,,ii #aah? ,,congress #b;d ,session ,s4 #ciej ,,9 ,,! ,,s5ate ,,( ,,! ,,unit$ ,,/ates ,m>* #ad1 #bjbd,mr4 ,cassidy 7= himself1 ,mr4 ,c>p]1 ,mr4 ,cornyn1 ,mr4 ,w>n]1 ,mr4 ,scott ( ,s\? ,c>ol9a1 & ,mr4 ,m55dez7 introduc$ ! foll[+ bill2 :i* 0 read twice & ref]r$ to ! ,committee on ,f9ance ,a ,,bill ,to provide ,/ates ) support to e/abli% integrat$ c>e programs = individuals :o are dually eligible = ,m$ic>e & ,m$icaid1 & = o!r purposes4 #a4 ,%ort title2 table ( cont5ts 7a7 ,%ort title ,?is ,act may be cit$ z ! ,deliv]+ ,unifi$ ,access to ,lifesav+ ,s]vices ,act ( #bjbd or ! ,,duals ,act ( #bjbd4 7b7 ,table ( cont5ts ,! table ( cont5ts = ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 table ( cont5ts4,,title ,i--,/ate ,integrat$ ,c>e ,programs = ,dual ,eligible ,individuals,sec4 #aja4 ,/ate implem5tation4,,title ,,xxii--,/ate ,integrat$ ,c>e ,programs = ,dual ,eligible ,individuals,sec4 #bbja4 ,def9itions4,sec4 #bbjb4 ,/ate selection ( program models1 developm5t1 & implem5tation4,sec4 #bbjc4 ,enrollm5t 9 integrat$ c>e plans4,sec4 #bbjd4 ,plan requirem5ts & paym5ts4,sec4 #bbje4 ,data collection & report+4,sec4 #bbjf4 ,/ate ombudsman4,sec4 #bbjg4 ,fund+4,sec4 #bbjh4 ,f$]al adm9i/ration ?r\gh ! ,f$]al ,coord9at$ ,heal? ,c>e ,(fice4,sec4 #ajb4 ,provid+ ,f$]al ,coord9at$ ,heal? ,c>e ,(fice au?ority ov] dual snps4,sec4 #ajc4 ,additional con=m+ am5dm5ts4,,title ,,ii--,improv+ ,eligibility ,det]m9ations1 ,enrollm5t ,processes1 & ,quality ( ,c>e = ,dual ,eligible ,individuals,sec4 #bja4 ,id5tify+ opportunities = ,/ate coord9ation ) respect to eligibility det]m9ations4,sec4 #bjb4 ,alignm5t ( bidd+1 report+1 & o!r dates & deadl9es = integrat$ c>e plans4,sec4 #bjc4 ,grants to ,/ate & local community organizations = outrea* & enrollm5t4,sec4 #bjd4 ,application ( model /&>ds to in=mation requirem5ts = integrat$ c>e plans4,sec4 #bje4 ,enrollm5t ?r\gh indep5d5t brok]s4,sec4 #bjf4 ,r$uc+ ?re%old = look-alike ,d-,,snp plans "u ,m$ic>e ,advantage4,sec4 #bjg4 ,requir+ regul> update ( provid] directories4,sec4 #bjh4 ,review ( hospital quality /> rat+ sy/em4,sec4 #bji4 ,requirem5t = ,,f*co & ,/ate ,m$icaid ag5cies to develop maximum /aff+ ratios = c>e coord9ators4,sec4 #baj4 ,,cmmi te/+ ( cov]age ( p>tial b5efit dual eligible individuals ?r\gh ,/ate ,integrat$ ,c>e ,programs4,,title ,,iii--,administration,sec4 #cja4 ,alignm5t ( bill+ codes "u titles ,,xviii1 ,,xix1 & ,,xxii4,,title ,,iv--,p,a,c,e,sec4 #dja4 ,requir+ ,/ates to (f] ,,pace program s]vices to eligible individuals4,sec4 #djb4 ,enrollm5t ( ,,pace b5efici>ies at any "t4,sec4 #djc4 ,ext5d+ eligibility = ,,pace to m$ic>e-eligible individuals "u ! age ( #ee4,sec4 #djd4 ,removal ( qu>t]ly re/rictions = submission ( a new pace organization application1 & removal qu>t]ly re/rictions = applications 9 a new s]vice area4,sec4 #dje4 ,ensur+ ,m$ic>e-only ,,pace program enrollees h a *oice ( prescription drug plans "u ,m$ic>e "p ,d4 ,i ,/ate ,integrat$ ,c>e ,programs = ,dual ,eligible ,individuals #aja4 ,/ate implem5tation ,! ,social ,security ,act is am5d$ by add+ at ! end ! foll[+ new title3 ,,xxii ,/ate ,integrat$ ,c>e ,programs = ,dual ,eligible ,individuals #bbja4 ,def9itions ,9 ?is title3 7#a7 ,director ,! t]m ,director means ! ,director ( ! ,f$]al ,coord9at$ ,heal? ,c>e ,(fice ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices4 7#b7 ,dual eligible individual ,! t]m dual eligible individual means an individual :o is entitl$ to1 or enroll$ =1 b5efits "u "p ,a ( title ,,xviii1 or enroll$ = b5efits "u "p ,b ( title ,,xviii1 & is eligible = m$ical assi/ance = full b5efits "u title ,,xix "u section #aijb7;a77#aj77;,a7 or #aijb7;a77#aj77;,c71 by reason ( section #aijb7;f71 or "u any o!r category ( eligibility = m$ical assi/ance = full b5efits "u su* title1 z det]m9$ by ! ,secret>y4 7#c7 ,integrat$ c>e plan ,! t]m integrat$ c>e plan means an entity or organization t is select$ by a ,/ate "u section #bbjb7;a7 to provide fully integrat$ c>e = a dual eligible individual 9 accordance ) ! requirem5ts ( ?is title & relat$ ,f$]al & ,/ate regulations4 ,su* t]m %all n include a ,,pace program 7z def9$ 9 sections #ahid7;a77#b7 & #aicd7;a77#b774 #bbjb4 ,/ate selection ( program models1 developm5t1 & implem5tation 7a7 ,/ate selection ( program models ,n lat] ?an #a ye> aft] ! date on :i* ! ,director fir/ publi%es ! range ( program models = provid+ integrat$ c>e = dual eligible individuals requir$ by section #bbjh7;b77#a71 ea* ,/ate %all select f su* publi%$ models1 & %all "w ) ! ,director to implem5t su* models 9 ! ,/ate 9 accordance ) ! requirem5ts ( ?is title a program model to provide compreh5sive1 fully integrat$ c>e = dual eligible individuals4 7b7 ,tim+ ,ea* ,/ate %all "w ) ! ,director to implem5t ! models select$ by ! ,/ate "u subsection 7a7 s t1 to ! ext5t practicable1 ! ,/ate may beg9 to enroll dual eligible individuals 9 ! program models select$ dur+ ! #d? ye> t occurs aft] ! ye> 9 :i* ! ,/ate makes su* selection &1 by ! end ( su* #d? ye>1 ! models are fully implem5t$ & op]at$ 9 accordance ) ! requirem5ts ( ?is title & relat$ ,f$]al & ,/ate regulations4 ,no?+ 9 ?is subsection %all prohibit a ,/ate f enroll+ dual eligible individuals 9 su* program models e>li] ?an ! end ( su* #d? ye> if ! models are fully implem5t$ & op]at$ 9 accordance ) ! requirem5ts ( ?is title & relat$ ,f$]al & ,/ate regulations4 7c7 ,adju/m5t au?ority ,! ,director may modify ! tim+ requir$ by subsections 7a7 & 7b7 z appropriate to acc\nt = ! p>ticul> ne$s or circum/ances ( a ,/ate4 7d7 ,implem5tation c\ncil 7#a7 ,9 g5]al ,a ,/ate %all e/abli% an implem5tation c\ncil 9 accordance ) su* requirem5ts z ! ,secret>y %all e/abli%4 ,! memb]s ( ! c\ncil %all include repres5tatives ( a wide range ( /akehold]s relevant to ! provision ( integrat$ c>e = dual eligible individuals4 7#b7 ,duties ,! implem5tation c\ncil %all provide advice & c\nsel to ! ,/ate ) respect to ! implem5tation ( ! models select$ by ! ,/ate "u subsection 7a74 #bbjc4 ,enrollm5t 9 integrat$ c>e plans 7a7 ,passive enrollm5t2 opt-,out p]mitt$ 7#a7 ,passive enrollm5t & notice requirem5ts ,a ,/ate %all automatically enroll a dual eligible individual ) an integrat$ c>e plan "u a contract ) ! ,/ate provid$ t ! ,/ate notifies ! individual t ! individual w be enroll$ ) su* plan at lea/ #fj days 7#ij days1 9 ! case ( ! fir/ "t ! individual is provid$ su* notice7 prior to ! effective date ( su* enrollm5t4 ,notice provid$ to a dual eligible individual "u ?is p>agraph %all include ! foll[+3 7,a7 ,! "n & contact in=mation = ! integrat$ c>e plan4 7,b7 ,! date on :i* ! enrollm5t takes effect &1 if applicable1 :e!r ! ,/ate has elect$ ! option = a #ab-mon? cont9u\s eligibility p]iod "u p>agraph 7#d74 7,c7 ,a summ>y ( ! b5efits to be provid$ by ! plan4 7,d7 ,in=mation reg>d+ ! provid] network ( ! plan4 7,e7 ,in=mation reg>d+ h[ ! dual eligible individual may elect to opt-out ( enrollm5t ) ! plan )9 #fj days 7#ij days1 9 ! case ( ! fir/ "t ! individual is provid$ su* notice74 7#b7 ,enrollm5t 9 plan ) 9-network1 p>ticipat+ prim>y c>e provid] requir$ ,a ,/ate %all n passively enroll a dual eligible individual 9 an integrat$ c>e plan unless ! individual's prim>y c>e physician is an 9-network1 p>ticipat+ provid] = ! plan4 7#c7 ,volunt>y enrollm5t ,a ,/ate %all (f] a dual eligible individual ! option to enroll 9 an integrat$ c>e plan )\t reg>d to meet+ ! requirem5t ( p>agraph 7#b74 7#d7 ,/ate option = cont9u\s eligibility & enrollm5t ,a ,/ate may elect = a dual eligible individual :o is det]m9$ to be eligible = m$ical assi/ance "u ! ,/ate plan "u title ,,xix or "u a waiv] ( su* plan & :o is enroll$ ) an integrat$ c>e plan "u a contract ) ! ,/ate to rema9 eligible = m$ical assi/ance & enroll$ ) su* plan until ! e>li] (-- 7,a7 ! end ( ! #ab-mon? p]iod beg9n+ on ! date ( su* det]m9ation2 or 7,b7 ! date t su* individual ceases to be a resid5t ( su* ,/ate4 7b7 ,*ange ( enrollm5t ,a ,/ate %all p]mit a dual eligible individual to *ange enrollm5t 9 an integrat$ c>e plan-- 7#a7 on a mon?ly basis if ! individual is elect+ to enroll 9 ano!r integrat$ c>e plan2 7#b7 dur+ ! g5]al enrollm5t p]iod applicable "u section #ahcg1 if ! individual is elect+ to dis5roll f an integrat$ c>e plan & n enroll 9 ano!r integrat$ c>e plan2 & 7#c7 dur+ ! #fj-;day p]iod beg9n+ on ! date ! individual receives notice f ! ,/ate t ! individual has be5 det]m9$ to no long] be eligible = treatm5t z a dual eligible individual1 if ! individual is no long] eligible to enroll 9 an integrat$ c>e plan4 7c7 ,contact by plan c>e coord9ator p]mitt$ prior to effective date ( enrollm5t ,a c>e coord9ator = an integrat$ c>e plan may contact a dual eligible individual :o has be5 passively enroll$ 9 ! plan prior to ! effective date ( ! enrollm5t4 #bbjd4 ,plan requirem5ts & paym5ts 7a7 ,9 g5]al ,a contract betwe5 a ,/ate1 an (f]or ( an integrat$ c>e plan1 & ! ,director %all n be consid]$ to meet ! requirem5ts ( ?is title unless-- 7#a7 9 ! case ( a dual eligible individual enroll$ ) ! plan :o *anges enrollm5t to ano!r integrat$ c>e plan = :i* ! individual's prim>y c>e provid] is n a p>ticipat+1 9-network provid]1 or :o dis5rolls f ! plan & does n enroll 9 ano!r integrat$ c>e plan1 ! (f]or ( ! plan w1 dur+ ! #cj-;day p]iod t beg9s on ! date on :i* ! individual's dis5rollm5t f ! plan takes effect-- 7,a7 all[ ! individual to cont9ue to be treat$ by ! individual's prim>y c>e provid]2 & 7,b7 cov] any treatm5t provid$ to ! individual by su* provid] z if ! individual 7 /ill enroll$ ) ! plan2 7#b7 ! (f]or ( ! plan adm9i/]s a heal? risk assessm5t to ea* dual eligible individual enroll$ ) ! plan )9 #ij days ( ! effective date ( ! individual's enrollm5t 9 accordance ) ! requirem5ts ( subsection 7c7 & %all affirm t !re are no *anges 9 ! in=mation provid$ at lea/ e #ab mon?s !reaft]2 7#c7 ! (f]or ( ! plan provides b5efits = a dual eligible individual "u a compreh5sive c>e plan 9 accordance ) ! requirem5ts ( subsections 7d7 & 7f72 7#d7 ! (f]or ( ! plan assigns a c>e coord9ator to ea* dual eligible individual enroll$ ) ! plan 9 accordance ) ! requirem5ts ( subsection 7e7 & notifies su* individual 9 a timely & accessible mann] :5 a new c>e coord9ator is assign$2 & 7#e7 ! contract provides = paym5t to ! (f]or = b5efits provid$ to dual eligible individuals enroll$ ) ! plan us+ a f9anc+ /ructure t satisfies ! requirem5ts ( section #bbjh7;c74 7b7 ,disreg>d ( c]ta9 dis5rollm5t data = rat+s purposes ,! dis5rollm5t ( a dual eligible individual f an integrat$ c>e plan :o 0 passively enroll$ 9 ! plan "u section #bbjc %all be disreg>d$ = purposes ( any data us$ = rat+ ( ! plan = su* plan ye>4 7c7 ,heal? risk assessm5t ,an (f]or ( an integrat$ c>e plan %all adm9i/] a heal? risk assessm5t to ea* dual eligible individual enroll$ ) ! plan us+ ! /&>diz$ heal? risk assessm5t que/ionnaire develop$ by ! ,director "u section #bbjh7;b77#c7 & 9 accordance ) su* additional requirem5ts z ! ,/ate may e/abli%4 ,an integrat$ c>e plan may rely on ! results ( a previ\sly adm9i/]$ heal? risk assessm5t ( a dual eligible individual if su* results are accessible to ! plan & ! dual eligible individual affirms t !re are no *anges 9 ! in=mation previ\sly provid$4 7d7 ,b5efits 7#a7 ,9 g5]al ,an integrat$ c>e plan %all provide b5efits "u ! plan 9 accordance ) requirem5ts e/abli%$ by ! ,director & ! ,/ate1 & :i* %all include ! foll[+3 7,a7 ,cl9ical heal? s]vices4 7,b7 ,behavioral heal? s]vices4 7,c7 ,long-t]m s]vices & supports4 7#b7 ,c>ve-out exceptions ,! ,director may p]mit a ,/ate & integrat$ c>e plan to sep>ately contract = ! provision ( s]vices or supports requir$ "u p>agraph 7#a7 b only if ! ,/ate demon/rates to ! ,director t-- 7,a7 ! level ( c>e provid$ = a dual eligible individual "u ! sep>ate contract ) respect to su* s]vices or supports is n less ?an ! level ( c>e t w\ld be provid$ )\t ! exception2 & 7,b7 ! dual eligible individual w n be subject to any unreasonable adm9i/rative requirem5ts to access ! s]vices or supports1 z det]m9$ by ! ,secret>y4 7#c7 ,supplem5tal b5efits ,an integrat$ c>e plan may provide cu/omiz$1 supplem5tal b5efits to a dual eligible individual enroll$ ) ! plan1 includ+ supplem5tal heal? c>e b5efits describ$ 9 section #aheb7;a77#c71 o!r prim>ily heal?-relat$ b5efits (f]$ by ,m$ic>e ,advantage plans & b5efits p]mitt$ by ! ,secret>y to be (f]$ z ,special ,supplem5tal ,b5efits = ! ,*ronically ,ill 7,,ssbci71 )\t reg>d to :e!r ! dual eligible individual has a requisite condition or diagnosis1 s long z ! plan demon/rates to ! ,director & ! ,/ate t ! (f]+ ( su* b5efits has a positive impact on pati5t heal?4 7e7 ,c>e coord9ator requirem5ts ,a c>e coord9ator assign$ to a dual eligible individual enroll$ 9 an integrat$ c>e plan %all-- 7#a7 s]ve z ! s+le po9t ( contact betwe5 ! individual & ! plan2 7#b7 be responsible = help+ ! individual & ! individual's c>egiv]s & family make b5efit & s]vice decisions2 7#c7 design a b5efici>y-focus$ compreh5sive c>e plan = ! individual t meets ! requirem5ts ( subsection 7f72 & 7#d7 connect & coord9ate acute1 subacute1 social1 prim>y1 & specialty c>e = ! individual & ! provision ( long-t]m s]vices & supports = ! individual4 7f7 ,compreh5sive c>e plan requirem5ts ,! compreh5sive c>e plan = a dual eligible individual enroll$ 9 an integrat$ c>e plan %all be-- 7#a7 design$ to address ! totality ( ! individual's m$ical1 functional1 behavioral1 social1 & c>egiv+ ne$s & goals1 & to ! ext5t practicable1 to apply to multiple ye>s2 7#b7 be bas$ on ! heal? risk assessm5t ( ! individual requir$ by subsection 7c72 7#c7 be implem5t$ by an int]discipl9>y c>e team t includes relevant speciali/s to ensure access to all aspects ( c>e t are requir$ = ! individual2 7#d7 be approv$ by ! individual 7or by an au?oriz$ c>egiv] or gu>dian7 prior to implem5tation2 & 7#e7 be review$ at lea/ annually & )9 #cj days ( a major heal? ev5t1 su* z hospitalization or an em]g5cy room visit4 7g7 ,cont9uity ( c>e requirem5t ,an integrat$ c>e plan %all provide a dual eligible individual enroll$ 9 ! plan ) a m9imum #ij-;day transition p]iod = any active c\rse ( treatm5t :5 ! individual has enroll$ 9 an integrat$ c>e plan aft] />t+ a c\rse ( treatm5t1 ev5 if ! s]vice is furni%$ by an out-(-network provid]4 ,?is includes enrollees new to a plan & enrollees new to ,m$ic>e4 ,! integrat$ c>e plan mu/ n disrupt or require reau?orization = an active c\rse ( treatm5t = new plan enrollees = a p]iod ( at lea/ #ij days4 ,an integrat$ c>e plan may provide = a long] transition p]iod ?an #ij days at ! option ( ! plan4 ,= purposes ( ?is subsection ! foll[+ def9itions apply3 7#a7 ,! t]m c\rse ( treatm5t means z a prescrib$ ord] or ord]$ c\rse ( treatm5t = a specific individual ) a specific condition is outl9$ & decid$ ^u ahead ( "t ) ! pati5t & provid]4 ,a c\rse ( treatm5t may b is n requir$ to be "p ( a treatm5t plan4 7#b7 ,! t]m active c\rse ( treatm5t means a c\rse ( treatm5t 9 :i* a pati5t is actively see+ ! provid] & foll[+ ! c\rse ( treatm5t4 7h7 ,au?ority ,to apply frailty adju/m5t factor ,to plan paym5ts ,a contract betwe5 a ,/ate1 an integrat$ c>e plan1 & ! ,director "u ?is title may apply a frailty adju/m5t factor ) respect to dual eligible individuals enroll$ 9 ! plan 9 ! same mann] z is p]mitt$ "u section #ahec7;a77#a77;,b77iv71 b )\t reg>d to requir+ ! plan to demon/rate enrollm5t ( a high conc5tration ( frail individuals4 #bbje4 ,data collection & report+ 7a7 ,annual collection & report+ by ,/ates & integrat$ c>e plans ,ea* ,/ate1 & ea* integrat$ c>e plan ) a contract ) a ,/ate "u ?is title1 annually %all collect & report in=mation & data to ! ,director 9 accordance ) ! requirem5ts ( ?is section & guidance & regulations issu$ "u section #bbjh7;b77#g7 t includes data collect$ by su* ,/ates & plans ) respect to a plan ye> reg>d+ age1 g5d]1 disability 7includ+ specific disability /atuses requir$ to be report$ by ! ,director71 smok+ /atus1 mobility1 employm5t /atus1 education1 race & e?nicity1 & ,,zip ,code1 ( dual eligible individuals enroll$ 9 ! plan4 7b7 ,collection & report+ ( additional data & in=mation p]mitt$ ,a ,/ate may require an integrat$ c>e plan ) a contract ) ! ,/ate "u ?is title to collect & report to ! ,/ate additional data & in=mation4 #bbjf4 ,/ate ombudsman 7a7 ,9 g5]al ,ea* ,/ate %all e/abli% & op]ate an ,(fice ( ! ,ombudsman = ,integrat$ ,c>e ,plans = ,dual ,eligible ,individuals 79 ?is section ref]r$ to z ! ,(fice74 ,! ,(fice may op]ate indep5d5tly (1 or 9 connection )1 ! ,/ate ag5cy responsible = adm9i/]+ ! ,m$icaid program "u title ,,xix4 7b7 ,ombudsman ,! ,(fice %all be head$ by an individual1 to be kn[n z ! ,/ate ,integrat$ ,c>e = ,dual ,eligible ,individuals ,ombudsman1 :o %all be select$ f among individuals ) exp]tise 9 & exp]i5ce ) integrat$ c>e models = dual eligible individuals1 ! ,m$ic>e program "u title ,,xviii1 & ! ,m$icaid program "u title ,,xix4 ,! ,ombudsman %all be responsible = ! managem5t1 includ+ ! fiscal managem5t1 ( ! ,(fice4 7c7 ,requirem5ts 7#a7 ,9 g5]al ,! prim>y responsibility ( ! ,(fice %all be to provide support & fe$back = dual eligible individuals enroll$ 9 integrat$ c>e plans "u ?is title & c>egiv]s or family memb]s ( su* individuals :o ne$ assi/ance4 7#b7 ,m9imum /aff+ ratio ,! ,(fice %all h a m9imum /aff+ ratio ( #a employee = e #b1jjj dual eligible individuals 9 ! ,/ate4 7d7 ,fund+ 7#a7 ,initial fund+ ,dur+ ! fir/ #b ye>s 9 :i* a ,/ate op]ates ! ,(fice1 ! ,secret>y %all pay to ! ,/ate = ea* su* ye> = exp5ditures necess>y to e/abli% & op]ate ! ,(fice1 f am\nts appropriat$ "u section #bbjg7;c71 an am\nt equal to #ej1jjj1jjj multipli$ by ! ratio (-- 7,a7 ! numb] ( dual eligible individuals 9 ! ,/ate2 to 7,b7 ! numb] ( dual eligible individuals 9 all ,/ates4 7#b7 ,subsequ5t fund+ ,beg9n+ ) ! #crd ye> ( ! ,(fice's op]ation1 exp5ditures necess>y to op]ate ! ,(fice %all be consid]$1 = purposes ( section #aijc7;a77#g71 to be necess>y = ! prop] & effici5t adm9i/ration ( ! ,/ate plan "u title ,,xix & reimburs$ to a ,/ate 9 accordance ) t section4 #bbjg4 ,fund+ 7a7 ,treatm5t ( ,/ate paym5ts to integrat$ c>e plans z m$ical assi/ance ,am\nts exp5d$ by a ,/ate = paym5ts to an integrat$ c>e plan = ! ,m$icaid compon5t ( ! capitation paym5t describ$ 9 section #bbjh7;c7 %all be treat$ z m$ical assi/ance = :i* paym5t is made "u section #aijc7;a74 ,no?+ 9 ?is title %all prev5t a ,/ate f provid+ m$ical assi/ance "u title ,,xix to a dual eligible individual = s]vices = :i* cov]age is n provid$ "u ! integrat$ c>e plan ) :i* ! individual is enroll$ or f receiv+ paym5t "u section #aijc7;a7 ) respect to exp5ditures attributable to provid+ su* m$ical assi/ance4 7b7 ,paym5ts to ,/ates ,f ! sums appropriat$ "u subsection 7c71 ! ,secret>y %all pay to ea* ,/ate = ea* cal5d> ye> 7beg9n+ ,janu>y #a ( ! fir/ full cal5d> ye> 9 :i* ?is title is implem5t$ 9 ! ,/ate71 an am\nt equal to ! sum ( ! foll[+3 7#a7 ,%>$ sav+s compon5t ,! %>$ sav+s paym5t applicable to ! ,/ate & ! ye>1 z det]m9$ 9 accordance ) section #bbjh7;b77#f77;,d74 7#b7 ,g5]al adm9i/rative exp5ses ,= adm9i/rative exp5ses to c>ry out ?is title1 o!r ?an section #bbje1 an am\nt t be>s ! same proportion to #ej1jjj1jjj z ! numb] ( dual eligible individuals 9 ! ,/ate be>s to ! numb] ( dual eligible individuals 9 all ,/ates1 z det]m9$ by ! ,secret>y4 7#c7 ,data collection & report+ ,= data collection & report+ exp5ses "u section #bbje1 an am\nt t be>s ! same proportion to #ej1jjj1jjj z ! numb] ( dual eligible individuals 9 ! ,/ate be>s to ! numb] ( dual eligible individuals 9 all ,/ates1 z det]m9$ by ! ,secret>y4 7c7 ,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 = ea* cal5d> ye> 7beg9n+ ,janu>y #a ( ! fir/ full cal5d> ye> 9 :i* ?is title is implem5t$ 9 any ,/ate71 r$uc$ by any am\nts made available f ! ,m$ic>e tru/ funds "u subsection 7d74 7d7 ,relation to m$ic>e tru/ funds ,!re %all be made available = c>ry+ out ?is title1 & ! ,secret>y %all provide = ! transf] 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$uctions 9 paym5ts f su* ,tru/ ,funds & ,acc\nt t are attributable to ! enrollm5t ( dual eligible individuals 9 integrat$ c>e plans "u ?is title1 = ea* cal5d> ye> 7beg9n+ ,janu>y #a ( ! fir/ full cal5d> ye> 9 :i* ?is title is implem5t$ 9 any ,/ate74 7e7 ,relation to o!r paym5ts ,paym5ts provid$ "u ?is section to a ,/ate are 9 addition to paym5ts provid$ "u section #bbjh4 #bbjh4 ,f$]al adm9i/ration ?r\gh ! ,f$]al ,coord9at$ ,heal? ,c>e ,(fice 7a7 ,9 g5]al ,! ,director %all h prim>y au?ority = implem5t+ & c>ry+ out responsibilities ( ! ,f$]al ,gov]nm5t "u ?is title4 7b7 ,responsibilities ( ! ,,f*co ,9 c>ry+ out ?is title1 ! ,director %all h ! foll[+ responsibilities3 7#a7 ,developm5t & publication ( integrat$ c>e program models ,subject to subsection 7c71 to develop &1 n lat] ?an #ahj days aft] ! date ( enactm5t ( ?is p>agraph1 publi%1 a range ( program models 7includ+ b n limit$ to ,m$ic>e-,m$icaid plans1 acc\ntable c>e organizations1 & dual eligible special ne$s plans7 = provid+ integrat$ c>e = dual eligible individuals f :i* ,/ates %all select to develop & adm9i/] integrat$ c>e programs = dual eligible individuals 9 accordance ) ?is title4 7#b7 ,unifi$ appeals process ,to develop &1 n lat] ?an #a ye> aft] ! date ( enactm5t ( ?is p>agraph1 publi% a unifi$ adm9i/rative appeals process = ,/ate integrat$ c>e programs = dual eligible individuals "u ?is title to use 9 lieu ( o!r adm9i/rative appeals processes involv+ ,m$ic>e & ,m$icaid4 7#c7 ,heal? risk assessm5t ,to develop a /&>diz$ heal? risk assessm5t que/ionnaire = dual eligible individuals t collects /&>d demographic data & in=mation relat+ to food insecurity1 access to transportation1 int]net access1 utility difficulty1 int]p]sonal safety1 & h\s+ in/ability4 7#d7 ,supplem5tal b5efits /&>ds & report+ requirem5ts ,to e/abli% /&>ds = report+ by ,/ates & integrat$ c>e plans "u title ,,xxii in=mation relat+ to ! (f]+ & provision ( supplem5tal b5efits "u section #bbjd7;d77#c71 includ+ data relat+ to enrollm5t1 utilization1 & outcomes1 to annually publi% a report reg>d+ ! (f]+ & utilization ( su* b5efits1 & to /udy & report to ! ,secret>y on :e!r to cap ! actu>ial doll> value all[$ = su* b5efits "u titles ,,xviii1 ,,xix1 & ,,xxii4 7#e7 ,c>e coord9ator requirem5ts ,to-- 7,a7 e/abli% a =mula bas$ on pati5t *ronic conditions1 activities ( daily liv+ /&>ds1 geographic1 & su* o!r factors z ! ,director det]m9es are necess>y = ,/ates & integrat$ c>e plans to use to det]m9e ! maximum /aff+ ratio = assign+ c>e coord9ators to dual eligible individuals enroll$ ) integrat$ c>e plans "u ?is title2 & 7,b7 develop onl9e tra9+ & pr(essional developm5t mat]ials relat+ to ! /atutory & adm9i/rative requirem5ts = provid+ integrat$ c>e = c>e coord9ators = dual eligible individuals enroll$ ) integrat$ c>e plans "u ?is title4 7#f7 ,adm9i/ration & ov]sight ( integrat$ c>e plans = dual eligible individuals ,to-- 7,a7 develop & issue guidance & regulations relat$ to ! alignm5t ( policy & op]ational process "u ! ,m$ic>e program "u title ,,xviii & ! ,m$icaid program "u title ,,xix1 necess>y = implem5tation1 adm9i/ration1 & ov]sight ( integrat$ c>e plans = dual eligible individuals "u ?is title2 & 7,b7 adm9i/] & provide ov]sight ( integrat$ c>e plans = dual eligible individuals "u ?is title1 includ+ ) respect to-- 7i7 ! developm5t & application ( an integrat$ m$ical loss ratio = su* plans1 9 lieu ( compliance ) sep>ate m$ical loss ratio requirem5ts "u titles ,,xviii & ,,xix2 7ii7 ! e/abli%m5t & application ( network adequacy /&>ds = su* plans t-- 7,i7 apply only ) respect to su* plans2 7,,ii7 all[ ! ,director to waive compliance ) su* /&>ds = integrat$ c>e plans t _c meet ! requirem5ts 9 c]ta9 areas1 b mu/ op]ate /atewide to meet a ,/ate's selective contract+ requirem5ts2 & 7,,iii7 all[ ! ,director to consid] flexibilities to support innovative models t d n rely on traditional "t & di/ance /&>ds1 su* z ! use ( teleheal?2 & 7iii7 ! e/abli%m5t & application ( t>get$1 /reaml9$ model-(-c>e requirem5ts = su* plans t include an integrat$ audit process1 ) %>$ responsibilities betwe5 ! ,director & ,/ates1 & t requires ! ,director to %>e ! results ( su* audits ) ,/ate ,m$icaid programs4 ,to ! ext5t practicable1 su* requirem5ts also %all be design$ to be integrat$ ) model ( c>e requirem5ts applicable to ,m$icaid manag$ c>e organizations2 7,c7 develop contract managem5t teams1 consi/+ ( repres5tatives f integrat$ c>e plans ) contracts ) ,/ates "u ?is title1 ,/ate ag5cies responsible = adm9i/]+ ! ,/ate plan "u title ,,xix or a waiv] ( su* plan1 & ! ,f$]al ,coord9at$ ,heal? ,c>e ,(fice1 to ov]see compliance & p]=mance ( integrat$ c>e plans "u ?is title2 7,d7 develop & implem5t a %>$ sav+s paym5t = ,/ates to receive a %>e ( sav+s to ,f$]al sp5d+ 9 ! ,m$icaid program "u title ,,xix z a result ( ! implem5tation & op]ation ( integrat$ c>e plans = dual eligible individuals "u ?is title2 & 7,e7 develop a new /> rat+ sy/em = integrat$ c>e plans = dual eligible individuals "u ?is title t rates ! p]=mance ( ea* plan type sep>ately1 ) ,/ate-specific measures & ti$ to s+le contracts1 in/ead ( ! collective p]=mance ( all ( ! (f]or's plans "u contract ) ! ,/ate "u t title1 t include measures :i* directly reflect enrollee satisfaction1 & t aw>ds high] /> rat+s to plans bas$ on _! ability to reta9 enrollees4 7#g7 ,data collection & report+ ,to e/abli% data & in=mation collection & report+ requirem5ts = ,/ates & integrat$ c>e plans "u section #bbje1 includ+ requir$ report+ ( specific disability /atuses & safegu>ds to protect pati5t privacy1 & to annually publi% n lat] ?an ,april #cj ( any ye>1 ! data & in=mation collect$ & report$ to ! ,director "u su* section = ! prec$+ ye>4 7#h7 ,quality measures ,to develop quality measures = ! population ( dual eligible individuals t are design$ to be uni=mly implem5t$ across all plat=ms & heal? b5efits plans t provide integrat$ c>e = su* individuals "u ?is title4 ,su* measures %all include measures relat+ to pati5t satisfaction1 quality ( life1 rates ( em]g5cy room use1 in/itutionalization = long-t]m c>e1 hospital admission & readmission rates1 & m$ication errors4 ,! ,director %all regul>ly review & update su* measures z necess>y & may develop outcome-bas$ quality measures = det]m9+ paym5ts to heal? b5efits plans t provide integrat$ c>e = dual eligible individuals "u ?is title4 7#i7 ,be/ practices ,to n less ?an annually publi% be/ practices "u ?is title = ,/ates & integrat$ c>e plans1 includ+ ) respect to improv+ outrea* to b5efici>ies1 improv+ compreh5sive c>e plans & heal? risk assessm5ts = dual eligible individuals1 & develop+ a work=ce t provides culturally intellig5t & respectful c>e4 7#aj7 ,tra9+ programs ,to develop tra9+ programs relat$ to integrat$ c>e plans "u ?is title =-- 7,a7 provid]s ( c>e1 s]vices1 & supports "u su* plans ) respect to issues su* z coord9ation ( b5efits1 data %>+ b>ri]s1 quality rat+s1 & provid] inc5tives2 7,b7 ,/ate employees to increase ,m$ic>e exp]tise at ,/ate ag5cies responsible = adm9i/]+ ,m$icaid plans & waiv]s & contract+ ) integrat$ c>e plans "u ?is title2 & 7,c7 insurance brok]s & local c\nselors :o help enroll individuals 9 ,m$ic>e1 ,m$icaid1 & integrat$ c>e plans "u ?is title4 7c7 ,capitat$ paym5t /ructure = integrat$ c>e program models 7#a7 ,9 g5]al ,ea* program model t is design$ by ! ,director "u subsection 7b77#a7 %all provide t paym5ts %all be made to an integrat$ c>e plan = b5efits provid$ "u a contract "u ?is title us+ a capitat$ paym5t /ructure "u :i*1 = ea* mon? t ! integrat$ c>e plan provides su* b5efits-- 7,a7 ! ,/ate %all pay ! integrat$ c>e plan an am\nt equal to ! ,m$icaid compon5t paym5t det]m9$ = ! mon?2 & 7,b7 ! ,secret>y %all pay ! integrat$ c>e plan an am\nt equal to ! ,m$ic>e compon5t paym5t det]m9$ = ! mon?4 7#b7 ,det]m9ation ( ,m$icaid compon5t paym5t ,= purposes ( p>agraph 7#a71 ! ,m$icaid compon5t paym5t payable to an integrat$ c>e plan = a mon? %all be an am\nt equal to ! sum ( ! products (-- 7,a7 = ea* category ( b5efici>y1 ! ,m$icaid capitation rate applicable to ! category ( b5efici>y 7z det]m9$ by ! ,secret>y & specifi$ 9 ! contract betwe5 ! ,/ate1 ! ,secret>y1 & ! (f]or ( ! plan72 & 7,b7 ! numb] ( b5efici>ies 9 su* category enroll$ ) ! plan = ! mon?4 7#c7 ,det]m9ation ( ,m$ic>e compon5t paym5t ,= purposes ( p>agraph 7#a71 ! ,m$ic>e compon5t paym5t payable to an integrat$ c>e plan = a mon? %all be an am\nt equal to ! sum ( ! products (-- 7,a7 = ea* category ( b5efici>y1 ! ,m$ic>e capitation rate applicable to ! category ( b5efici>y 7z det]m9$ by ! ,secret>y & specifi$ 9 ! contract betwe5 ! ,/ate1 ! ,secret>y1 & ! (f]or ( ! plan72 & 7,b7 ! numb] ( b5efici>ies 9 su* category enroll$ ) ! plan = ! mon?4 7#d7 ,application ( risk adju/m5t model to capitation rates ,! ,m$icaid & ,m$ic>e capitation rates = ea* category ( b5efici>y specifi$ 9 a contract betwe5 a ,/ate1 ! ,secret>y1 & ! (f]or ( an integrat$ c>e plan %all be det]m9$ us+ ! risk adju/m5t paym5t model develop$ "u subsection 7d74 7d7 ,risk adju/m5t paym5t model = provid+ heal? b5efits cov]age = dual eligible individuals ,n lat] ?an #a ye> aft] ! date ( enactm5t ( ?is subsection1 ! ,director %all ent] into a contract or o!r agreem5t ) an indep5d5t entity to develop a risk adju/m5t paym5t model = dual eligible individuals t-- 7#a7 is design$ to be uni=mly implem5t$ across all plat=ms & heal? b5efits plans t provide integrat$ c>e = su* individuals "u title ,,xxii ( ! ,social ,security ,act2 7#b7 includes factors bas$ on ! heal? /atus ( su* individuals2 & 7#c7 all[s plan paym5ts to be made & updat$ on a mon?ly basis4 7e7 ,additional responsibilities ) respect to integrat$ c>e plans 7#a7 ,outrea* to ,m$icaid provid]s ,n lat] ?an #ahj days aft] ! date ( enactm5t ( ?is subsection1 ! ,director1 9 consultation ) ,/ate ,m$icaid programs1 %all develop outrea* plans = su* programs to use to contact provid]s ( heal? b5efits1 s]vices1 or supports = dual eligible individuals & provide in=mation & education reg>d+ ! ,/ate ,integrat$ ,c>e ,programs = ,dual ,eligible ,individuals e/abli%$ "u ?is title1 h[ su* program w op]ate 9 ! ,/ate :]e su* provid]s (f] heal? b5efits1 s]vices or supports = su* individuals1 & ! impact ( su* program on su* provid]s4 7#b7 ,collection ( data on quality measures f integrat$ c>e plans "u ,m$icaid & ,m$ic>e 7,a7 ,9 g5]al ,n lat] ?an #ahj days aft] ! date ( enactm5t ( ?is subsection1 ! ,director1 9 consultation ) ! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices & ,/ate ,m$icaid programs1 %all e/abli% a plan = collect+ data on quality measures f heal? b5efits plans t provide integrat$ c>e = dual eligible individuals "u ,m$ic>e or ,m$icaid4 ,su* data %all include1 at a m9imum1 data relat+ to provid] network availability 9 bo? ,m$ic>e & ,m$icaid1 provid]s 9-network :o are accept+ new ,m$ic>e & ,m$icaid pati5ts1 sp5d+ on supplem5tal b5efits1 & claims d5ials4 7,b7 ,au?ority to collect additional data & in=mation2 publication ,! ,director may-- 7i7 collect additional data & in=mation relat+ to ! quality ( c>e provid$ = dual eligible individuals by heal? b5efits plans t provide integrat$ c>e = su* individuals "u ,m$ic>e or ,m$icaid2 & 7ii7 make ! data & in=mation collect$ 9 accordance ) ?is p>agraph publicly available4 7#c7 ,developm5t ( an align$ program = ,in/itutional ,special ,ne$s ,plans "u ,m$icaid ,n lat] ?an #ahj days aft] ! date ( enactm5t ( ?is subsection1 ! ,director1 9 consultation ) ! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices & ,/ate ,m$icaid programs1 %all develop an align$ program = (f]+ ,in/itutional ,special ,ne$s ,plans "u ,m$icaid t has #a entity f9ancially responsible = provid+ heal? b5efits1 s]vices1 & supports = dual eligible individuals4 7#d7 ,assessm5t ( ne$ = crit]ia to regulate & exp& utilization ( ,in/itutional ,special ,ne$s ,plans ,n lat] ?an #ahj days aft] ! date ( enactm5t ( ?is subsection1 ! ,director1 9 consultation ) ! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices1 %all assess ! adequacy ( regulations & ov]sight ( ,in/itutional ,special ,ne$s ,plan to det]m9e :e!r new1 or additional requirem5ts %\ld be e/abli%$ to improve ! utilization1 p]=mance1 & ov]sight ( su* plans & h[ su* plans may be (f]$ "u ,/ate ,integrat$ ,c>e ,programs = ,dual ,eligible ,individuals e/abli%$ "u ?is title4 7f7 ,appropriations ,!re are h]eby appropriat$1 out ( any funds 9 ! ,treasury n o!rwise appropriat$1 = ! fir/ fiscal ye> t beg9s aft] ! date ( enactm5t ( ?is title1 & = ea* fiscal ye> !reaft]1 su* sums z are necess>y to c>ry out ?is title4 7g7 ,direct-,hire au?ority ,9 c>ry+ out ?is title1 ! ,director %all h direct-hire au?ority to ! ext5t requir$ to implem5t & adm9i/] ?is title on a timely basis4 4 #ajb4 ,provid+ ,f$]al ,coord9at$ ,heal? ,c>e ,(fice au?ority ov] dual snps 7a7 ,9 g5]al ,section #ahei7;f77#h7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7;f77#h77 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,f7 ,au?ority ( ,f$]al ,coord9at$ ,heal? ,c>e ,(fice ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbe1 ! ,f$]al ,coord9at$ ,heal? ,c>e ,(fice e/abli%$ "u section #bfjb ( ,public ,law #aaa-adh %all h prim>y au?ority = implem5t+ & c>ry+ out responsibilities ( ! ,secret>y ) respect to ! integration ( specializ$ ,,ma plans = special ne$s individuals describ$ 9 subsection 7b77#f77;,b77ii7 "u ?is subsection4 4 7b7 ,con=m+ am5dm5t ,section #bfjb7;d77#f7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #acae;b7d77#f77 is am5d$ by ins]t+ ! foll[+ be=e ! p]iod3 &1 = plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbe1 to c>ry out subsection 7f77#h77;,f7 ( su* section4 #ajc4 ,additional con=m+ am5dm5ts 7a7 ,def9ition ( ,/ate ,section #aaja7;a77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acja7;a77#a77 is am5d$-- 7#a7 by /rik+ ,,xix1 & ,,xxi & ins]t+ ,,xix1 ,,xxi1 & ,,xxii2 & 7#b7 by /rik+ ,,xix & ,,xxi & ins]t+ ,,xix1 ,,xxi1 & ,,xxii4 7b7 ,m$ic>e 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 = dual eligible individuals ,dual eligible individuals 7z def9$ 9 section #bbja7 may also be eligible to enroll 9 an integrat$ c>e plan "u title ,,xxii4 4 7c7 ,prev5t+ duplicate paym5ts "u ,m$icaid ,section #aijc7;i7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7i77 is am5d$-- 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$ical assi/ance = a dual eligible individual 7z def9$ 9 section #bbja7 enroll$ 9 an integrat$ c>e plan "u title ,,xxii1 except z specifically p]mitt$ "u su* title4 2 & 7#d7 9 ! ?ird s5t5ce1 by /rik+ 1 & 7#ah7 & ins]t+ 1 7#ah71 & 7#bh74 ,,ii ,improv+ ,eligibility ,det]m9ations1 ,enrollm5t ,processes1 & ,quality ( ,c>e = ,dual ,eligible ,individuals #bja4 ,id5tify+ opportunities = ,/ate coord9ation ) respect to eligibility det]m9ations ,n lat] ?an #a ye> aft] ! date ( enactm5t ( ?is ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices1 9 consultation ) ,/ates1 %all-- 7#a7 review ,/ate processes = det]m9+ :e!r an individual is a full-b5efit dual individual 7z def9$ 9 section #aice7;c77#f7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#e7;c77#f77 b )\t ! application ( subp>agraph 7,a77i7 ( su* section7 & :e!r an individual is eligible = ! l[-income subsidy program "u section #ahfj;,d-#ad ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aad7 & ! ,m$ic>e ,sav+s ,program 7z def9$ 9 section #aadd7;c77#g7 ( su* ,act 7#db ,u4,s4,c4 #acbj;b-#ad7;c77#g7772 & 7#b7 issue guidance = ,/ates t id5tifies opportunities = bett] coord9ation ( su* processes betwe5 ! ,/ates & ! ,f$]al ,gov]nm5t4 #bjb4 ,alignm5t ( bidd+1 report+1 & o!r dates & deadl9es = integrat$ c>e plans ,n lat] ?an #ahj days aft] ! date ( enactm5t ( ?is ,act1 ! ,director ( ! ,f$]al ,coord9at$ ,heal? ,c>e ,(fice ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices & ! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices %all-- 7#a7 review bidd+1 report+1 & o!r significant dates & deadl9es applicable to integrat$ c>e plans "u ! ,m$ic>e program1 ! ,m$icaid program1 & ,/ate ,integrat$ ,c>e ,programs = ,dual ,eligible ,individuals "u title ,,xxii ( ! ,social ,security ,act2 & 7#b7 id5tify su* adm9i/rative & legislative *anges z are ne$$ to ensure t all su* dates & deadl9es are align$ & consi/5t "u all su* programs4 #bjc4 ,grants to ,/ate & local community organizations = outrea* & enrollm5t 7a7 ,9 g5]al ,f ! am\nts appropriat$ "u subsection 7c7 = a fiscal ye>1 ! ,secret>y ( ,heal? & ,human ,s]vices 79 ?is section ref]r$ to z ! ,secret>y7 %all aw>d grants to ,/ate & local community organizations to conduct outrea* & enrollm5t ef=ts t are design$ to increase ! enrollm5t ( dual eligible individuals 7z def9$ 9 section #bbja ( ! ,social ,security ,act7 9 heal? b5efits plans t provide integrat$ c>e = su* individuals "u ,/ate ,integrat$ ,c>e ,programs = ,dual ,eligible ,individuals e/abli%$ "u ,,xxii ( ! ,social ,security ,act4 7b7 ,model /&>ds ,! ,secret>y1 9 consultation ) ! ,adm9i/rator ( ! ,adm9i/ration = ,community ,liv+ & ,/ates1 %all develop & issue model /&>ds = outrea* & education conduct$ by ,/ate & local community organizations aw>d$ grants "u ?is section t include ! foll[+3 7#a7 ,in=mation & education support is available = individuals 9 a range ( languages1 & onl9e1 ov] ! phone1 & 9 p]son4 7#b7 ,mat]ials pres5t$ are easy to read1 writt5 9 z l[ a read+ compreh5sion level z possible1 & are 9 ! prop] language = ! individual involv$4 7#c7 ,in=mation pres5t$ onl9e is accessible = individuals ) disabilities4 7#d7 ,in=mation is pres5t$ 9 a mann] t takes into consid]ation ! accessibility ne$s ( ! individual1 su* z language access requirem5ts & ! heal? lit]acy level ( ! individual4 7c7 ,appropriation ,!re is appropriat$1 out ( any money 9 ! ,treasury n o!rwise appropriat$1 = ! fir/ fiscal ye> t beg9s aft] ! date ( enactm5t ( ?is ,act1 & = ea* fiscal ye> !reaft]1 #ej1jjj1jjj to c>ry out ?is section4 #bjd4 ,application ( model /&>ds to in=mation requirem5ts = integrat$ c>e plans ,n lat] ?an #a ye> aft] ! date ( enactm5t ( ?is ,act1 ! ,director ( ! ,f$]al ,coord9at$ ,heal? ,c>e ,(fice ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices & ! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices jo9tly %all issue guidance or regulations requir+ t any notice or in=mational mat]ials provid$ to a dual eligible individual 7z def9$ 9 section #bbja ( ! ,social ,security ,act7 by su* ,director1 ,adm9i/rator1 ,/ates1 or heal? b5efits plans t provide integrat$ c>e = su* individuals "u ! ,m$ic>e program1 ! ,m$icaid program1 or "u ,/ate ,integrat$ ,c>e ,programs = ,dual ,eligible ,individuals e/abli%$ "u ,,xxii ( ! ,social ,security ,act complies ) ! model /&>ds issu$ "u section #bjc7;b74 #bje4 ,enrollm5t ?r\gh indep5d5t brok]s ,n lat] ?an #a ye> aft] ! date ( enactm5t ( ?is ,act1 ! ,director ( ! ,f$]al ,coord9at$ ,heal? ,c>e ,(fice ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices & ! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices jo9tly %all issue guidance or regulations provid+ t-- 7#a7 a dual eligible individual 7z def9$ 9 section #bbja ( ! ,social ,security ,act7 may n be enroll$ 9 a heal? b5efits plan t provides integrat$ c>e = su* individual "u title ,,xxii ( ! ,social ,security ,act ?r\gh a brok] unless ! brok] is an indep5d5t brok] 7z def9$ "u su* guidance or regulations72 7#b7 an indep5d5t brok] may receive a commission = ! initial enrollm5t ( a dual eligible individual 9 su* a plan1 b no commission %all be available to any brok] = any subsequ5t enrollm5t ( su* individual 9 any su* plan2 7#c7 if a brok] dis5rolls a dual eligible individual f any su* heal? b5efits plan to a plan t provides p>tial or no integrat$ c>e1 ! brok]1 9 accordance ) ! model /&>ds issu$ "u section #bjd7;b71 %all in=m ! individual-- 7,a7 ( ! heal? b5efits plan ! individual is be+ dis5roll$ f2 & 7,b7 t ! individual is be+ enroll$ 9 a heal? b5efits plan t provides p>tial or no integrat$ c>e & ! pot5tial implications ( su* dis5rollm5t & enrollm5t on ! individual's c>e4 #bjf4 ,r$uc+ ?re%old = look-alike ,d-,,snp plans "u ,m$ic>e ,advantage ,= ! fir/ full plan ye> t beg9s on or aft] ! date t is #a ye> aft] ! date ( enactm5t ( ?is ,act1 & ea* subsequ5t plan ye>1 ! ,secret>y ( ,heal? & ,human ,s]vices-- 7#a7 %all implem5t section #dbb4ead7;d77#a77;ii7 ( title #db1 ,code ( ,f$]al ,regulations 7or any successor regulations7 by sub/itut+ #ej p]c5t = #hj p]c5t2 & 7#b7 %all only c\nt full-b5efit dual eligible individuals 7z def9$ 9 section #aice7;c77#f7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#e7;c77#f777 = purposes ( apply+ ! ?re%old "u su* section4 #bjg4 ,requir+ regul> update ( provid] directories ,n lat] ?an #a ye> aft] ! date ( enactm5t ( ?is ,act1 ! ,director ( ! ,f$]al ,coord9at$ ,heal? ,c>e ,(fice ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices & ! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices %all promulgate regulations t-- 7#a7 require ,m$ic>e ,advantage plans "u "p ,c ( title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba7 & integrat$ c>e plans "u title ,,xxii ( su* ,act to regul>ly update provid] directories2 & 7#b7 include a measure relat+ to provid] director curr5cy rat+ on /> rat+ sy/ems = ,m$ic>e ,advantage plans "u section #ahec7o7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7o77 & integrat$ c>e plans "u title ,,xxii ( su* ,act4 #bjh4 ,review ( hospital quality /> rat+ sy/em ,n lat] ?an #ahj days aft] ! date ( enactm5t ( ?is ,act1 ! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices %all-- 7#a7 review ! hospital quality /> rat+ sy/em "u ! ,m$ic>e program "u title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq472 & 7#b7 id5tify su* adm9i/rative & legislative *anges z are ne$$ to ensure t suffici5t in=mation is collect$ "u su* sy/em reg>d+ hospitals to effectively measure hospital quality4 #bji4 ,requirem5t = ,,f*co & ,/ate ,m$icaid ag5cies to develop maximum /aff+ ratios = c>e coord9ators 7a7 ,9 g5]al ,! ,director ( ! ,f$]al ,coord9at$ ,heal? ,c>e ,(fice1 9 consultation ) ,/ate ,m$icaid ag5cies1 %all develop model ,f$]al legislation t w\ld e/abli% a process = det]m9+ a maximum c>e coord9ator-to-pati5t ratio = integrat$ c>e plans provid+ c>e to dual eligible individuals "u an integrat$ c>e model "u title ,,xxii ( ! ,social ,security ,act4 ,su* process %all take into acc\nt ! v>y+ ne$s requir$ by diff]5t categories ( pati5ts4 7b7 ,submission ( model legislation ,n lat] ?an #ahj days aft] ! date ( enactm5t ( ?is ,act1 ! ,director ( ! ,f$]al ,coord9at$ ,heal? ,c>e ,(fice %all submit ! model legislation develop$ "u subsection 7a7 to-- 7#a7 ! ,secret>y ( ,heal? & ,human ,s]vices2 7#b7 ! ,committee on ,f9ance ( ! ,s5ate2 7#c7 ! ,committee on ,en]gy & ,comm]ce ( ! ,h\se ( ,repres5tatives2 & 7#d7 ! ,committee on ,ways & ,means ( ! ,h\se ( ,repres5tatives4 #baj4 ,,cmmi te/+ ( cov]age ( p>tial b5efit dual eligible individuals ?r\gh ,/ate ,integrat$ ,c>e ,programs ,section #aaae;,a ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7 is am5d$-- 7#a7 9 subsection 7b77#b77;,a71 by add+ at ! end ! foll[+ new s5t5ce3 ,! models select$ "u ?is subp>agraph %all include ! te/+ ( ! model describ$ 9 subsection 7h77#a742 & 7#b7 by add+ at ! end ! foll[+ new subsection3 7h7 ,te/+ ( model = provid+ cov]age ( p>tial b5efit dual eligible individuals ?r\gh p>tially integrat$ c>e plans "u ,/ate ,integrat$ ,c>e ,programs 7#a7 ,9 g5]al ,! model describ$ 9 ?is p>agraph is a model "u :i* ,/ates may (f] cov]age to p>tial b5efit dual eligible individuals ?r\gh p>tially integrat$ c>e plans "u ,/ate ,integrat$ ,c>e ,programs e/abli%$ "u title ,,xxii4 7#b7 ,p>tial b5efit dual eligible individual ,= purposes ( ?is subsection1 ! t]m p>tial b5efit dual eligible individual means an individual :o-- 7,a7 is eligible = ! l[-income subsidy program "u section #ahfj;,d-#ad1 ! ,m$ic>e ,sav+s ,program 7z def9$ 9 section #aadd7;c77#g771 or bo?2 & 7,b7 is n a full-b5efit dual eligible individual 7z su* t]m is def9$ 9 section #aice7;c77#f71 b )\t ! application ( subp>agraph 7,a77i7 ( su* section74 4 ,,iii ,adm9i/ration #cja4 ,alignm5t ( bill+ codes "u titles ,,xviii1 ,,xix1 & ,,xxii ,n lat] ?an #ahj days aft] ! date ( enactm5t ( ?is ,act1 ! ,director ( ! ,f$]al ,coord9at$ ,heal? ,c>e ,(fice ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices & ! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices %all-- 7#a7 review bill+ codes "u ! ,m$ic>e program1 ! ,m$icaid program1 & ,/ate ,integrat$ ,c>e ,programs = ,dual ,eligible ,individuals "u ,,xxii ( ! ,social ,security ,act2 7#b7 conduct at lea/ #a li/5+ session op5 to ! public on ! alignm5t ( bill+ "u ! programs id5tifi$ 9 p>agraph 7#a72 & 7#c7 id5tify su* adm9i/rative & legislative *anges z are ne$$ to ensure t all su* bill+ codes are align$ & consi/5t "u all su* programs4 ,,iv ,,pace #dja4 ,requir+ ,/ates to (f] ,,pace program s]vices to eligible individuals 7a7 ,9 g5]al ,section #aicd ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#d7 is am5d$-- 7#a7 9 subsection 7a77#a7-- 7,a7 by /rik+ ,a ,/ate may elect to provide & ins]t+ ,a ,/ate %all provide2 & 7,b7 by /rik+ ,a ,/ate may e/abli% a num]ical limit on ! numb] ( individuals :o may be enroll$ 9 a ,,pace program "u a ,,pace program agreem5t42 7#b7 9 subsection 7e7-- 7,a7 9 p>agraph 7#a7-- 7i7 by /rik+ 7,a7 ,9 g5]al4--,! ,secret>y & ins]t+ ,! ,secret>y2 & 7ii7 by /rik+ subp>agraph 7,b72 7,b7 9 p>agraph 7#b77;,a77ii72 & 7#c7 9 subsection 7h77#b7-- 7,a7 by /rik+ 7,a7 ,9 g5]al4--,except z provid$ "u subp>agraph 7,b71 & & ins]t+ ,except z provid$ "u2 & 7,b7 by /rik+ subp>agraph 7,b74 7b7 ,/ate plan requirem5t ,section #aijb7;a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77 is am5d$-- 7#a7 9 p>agraph 7#hf71 by /rik+ 2 & & ins]t+ a semicolon2 7#b7 9 p>agraph 7#hg77;,d71 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 & 7#c7 by ins]t+ aft] p>agraph 7#hg7 ! foll[+ new p>agraph2 7#hh7 provide1 9 accordance ) section #aicd1 t ! ,/ate %all provide m$ical assi/ance ) respect to ,,pace program s]vices to ,,pace program eligible individuals :o are eligible = m$ical assi/ance "u ! ,/ate plan & :o are enroll$ 9 a ,,pace program "u a ,,pace program agreem5t4 4 7c7 ,effective date ,! am5dm5ts made by ?is section %all take effect on ! date t is #ahj days aft] ! date ( enactm5t ( ?is ,act4 #djb4 ,enrollm5t ( ,,pace b5efici>ies at any "t 7a7 ,9 g5]al ,sections #ahid7;d77#e77;,a7 & #aicd7;d77#e77;,a7 7#db ,u4,s4,c4 #acie;eee7d77#e77;,a71 #acifu-#d7;d77#e77;,a77 are ea* am5d$-- 7#a7 9 ! subp>agraph head]1 by ins]t+ enrollm5t or2 7#b7 by ins]t+ ,,pace program eligible individuals to enroll 9 a ,,pace program at any "t & aft] %all p]mit2 & 7#c7 by add+ at ! end ! foll[+ s5t5ce3 ,! am\nt ( any capitat$ paym5t made to a ,,pace provid] "u subsection 7d77#a7 may be adju/$ to acc\nt = any ,,pace program eligible individuals :o enroll aft] ! fir/ day ( a mon? 7) ! am\nt ( su* paym5t adju/m5t be+ proportional to ! portion ( su* mon? = :i* ! individual is enroll$74 7b7 ,effective date ,! am5dm5ts made by ?is section %all take effect on ! date t is #ahj days aft] ! date ( enactm5t ( ?is ,act4 #djc4 ,ext5d+ eligibility = ,,pace to m$ic>e-eligible individuals "u ! age ( #ee 7a7 ,9 g5]al ,sections #ahid7;a77#e77;,a7 & #aicd7;a77#e77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;eee7a77#e71 #acifu-#d7;a77#e77 are ea* am5d$ by ins]t+ 7or any age 9 ! case ( an individual :o is eligible = b5efits "u "p ,a1 or enroll$ "u "p ,b1 ( title ,,xviii7 aft] is #ee ye>s ( age or old]4 7b7 ,effective date ,! am5dm5ts made by ?is section %all take effect on ! date t is #ahj days aft] ! date ( enactm5t ( ?is ,act4 #djd4 ,removal ( qu>t]ly re/rictions = submission ( a new pace organization application1 & removal qu>t]ly re/rictions = applications 9 a new s]vice area 7a7 ,9 g5]al ,sections #ahid7;e7 & #aicd7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;eee7e71 #acifu-#d7;e77 are ea* am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#i7 ,no qu>t]ly or geographic limitations on applications = ,,pace provid] /atus ,! ,secret>y %all n prohibit an entity t meets ! requirem5ts = a ,,pace provid] "u ?is section f-- 7,a7 submitt+ multiple applications 9 ! same qu>t]2 or 7,b7 submitt+ multiple applications to op]ate a ,,pace program 9 ! same s]vice area4 4 7b7 ,effective date ,! am5dm5ts made by ?is section %all take effect on ! date t is #ahj days aft] ! date ( enactm5t ( ?is ,act4 #dje4 ,ensur+ ,m$ic>e-only ,,pace program enrollees h a *oice ( prescription drug plans "u ,m$ic>e "p ,d ,section #ahfj;,d-#ba7;f7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aca7;f77 is am5d$-- 7#a7 9 p>agraph 7#a71 by /rik+ & 7#c7 & ins]t+ 7#c71 & 7#d72 & 7#b7 by add+ at ! end ! foll[+ new p>agraph3 7#d7 ,ensur+ *oice ( prescription drug plans 7,a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbd1 subject to ! succe$+ provisions ( ?is p>agraph1 an applicable ,,pace program enrollee may elect to enroll 9 a qualifi$ /&alone prescription drug plan1 9 accordance ) rules e/abli%$ by ! ,secret>y pursuant to ?is p>agraph1 :ile enroll$ "u a ,,pace program4 7,b7 ,def9ition ( applicable pace program enrollee2 qualifi$ /&alone prescription drug plan ,9 ?is p>agraph3 7i7 ,applicable pace program enrollee ,! t]m applicable ,,pace program enrollee means a "p ,d eligible individual :o-- 7,i7 is n entitl$ to m$ical assi/ance "u title ,,xix2 & 7,,ii7 is enroll$ "u a ,,pace program (f]$ by a ,,pace provid]4 7ii7 ,qualifi$ /&alone prescription drug plan ,! t]m qualifi$ /&alone prescription drug plan means1 ) respect to an applicable ,,pace program enrollee1 a prescription drug plan-- 7,i7 t is n an ,,ma-,,pd plan2 7,,ii7 t is n op]at$ by ! ,,pace program "u :i* ! individual is enroll$2 & 7,,iii7 = :i* ! ,secret>y det]m9es1 ) respect to ! applicable ,,pace program enrollees enroll$ 9 a ,,pace program (f]$ by su* ,,pace provid]1 t-- 7aa7 ! e/imat$ b5efici>y out-(-pocket co/s 7z def9$ 9 clause 7iii77 = ! plan ye> = qualifi$ prescription drug cov]age "u ! plan is equal to or less ?an ! e/imat$ out-(-pocket co/s = su* cov]age "u ! prescription drug plan (f]$ by ! ,,pace program 9 :i* ! applicable ,,pace program enrollee is enroll$2 & 7bb7 ! e/imat$ total am\nt ( ,f$]al subsidies = ! plan ye> = qualifi$ prescription drug cov]age "u ! plan 7:i* may be e/imat$ us+ data f ! previ\s plan ye>7 is equal to or less ?an ! e/imat$ subsidy am\nt = su* cov]age "u ! prescription drug plan (f]$ by ! ,,pace program 9 :i* ! applicable ,,pace program enrollee is enroll$4 7iii7 ,out-(-pocket co/s def9$ ,9 ?is p>agraph1 ! t]m out-(-pocket co/s includes premiums impos$ "u a prescription drug plan &1 9 ! case ( cov]age "u a qualifi$ /&alone prescription drug plan1 d$uctibles1 copaym5ts1 co9surance1 & o!r co/-%>+4 7,c7 ,out-(-pocket co/s ,9 ! case :]e an applicable ,,pace program enrollee elects to enroll 9 a qualifi$ /&alone prescription drug plan pursuant to ?is p>agraph1 ! individual %all be responsible = any out-(-pocket co/s impos$ "u ! plan 7includ+ co/s = non=mul>y drugs7 aft] ! application ( any subsidies "u section #ahfj;,d-#ad = an applicable ,,pace program enrollee :o is a subsidy eligible individual 7z def9$ 9 section #ahfj;,d-#ad7;a77#c774 7,d7 ,requirem5ts = pace programs 7i7 ,educat+ & help+ enroll b5efici>ies into a "p d plan option ,a ,,pace program %all be requir$ to provide-- 7,i7 in=mation to all applicable ,,pace program enrollees :o are enroll$ "u ! ,,pace program reg>d+ ! option to enroll 9 a qualifi$ /&alone prescription drug plan "u ?is p>agraph2 & 7,,ii7 ^u reque/ ( an applicable ,,pace program enrollee1 c\nsel+ & coord9ation to assi/ applicable ,,pace program enrollees 9 mak+ decisions reg>d+ ! selection ( qualifi$ /&alone prescription drug plans available to !m4 7ii7 ,monitor+ drug utilization1 adh]5ce1 & sp5d ,a ,,pace program %all be requir$ to monitor drug utilization1 m$ication adh]5ce1 & drug sp5d+ 7?r\gh claims data %>$ pursuant to subp>agraph 7,f7 & o!rwise7 ?r\gh\t ! ye> ) respect to any applicable ,,pace program enrollee :o elects to enroll 9 a qualifi$ /&alone prescription drug plan "u ?is p>agraph 9 ord] to coord9ate ) ! ,,pdp sponsor ( su* plan reg>d+ ! drug b5efits (f]$ by ! plan1 includ+ ^u reque/ ( an applicable ,,pace program enrollee ! fil+ ( any grievances or appeals ) ! plan on behalf ( ! applicable ,,pace program enrollee4 7,e7 ,dis5rollm5t ,an applicable ,,pace program enrollee may dis5roll f ! qualifi$ /&alone prescription drug plan elect$ by su* applicable ,,pace program enrollee "u subp>agraph 7,a7 if ! enrollee *anges m$ication dur+ ! plan ye> or c demon/rate an unexpect$ increase 9 out-(-pocket co/s po/ enrollm5t4 7,f7 ,claims %>+ ,9 ! case :]e an applicable ,,pace program enrollee enrolls 9 a qualifi$ /&alone prescription drug plan1 ! ,,pace program 9 :i* ! individual is enroll$ & ! ,,pdp sponsor ( ! qualifi$ /&alone prescription drug plan %all %>e claims data ) ea* o!r ) respect to ! applicable ,,pace program enrollee z ne$$ to support c>e managem5t = ! applicable ,,pace program enrollee 7includ+ = purposes ( monitor+ & coord9ation requir$ "u subp>agraph 7,d77ii77 & = purposes ( compreh5sive risk adju/m5t "u section #ahid7;d74 ,su* data %all be %>$ )\t ! ne$ = any =mal or in=mal reque/ ( ! ,,pace program 9 :i* ! individual is enroll$ or ! ,,pdp sponsor ( ! qualifi$ /&alone prescription drug plan 9 :i* ! applicable ,,pace program enrollee is enroll$4 7,g7 ,rule ( con/ruction ,! au?ority e/abli%$ "u ?is p>agraph = an applicable ,,pace program enrollee to elect to enroll 9 a qualifi$ /&alone prescription drug plan %all n be con/ru$ z p]mitt+ an applicable ,,pace program enrollee to enroll 9 a prescription drug plan t is n a qualifi$ /&alone prescription drug plan4 7,h7 ,relation to ,,pace /atutes 7i7 ,9 g5]al ,! au?ority provid$ "u ?is p>agraph = an applicable ,,pace program enrollee to elect to enroll 9 a qualifi$ /&alone prescription drug plan %all apply not)/&+ subsection 7a77#a77;,b77#a7 ( section #ahid & su* o!r provisions ( sections #ahid & #aicd z ! ,secret>y det]m9es may conflict ) ! au?ority provid$ = "u ?is p>agraph1 includ+ subsections 7a77#b77;,b71 7b77#a77;,a77i71 7b77#a77;,c71 7f77#b77;,b77ii71 & 7f77#b77;,b77v7 ( su* sections4 7ii7 ,cl>ification on paym5t = "p ,d drug cov]age ,ins(> z an applicable ,,pace program enrollee is enroll$ 9 a qualifi$ /&alone prescription drug plan "u ?is p>agraph1 ! ,,pace program %all n be entitl$ to paym5t "u section #ahid7;d7 = ! provision ( qualifi$ prescription drug cov]age "u su* /&alone prescription drug plan ) respect to su* applicable ,,pace program enrollee4 4