,identifying opportunities for ,state coordination with respect to eligibility determinations ,not later than #a year after the date of enactment of this ,act1 the ,secretary of ,health and ,human ,services1 in consultation with ,states1 shall-- 7#a7 review ,state processes for determining whether an individual is a full-benefit dual individual 7as defined in section #aice7;c77#f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#e7;c77#f77 but without the application of subparagraph 7,a77i7 of such section7 and whether an individual is eligible for the low-income subsidy program under section #ahfj;,d-#ad of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aad7 and the ,medicare ,savings ,program 7as defined in section #aadd7;c77#g7 of such ,act 7#db ,u4,s4,c4 #acbj;b-#ad7;c77#g7772 and 7#b7 issue guidance for ,states that identifies opportunities for better coordination of such processes between the ,states and the ,federal ,government4 #bjb4 ,alignment of bidding1 reporting1 and other dates and deadlines for integrated care plans ,not later than #ahj days after the date of enactment of this ,act1 the ,director of the ,federal ,coordinated ,health ,care ,office of the ,centers for ,medicare ,medicaid ,services and the ,administrator of the ,centers for ,medicare ,medicaid ,services shall-- 7#a7 review bidding1 reporting1 and other significant dates and deadlines applicable to integrated care plans under the ,medicare program1 the ,medicaid program1 and ,state ,integrated ,care ,programs for ,dual ,eligible ,individuals under title ,,xxii of the ,social ,security ,act2 and 7#b7 identify such administrative and legislative changes as are needed to ensure that all such dates and deadlines are aligned and consistent under all such programs4 #bjc4 ,grants to ,state and local community organizations for outreach and enrollment 7a7 ,in general ,from the amounts appropriated under subsection 7c7 for a fiscal year1 the ,secretary of ,health and ,human ,services 7in this section referred to as the ,secretary7 shall award grants to ,state and local community organizations to conduct outreach and enrollment efforts that are designed to increase the enrollment of dual eligible individuals 7as defined in section #bbja of the ,social ,security ,act7 in health benefits plans that provide integrated care for such individuals under ,state ,integrated ,care ,programs for ,dual ,eligible ,individuals established under ,,xxii of the ,social ,security ,act4 7b7 ,model standards ,the ,secretary1 in consultation with the ,administrator of the ,administration for ,community ,living and ,states1 shall develop and issue model standards for outreach and education conducted by ,state and local community organizations awarded grants under this section that include the following3 7#a7 ,information and education support is available for individuals in a range of languages1 and online1 over the phone1 and in person4 7#b7 ,materials presented are easy to read1 written in as low a reading comprehension level as possible1 and are in the proper language for the individual involved4 7#c7 ,information presented online is accessible for individuals with disabilities4 7#d7 ,information is presented in a manner that takes into consideration the accessibility needs of the individual1 such as language access requirements and the health literacy level of the individual4 7c7 ,appropriation ,there is appropriated1 out of any money in the ,treasury not otherwise appropriated1 for the first fiscal year that begins after the date of enactment of this ,act1 and for each fiscal year thereafter1 #ej1jjj1jjj to carry out this section4 #bjd4 ,application of model standards to information requirements for integrated care plans ,not later than #a year after the date of enactment of this ,act1 the ,director of the ,federal ,coordinated ,health ,care ,office of the ,centers for ,medicare ,medicaid ,services and the ,administrator of the ,centers for ,medicare ,medicaid ,services jointly shall issue guidance or regulations requiring that any notice or informational materials provided to a dual eligible individual 7as defined in section #bbja of the ,social ,security ,act7 by such ,director1 ,administrator1 ,states1 or health benefits plans that provide integrated care for such individuals under the ,medicare program1 the ,medicaid program1 or under ,state ,integrated ,care ,programs for ,dual ,eligible ,individuals established under ,,xxii of the ,social ,security ,act complies with the model standards issued under section #bjc7;b74 #bje4 ,enrollment through independent brokers ,not later than #a year after the date of enactment of this ,act1 the ,director of the ,federal ,coordinated ,health ,care ,office of the ,centers for ,medicare ,medicaid ,services and the ,administrator of the ,centers for ,medicare ,medicaid ,services jointly shall issue guidance or regulations providing that-- 7#a7 a dual eligible individual 7as defined in section #bbja of the ,social ,security ,act7 may not be enrolled in a health benefits plan that provides integrated care for such individual under title ,,xxii of the ,social ,security ,act through a broker unless the broker is an independent broker 7as defined under such guidance or regulations72 7#b7 an independent broker may receive a commission for the initial enrollment of a dual eligible individual in such a plan1 but no commission shall be available to any broker for any subsequent enrollment of such individual in any such plan2 7#c7 if a broker disenrolls a dual eligible individual from any such health benefits plan to a plan that provides partial or no integrated care1 the broker1 in accordance with the model standards issued under section #bjd7;b71 shall inform the individual-- 7,a7 of the health benefits plan the individual is being disenrolled from2 and 7,b7 that the individual is being enrolled in a health benefits plan that provides partial or no integrated care and the potential implications of such disenrollment and enrollment on the individual's care4 #bjf4 ,reducing threshold for look-alike ,d-,,snp plans under ,medicare ,advantage ,for the first full plan year that begins on or after the date that is #a year after the date of enactment of this ,act1 and each subsequent plan year1 the ,secretary of ,health and ,human ,services-- 7#a7 shall implement section #dbb4ead7;d77#a77;ii7 of title #db1 ,code of ,federal ,regulations 7or any successor regulations7 by substituting #ej percent for #hj percent2 and 7#b7 shall only count full-benefit dual eligible individuals 7as defined in section #aice7;c77#f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#e7;c77#f777 for purposes of applying the threshold under such section4 #bjg4 ,requiring regular update of provider directories ,not later than #a year after the date of enactment of this ,act1 the ,director of the ,federal ,coordinated ,health ,care ,office of the ,centers for ,medicare ,medicaid ,services and the ,administrator of the ,centers for ,medicare ,medicaid ,services shall promulgate regulations that-- 7#a7 require ,medicare ,advantage plans under part ,c of title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba7 and integrated care plans under title ,,xxii of such ,act to regularly update provider directories2 and 7#b7 include a measure relating to provider director currency rating on star rating systems for ,medicare ,advantage plans under section #ahec7o7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7o77 and integrated care plans under title ,,xxii of such ,act4 #bjh4 ,review of hospital quality star rating system ,not later than #ahj days after the date of enactment of this ,act1 the ,administrator of the ,centers for ,medicare ,medicaid ,services shall-- 7#a7 review the hospital quality star rating system under the ,medicare program under title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq472 and 7#b7 identify such administrative and legislative changes as are needed to ensure that sufficient information is collected under such system regarding hospitals to effectively measure hospital quality4 #bji4 ,requirement for ,,fchco and ,state ,medicaid agencies to develop maximum staffing ratios for care coordinators 7a7 ,in general ,the ,director of the ,federal ,coordinated ,health ,care ,office1 in consultation with ,state ,medicaid agencies1 shall develop model ,federal legislation that would establish a process for determining a maximum care coordinator-to-patient ratio for integrated care plans providing care to dual eligible individuals under an integrated care model under title ,,xxii of the ,social ,security ,act4 ,such process shall take into account the varying needs required by different categories of patients4 7b7 ,submission of model legislation ,not later than #ahj days after the date of enactment of this ,act1 the ,director of the ,federal ,coordinated ,health ,care ,office shall submit the model legislation developed under subsection 7a7 to-- 7#a7 the ,secretary of ,health and ,human ,services2 7#b7 the ,committee on ,finance of the ,senate2 7#c7 the ,committee on ,energy and ,commerce of the ,house of ,representatives2 and 7#d7 the ,committee on ,ways and ,means of the ,house of ,representatives4 #baj4 ,,cmmi testing of coverage of partial benefit dual eligible individuals through ,state ,integrated ,care ,programs ,section #aaae;,a of the ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7 is amended-- 7#a7 in subsection 7b77#b77;,a71 by adding at the end the following new sentence3 ,the models selected under this subparagraph shall include the testing of the model described in subsection 7h77#a742 and 7#b7 by adding at the end the following new subsection3 7h7 ,testing of model for providing coverage of partial benefit dual eligible individuals through partially integrated care plans under ,state ,integrated ,care ,programs 7#a7 ,in general ,the model described in this paragraph is a model under which ,states may offer coverage to partial benefit dual eligible individuals through partially integrated care plans under ,state ,integrated ,care ,programs established under title ,,xxii4 7#b7 ,partial benefit dual eligible individual ,for purposes of this subsection1 the term partial benefit dual eligible individual means an individual who-- 7,a7 is eligible for the low-income subsidy program under section #ahfj;,d-#ad1 the ,medicare ,savings ,program 7as defined in section #aadd7;c77#g771 or both2 and 7,b7 is not a full-benefit dual eligible individual 7as such term is defined in section #aice7;c77#f71 but without the application of subparagraph 7,a77i7 of such section74 4 ,,iii ,administration #cja4 ,alignment of billing codes under titles ,,xviii1 ,,xix1 and ,,xxii ,not later than #ahj days after the date of enactment of this ,act1 the ,director of the ,federal ,coordinated ,health ,care ,office of the ,centers for ,medicare ,medicaid ,services and the ,administrator of the ,centers for ,medicare ,medicaid ,services shall-- 7#a7 review billing codes under the ,medicare program1 the ,medicaid program1 and ,state ,integrated ,care ,programs for ,dual ,eligible ,individuals under ,,xxii of the ,social ,security ,act2 7#b7 conduct at least #a listening session open to the public on the alignment of billing under the programs identified in paragraph 7#a72 and 7#c7 identify such administrative and legislative changes as are needed to ensure that all such billing codes are aligned and consistent under all such programs4 ,,iv ,,pace #dja4 ,requiring ,states to offer ,,pace program services to eligible individuals 7a7 ,in general ,section #aicd of the ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#d7 is amended-- 7#a7 in subsection 7a77#a7-- 7,a7 by striking ,a ,state may elect to provide and inserting ,a ,state shall provide2 and 7,b7 by striking ,a ,state may establish a numerical limit on the number of individuals who may be enrolled in a ,,pace program under a ,,pace program agreement42 7#b7 in subsection 7e7-- 7,a7 in paragraph 7#a7-- 7i7 by striking 7,a7 ,in general4--,the ,secretary and inserting ,the ,secretary2 and 7ii7 by striking subparagraph 7,b72 7,b7 in paragraph 7#b77;,a77ii72 and 7#c7 in subsection 7h77#b7-- 7,a7 by striking 7,a7 ,in general4--,except as provided under subparagraph 7,b71 and and inserting ,except as provided under2 and 7,b7 by striking subparagraph 7,b74 7b7 ,state plan requirement ,section #aijb7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77 is amended-- 7#a7 in paragraph 7#hf71 by striking 2 and and inserting a semicolon2 7#b7 in paragraph 7#hg77;,d71 by striking the period at the end and inserting 2 and2 and 7#c7 by inserting after paragraph 7#hg7 the following new paragraph2 7#hh7 provide1 in accordance with section #aicd1 that the ,state shall provide medical assistance with respect to ,,pace program services to ,,pace program eligible individuals who are eligible for medical assistance under the ,state plan and who are enrolled in a ,,pace program under a ,,pace program agreement4 4 7c7 ,effective date ,the amendments made by this section shall take effect on the date that is #ahj days after the date of enactment of this ,act4 #djb4 ,enrollment of ,,pace beneficiaries at any time 7a7 ,in general ,sections #ahid7;d77#e77;,a7 and #aicd7;d77#e77;,a7 7#db ,u4,s4,c4 #acie;eee7d77#e77;,a71 #acifu-#d7;d77#e77;,a77 are each amended-- 7#a7 in the subparagraph header1 by inserting enrollment or2 7#b7 by inserting ,,pace program eligible individuals to enroll in a ,,pace program at any time and after shall permit2 and 7#c7 by adding at the end the following sentence3 ,the amount of any capitated payment made to a ,,pace provider under subsection 7d77#a7 may be adjusted to account for any ,,pace program eligible individuals who enroll after the first day of a month 7with the amount of such payment adjustment being proportional to the portion of such month for which the individual is enrolled74 7b7 ,effective date ,the amendments made by this section shall take effect on the date that is #ahj days after the date of enactment of this ,act4 #djc4 ,extending eligibility for ,,pace to medicare-eligible individuals under the age of #ee 7a7 ,in general ,sections #ahid7;a77#e77;,a7 and #aicd7;a77#e77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;eee7a77#e71 #acifu-#d7;a77#e77 are each amended by inserting 7or any age in the case of an individual who is eligible for benefits under part ,a1 or enrolled under part ,b1 of title ,,xviii7 after is #ee years of age or older4 7b7 ,effective date ,the amendments made by this section shall take effect on the date that is #ahj days after the date of enactment of this ,act4 #djd4 ,removal of quarterly restrictions for submission of a new pace organization application1 and removal quarterly restrictions for applications in a new service area 7a7 ,in general ,sections #ahid7;e7 and #aicd7;e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;eee7e71 #acifu-#d7;e77 are each amended by adding at the end the following new paragraph3 7#i7 ,no quarterly or geographic limitations on applications for ,,pace provider status ,the ,secretary shall not prohibit an entity that meets the requirements for a ,,pace provider under this section from-- 7,a7 submitting multiple applications in the same quarter2 or 7,b7 submitting multiple applications to operate a ,,pace program in the same service area4 4 7b7 ,effective date ,the amendments made by this section shall take effect on the date that is #ahj days after the date of enactment of this ,act4 #dje4 ,ensuring ,medicare-only ,,pace program enrollees have a choice of prescription drug plans under ,medicare part ,d ,section #ahfj;,d-#ba7;f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aca7;f77 is amended-- 7#a7 in paragraph 7#a71 by striking and 7#c7 and inserting 7#c71 and 7#d72 and 7#b7 by adding at the end the following new paragraph3 7#d7 ,ensuring choice of prescription drug plans 7,a7 ,in general ,for plan years beginning on or after ,january #a1 #bjbd1 subject to the succeeding provisions of this paragraph1 an applicable ,,pace program enrollee may elect to enroll in a qualified standalone prescription drug plan1 in accordance with rules established by the ,secretary pursuant to this paragraph1 while enrolled under a ,,pace program4 7,b7 ,definition of applicable pace program enrollee2 qualified standalone prescription drug plan ,in this paragraph3 7i7 ,applicable pace program enrollee ,the term applicable ,,pace program enrollee means a part ,d eligible individual who-- 7,i7 is not entitled to medical assistance under title ,,xix2 and 7,,ii7 is enrolled under a ,,pace program offered by a ,,pace provider4 7ii7 ,qualified standalone prescription drug plan ,the term qualified standalone prescription drug plan means1 with respect to an applicable ,,pace program enrollee1 a prescription drug plan-- 7,i7 that is not an ,,ma-,,pd plan2 7,,ii7 that is not operated by the ,,pace program under which the individual is enrolled2 and 7,,iii7 for which the ,secretary determines1 with respect to the applicable ,,pace program enrollees enrolled in a ,,pace program offered by such ,,pace provider1 that-- 7aa7 the estimated beneficiary out-of-pocket costs 7as defined in clause 7iii77 for the plan year for qualified prescription drug coverage under the plan is equal to or less than the estimated out-of-pocket costs for such coverage under the prescription drug plan offered by the ,,pace program in which the applicable ,,pace program enrollee is enrolled2 and 7bb7 the estimated total amount of ,federal subsidies for the plan year for qualified prescription drug coverage under the plan 7which may be estimated using data from the previous plan year7 is equal to or less than the estimated subsidy amount for such coverage under the prescription drug plan offered by the ,,pace program in which the applicable ,,pace program enrollee is enrolled4 7iii7 ,out-of-pocket costs defined ,in this paragraph1 the term out-of-pocket costs includes premiums imposed under a prescription drug plan and1 in the case of coverage under a qualified standalone prescription drug plan1 deductibles1 copayments1 coinsurance1 and other cost-sharing4 7,c7 ,out-of-pocket costs ,in the case where an applicable ,,pace program enrollee elects to enroll in a qualified standalone prescription drug plan pursuant to this paragraph1 the individual shall be responsible for any out-of-pocket costs imposed under the plan 7including costs for nonformulary drugs7 after the application of any subsidies under section #ahfj;,d-#ad for an applicable ,,pace program enrollee who is a subsidy eligible individual 7as defined in section #ahfj;,d-#ad7;a77#c774 7,d7 ,requirements for pace programs 7i7 ,educating and helping enroll beneficiaries into a part d plan option ,a ,,pace program shall be required to provide-- 7,i7 information to all applicable ,,pace program enrollees who are enrolled under the ,,pace program regarding the option to enroll in a qualified standalone prescription drug plan under this paragraph2 and 7,,ii7 upon request of an applicable ,,pace program enrollee1 counseling and coordination to assist applicable ,,pace program enrollees in making decisions regarding the selection of qualified standalone prescription drug plans available to them4 7ii7 ,monitoring drug utilization1 adherence1 and spend ,a ,,pace program shall be required to monitor drug utilization1 medication adherence1 and drug spending 7through claims data shared pursuant to subparagraph 7,f7 and otherwise7 throughout the year with respect to any applicable ,,pace program enrollee who elects to enroll in a qualified standalone prescription drug plan under this paragraph in order to coordinate with the ,,pdp sponsor of such plan regarding the drug benefits offered by the plan1 including upon request of an applicable ,,pace program enrollee the filing of any grievances or appeals with the plan on behalf of the applicable ,,pace program enrollee4 7,e7 ,disenrollment ,an applicable ,,pace program enrollee may disenroll from the qualified standalone prescription drug plan elected by such applicable ,,pace program enrollee under subparagraph 7,a7 if the enrollee changes medication during the plan year or can demonstrate an unexpected increase in out-of-pocket costs post enrollment4 7,f7 ,claims sharing ,in the case where an applicable ,,pace program enrollee enrolls in a qualified standalone prescription drug plan1 the ,,pace program in which the individual is enrolled and the ,,pdp sponsor of the qualified standalone prescription drug plan shall share claims data with each other with respect to the applicable ,,pace program enrollee as needed to support care management for the applicable ,,pace program enrollee 7including for purposes of monitoring and coordination required under subparagraph 7,d77ii77 and for purposes of comprehensive risk adjustment under section #ahid7;d74 ,such data shall be shared without the need for any formal or informal request of the ,,pace program in which the individual is enrolled or the ,,pdp sponsor of the qualified standalone prescription drug plan in which the applicable ,,pace program enrollee is enrolled4 7,g7 ,rule of construction ,the authority established under this paragraph for an applicable ,,pace program enrollee to elect to enroll in a qualified standalone prescription drug plan shall not be construed as permitting an applicable ,,pace program enrollee to enroll in a prescription drug plan that is not a qualified standalone prescription drug plan4 7,h7 ,relation to ,,pace statutes 7i7 ,in general ,the authority provided under this paragraph for an applicable ,,pace program enrollee to elect to enroll in a qualified standalone prescription drug plan shall apply notwithstanding subsection 7a77#a77;,b77#a7 of section #ahid and such other provisions of sections #ahid and #aicd as the ,secretary determines may conflict with the authority provided for under this paragraph1 including subsections 7a77#b77;,b71 7b77#a77;,a77i71 7b77#a77;,c71 7f77#b77;,b77ii71 and 7f77#b77;,b77v7 of such sections4 7ii7 ,clarification on payment for part ,d drug coverage ,insofar as an applicable ,,pace program enrollee is enrolled in a qualified standalone prescription drug plan under this paragraph1 the ,,pace program shall not be entitled to payment under section #ahid7;d7 for the provision of qualified prescription drug coverage under such standalone prescription drug plan with respect to such applicable ,,pace program enrollee4 4