Delivering Unified Access to Lifesaving Services Act of 2024 or the DUALS Act of 2024
This bill creates a program to provide integrated care for individuals who are fully eligible for both Medicare and Medicaid (i.e., dual-eligible individuals).
The Centers for Medicare & Medicaid Services (CMS) must develop a set of models for states to provide integrated care coordination for dual-eligible individuals; states must choose one of these models and implement the model within four years of their selection. Benefits must include clinical health services, behavioral health services, and long-term services and supports. Care coordination plans must be based on individualized health risk assessments and involve interdisciplinary health care teams. Each individual must be assigned a care coordinator to help the individual with respect to benefits and health care decisions.
The bill provides funds for states and the CMS to implement this program. It also provides funds for outreach and other activities to raise awareness about the program.
The bill also modifies Programs of All-Inclusive Care for the Elderly (PACE), including by allowing those under age 55 to enroll in PACE if they are eligible for Medicare. (PACE is a program under Medicare and Medicaid that provides in-home and community services for certain individuals as an alternative to nursing home care.)
[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 3950 Introduced in Senate (IS)]
<DOC>
118th CONGRESS
2d Session
S. 3950
To provide States with support to establish integrated care programs
for individuals who are dually eligible for Medicare and Medicaid, and
for other purposes.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
March 14, 2024
Mr. Cassidy (for himself, Mr. Carper, Mr. Cornyn, Mr. Warner, Mr. Scott
of South Carolina, and Mr. Menendez) introduced the following bill;
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 Medicaid, and
for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Delivering Unified
Access to Lifesaving Services Act of 2024'' or the ``DUALS Act of
2024''.
(b) Table of Contents.--The table of contents for this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--STATE INTEGRATED CARE PROGRAMS FOR DUAL ELIGIBLE INDIVIDUALS
Sec. 101. State implementation.
``TITLE XXII--STATE INTEGRATED CARE PROGRAMS FOR DUAL ELIGIBLE
INDIVIDUALS
``Sec. 2201. Definitions.
``Sec. 2202. State selection of program models, development,
and implementation.
``Sec. 2203. Enrollment in integrated care plans.
``Sec. 2204. Plan requirements and payments.
``Sec. 2205. Data collection and reporting.
``Sec. 2206. State ombudsman.
``Sec. 2207. Funding.
``Sec. 2208. Federal administration through the Federal
Coordinated Health Care Office.
Sec. 102. Providing Federal Coordinated Health Care Office authority
over dual snps.
Sec. 103. Additional conforming amendments.
TITLE II--IMPROVING ELIGIBILITY DETERMINATIONS, ENROLLMENT PROCESSES,
AND QUALITY OF CARE FOR DUAL ELIGIBLE INDIVIDUALS
Sec. 201. Identifying opportunities for State coordination with respect
to eligibility determinations.
Sec. 202. Alignment of bidding, reporting, and other dates and
deadlines for integrated care plans.
Sec. 203. Grants to State and local community organizations for
outreach and enrollment.
Sec. 204. Application of model standards to information requirements
for integrated care plans.
Sec. 205. Enrollment through independent brokers.
Sec. 206. Reducing threshold for look-alike D-SNP plans under Medicare
Advantage.
Sec. 207. Requiring regular update of provider directories.
Sec. 208. Review of hospital quality star rating system.
Sec. 209. Requirement for FCHCO and State Medicaid agencies to develop
maximum staffing ratios for care
coordinators.
Sec. 210. CMMI testing of coverage of partial benefit dual eligible
individuals through State Integrated Care
Programs.
TITLE III--ADMINISTRATION
Sec. 301. Alignment of billing codes under titles XVIII, XIX, and XXII.
TITLE IV--PACE
Sec. 401. Requiring States to offer PACE program services to eligible
individuals.
Sec. 402. Enrollment of PACE beneficiaries at any time.
Sec. 403. Extending eligibility for PACE to medicare-eligible
individuals under the age of 55.
Sec. 404. Removal of quarterly restrictions for submission of a new
pace organization application, and removal
quarterly restrictions for applications in
a new service area.
Sec. 405. Ensuring Medicare-only PACE program enrollees have a choice
of prescription drug plans under Medicare
part D.
TITLE I--STATE INTEGRATED CARE PROGRAMS FOR DUAL ELIGIBLE INDIVIDUALS
SEC. 101. STATE IMPLEMENTATION.
The Social Security Act is amended by adding at the end the
following new title:
``TITLE XXII--STATE INTEGRATED CARE PROGRAMS FOR DUAL ELIGIBLE
INDIVIDUALS
``SEC. 2201. DEFINITIONS.
``In this title:
``(1) Director.--The term `Director' means the Director of
the Federal Coordinated Health Care Office of the Centers for
Medicare & Medicaid Services.
``(2) Dual eligible individual.--The term `dual eligible
individual' means an individual who is entitled to, or enrolled
for, benefits under part A of title XVIII, or enrolled for
benefits under part B of title XVIII, and is eligible for
medical assistance for full benefits under title XIX under
section 1902(a)(10)(A) or 1902(a)(10)(C), by reason of section
1902(f), or under any other category of eligibility for medical
assistance for full benefits under such title, as determined by
the Secretary.
``(3) Integrated care plan.--The term `integrated care
plan' means an entity or organization that is selected by a
State under section 2202(a) to provide fully integrated care
for a dual eligible individual in accordance with the
requirements of this title and related Federal and State
regulations. Such term shall not include a PACE program (as
defined in sections 1894(a)(2) and 1934(a)(2)).
``SEC. 2202. STATE SELECTION OF PROGRAM MODELS, DEVELOPMENT, AND
IMPLEMENTATION.
``(a) State Selection of Program Models.--Not later than 1 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 2208(b)(1), each State shall select
from such published models, 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 comprehensive, fully
integrated care for dual eligible individuals.
``(b) Timing.--Each State shall work with the Director to implement
the models selected by the State under subsection (a) so that, to the
extent practicable, the State may begin to enroll dual eligible
individuals in the program models selected during the 4th year that
occurs after the year in which the State makes such selection and, by
the end of such 4th year, the models are fully implemented and operated
in accordance with the requirements of this title and related Federal
and State regulations. Nothing in this subsection shall prohibit a
State from enrolling dual eligible individuals in such program models
earlier than the end of such 4th year if the models are fully
implemented and operated in accordance with the requirements of this
title and related Federal and State regulations.
``(c) Adjustment Authority.--The Director may modify the timing
required by subsections (a) and (b) as appropriate to account for the
particular needs or circumstances of a State.
``(d) Implementation Council.--
``(1) In general.--A State shall establish an
implementation council in accordance with such requirements as
the Secretary shall establish. The members of the council shall
include representatives of a wide range of stakeholders
relevant to the provision of integrated care for dual eligible
individuals.
``(2) 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 (a).
``SEC. 2203. ENROLLMENT IN INTEGRATED CARE PLANS.
``(a) Passive Enrollment; Opt-Out Permitted.--
``(1) 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 60 days (90 days, in the
case of the first time the individual is provided such notice)
prior to the effective date of such enrollment. Notice provided
to a dual eligible individual under this paragraph shall
include the following:
``(A) The name and contact information for the
integrated care plan.
``(B) The date on which the enrollment takes effect
and, if applicable, whether the State has elected the
option for a 12-month continuous eligibility period
under paragraph (4).
``(C) A summary of the benefits to be provided by
the plan.
``(D) Information regarding the provider network of
the plan.
``(E) Information regarding how the dual eligible
individual may elect to opt-out of enrollment with the
plan within 60 days (90 days, in the case of the first
time the individual is provided such notice).
``(2) Enrollment in plan with in-network, 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-
network, participating provider for the plan.
``(3) 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
(2).
``(4) 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--
``(A) the end of the 12-month period beginning on
the date of such determination; or
``(B) the date that such individual ceases to be a
resident of such State.
``(b) Change of Enrollment.--A State shall permit a dual eligible
individual to change enrollment in an integrated care plan--
``(1) on a monthly basis if the individual is electing to
enroll in another integrated care plan;
``(2) during the general enrollment period applicable under
section 1837, if the individual is electing to disenroll from
an integrated care plan and not enroll in another integrated
care plan; and
``(3) during the 60-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 individual, if the individual is no longer
eligible to enroll in an integrated care plan.
``(c) 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 enrollment.
``SEC. 2204. PLAN REQUIREMENTS AND PAYMENTS.
``(a) In General.--A contract between a State, an offeror of an
integrated care plan, and the Director shall not be considered to meet
the requirements of this title unless--
``(1) 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
participating, in-network provider, or who disenrolls from the
plan and does not enroll in another integrated care plan, the
offeror of the plan will, during the 30-day period that begins
on the date on which the individual's disenrollment from the
plan takes effect--
``(A) allow the individual to continue to be
treated by the individual's primary care provider; and
``(B) cover any treatment provided to the
individual by such provider as if the individual were
still enrolled with the plan;
``(2) the offeror of the plan administers a health risk
assessment to each dual eligible individual enrolled with the
plan within 90 days of the effective date of the individual's
enrollment in accordance with the requirements of subsection
(c) and shall affirm that there are no changes in the
information provided at least every 12 months thereafter;
``(3) the offeror of the plan provides benefits for a dual
eligible individual under a comprehensive care plan in
accordance with the requirements of subsections (d) and (f);
``(4) 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 (e) and notifies
such individual in a timely and accessible manner when a new
care coordinator is assigned; and
``(5) 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 2208(c).
``(b) 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 2203 shall be disregarded for purposes of any data used for
rating of the plan for such plan year.
``(c) 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
2208(b)(3) and in accordance with such additional requirements as the
State may establish. 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 provided.
``(d) Benefits.--
``(1) In general.--An integrated care plan shall provide
benefits under the plan in accordance with requirements
established by the Director and the State, and which shall
include the following:
``(A) Clinical health services.
``(B) Behavioral health services.
``(C) Long-term services and supports.
``(2) 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 (1)
but only if the State demonstrates to the Director that--
``(A) 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
exception; and
``(B) the dual eligible individual will not be
subject to any unreasonable administrative requirements
to access the services or supports, as determined by
the Secretary.
``(3) Supplemental benefits.--An integrated care plan may
provide customized, supplemental benefits to a dual eligible
individual enrolled with the plan, including supplemental
health care benefits described in section 1852(a)(3), 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 (SSBCI),
without regard to whether the dual eligible individual has a
requisite condition or diagnosis, so long as the plan
demonstrates to the Director and the State that the offering of
such benefits has a positive impact on patient health.
``(e) Care Coordinator Requirements.--A care coordinator assigned
to a dual eligible individual enrolled in an integrated care plan
shall--
``(1) serve as the single point of contact between the
individual and the plan;
``(2) be responsible for helping the individual and the
individual's caregivers and family make benefit and service
decisions;
``(3) design a beneficiary-focused comprehensive care plan
for the individual that meets the requirements of subsection
(f); and
``(4) connect and coordinate acute, subacute, social,
primary, and specialty care for the individual and the
provision of long-term services and supports for the
individual.
``(f) Comprehensive Care Plan Requirements.--The comprehensive care
plan for a dual eligible individual enrolled in an integrated care plan
shall be--
``(1) designed to address the totality of the individual's
medical, functional, behavioral, social, and caregiving needs
and goals, and to the extent practicable, to apply to multiple
years;
``(2) be based on the health risk assessment of the
individual required by subsection (c);
``(3) be implemented by an interdisciplinary care team that
includes relevant specialists to ensure access to all aspects
of care that are required for the individual;
``(4) be approved by the individual (or by an authorized
caregiver or guardian) prior to implementation; and
``(5) be reviewed at least annually and within 30 days of a
major health event, such as hospitalization or an emergency
room visit.
``(g) Continuity of Care Requirement.--An integrated care plan
shall provide a dual eligible individual enrolled in the plan with a
minimum 90-day transition period for any active course of treatment
when the individual has enrolled in an integrated care plan after
starting a course of treatment, even if the service is furnished by an
out-of-network provider. This includes enrollees new to a plan and
enrollees new to Medicare. 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 90 days. An integrated care plan may
provide for a longer transition period than 90 days at the option of
the plan. For purposes of this subsection the following definitions
apply:
``(1) 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 provider. A course of treatment may
but is not required to be part of a treatment plan.
``(2) 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 treatment.
``(h) Authority To Apply Frailty Adjustment Factor To Plan
Payments.--A contract between a State, an integrated care plan, 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 1853(a)(1)(B)(iv), but without
regard to requiring the plan to demonstrate enrollment of a high
concentration of frail individuals.
``SEC. 2205. DATA COLLECTION AND REPORTING.
``(a) Annual Collection and Reporting by States and Integrated Care
Plans.--Each State, and each integrated care plan with a contract with
a State under this title, 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 2208(b)(7)
that includes data collected by such States and plans with respect to a
plan year regarding age, gender, disability (including specific
disability statuses required to be reported by the Director), smoking
status, mobility, employment status, education, race and ethnicity, and
ZIP Code, of dual eligible individuals enrolled in the plan.
``(b) 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 information.
``SEC. 2206. STATE OMBUDSMAN.
``(a) In General.--Each State shall establish and operate an Office
of the Ombudsman for Integrated Care Plans for Dual Eligible
Individuals (in this section referred to as the `Office'). The Office
may operate independently of, or in connection with, the State agency
responsible for administering the Medicaid program under title XIX.
``(b) Ombudsman.--The Office shall be headed by an individual, to
be known as the State Integrated Care for Dual Eligible Individuals
Ombudsman, who shall be selected from among individuals with expertise
in and experience with integrated care models for dual eligible
individuals, the Medicare program under title XVIII, and the Medicaid
program under title XIX. The Ombudsman shall be responsible for the
management, including the fiscal management, of the Office.
``(c) Requirements.--
``(1) 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
assistance.
``(2) Minimum staffing ratio.--The Office shall have a
minimum staffing ratio of 1 employee for every 2,000 dual
eligible individuals in the State.
``(d) Funding.--
``(1) Initial funding.--During the first 2 years in which a
State operates the Office, the Secretary shall pay to the State
for each such year for expenditures necessary to establish and
operate the Office, from amounts appropriated under section
2207(c), an amount equal to $50,000,000 multiplied by the ratio
of--
``(A) the number of dual eligible individuals in
the State; to
``(B) the number of dual eligible individuals in
all States.
``(2) Subsequent funding.--Beginning with the 3rd year of
the Office's operation, expenditures necessary to operate the
Office shall be considered, for purposes of section 1903(a)(7),
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 section.
``SEC. 2207. FUNDING.
``(a) 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 2208(c) shall be treated as medical
assistance for which payment is made under section 1903(a). 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 1903(a)
with respect to expenditures attributable to providing such medical
assistance.
``(b) Payments to States.--From the sums appropriated under
subsection (c), the Secretary shall pay to each State for each calendar
year (beginning January 1 of the first full calendar year in which this
title is implemented in the State), an amount equal to the sum of the
following:
``(1) Shared savings component.--The shared savings payment
applicable to the State and the year, as determined in
accordance with section 2208(b)(6)(D).
``(2) General administrative expenses.--For administrative
expenses to carry out this title, other than section 2205, an
amount that bears the same proportion to $50,000,000 as the
number of dual eligible individuals in the State bears to the
number of dual eligible individuals in all States, as
determined by the Secretary.
``(3) Data collection and reporting.--For data collection
and reporting expenses under section 2205, an amount that bears
the same proportion to $50,000,000 as the number of dual
eligible individuals in the State bears to the number of dual
eligible individuals in all States, as determined by the
Secretary.
``(c) Appropriation.--There is appropriated, out of any money in
the Treasury not otherwise appropriated, such amounts as may be
required to provide payments to States under this section, for each
calendar year (beginning January 1 of the first full calendar year in
which this title is implemented in any State), reduced by any amounts
made available from the Medicare trust funds under subsection (d).
``(d) Relation to Medicare Trust Funds.--There shall be made
available for carrying out this title, and the Secretary shall provide
for the transfer from the Federal Hospital Insurance Trust Fund (under
section 1817) and from the Federal Supplementary Medical Insurance
Trust Fund (under section 1841) (and from the Medicare Prescription
Drug Account (under section 1860D-16) within such Trust Fund) such
amounts as the Secretary determines appropriate, 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 title, for each calendar year
(beginning January 1 of the first full calendar year in which this
title is implemented in any State).
``(e) Relation to Other Payments.--Payments provided under this
section to a State are in addition to payments provided under section
2208.
``SEC. 2208. FEDERAL ADMINISTRATION THROUGH THE FEDERAL COORDINATED
HEALTH CARE OFFICE.
``(a) In General.--The Director shall have primary authority for
implementing and carrying out responsibilities of the Federal
Government under this title.
``(b) Responsibilities of the FCHCO.--In carrying out this title,
the Director shall have the following responsibilities:
``(1) Development and publication of integrated care
program models.--Subject to subsection (c), to develop and, not
later than 180 days after the date of enactment of this
paragraph, publish, a range of program models (including but
not limited to Medicare-Medicaid plans, accountable care
organizations, and dual eligible special needs plans) 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 title.
``(2) Unified appeals process.--To develop and, not later
than 1 year after the date of enactment of this paragraph,
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 Medicaid.
``(3) 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 insecurity, access to
transportation, internet access, utility difficulty,
interpersonal safety, and housing instability.
``(4) 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 2204(d)(3), including data relating to enrollment,
utilization, and outcomes, to annually publish a report
regarding the offering and utilization of such benefits, and to
study and report to the Secretary on whether to cap the
actuarial dollar value allowed for such benefits under titles
XVIII, XIX, and XXII.
``(5) Care coordinator requirements.--To--
``(A) establish a formula based on patient chronic
conditions, activities of daily living standards,
geographic, 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 title; and
``(B) 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 title.
``(6) Administration and oversight of integrated care plans
for dual eligible individuals.--To--
``(A) 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 XIX, necessary for
implementation, administration, and oversight of
integrated care plans for dual eligible individuals
under this title; and
``(B) administer and provide oversight of
integrated care plans for dual eligible individuals
under this title, including with respect to--
``(i) the development and application of an
integrated medical loss ratio for such plans,
in lieu of compliance with separate medical
loss ratio requirements under titles XVIII and
XIX;
``(ii) the establishment and application of
network adequacy standards for such plans
that--
``(I) apply only with respect to
such plans;
``(II) allow the Director to waive
compliance with such standards for
integrated care plans that cannot meet
the requirements in certain areas, but
must operate statewide to meet a
State's selective contracting
requirements; and
``(III) allow the Director to
consider flexibilities to support
innovative models that do not rely on
traditional time and distance
standards, such as the use of
telehealth; and
``(iii) the establishment and application
of targeted, streamlined model-of-care
requirements for such plans that include an
integrated audit process, with shared
responsibilities between the Director and
States, and that requires the Director to share
the results of such audits with State Medicaid
programs. To the extent practicable, such
requirements also shall be designed to be
integrated with model of care requirements
applicable to Medicaid managed care
organizations;
``(C) develop contract management teams, consisting
of representatives from integrated care plans with
contracts with States under this title, State agencies
responsible for administering the State plan under
title XIX or a waiver of such plan, and the Federal
Coordinated Health Care Office, to oversee compliance
and performance of integrated care plans under this
title;
``(D) 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 title; and
``(E) 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 separately, with State-specific measures and
tied to single contracts, instead of the collective
performance of all of the offeror's plans under
contract with the State under that title, that include
measures which directly reflect enrollee satisfaction,
and that awards higher star ratings to plans based on
their ability to retain enrollees.
``(7) Data collection and reporting.--To establish data and
information collection and reporting requirements for States
and integrated care plans under section 2205, including
required reporting of specific disability statuses and
safeguards to protect patient privacy, and to annually publish
not later than April 30 of any year, the data and information
collected and reported to the Director under such section for
the preceding year.
``(8) 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 title. Such measures shall include
measures relating to patient satisfaction, quality of life,
rates of emergency room use, institutionalization for long-term
care, hospital admission and readmission rates, and medication
errors. 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 title.
``(9) Best practices.--To not less than annually publish
best practices under this title for States and integrated care
plans, including with respect to improving outreach to
beneficiaries, improving comprehensive care plans and health
risk assessments for dual eligible individuals, and developing
a workforce that provides culturally intelligent and respectful
care.
``(10) Training programs.--To develop training programs
related to integrated care plans under this title for--
``(A) providers of care, services, and supports
under such plans with respect to issues such as
coordination of benefits, data sharing barriers,
quality ratings, and provider incentives;
``(B) State employees to increase Medicare
expertise at State agencies responsible for
administering Medicaid plans and waivers and
contracting with integrated care plans under this
title; and
``(C) insurance brokers and local counselors who
help enroll individuals in Medicare, Medicaid, and
integrated care plans under this title.
``(c) Capitated Payment Structure for Integrated Care Program
Models.--
``(1) In general.--Each program model that is designed by
the Director under subsection (b)(1) 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 which, for each month that the
integrated care plan provides such benefits--
``(A) the State shall pay the integrated care plan
an amount equal to the Medicaid component payment
determined for the month; and
``(B) the Secretary shall pay the integrated care
plan an amount equal to the Medicare component payment
determined for the month.
``(2) Determination of medicaid component payment.--For
purposes of paragraph (1), 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--
``(A) for each category of beneficiary, the
Medicaid capitation rate applicable to the category of
beneficiary (as determined by the Secretary and
specified in the contract between the State, the
Secretary, and the offeror of the plan); and
``(B) the number of beneficiaries in such category
enrolled with the plan for the month.
``(3) Determination of medicare component payment.--For
purposes of paragraph (1), 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--
``(A) for each category of beneficiary, the
Medicare capitation rate applicable to the category of
beneficiary (as determined by the Secretary and
specified in the contract between the State, the
Secretary, and the offeror of the plan); and
``(B) the number of beneficiaries in such category
enrolled with the plan for the month.
``(4) 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
State, the Secretary, and the offeror of an integrated care
plan shall be determined using the risk adjustment payment
model developed under subsection (d).
``(d) Risk Adjustment Payment Model for Providing Health Benefits
Coverage for Dual Eligible Individuals.--Not later than 1 year after
the date of enactment of this subsection, 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--
``(1) 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 Act;
``(2) includes factors based on the health status of such
individuals; and
``(3) allows plan payments to be made and updated on a
monthly basis.
``(e) Additional Responsibilities With Respect to Integrated Care
Plans.--
``(1) Outreach to medicaid providers.--Not later than 180
days after the date of enactment of this subsection, the
Director, in consultation with State Medicaid programs, shall
develop outreach plans for such programs to use to contact
providers of health benefits, services, or supports for dual
eligible individuals and provide information and education
regarding the State Integrated Care Programs for Dual Eligible
Individuals established under this title, how such program will
operate in the State where such providers offer health
benefits, services or supports for such individuals, and the
impact of such program on such providers.
``(2) Collection of data on quality measures from
integrated care plans under medicaid and medicare.--
``(A) In general.--Not later than 180 days after
the date of enactment of this subsection, the Director,
in consultation with the Administrator of the Centers
for Medicare & Medicaid Services and State Medicaid
programs, 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 Medicaid. Such data shall include, at
a minimum, data relating to provider network
availability in both Medicare and Medicaid, providers
in-network who are accepting new Medicare and Medicaid
patients, spending on supplemental benefits, and claims
denials.
``(B) Authority to collect additional data and
information; publication.--The Director may--
``(i) 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
Medicaid; and
``(ii) make the data and information
collected in accordance with this paragraph
publicly available.
``(3) Development of an aligned program for institutional
special needs plans under medicaid.--Not later than 180 days
after the date of enactment of this subsection, the Director,
in consultation with the Administrator of the Centers for
Medicare & Medicaid Services and State Medicaid programs, shall
develop an aligned program for offering Institutional Special
Needs Plans under Medicaid that has 1 entity financially
responsible for providing health benefits, services, and
supports for dual eligible individuals.
``(4) Assessment of need for criteria to regulate and
expand utilization of institutional special needs plans.--Not
later than 180 days after the date of enactment of this
subsection, the Director, in consultation with the
Administrator of the Centers for Medicare & Medicaid Services,
shall assess the adequacy of regulations and oversight of
Institutional Special Needs Plan to determine whether new, or
additional requirements should be established to improve the
utilization, performance, and oversight of such plans and how
such plans may be offered under State Integrated Care Programs
for Dual Eligible Individuals established under this title.
``(f) Appropriations.--There are hereby appropriated, out of any
funds in the Treasury not otherwise appropriated, for the first fiscal
year that begins after the date of enactment of this title, and for
each fiscal year thereafter, such sums as are necessary to carry out
this title.
``(g) Direct-Hire Authority.--In carrying out this title, the
Director shall have direct-hire authority to the extent required to
implement and administer this title on a timely basis.''.
SEC. 102. PROVIDING FEDERAL COORDINATED HEALTH CARE OFFICE AUTHORITY
OVER DUAL SNPS.
(a) In General.--Section 1859(f)(8) of the Social Security Act (42
U.S.C. 1395w-28(f)(8)) is amended by adding at the end the following
new subparagraph:
``(F) Authority of federal coordinated health care
office.--For plan years beginning on or after January
1, 2025, the Federal Coordinated Health Care Office
established under section 2602 of Public Law 111-148
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
(b)(6)(B)(ii) under this subsection.''.
(b) Conforming Amendment.--Section 2602(d)(6) of the Patient
Protection and Affordable Care Act (42 U.S.C. 1315b(d)(6)) is amended
by inserting the following before the period: ``and, for plan years
beginning on or after January 1, 2025, to carry out subsection
(f)(8)(F) of such section''.
SEC. 103. ADDITIONAL CONFORMING AMENDMENTS.
(a) Definition of State.--Section 1101(a)(1) of the Social Security
Act (42 U.S.C. 1301(a)(1)) is amended--
(1) by striking ``XIX, and XXI'' and inserting ``XIX, XXI,
and XXII''; and
(2) by striking ``XIX and XXI'' and inserting ``XIX, XXI,
and XXII''.
(b) Medicare Enrollment.--Section 1851(a) of the Social Security
Act (42 U.S.C. 1395w-21(a)) is amended by adding at the end the
following new paragraph:
``(4) Additional enrollment option for dual eligible
individuals.--Dual eligible individuals (as defined in section
2201) may also be eligible to enroll in an integrated care plan
under title XXII.''.
(c) Preventing Duplicate Payments Under Medicaid.--Section 1903(i)
of the Social Security Act (42 U.S.C. 1396b(i)) is amended--
(1) by striking ``or'' at the end of paragraph (26);
(2) by striking the period at the end of paragraph (27) and
inserting ``; or'';
(3) by inserting after paragraph (27) the following new
paragraph:
``(28) with respect to any amount expended for medical
assistance for a dual eligible individual (as defined in
section 2201) enrolled in an integrated care plan under title
XXII, except as specifically permitted under such title.''; and
(4) in the third sentence, by striking ``, and (18)'' and
inserting ``, (18), and (28)''.
TITLE II--IMPROVING ELIGIBILITY DETERMINATIONS, ENROLLMENT PROCESSES,
AND QUALITY OF CARE FOR DUAL ELIGIBLE INDIVIDUALS
SEC. 201. IDENTIFYING OPPORTUNITIES FOR STATE COORDINATION WITH RESPECT
TO ELIGIBILITY DETERMINATIONS.
Not later than 1 year after the date of enactment of this Act, the
Secretary of Health and Human Services, in consultation with States,
shall--
(1) review State processes for determining whether an
individual is a full-benefit dual individual (as defined in
section 1935(c)(6) of the Social Security Act (42 U.S.C. 1396u-
5(c)(6)) but without the application of subparagraph (A)(i) of
such section) and whether an individual is eligible for the
low-income subsidy program under section 1860D-14 of the Social
Security Act (42 U.S.C. 1395w-114) and the Medicare Savings
Program (as defined in section 1144(c)(7) of such Act (42
U.S.C. 1320b-14(c)(7))); and
(2) issue guidance for States that identifies opportunities
for better coordination of such processes between the States
and the Federal Government.
SEC. 202. ALIGNMENT OF BIDDING, REPORTING, AND OTHER DATES AND
DEADLINES FOR INTEGRATED CARE PLANS.
Not later than 180 days after the date of enactment of this Act,
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--
(1) review bidding, reporting, and other significant dates
and deadlines applicable to integrated care plans under the
Medicare program, the Medicaid program, and State Integrated
Care Programs for Dual Eligible Individuals under title XXII of
the Social Security Act; and
(2) identify such administrative and legislative changes as
are needed to ensure that all such dates and deadlines are
aligned and consistent under all such programs.
SEC. 203. GRANTS TO STATE AND LOCAL COMMUNITY ORGANIZATIONS FOR
OUTREACH AND ENROLLMENT.
(a) In General.--From the amounts appropriated under subsection (c)
for a fiscal year, the Secretary of Health and Human Services (in this
section referred to as the ``Secretary'') 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 (as defined in section 2201 of the Social Security Act) 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 Act.
(b) Model Standards.--The Secretary, in consultation with the
Administrator of the Administration for Community Living and States,
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 following:
(1) Information and education support is available for
individuals in a range of languages, and online, over the
phone, and in person.
(2) Materials presented are easy to read, written in as low
a reading comprehension level as possible, and are in the
proper language for the individual involved.
(3) Information presented online is accessible for
individuals with disabilities.
(4) Information is presented in a manner that takes into
consideration the accessibility needs of the individual, such
as language access requirements and the health literacy level
of the individual.
(c) Appropriation.--There is appropriated, out of any money in the
Treasury not otherwise appropriated, for the first fiscal year that
begins after the date of enactment of this Act, and for each fiscal
year thereafter, $50,000,000 to carry out this section.
SEC. 204. APPLICATION OF MODEL STANDARDS TO INFORMATION REQUIREMENTS
FOR INTEGRATED CARE PLANS.
Not later than 1 year after the date of enactment of this Act, 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 (as defined in section 2201 of
the Social Security Act) by such Director, Administrator, States, or
health benefits plans that provide integrated care for such individuals
under the Medicare program, the Medicaid program, 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 203(b).
SEC. 205. ENROLLMENT THROUGH INDEPENDENT BROKERS.
Not later than 1 year after the date of enactment of this Act, 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--
(1) a dual eligible individual (as defined in section 2201
of the Social Security Act) 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 (as defined under
such guidance or regulations);
(2) an independent broker may receive a commission for the
initial enrollment of a dual eligible individual in such a
plan, but no commission shall be available to any broker for
any subsequent enrollment of such individual in any such plan;
(3) if a broker disenrolls a dual eligible individual from
any such health benefits plan to a plan that provides partial
or no integrated care, the broker, in accordance with the model
standards issued under section 204(b), shall inform the
individual--
(A) of the health benefits plan the individual is
being disenrolled from; and
(B) 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 care.
SEC. 206. 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 1 year after the date of enactment of this Act, and each subsequent
plan year, the Secretary of Health and Human Services--
(1) shall implement section 422.514(d)(1)(ii) of title 42,
Code of Federal Regulations (or any successor regulations) by
substituting ``50 percent'' for ``80 percent''; and
(2) shall only count full-benefit dual eligible individuals
(as defined in section 1935(c)(6) of the Social Security Act
(42 U.S.C. 1396u-5(c)(6))) for purposes of applying the
threshold under such section.
SEC. 207. REQUIRING REGULAR UPDATE OF PROVIDER DIRECTORIES.
Not later than 1 year after the date of enactment of this Act, 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--
(1) require Medicare Advantage plans under part C of title
XVIII of the Social Security Act (42 U.S.C. 1395w-21) and
integrated care plans under title XXII of such Act to regularly
update provider directories; and
(2) include a measure relating to provider director
currency rating on star rating systems for Medicare Advantage
plans under section 1853(o) of the Social Security Act (42
U.S.C. 1395w-23(o)) and integrated care plans under title XXII
of such Act.
SEC. 208. REVIEW OF HOSPITAL QUALITY STAR RATING SYSTEM.
Not later than 180 days after the date of enactment of this Act,
the Administrator of the Centers for Medicare & Medicaid Services
shall--
(1) review the hospital quality star rating system under
the Medicare program under title XVIII of the Social Security
Act (42 U.S.C. 1395 et seq.); and
(2) 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 quality.
SEC. 209. REQUIREMENT FOR FCHCO AND STATE MEDICAID AGENCIES TO DEVELOP
MAXIMUM STAFFING RATIOS FOR CARE COORDINATORS.
(a) In General.--The Director of the Federal Coordinated Health
Care Office, in consultation with State Medicaid agencies, 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 Act. Such
process shall take into account the varying needs required by different
categories of patients.
(b) Submission of Model Legislation.--Not later than 180 days after
the date of enactment of this Act, the Director of the Federal
Coordinated Health Care Office shall submit the model legislation
developed under subsection (a) to--
(1) the Secretary of Health and Human Services;
(2) the Committee on Finance of the Senate;
(3) the Committee on Energy and Commerce of the House of
Representatives; and
(4) the Committee on Ways and Means of the House of
Representatives.
SEC. 210. CMMI TESTING OF COVERAGE OF PARTIAL BENEFIT DUAL ELIGIBLE
INDIVIDUALS THROUGH STATE INTEGRATED CARE PROGRAMS.
Section 1115A of the Social Security Act (42 U.S.C. 1315a) is
amended--
(1) in subsection (b)(2)(A), by adding at the end the
following new sentence: ``The models selected under this
subparagraph shall include the testing of the model described
in subsection (h)(1).''; and
(2) by adding at the end the following new subsection:
``(h) Testing of Model for Providing Coverage of Partial Benefit
Dual Eligible Individuals Through Partially Integrated Care Plans Under
State Integrated Care Programs.--
``(1) 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 XXII.
``(2) Partial benefit dual eligible individual.--For
purposes of this subsection, the term `partial benefit dual
eligible individual' means an individual who--
``(A) is eligible for the low-income subsidy
program under section 1860D-14, the Medicare Savings
Program (as defined in section 1144(c)(7)), or both;
and
``(B) is not a full-benefit dual eligible
individual (as such term is defined in section
1935(c)(6), but without the application of subparagraph
(A)(i) of such section).''.
TITLE III--ADMINISTRATION
SEC. 301. ALIGNMENT OF BILLING CODES UNDER TITLES XVIII, XIX, AND XXII.
Not later than 180 days after the date of enactment of this Act,
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--
(1) review billing codes under the Medicare program, the
Medicaid program, and State Integrated Care Programs for Dual
Eligible Individuals under XXII of the Social Security Act;
(2) conduct at least 1 listening session open to the public
on the alignment of billing under the programs identified in
paragraph (1); and
(3) identify such administrative and legislative changes as
are needed to ensure that all such billing codes are aligned
and consistent under all such programs.
TITLE IV--PACE
SEC. 401. REQUIRING STATES TO OFFER PACE PROGRAM SERVICES TO ELIGIBLE
INDIVIDUALS.
(a) In General.--Section 1934 of the Social Security Act (42 U.S.C.
1396u-4) is amended--
(1) in subsection (a)(1)--
(A) by striking ``A State may elect to provide''
and inserting ``A State shall provide''; and
(B) 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 agreement.'';
(2) in subsection (e)--
(A) in paragraph (1)--
(i) by striking ``(A) In general.--The
Secretary'' and inserting ``The Secretary'';
and
(ii) by striking subparagraph (B);
(B) in paragraph (2)(A)(ii); and
(3) in subsection (h)(2)--
(A) by striking ``(A) In general.--Except as
provided under subparagraph (B), and'' and inserting
``Except as provided under''; and
(B) by striking subparagraph (B).
(b) State Plan Requirement.--Section 1902(a) of the Social Security
Act (42 U.S.C. 1396a(a)) is amended--
(1) in paragraph (86), by striking ``; and'' and inserting
a semicolon;
(2) in paragraph (87)(D), by striking the period at the end
and inserting ``; and''; and
(3) by inserting after paragraph (87) the following new
paragraph;
``(88) provide, in accordance with section 1934, 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
agreement.''.
(c) Effective Date.--The amendments made by this section shall take
effect on the date that is 180 days after the date of enactment of this
Act.
SEC. 402. ENROLLMENT OF PACE BENEFICIARIES AT ANY TIME.
(a) In General.--Sections 1894(d)(5)(A) and 1934(d)(5)(A) (42
U.S.C. 1395eee(d)(5)(A), 1396u-4(d)(5)(A)) are each amended--
(1) in the subparagraph header, by inserting ``enrollment
or'';
(2) by inserting ``PACE program eligible individuals to
enroll in a PACE program at any time and'' after ``shall
permit''; and
(3) by adding at the end the following sentence: ``The
amount of any capitated payment made to a PACE provider under
subsection (d)(1) may be adjusted to account for any PACE
program eligible individuals who enroll after the first day of
a month (with the amount of such payment adjustment being
proportional to the portion of such month for which the
individual is enrolled)''.
(b) Effective Date.--The amendments made by this section shall take
effect on the date that is 180 days after the date of enactment of this
Act.
SEC. 403. EXTENDING ELIGIBILITY FOR PACE TO MEDICARE-ELIGIBLE
INDIVIDUALS UNDER THE AGE OF 55.
(a) In General.--Sections 1894(a)(5)(A) and 1934(a)(5)(A) of the
Social Security Act (42 U.S.C. 1395eee(a)(5), 1396u-4(a)(5)) are each
amended by inserting ``(or any age in the case of an individual who is
eligible for benefits under part A, or enrolled under part B, of title
XVIII)'' after ``is 55 years of age or older''.
(b) Effective Date.--The amendments made by this section shall take
effect on the date that is 180 days after the date of enactment of this
Act.
SEC. 404. REMOVAL OF QUARTERLY RESTRICTIONS FOR SUBMISSION OF A NEW
PACE ORGANIZATION APPLICATION, AND REMOVAL QUARTERLY
RESTRICTIONS FOR APPLICATIONS IN A NEW SERVICE AREA.
(a) In General.--Sections 1894(e) and 1934(e) of the Social
Security Act (42 U.S.C. 1395eee(e), 1396u-4(e)) are each amended by
adding at the end the following new paragraph:
``(9) 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--
``(A) submitting multiple applications in the same
quarter; or
``(B) submitting multiple applications to operate a
PACE program in the same service area.''.
(b) Effective Date.--The amendments made by this section shall take
effect on the date that is 180 days after the date of enactment of this
Act.
SEC. 405. ENSURING MEDICARE-ONLY PACE PROGRAM ENROLLEES HAVE A CHOICE
OF PRESCRIPTION DRUG PLANS UNDER MEDICARE PART D.
Section 1860D-21(f) of the Social Security Act (42 U.S.C. 1395w-
131(f)) is amended--
(1) in paragraph (1), by striking ``and (3)'' and inserting
``(3), and (4)''; and
(2) by adding at the end the following new paragraph:
``(4) Ensuring choice of prescription drug plans.--
``(A) In general.--For plan years beginning on or
after January 1, 2024, subject to the succeeding
provisions of this paragraph, an applicable PACE
program enrollee may elect to enroll in a qualified
standalone prescription drug plan, in accordance with
rules established by the Secretary pursuant to this
paragraph, while enrolled under a PACE program.
``(B) Definition of applicable pace program
enrollee; qualified standalone prescription drug
plan.--In this paragraph:
``(i) Applicable pace program enrollee.--
The term `applicable PACE program enrollee'
means a part D eligible individual who--
``(I) is not entitled to medical
assistance under title XIX; and
``(II) is enrolled under a PACE
program offered by a PACE provider.
``(ii) Qualified standalone prescription
drug plan.--The term `qualified standalone
prescription drug plan' means, with respect to
an applicable PACE program enrollee, a
prescription drug plan--
``(I) that is not an MA-PD plan;
``(II) that is not operated by the
PACE program under which the individual
is enrolled; and
``(III) for which the Secretary
determines, with respect to the
applicable PACE program enrollees
enrolled in a PACE program offered by
such PACE provider, that--
``(aa) the estimated
beneficiary out-of-pocket costs
(as defined in clause (iii))
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
enrolled; and
``(bb) the estimated total
amount of Federal subsidies for
the plan year for qualified
prescription drug coverage
under the plan (which may be
estimated using data from the
previous plan year) 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
enrolled.
``(iii) Out-of-pocket costs defined.--In
this paragraph, the term `out-of-pocket costs'
includes premiums imposed under a prescription
drug plan and, in the case of coverage under a
qualified standalone prescription drug plan,
deductibles, copayments, coinsurance, and other
cost-sharing.
``(C) 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 paragraph, the individual shall be responsible for
any out-of-pocket costs imposed under the plan
(including costs for nonformulary drugs) after the
application of any subsidies under section 1860D-14 for
an applicable PACE program enrollee who is a subsidy
eligible individual (as defined in section 1860D-
14(a)(3)).
``(D) Requirements for pace programs.--
``(i) Educating and helping enroll
beneficiaries into a part d plan option.--A
PACE program shall be required to provide--
``(I) 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 paragraph; and
``(II) upon request of an
applicable PACE program enrollee,
counseling and coordination to assist
applicable PACE program enrollees in
making decisions regarding the
selection of qualified standalone
prescription drug plans available to
them.
``(ii) Monitoring drug utilization,
adherence, and spend.--A PACE program shall be
required to monitor drug utilization,
medication adherence, and drug spending
(through claims data shared pursuant to
subparagraph (F) and otherwise) 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 plan, 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 enrollee.
``(E) Disenrollment.--An applicable PACE program
enrollee may disenroll from the qualified standalone
prescription drug plan elected by such applicable PACE
program enrollee under subparagraph (A) if the enrollee
changes medication during the plan year or can
demonstrate an unexpected increase in out-of-pocket
costs post enrollment.
``(F) Claims sharing.--In the case where an
applicable PACE program enrollee enrolls in a qualified
standalone prescription drug plan, 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 (including for purposes of monitoring and
coordination required under subparagraph (D)(ii)) and
for purposes of comprehensive risk adjustment under
section 1894(d). 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
enrolled.
``(G) 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 plan.
``(H) Relation to pace statutes.--
``(i) 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
(a)(1)(B)(1) of section 1894 and such other
provisions of sections 1894 and 1934 as the
Secretary determines may conflict with the
authority provided for under this paragraph,
including subsections (a)(2)(B), (b)(1)(A)(i),
(b)(1)(C), (f)(2)(B)(ii), and (f)(2)(B)(v) of
such sections.
``(ii) 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
paragraph, the PACE program shall not be
entitled to payment under section 1894(d) for
the provision of qualified prescription drug
coverage under such standalone prescription
drug plan with respect to such applicable PACE
program enrollee.''.
<all>
Introduced in Senate
Read twice and referred to the Committee on Finance.
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