II 

117TH CONGRESS 

2D SESSION S. 4635 

To amend the Social Security Act to establish an optional State-administered 

program to provide fully integrated, comprehensive, coordinated care 

for full-benefit dual eligible individuals under the Medicare and Medicaid 

programs, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

JULY 27, 2022 

Mr. BROWN (for himself and Mr. PORTMAN) introduced the following bill; 

which was read twice and referred to the Committee on Finance 

A BILL 

To amend the Social Security Act to establish an optional 

State-administered program to provide fully integrated, 

comprehensive, coordinated care for full-benefit dual eligible individuals under the Medicare and Medicaid programs, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘Comprehensive Care for Dual Eligible Individuals Act’’. 

6 (b) TABLE OF CONTENTS.—The table of contents for 

7 this Act is as follows: 


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Sec. 1. Short title; table of contents. 

Sec. 2. Establishment of All Inclusive Medicare-Medicaid Program for FullBenefit Dual Eligible Individuals. 

‘‘TITLE XXII—ALL INCLUSIVE MEDICARE-MEDICAID (AIM) 

PROGRAM FOR FULL-BENEFIT DUAL ELIGIBLE INDIVIDUALS 

‘‘Sec. 2201. Purpose; General requirements. 

‘‘Sec. 2202. Eligibility. 

‘‘Sec. 2203. Enrollment. 

‘‘Sec. 2204. Benefits. 

‘‘Sec. 2205. Beneficiary protections. 

‘‘Sec. 2206. Federal administration. 

‘‘Sec. 2207. Selection and role of AIM-administering entities. 

‘‘Sec. 2208. Program financing. 

‘‘Sec. 2209. Accountability and oversight. 

‘‘Sec. 2210. Definitions; miscellaneous provisions. 

Sec. 3. MedPAC study and report. 

1 SEC. 2. ESTABLISHMENT OF ALL INCLUSIVE MEDICARE2 MEDICAID PROGRAM FOR FULL-BENEFIT 

3 DUAL ELIGIBLE INDIVIDUALS. 

4 (a) IN GENERAL.—The Social Security Act is amend5 ed by adding at the end the following new title: 

6 ‘‘TITLE XXII—ALL INCLUSIVE 

7 MEDICARE-MEDICAID (AIM) 

8 PROGRAM FOR FULL-BEN9 EFIT DUAL ELIGIBLE INDI10 VIDUALS 

11 ‘‘SEC. 2201. PURPOSE; GENERAL REQUIREMENTS. 

12 ‘‘(a) PURPOSE.—The purpose of this title is to pro13 vide, at the option of a State, for a program implemented 

14 and administered by the State of comprehensive, coordi15 nated care for individuals eligible for benefits under the 

16 Medicare program under title XVIII and for full benefits 

17 under the Medicaid program under title XIX in order to 


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1 improve quality, control costs, address health disparities, 

2 and support independence, community participation, and 

3 quality of life. 

4 ‘‘(b) REQUIREMENT FOR APPROVED AIM PROGRAM

5 APPLICATION.—A State may not be approved to imple6 ment an AIM program under this title unless, consistent 

7 with the process specified for approval of AIM programs 

8 under subsection (c)— 

9 ‘‘(1) the State has completed, in a pre-printed 

10 format and manner specified by the Secretary, a no11 tice of intent to establish such a program not earlier 

12 than 3 years after the date on which the State sub13 mits the notice of intent to the Secretary, and which 

14 includes a plan for such a program (or the State is 

15 working with the Federal Coordinated Health Care 

16 Office to transition an integrated care program of 

17 the State into an AIM program under this title); 

18 and 

19 ‘‘(2) the Secretary has received assurances, sat20 isfactory to the Secretary, that the proposed State 

21 AIM program and its plan (or, in the case of a State 

22 working with the Federal Coordinated Health Care 

23 Office to transition an integrated care program of 

24 the State into an AIM program under this title, the 

25 State AIM program after such transition is comVerDate Sep 11 2014 16:10 Aug 05, 2022 Jkt 029200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S4635.IS S4635

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1 pleted) meet the applicable requirements for such a 

2 program under this title, including the requirements 

3 specified in subsection (c). 

4 ‘‘(c) GENERAL REQUIREMENTS.—The requirements 

5 specified in this subsection for an AIM program of a State 

6 are as follows: 

7 ‘‘(1) ELIGIBILITY AND ENROLLMENT.—The 

8 program provides for eligibility and enrollment of 

9 AIMP-eligible individuals under the program in ac10 cordance with sections 2202 and 2203. 

11 ‘‘(2) BENEFITS.—The program provides for 

12 benefits for AIMP enrollees under the program in 

13 accordance with section 2204. 

14 ‘‘(3) BENEFICIARY PROTECTIONS.—The pro15 gram provides for beneficiary protections for AIMP 

16 enrollees under the program that are not less than 

17 those required under section 2205. 

18 ‘‘(4) COORDINATING AND INTEGRATION OF

19 BENEFITS.—The program provides for the coordina20 tion and integration of benefits by AIM-admin21 istering entities in accordance with section 2205. 

22 ‘‘(5) PROGRAM ACCOUNTABILITY.—The pro23 gram provides for accountability in administration 

24 and financing in accordance with section 2208. 


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1 ‘‘(6) OTHER REQUIREMENTS.—The program 

2 meets such other requirements as the Secretary may 

3 establish to carry out this title. 

4 ‘‘(d) PROGRAM APPROVAL PROCESS.—The Secretary 

5 shall establish a process for the initial approval of AIM 

6 programs of States based on the process used for approval 

7 of waivers under section 1115 with respect to title XIX. 

8 The process established under this subsection shall include 

9 at least the following elements: 

10 ‘‘(1) NOTICE OF INTENT.— 

11 ‘‘(A) IN GENERAL.—Subject to subpara12 graph (B), the State submits to the Secretary 

13 a notice of intent to establish the AIMP. 

14 ‘‘(B) CONDITIONS FOR TRANSPARENT

15 PROCESS.—The Secretary shall not accept a no16 tice of intent submitted under subparagraph 

17 (A) unless, before the date of such submission, 

18 the State— 

19 ‘‘(i) has provided a period of not less 

20 than 90 days for notice and public com21 ment on the proposed establishment of the 

22 program in the State; 

23 ‘‘(ii) has held at least 2 public meet24 ings regarding the establishment of the 

25 program; and 


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1 ‘‘(iii) has conducted relevant consulta2 tion with any relevant tribal authorities of 

3 Federally recognized Indian tribes located 

4 in the State. 

5 ‘‘(2) FEDERAL READINESS REVIEW COM6 PLETED.—At least 1 year before the identified ini7 tial implementation date for an AIM program in a 

8 State, the State has passed a review by the Sec9 retary of the State’s readiness to implement the pro10 gram. 

11 ‘‘(3) STATE READINESS REVIEW OF AIM-ADMIN12 ISTERING ENTITIES.—After a State passes the Fed13 eral readiness review under paragraph (2), the State 

14 shall conduct a review of the proposed AIM-admin15 istering entities under proposed AIMP contracts 

16 with the State with respect to their readiness to ad17 minister the program for benefits for AIMP enroll18 ees assigned to such entities. Such review— 

19 ‘‘(A) shall include elements specified by the 

20 Secretary, including a network adequacy review; 

21 ‘‘(B) may include activities such as a desk 

22 review, separate network validation review, and 

23 site visit; and 

24 ‘‘(C) must be passed by an AIMP-admin25 istering entity before any outreach or marketing 


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1 of or by that entity is permitted under a State 

2 AIM program. 

3 ‘‘(e) TECHNICAL ASSISTANCE PLANNING GRANTS.— 

4 ‘‘(1) ELIGIBILITY.—A State that has provided 

5 a notice of intent under subsection (d)(1) to imple6 ment an AIM program is eligible for funding assist7 ance with technical planning necessary to implement 

8 the program. Such funding shall be provided in 

9 amounts of up to $10,000,000 per State, and under 

10 such conditions as the Secretary shall specify. 

11 ‘‘(2) USE OF FUNDS.—Funding made available 

12 to a State under this subsection may be used to as13 sist the State with the staffing, information tech14 nology, planning and evaluation, and initial imple15 mentation of the AIM program in the State for ex16 penses incurred during the 3-year period that begins 

17 on the date the State submits a notice of intent 

18 under subsection (d)(1). 

19 ‘‘(3) FUNDING.—For the purpose of providing 

20 funding assistance under this subsection, there is 

21 appropriated, out of any money in the Treasury not 

22 otherwise appropriated, such sums as may be nec23 essary to carry out this subsection. 


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1 ‘‘SEC. 2202. ELIGIBILITY. 

2 ‘‘(a) IN GENERAL.—In this title, the term ‘AIMP3 eligible individual’ means, with respect to an AIMP-par4 ticipating State, an individual who— 

5 ‘‘(1) is 21 years of age or older; 

6 ‘‘(2) is entitled (or eligible to be enrolled) under 

7 part A or part B, or both, of title XVIII; 

8 ‘‘(3) subject to subsection (c), is eligible for 

9 medical assistance under the State plan (including a 

10 waiver thereof) under title XIX as a full-benefit dual 

11 eligible individual; and 

12 ‘‘(4) meets such income and asset standards as 

13 the State may establish for the AIM program in ac14 cordance with subsection (d) (and which shall be ap15 plied in addition to the income and asset standards 

16 the individual is required to meet for purposes of eli17 gibility for medical assistance under the State plan 

18 (or a waiver) under title XIX). 

19 ‘‘(b) PROCESS FOR DETERMINATION OF ELIGI20 BILITY.—Except as otherwise provided in this title, the de21 termination of whether an individual is an AIMP-eligible 

22 individual with respect to the AIM program of a State 

23 shall be made in accordance with the processes used to 

24 determine the individual’s eligibility for medical assistance 

25 under the State plan (or waiver thereof) under title XIX 

26 of the State. 


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1 ‘‘(c) FLEXIBILITY PERMITTED.— 

2 ‘‘(1) GEOGRAPHIC SCOPE.— 

3 ‘‘(A) STATEWIDE.—Except as provided in 

4 subparagraph (B), an AIMP-participating State 

5 shall provide for the implementation of its AIM 

6 program on a statewide basis. 

7 ‘‘(B) PHASE-IN PERMITTED ON A TIME8 LIMITED BASIS.—An AIMP-participating State 

9 may provide for the implementation of its AIM 

10 program not on a statewide basis so long as the 

11 program is phased in geographically in a man12 ner so that it is implemented statewide no later 

13 than the 4th year of implementation, except 

14 that the Secretary may permit a longer phase15 in period due to extenuating circumstances. 

16 ‘‘(2) NEW POPULATION PHASE-IN PER17 MITTED.— 

18 ‘‘(A) CARVE-OUTS NOT PERMITTED.—Ex19 cept as provided in subparagraph (B), an 

20 AIMP-participating State may not deny eligi21 bility under its AIM program to subpopulations 

22 of AIMP-eligible individuals and shall enroll all 

23 AIMP-eligible individuals under the program 

24 without the application of any waiting lists. 


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1 ‘‘(B) TIME-LIMITED EXCEPTION PER2 MITTED.—The Secretary may allow States to 

3 phase in the enrollment of certain subpopula4 tions over a specified period, not to exceed a pe5 riod of 4 years. 

6 ‘‘(3) PACE CONTINUATION PERMITTED.—Noth7 ing in this title shall be construed as preventing an 

8 AIMP-participating State from continuing to offer a 

9 Program of All-Inclusive Care for the Elderly 

10 (PACE) under section 1894 or 1934. 

11 ‘‘(d) INCOME AND ASSET STANDARDS.— 

12 ‘‘(1) INCOME ELIGIBILITY FLOOR.—In no case 

13 shall an AIMP-participating State have an income 

14 eligibility threshold under its AIM program that is 

15 less than 73 percent of the official poverty line (as 

16 defined by the Office of Management and Budget, 

17 and revised annually in accordance with section 

18 673(2) of the Omnibus Budget Reconciliation Act of 

19 1981) applicable to a family of the size involved or, 

20 if greater, the income threshold applied during the 

21 fiscal year preceding the year in which this title is 

22 enacted. 

23 ‘‘(2) ASSET THRESHOLD FLOOR.—In no case 

24 shall an AIMP-participating State apply an asset 


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1 threshold for eligibility for a fiscal year that is less 

2 than the following: 

3 ‘‘(A) FOR FIRST FISCAL YEAR.—For the 

4 1st fiscal year (or portion of a fiscal year) in 

5 which the AIM program is implemented in the 

6 State, the greater of— 

7 ‘‘(i) $2,000; and 

8 ‘‘(ii) the asset eligibility standard ap9 plied under the State plan (including a 

10 waiver thereof) under title XIX for a full11 benefit dual eligible individual during the 

12 fiscal year preceding the fiscal year in 

13 which this title is enacted. 

14 ‘‘(B) FOR SUBSEQUENT FISCAL YEAR.— 

15 For a subsequent fiscal year, the minimum 

16 asset threshold applied under this paragraph 

17 for the previous fiscal year increased (and 

18 rounded to the nearest $10) by the annual in19 crease in the consumer price index for all urban 

20 consumers (United States city average). 

21 ‘‘(3) FLEXIBILITY.—Nothing in this subsection 

22 shall be construed as limiting the ability of an 

23 AIMP-participating State to increase the income eli24 gibility threshold, asset eligibility threshold, or in25 come or asset disregards, including by allowing buyVerDate Sep 11 2014 16:10 Aug 05, 2022 Jkt 029200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S4635.IS S4635

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1 ins or spenddowns, above the minimum levels re2 quired under this subsection. 

3 ‘‘(4) ELIGIBILITY THRESHOLD.—The income 

4 and asset thresholds that a State establishes under 

5 this subsection shall be applied under the State AIM 

6 program to determine whether an individual is an 

7 AIMP-eligible individual without regard to whether 

8 the individual elects to enroll, or is enrolled, in the 

9 State AIM program. 

10 ‘‘(e) USE OF STREAMLINED ELIGIBILITY DETER11 MINATION AND ENROLLMENT PROCESSES.— 

12 ‘‘(1) IN GENERAL.—Each AIMP-participating 

13 State shall use streamlined eligibility and enrollment 

14 processes in order to promote continuity and 

15 incentivize States that invest in improving quality 

16 and costs, including those specified in this sub17 section. 

18 ‘‘(2) SPECIFIC STREAMLINED ELIGIBILITY RE19 QUIRED.—Each AIMP-participating State shall uti20 lize the following with respect to streamlining the 

21 eligibility determination and enrollment of individ22 uals in the State’s AIM program: 

23 ‘‘(A) 12-month continuous eligibility. 

24 ‘‘(B) Use of electronic data matches with 

25 trusted third-party sources (such as the Social 


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1 Security Administration or the Supplemental 

2 Nutrition Assistance Program) to verify eligi3 bility under the State AIM program both for 

4 initial eligibility applications and for renewals. 

5 ‘‘(C) Streamlined eligibility recertification 

6 every 12 months, including— 

7 ‘‘(i) for individuals who have been de8 termined eligible and enrolled, only requir9 ing submission of information on any 

10 changes to their financial or disability sta11 tus (instead of submitting an entire re12 newal application); 

13 ‘‘(ii) with respect to verification of eli14 gibility, initially using of available informa15 tion to auto-verify eligibility; 

16 ‘‘(iii) if additional information is need17 ed for renewal of eligibility, using pre-pop18 ulated forms and allowing submission of 

19 information online, in person, by telephone, 

20 fax, or mail; and 

21 ‘‘(iv) using a standard reconsideration 

22 period of 90 days from the time of termi23 nation of coverage. 


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1 ‘‘(3) USE OF DEEMING.—Each AIMP-partici2 pating State shall use deemed eligibility for a period 

3 of not less than 6 months. 

4 ‘‘(4) DATA SHARING ON ENROLLMENT.—Under 

5 an AIMP contract, an AIMP-participating State, the 

6 Secretary, and AIM-administering entities shall rou7 tinely and frequently share data among themselves 

8 with regard to eligibility and enrollment of individ9 uals under AIM programs. Such data sharing may 

10 include monthly changes in program enrollment and 

11 eligibility, beneficiary opt-out rates, and other 

12 changes specified by the Secretary. 

13 ‘‘(f) RULE OF CONSTRUCTION OF CONTINUATION AS

14 A MEDICARE AND MEDICAID BENEFICIARY FOR PUR15 POSES OTHER THAN BENEFITS.—The fact that an indi16 vidual qualifies as an AIMP-eligible individual shall not 

17 be construed as removing the individual’s status as an in18 dividual entitled to benefits under title XVIII or XIX, but 

19 insofar as the individual becomes an AIMP enrollee enti20 tled to benefits under this title, such entitlement to bene21 fits under titles XVIII and XIX shall be considered as met 

22 through the provision of benefits under this title. 

23 ‘‘SEC. 2203. ENROLLMENT. 

24 ‘‘(a) BENEFICIARY CHOICE.—In an AIMP-partici25 pating State under its AIM program, an AIMP-eligible inVerDate Sep 11 2014 16:10 Aug 05, 2022 Jkt 029200 PO 00000 Frm 00014 Fmt 6652 Sfmt 6201 E:\BILLS\S4635.IS S4635

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1 dividual may select (in a manner specified by the State 

2 consistent with this section) to receive benefits through 

3 any of the following: 

4 ‘‘(1) The State AIM program. 

5 ‘‘(2) A PACE program (if available to the indi6 vidual in the State). 

7 ‘‘(3) A combination of Medicare fee-for-service 

8 program (under parts A, B, and D, as applicable, of 

9 title XVIII) and medical assistance under title XIX 

10 (whether delivered through fee-for-service or man11 aged care, as provided by the State under such 

12 title). 

13 ‘‘(b) INITIAL ASSIGNMENT AT TIME OF PROGRAM IM14 PLEMENTATION OR INITIAL ENROLLMENT.—An AIMP15 participating State may provide that all AIMP-eligible in16 dividuals in the State who are not enrolled in a PACE 

17 program under section 1894 or 1934 and who do not make 

18 an affirmative selection under subsection (a)(3) shall be 

19 deemed to have elected to enroll in the AIM program of 

20 the State. 

21 ‘‘(c) COORDINATION OF SELECTION AND ENROLL22 MENT WITH MEDICARE ENROLLMENT PROCESSES.—The 

23 process for selection and enrollment of AIMP-eligible indi24 viduals in AIM programs shall be consistent and coordi25 nated with the processes for enrollment in Medicare AdVerDate Sep 11 2014 16:10 Aug 05, 2022 Jkt 029200 PO 00000 Frm 00015 Fmt 6652 Sfmt 6201 E:\BILLS\S4635.IS S4635

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1 vantage plans under part C of title XVIII during open 

2 and special enrollment periods. Such processes shall, con3 sistent with section 423.38(c) of title 42, Code of Federal 

4 Regulations (or any successor regulation) and any other 

5 applicable regulations, provide— 

6 ‘‘(1) a special enrollment period for individuals 

7 who— 

8 ‘‘(A) are dually eligible individuals enrolled 

9 in fee-for-service Medicare when the State AIM 

10 program is first established to permit such indi11 viduals to elect to enroll in the State AIM pro12 gram; or 

13 ‘‘(B) become AIMP-eligible individuals; 

14 and 

15 ‘‘(2) for the right of an AIMP-enrolled indi16 vidual to disenroll from the AIM program and to 

17 otherwise to make changes in the selection in enroll18 ment described in subsection (a). 

19 ‘‘(d) ASSISTANCE IN ENROLLMENT CHOICE.—An 

20 AIMP-participating State must contract with 1 or more 

21 independent enrollment brokers, at least 1 of which is a 

22 nonprofit, community-based organization, and all of which 

23 are approved by the Secretary, to assist AIMP-eligible in24 dividuals in understanding the AIM program and making 

25 enrollment choices under this section in the same manner 


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1 as such brokers are permitted with respect to enrollment 

2 of individuals under its State plan under title XIX (or 

3 waiver thereof), except that no individual sales commis4 sions shall be permitted (including to the extent such com5 missions may otherwise be permitted by brokers and em6 ployed or captive agents under the Medicare Advantage 

7 program under part C of title XVIII). 

8 ‘‘(e) CONSTRUCTION REGARDING CONTINUED MED9 ICAID USE OF MANAGED CARE.—Nothing in this sub10 section shall be construed as affecting the authority of an 

11 AIMP-participating State to require, in the case of an 

12 AIMP-eligible individual who makes the election described 

13 in subsection (a)(3) (or otherwise opts-out of enrollment 

14 in the AIM program and into benefits under title XIX), 

15 to obtain benefits for covered services under title XIX 

16 through participation in a managed care plan or arrange17 ment. 

18 ‘‘(f) ASSIGNMENT OF ENROLLEES TO AIMP-ADMIN19 ISTERING ENTITIES.— 

20 ‘‘(1) IN GENERAL.—An AIMP-eligible indi21 vidual enrolled under an AIM program shall be pro22 vided with a choice of the AIMP-administering enti23 ty to which the individual is assigned for purposes 

24 of obtaining benefits under the program. 


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1 ‘‘(2) INITIAL ASSIGNMENT AT TIME OF PRO2 GRAM IMPLEMENTATION OR INITIAL ENROLL3 MENT.— 

4 ‘‘(A) IN GENERAL.—In the case of an 

5 AIMP-eligible individual who, at the time of en6 rollment under an AIM program, is enrolled in 

7 an integrated program for individuals dually eli8 gible for Medicare and Medicaid participating 

9 in the Financial Alignment Initiative of the 

10 Federal Coordinated Health Care Office, or en11 rolled in a Medicare Advantage plan that is a 

12 highly integrated dual eligible special needs 

13 plan or a fully integrated dual eligible special 

14 needs plan, the State AIM program may ini15 tially assign the individual to the AIMP-admin16 istering entity for such Medicare Advantage 

17 plan (or, in the case of an AIMP-eligible indi18 vidual who, at the time of enrollment under an 

19 AIM program, is enrolled in an integrated pro20 gram for individuals dually eligible for Medicare 

21 and Medicaid participating in the Financial 

22 Alignment Initiative of the Federal Coordinated 

23 Health Care Office, to the AIMP-administering 

24 entity designated by the State), or another 

25 AIMP-administering entity, if necessary if— 


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1 ‘‘(i) the provider network of such enti2 ty under the AIM program is substantially 

3 similar to the network used under the plan 

4 offered by the entity that the individual is 

5 enrolled in prior to such assignment; and 

6 ‘‘(ii) the individual is provided with— 

7 ‘‘(I) at least 1 written notice of 

8 such assignment at least 60 days in 

9 advance of the effective date of the as10 signment; and 

11 ‘‘(II) at least 1 phone call noti12 fying the individual of the assignment 

13 in advance of the effective date of the 

14 assignment. 

15 ‘‘(B) CONTINUITY OF CARE.—To the ex16 tent possible to prevent disruption and promote 

17 continuity of care, a State AIM program shall 

18 seek to ensure that individuals described in sub19 paragraph (A) are assigned to the AIMP-ad20 ministering entity that offers the plan or pro21 gram in which the individual is enrolled in prior 

22 to the individual’s transfer to, and enrollment 

23 in, the State AIM program. 

24 ‘‘(C) CONDITIONAL INITIAL ASSIGNMENT

25 FOR OTHER AIMP-ELIGIBLE INDIVIDUALS.—In 


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1 the case of an AIMP-eligible individual who, at 

2 the time of enrollment under a State AIM pro3 gram is enrolled in a Medicare Advantage plan 

4 that is operating as an AIMP-administering en5 tity other than a plan described in subpara6 graph (A), or is enrolled in a Medicaid managed 

7 care plan offered by the same entity that is op8 erating as an AIMP-administering entity in the 

9 State AIM Program, the State AIM program 

10 may initially assign the individual to that 

11 AIMP-administering entity if— 

12 ‘‘(i) the provider network of such enti13 ty under the State AIM program is sub14 stantially similar to the network used 

15 under the Medicare Advantage plan or 

16 Medicaid managed care plan offered by the 

17 entity that the individual is enrolled in 

18 prior to such assignment; and 

19 ‘‘(ii) the individual is provided with— 

20 ‘‘(I) at least 1 written notice of 

21 such assignment at least 60 days in 

22 advance of the effective date of the as23 signment; and 

24 ‘‘(II) at least 1 phone call noti25 fying the individual of the assignment 


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1 in advance of the effective date of the 

2 assignment. 

3 ‘‘(3) RULE OF CONSTRUCTION.—Nothing in 

4 this subsection shall be construed as— 

5 ‘‘(A) preventing an individual from choos6 ing to be assigned to a different participating 

7 AIMP-administering entity; 

8 ‘‘(B) preventing an individual from chang9 ing their assignment to an AIMP-administering 

10 entity or from opting-out of participating in the 

11 State AIM program; or 

12 ‘‘(C) constraining or changing the author13 ity of a State under the State plan under title 

14 XIX or under a waiver of such plan to require 

15 a Medicaid-eligible individual to enroll with a 

16 managed care entity if the individual chooses 

17 not to participate in the AIM Program. 

18 ‘‘(4) CHOICE OF ENROLLMENT FROM FEE-FOR19 SERVICE MEDICARE.—An AIMP-eligible individual 

20 who, as of the date on which a State first imple21 ments the State AIM program, is enrolled in the 

22 Medicare fee-for-service program under title XVIII, 

23 may elect to enroll in the State AIM Program 

24 through a special enrollment period established for 

25 such individuals, consistent with the requirements of 


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1 section 423.38(c)(4) of title 42, Code of Federal 

2 Regulations (or a successor regulation). 

3 ‘‘(g) EFFECT OF ENROLLMENT ON MEDICARE AND

4 MEDICAID PAYMENTS TO STATES.—Except as provided in 

5 this title, in the case of an individual who is enrolled as 

6 an AIMP enrollee under a State AIM program under this 

7 title, during the period of such enrollment payment to the 

8 State under this title shall be instead of the payment 

9 amounts which would otherwise be payable under title 

10 XVIII or XIX for items and services furnished to the en11 rollee. 

12 ‘‘(h) OUTREACH AND ENROLLMENT SUPPORT.— 

13 ‘‘(1) FUNDING.—For the purpose of providing 

14 funding assistance to AIMP-participating States for 

15 outreach to, and enrollment support of, AIMP-eligi16 ble individuals, there is appropriated, out of any 

17 money in the Treasury not otherwise appropriated, 

18 such sums as may be necessary for each fiscal year 

19 beginning with the first fiscal year that begins on or 

20 after the date of enactment of this title. 

21 ‘‘(2) USE OF FUNDS.—An AIMP-participating 

22 State shall use funds provided to the State under 

23 this subsection for outreach to, and enrollment sup24 port of, AIMP-eligible individuals, that includes the 

25 following: 


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1 ‘‘(A) Distributing outreach and enrollment 

2 materials printed in accessible language formats 

3 (including primary languages, Braille, large 

4 print, and alternative texts). 

5 ‘‘(B) Engaging community-based organiza6 tions to conduct outreach to, and provide enroll7 ment assistance for, AIMP-eligible individuals. 

8 ‘‘(C) Referring AIMP-eligible individuals to 

9 the State long-term care ombudsman, the quali10 fied nonprofit AIM Ombudsman selected for the 

11 AIM program under section 2205(c), and other 

12 beneficiary support entities for enrollment as13 sistance and information. 

14 ‘‘SEC. 2204. BENEFITS. 

15 ‘‘(a) COVERED BENEFITS.— 

16 ‘‘(1) IN GENERAL.—A State AIM program shall 

17 provide a core package of covered benefits to address 

18 medical, behavioral, long-term care, and social needs 

19 of AIMP enrollees in accordance with an individual 

20 assessment and plan of care. Such core package of 

21 available benefits shall include the following: 

22 ‘‘(A) MEDICARE BENEFITS.—All benefits 

23 available under parts A, B, and D of title 

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1 able under such part D, coverage of the 6 pro2 tected classes and 2 drugs from each class. 

3 ‘‘(B) MEDICAID MANDATORY BENEFITS.— 

4 All benefits otherwise required to be provided to 

5 AIMP-eligible individuals under title XIX in the 

6 State if they were not AIMP enrollees. 

7 ‘‘(C) HISTORIC BENEFITS.—All Medicaid 

8 services and benefits offered as of 1 year prior 

9 to the enactment of this title, as required by 

10 section 2204(d). 

11 ‘‘(D) DRUGS.—All prescription drugs and 

12 covered outpatient drugs available under the 

13 State Medicaid program, including any such 

14 drugs that are available under a prescription 

15 drug plan under part D of title XVIII. 

16 ‘‘(E) ADDITIONAL SERVICES.—An AIMP17 participating State may, with approval from the 

18 Federal Coordinated Health Care Office, make 

19 available under the State AIM program addi20 tional behavioral health, social, and supportive 

21 services that enable flexibility to achieve person22 centered outcomes in the most cost-effective set23 ting. 

24 ‘‘(2) LIMITATION ON BENEFIT CARVE-OUTS.— 

25 The Secretary may permit a State AIM program to 


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1 exclude benefits for some services under paragraph 

2 (1)(C) if the Secretary determines that such an ex3 clusion is essential for the State to implement the 

4 AIM program but such exclusion may not extend 

5 over a period of longer than 4 years. 

6 ‘‘(b) BENEFIT ASSESSMENT PROCESS.— 

7 ‘‘(1) ASSESSMENT TOOL AND PLAN OF CARE.— 

8 ‘‘(A) DEVELOPMENT.—Not later than 18 

9 months after the date of the enactment of this 

10 title, the Secretary, in consultation with State 

11 agencies administering State plans or waivers 

12 under title XIX and with input from other 

13 stakeholders, shall develop and publish a ro14 bust, comprehensive standard assessment tool 

15 for use by all AIM programs in evaluating the 

16 condition and needs of AIMP enrollees for ben17 efits under the program. 

18 ‘‘(B) APPLICATION TO PLAN OF CARE.— 

19 Each AIM program shall provide for an assess20 ment for each AIMP enrollee, using such stand21 ard assessment tool, to form a basis for the en22 rollee’s plan of care under the program. Such 

23 an assessment shall be conducted at least annu24 ally, and when a triggering event (as defined by 


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1 the Secretary) affecting the enrollee’s need for 

2 care occurs. 

3 ‘‘(C) APPLICATION OF GRIEVANCE AND AP4 PEALS PROCEDURES.—Disagreements con5 cerning the plan of care for an AIM enrollee 

6 shall be subject to grievance and appeal rights 

7 under section 2205(b). 

8 ‘‘(2) STANDARD ASSESSMENT TOOL.—The 

9 standard assessment tool under paragraph (1) 

10 shall— 

11 ‘‘(A) contain a required set of core ele12 ments, to which States and AIMP-admin13 istering entities may add additional require14 ments so long as the requirements a State or 

15 AIMP administering entity uses contain at a 

16 minimum the core set of elements; 

17 ‘‘(B) cover multiple domains, including 

18 medical, functional, behavioral, and social do19 mains; and 

20 ‘‘(C) be applicable to the full range of 

21 AIMP enrollees, including individuals with seri22 ous mental illness and with needs for assistance 

23 with activities of daily living. 

24 ‘‘(c) STATE PROVISION OF COVERED BENEFITS.— 


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1 ‘‘(1) USE OF TIERED-BENEFIT MODEL.—An 

2 AIMP-participating State may establish a tiered3 benefit design structure for benefits so that special4 ized benefits may be available to meet the needs of 

5 specific subpopulations of AIMP enrollees so long as 

6 such tiering— 

7 ‘‘(A) only applies to benefits described in 

8 subparagraph (E) of subsection (a)(1) and does 

9 not limit the coverage of core covered benefits 

10 described in subparagraphs (A) and (B) of such 

11 subsection; and 

12 ‘‘(B) is no more restrictive than the benefit 

13 structure in place in the State under title XIX 

14 in the year before the date of the enactment of 

15 this title. 

16 ‘‘(2) IN-LIEU-THEREOF ALTERNATIVE SERVICES

17 PERMITTED.—An AIMP-participating State may 

18 permit AIMP-administering entities to cover benefits 

19 for cost-effective alternative services (known as ‘in 

20 lieu of services’) instead of benefits for services oth21 erwise included under the AIM program but in no 

22 case shall an AIMP enrollee be required to use such 

23 alternative services. 

24 ‘‘(3) CONTINUITY OF SERVICES.— 


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1 ‘‘(A) IN GENERAL.—Except as provided in 

2 subparagraph (B), during the first 6 months of 

3 an AIM enrollee’s enrollment in an AIM pro4 gram (or for such longer period as the AIM 

5 program may provide) an AIMP-participating 

6 State shall continue to provide access to all 

7 medically necessary covered items and services 

8 and providers (for continuity of care) that were 

9 being provided at the time of enrollment. 

10 ‘‘(B) EXCEPTION.—Subparagraph (A) 

11 shall not apply in cases in which it is deter12 mined by the State, and agreed to by the Sec13 retary, that the AIMP enrollee was not eligible 

14 for such services at the time of enrollment or 

15 was enrolled in the AIM program due to error 

16 or fraud. 

17 ‘‘(d) MAINTENANCE OF EFFORT.—As a condition for 

18 approval of an AIM program of a State, the State shall 

19 maintain levels of benefits for AIM enrollees under the 

20 program that are not less than the level of benefits under 

21 its State plan (including under a waiver) under title XIX 

22 for full-benefit dual eligible individuals as of fiscal year 

23 2021, as of the fiscal year before the fiscal year in which 

24 this title is enacted, or as of the fiscal year before the 

25 1st fiscal year in which the program is implemented in 


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1 the State, whichever fiscal year has the highest level of 

2 benefits. 

3 ‘‘(e) ADMINISTRATION OF BENEFITS THROUGH AIM4 ADMINISTERING ENTITIES.—AIMP-participating States 

5 shall provide for the coordination of, and the responsibility 

6 for the delivery of covered services through AIM-admin7 istering entities under an AIM contract under section 

8 2207. 

9 ‘‘SEC. 2205. BENEFICIARY PROTECTIONS. 

10 ‘‘(a) IN GENERAL.—Except as otherwise provided, 

11 the beneficiary protections applicable to individuals en12 rolled under plans under parts C and D of title XVIII 

13 and under a State plan under title XIX shall apply in a 

14 manner specified by the Secretary to AIMP enrollees 

15 under an AIM program under this title and are in addition 

16 to beneficiary protections provided under this title. 

17 ‘‘(b) APPLICATION OF GRIEVANCES AND INTERNAL

18 AND EXTERNAL APPEALS UNDER AIMP CONTRACTS.— 

19 The rights of individuals with respect to internal and ex20 ternal complaints and appeals processes shall be specified 

21 in the contract between the AIMP-participating State and 

22 an AIMP-administering entity. Such processes shall, at a 

23 minimum, incorporate relevant rights and processes from 

24 the requirements for plans under parts C and D of title 


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1 XVIII as well as requirements for Medicaid managed care 

2 organizations under title XIX. 

3 ‘‘(c) REQUIREMENT FOR QUALIFIED AIM OMBUDS4 MAN PROGRAM.— 

5 ‘‘(1) IN GENERAL.—As a condition for approval 

6 of an AIM program for a State under this title— 

7 ‘‘(A) the State shall have established and 

8 have ready for implementation not later than 

9 18 months prior to implementing the AIM pro10 gram, a qualified nonprofit AIM Ombudsman 

11 program run by a community-based organiza12 tion for such AIM program; and 

13 ‘‘(B) the State, before implementation of 

14 its AIM program, shall demonstrate to the sat15 isfaction of the Secretary (through an applica16 tion of certification process specified by the 

17 Secretary) that its AIM Ombudsman program 

18 has the capacity to carry out its functions in 

19 the State, including that the program has the 

20 independence, expertise, and adequate resources 

21 in place to serve AIMP-eligible individuals and 

22 AIMP enrollees under the State AIM program. 

23 ‘‘(2) QUALIFICATIONS FOR QUALIFIED AIM OM24 BUDSMAN PROGRAM.— 


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1 ‘‘(A) IN GENERAL.—In order to be a quali2 fied AIM Ombudsman program, such program 

3 must meet the requirements of this subsection 

4 for such a program. 

5 ‘‘(B) CONSTRUCTION.—Nothing in this 

6 subsection shall be construed as preventing a 

7 qualified AIM Ombudsman program from being 

8 structured as part of another protection service 

9 (including those specified in paragraph (3)), so 

10 long as such other protection service meets the 

11 requirements of this subsection for a qualified 

12 AIM Ombudsman program. 

13 ‘‘(3) COORDINATION WITH OTHER BENEFICIARY

14 PROTECTION SERVICES.—A qualified AIM Ombuds15 man program shall coordinate with State and Fed16 eral beneficiary protection services, including the fol17 lowing: 

18 ‘‘(A) Demonstration Ombudsman Pro19 grams Serving Medicare-Medicaid Enrollees. 

20 ‘‘(B) Managed Care Beneficiary Support 

21 Systems. 

22 ‘‘(C) Long-Term Care Ombudsman Pro23 grams. 

24 ‘‘(D) Disability Protection and Advocacy 

25 Programs. 


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1 ‘‘(4) CORE SERVICES.—A qualified AIM Om2 budsman program for an AIMP-participating State 

3 shall have authority to provide the following core 

4 services with respect to the AIM program in the 

5 State: 

6 ‘‘(A) Individual assistance (including con7 sumer education and empowerment, assistance 

8 with and representation in beneficiary appeals, 

9 fair hearings, and grievances, guidance regard10 ing plan and provider selection, and support 

11 during enrollment and disenrollment) for 

12 AIMP-eligible individuals considering enroll13 ment in the State AIM program and for AIMP 

14 enrollees in such program. 

15 ‘‘(B) Systemic monitoring and reporting to 

16 the State regarding compliance with applicable 

17 requirements. 

18 ‘‘(5) PROVIDING REPORTS TO CONSUMER ADVI19 SORY BOARDS.—A qualified AIM Ombudsman pro20 gram for a State shall provide, on a timely basis, 

21 any reports it produces to the consumer advisory 

22 boards (established under subsection (e)) for the 

23 State and shall make them publicly available. 

24 ‘‘(6) FUNDING AND OVERSIGHT.— 


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1 ‘‘(A) IN GENERAL.—The Secretary shall 

2 oversee and administer Federal funding directly 

3 to qualified AIM Ombudsman programs estab4 lished by States. 

5 ‘‘(B) FUNDING LEVEL.—For the purpose 

6 of providing funding to qualified AIMP Om7 budsman programs in each State over a period 

8 of 3 fiscal years, there is appropriated, out of 

9 any money in the Treasury not otherwise ap10 propriated, not less than $1,000,000, and not 

11 more than $5,000,000. The Secretary shall de12 termine the funding for each such program 

13 based on the estimated number of AIMP-eligi14 ble individuals in each State. 

15 ‘‘(C) SUPPLEMENTAL FUNDING.—Nothing 

16 in this paragraph shall be construed as pre17 venting an AIMP-participating State from pro18 viding supplemental funding for the qualified 

19 AIM Ombudsman program for the State. 

20 ‘‘(d) BENEFICIARY ADVISORY COUNCIL.—Each 

21 AIMP-participating State shall have in operation a Bene22 ficiary Advisory Council to advise the State regarding the 

23 treatment of AIMP-eligible individuals and AIMP enroll24 ees under this title. The composition and specific functions 

25 and authority of such a Council shall be delineated in 


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1 readiness review requirements specified by the Secretary 

2 in carrying out paragraphs (2) and (3) of section 2201(d). 

3 ‘‘(e) CONSUMER ADVISORY BOARDS.— 

4 ‘‘(1) IN GENERAL.—Each AIMP-participating 

5 State and each AIMP-administering entity in each 

6 such State shall establish a consumer advisory board 

7 that will provide regular feedback to the State or 

8 governing board of the entity, respectively, on issues 

9 of care of AIMP enrollees under the AIM program 

10 in that State or through that entity, respectively. 

11 ‘‘(2) COMPOSITION; FUNCTIONS.—Each such 

12 consumer advisory board shall— 

13 ‘‘(A) meet at least quarterly; 

14 ‘‘(B) be comprised of members who— 

15 ‘‘(i) may be subject to approval by the 

16 Secretary and the AIMP-participating 

17 State; 

18 ‘‘(ii) are AIMP enrollees; 

19 ‘‘(iii) are family members and other 

20 caregivers for AIMP enrollees; and 

21 ‘‘(iv) are chosen in a manner that re22 flects the demographic diversity of the pop23 ulation of AIMP enrollees, including with 

24 respect to race, ethnicity, age, and urban 


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1 and rural populations, and which includes 

2 individuals with disabilities; 

3 ‘‘(C) meet the requirements for member 

4 advisory committees under section 438.110 of 

5 title 42, Code of Federal Regulations; and 

6 ‘‘(D) file and make publicly available an 

7 annual report that includes at least information 

8 on— 

9 ‘‘(i) the dates for its meetings held 

10 within the reporting year; 

11 ‘‘(ii) the names of board members in12 vited and of those members in attendance 

13 at each such meeting; and 

14 ‘‘(iii) the agenda and minutes for each 

15 such meeting. 

16 ‘‘SEC. 2206. FEDERAL ADMINISTRATION. 

17 ‘‘(a) PRIMARY ADMINISTRATION THROUGH THE

18 FEDERAL COORDINATED HEALTH CARE OFFICE.— 

19 ‘‘(1) IN GENERAL.—The Secretary shall carry 

20 out this title through the Federal Coordinated 

21 Health Care Office, except that with respect to pay22 ments under section 2208, the Secretary may dele23 gate such authority to the Administrator of the Cen24 ters for Medicare & Medicaid Services. 


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1 ‘‘(2) APPROPRIATIONS.—There are hereby ap2 propriated to the Secretary to carry out this title, 

3 out of any funds in the Treasury not otherwise ap4 propriated— 

5 ‘‘(A) for each of fiscal years 2022, 2023, 

6 and 2024, $100,000,000; and 

7 ‘‘(B) for each succeeding fiscal year, 

8 $30,000,000. 

9 ‘‘(b) STANDARDS AND PROCESS.— 

10 ‘‘(1) FEDERAL STANDARDS.—In carrying out 

11 this title, the Secretary shall specify a minimum set 

12 of Federal standards, including standards relating to 

13 access to care, quality of care, beneficiary protec14 tions, marketing and enrollment, grievances and ap15 peals, and procurement. 

16 ‘‘(2) TRANSPARENCY IN RULEMAKING.—In im17 plementing the provisions of this title, to the extent 

18 practical, the Secretary shall utilize notice and com19 ment rulemaking to ensure transparency for stake20 holders. 

21 ‘‘(3) APPLICATION OF KNOWLEDGE GAINED

22 FROM DEMONSTRATION PROJECTS AND CONTRACT

23 MANAGEMENT TEAMS UNDER THE FINANCIAL

24 ALIGNMENT INITIATIVE.—The Secretary shall carry 

25 out this title taking into account the knowledge 


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1 gained from the use of contract management teams 

2 in demonstration projects under the Financial Align3 ment Initiative for Medicare-Medicaid Enrollees ad4 ministered by the Federal Coordinated Health Care 

5 Office. 

6 ‘‘(c) DIRECT-HIRE AUTHORITY.—In carrying out 

7 this title, the Secretary (acting through the Federal Co8 ordinated Health Care Office) shall have direct-hire au9 thority to the extent required to implement and administer 

10 this title on a timely basis. 

11 ‘‘SEC. 2207. SELECTION AND ROLE OF AIM-ADMINISTERING 

12 ENTITIES. 

13 ‘‘(a) REQUIREMENTS FOR STATE SELECTION OF

14 AIM-ADMINISTERING ENTITIES.—The Secretary, in con15 sultation with States, shall develop (not later than 1 year 

16 after the date of the enactment of this title) a set of stand17 ardized requirements for the selection of qualified organi18 zations to serve as AIMP-administering entities in the 

19 AIM programs in each AIMP-participating State. 

20 ‘‘(b) APPLICATION OF CRITERIA FOR THE QUALI21 FICATION AND SELECTION OF AIMP-ADMINISTERING EN22 TITIES.— 

23 ‘‘(1) IN GENERAL.—Each AIM program in an 

24 AIMP-participating State shall be implemented 

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1 pating State and organizations that qualify as 

2 AIMP-administering entities under this title. A con3 tract with an AIMP-administrating entity shall re4 quire the entity to assume 2-sided financial risk in 

5 return for payment for the arrangement and delivery 

6 of covered benefits to AIMP enrollees assigned to 

7 the entity under the program. 

8 ‘‘(2) SPECIFICATION OF CRITERIA.—The Sec9 retary and AIMP-participating States shall establish 

10 basic national criteria for the qualification and selec11 tion of organizations to be AIMP-administering enti12 ties. Such criteria shall take into account the prior 

13 experience (including under both the Medicare pro14 gram under title XVIII and Medicaid programs 

15 under title XIX) of such an organization in serving 

16 the population of AIMP-eligible individuals as well 

17 as other criteria, including the following: 

18 ‘‘(A) The organization’s experience serving 

19 AIMP-eligible individuals in that State (or an20 other State), including the organization’s expe21 rience in providing covered services described in 

22 section 2204(a)(1) (including long-term services 

23 and supports and behavioral health services) to 

24 such individuals, and in integrating all of those 


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1 services and supports for such individuals in 

2 that State (or another State). 

3 ‘‘(B) The organization’s performance on 

4 key quality measures in providing such services, 

5 such as on measures of key health outcomes 

6 and enrollee satisfaction. 

7 ‘‘(C) The adequacy of the organization’s 

8 provider network in ensuring timely access to 

9 care. 

10 ‘‘(D) The organization’s demonstrated ex11 perience in implementing models of care for the 

12 full range of such services, including with re13 spect to non-medical services described in sec14 tion 2204(a)(1). 

15 ‘‘(3) ADDITIONAL STATE-SPECIFIC CRITERIA.— 

16 Nothing in this subsection shall be construed as pre17 venting a State, with the approval of the Secretary, 

18 from applying additional criteria or requirements re19 garding health care quality, equity, or access on 

20 AIMP-administering entities specific to quality, eq21 uity, or access, so long as such requirements and cri22 teria— 

23 ‘‘(A) can be applied consistently to all 

24 AIMP-administering entities; and 


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1 ‘‘(B) are made available for public com2 ment prior to being imposed. 

3 ‘‘(4) APPLICATION OF MEDICAL LOSS RATIO RE4 QUIREMENTS.— 

5 ‘‘(A) IN GENERAL.—Any AIMP contract 

6 between an AIMP-participating State and an 

7 AIMP-administering entity to administer bene8 fits under an AIM program shall include a re9 quirement that the medical loss ratio under the 

10 AIM program shall not be not less than a per11 centage (not less than 85 percent) specified by 

12 the State and that the entity shall return to the 

13 State payment amounts that result in the med14 ical loss ratio being below such percentage. 

15 ‘‘(B) SPECIAL RULES.—If an admin16 istering entity who is contracting with a partici17 pating State to administer a program under 

18 this title is an entity bearing 2-sided risk, the 

19 State shall establish with the approval of the 

20 Secretary a mechanism comparable to a medical 

21 loss ratio target to ensure appropriate spending 

22 on services by the entity. 

23 ‘‘(c) STATE PROCUREMENT PROCESS FOR AIMP-AD24 MINISTERING ENTITIES.— 


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1 ‘‘(1) IN GENERAL.—Each AIMP-participating 

2 State shall be responsible for establishing and imple3 menting a process for the procurement and selection 

4 of AIMP-administering entities for the State AIM 

5 program, subject to the approval of the Secretary. 

6 The Secretary shall not approve such a process un7 less the State demonstrates to the Secretary’s satis8 faction that the process results in the selection of 

9 AIMP-administering entities that meet the require10 ments of this title and are qualified to serve the 

11 needs of AIMP enrollees in the State under the 

12 State’s AIM program. An AIMP-participating State 

13 may add additional requirements specific to quality, 

14 equity, or access that further the State’s overall in15 tegrated care strategy and goals, so long as such re16 quirements are posted for public comment and ap17 proved by the Federal Coordinated Health Care Of18 fice. 

19 ‘‘(2) SEPARATE PROCUREMENT PROCESS RE20 QUIRED FOR INITIAL PROCUREMENT.—For the ini21 tial procurement executed to establish an AIM pro22 gram in an AIMP-participating State, the State 

23 shall not combine its AIM administering entity pro24 curement process with a procurement process that is 

25 also used for procurement under the State plan or 


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1 waiver under title XIX and shall select AIM admin2 istering entities through a standalone procurement 

3 process. 

4 ‘‘(d) PAYMENTS TO AIM-ADMINISTERING ENTI5 TIES.—Each AIMP-participating State shall make pay6 ments to AIM-administering entities under a risk-adjusted 

7 payment model that— 

8 ‘‘(1) reflects the risk of the population of AIMP 

9 enrollees served by each entity; 

10 ‘‘(2) ensures that there are appropriate re11 sources to serve the AIMP enrollees in the State; 

12 and 

13 ‘‘(3) protects against any adverse selection of 

14 AIMP enrollees by entities. 

15 ‘‘SEC. 2208. PROGRAM FINANCING. 

16 ‘‘(a) PAYMENTS TO STATES WITH AIM PRO17 GRAMS.— 

18 ‘‘(1) FOR PROGRAM BENEFITS.— 

19 ‘‘(A) IN GENERAL.—From the sums appro20 priated under paragraph (3), the Secretary 

21 shall pay to each AIMP-participating State for 

22 each quarter in a fiscal year (beginning with 

23 the first fiscal year that begins after the date 

24 of enactment of this title), an amount equal to 

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1 fined in subsection (b)(1)) of the total amount 

2 expended during the quarter as AIMP assist3 ance (as defined in subparagraph (B). 

4 ‘‘(B) AIMP ASSISTANCE DEFINED.—In 

5 this title, the term ‘AIMP assistance’ has the 

6 meaning given the term ‘medical assistance’ 

7 under section 1905(a), except that in applying 

8 such term under this subparagraph— 

9 ‘‘(i) the services described in section 

10 2204(a)(1) shall be substituted for the 

11 services described in paragraph (1) and the 

12 subsequent paragraphs of such section 

13 1905(a); 

14 ‘‘(ii) an AIMP enrollee shall be treat15 ed as an individual referred to in the mat16 ter in section 1905(a) before paragraph (1) 

17 of such section; and 

18 ‘‘(iii) the exclusion in the subdivision 

19 (B) following the last paragraph of the 

20 first sentence of section 1905(a) shall not 

21 apply. 

22 ‘‘(2) FOR ADMINISTRATIVE EXPENSES.—In ad23 dition to the amount paid for each quarter in a fis24 cal year to an AIMP-participating State under para25 graph (1), the Secretary shall pay to each such 


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1 State for each quarter in a fiscal year (beginning 

2 with the first fiscal year that begins after the date 

3 of enactment of this title), from the sums appro4 priated under paragraph (3), not less than 50 per5 cent of the total amount expended during such quar6 ter as found necessary by the Secretary for the prop7 er and efficient administration of the State AIM 

8 program under this title. 

9 ‘‘(3) APPROPRIATION.—There is appropriated, 

10 out of any money in the Treasury not otherwise ap11 propriated, such amounts as may be required to pro12 vide payments to States under this section, reduced 

13 by any amounts made available from the Medicare 

14 trust funds under paragraph (5). 

15 ‘‘(4) RELATION TO OTHER PAYMENTS.—Pay16 ment amounts provided under this subsection are in 

17 addition to payments provided under other provi18 sions of this title. 

19 ‘‘(5) RELATION TO MEDICARE TRUST FUNDS.— 

20 There shall be made available for application under 

21 this title from the Federal Hospital Insurance Trust 

22 Fund (under section 1817) and from the Federal 

23 Supplementary Medical Insurance Trust Fund 

24 (under section 1841) (and from the Medicare Pre25 scription Drug Account (under section 1860D–16) 


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1 within such Trust Fund) such amounts as the Sec2 retary determines appropriate, taking into account 

3 the reductions in payments from such Trust Funds 

4 and Account that are attributable to the coverage of 

5 AIMP enrollees under AIM programs under this 

6 title. 

7 ‘‘(b) FEDERAL AIMP MATCHING PERCENTAGE.— 

8 ‘‘(1) IN GENERAL.—In this section, the term 

9 ‘Federal AIMP matching percentage’ means, for an 

10 AIMP-participating State for a fiscal year, 100 per11 cent minus the State contribution percentage (as de12 fined in paragraph (2)) for the State and fiscal year. 

13 ‘‘(2) STATE CONTRIBUTION PERCENTAGE FOR14 MULA.— 

15 ‘‘(A) IN GENERAL.—In this section, the 

16 term ‘State contribution percentage’ means, 

17 subject to adjustment under the subsequent 

18 provisions of this paragraph, with respect to an 

19 AIMP-participating State for— 

20 ‘‘(i) the 1st fiscal year of the AIM 

21 program in the State, the base AIMP 

22 State percentage computed under sub23 section (c); or 

24 ‘‘(ii) a subsequent fiscal year, the 

25 State contribution percentage under this 


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1 paragraph for the previous fiscal year ad2 justed in accordance with subparagraph 

3 (B) or (C), as applicable. 

4 ‘‘(B) ANNUAL ADJUSTMENT BASED ON

5 CHANGES IN EXPENDITURES.—For an AIMP6 participating State for a fiscal year after such 

7 1st fiscal year, if the expenditures for AIMP as8 sistance for which payment is made under sub9 section (a)(1) under the State AIM program for 

10 the second previous fiscal year— 

11 ‘‘(i) are not greater than 110 percent, 

12 or less than 90 percent, of the AIMP as13 sistance expenditures for the previous fis14 cal year, there shall be no adjustment for 

15 the fiscal year involved under this subpara16 graph; 

17 ‘‘(ii) is greater than 110 percent of 

18 the AIMP assistance expenditures for the 

19 previous fiscal year, the adjustment under 

20 this subparagraph for the fiscal year in21 volved shall be an increase in the State 

22 contribution percentage of 1 percentage 

23 point for each multiple of 10 percentage 

24 points by which such AIMP assistance ex25 penditures exceed 110 percent; or 


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1 ‘‘(iii) is less than 90 percent of the 

2 AIMP assistance expenditures for the pre3 vious fiscal year, the adjustment under this 

4 subparagraph for the fiscal year involved 

5 shall be a decrease in the State contribu6 tion percentage of 1 percentage point for 

7 each multiple of 10 percentage points by 

8 which such AIMP assistance expenditures 

9 is less than 90 percent. 

10 ‘‘(C) ADDITIONAL ADJUSTMENTS FOR EX11 CEPTIONS.—The Secretary shall provide a proc12 ess by which adjustments may be made to the 

13 State contribution percentage to take into ac14 count increases and decreases in AIMP expend15 itures described in clause (ii) or (iii) of sub16 paragraph (B) in which the adjustments under 

17 such clauses would not apply, such as in cases 

18 of a significant increase or decrease in AIMP 

19 enrollees, a declaration of a national emergency 

20 that impacts on AIMP expenditures under this 

21 title, or a significant cost increase beyond the 

22 control of the State, as determined by the Sec23 retary. 

24 ‘‘(c) BASELINE EXPENDITURE AND PERCENTAGE

25 COMPUTATIONS.— 


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1 ‘‘(1) IN GENERAL.—Using the data reported 

2 under paragraph (2): 

3 ‘‘(A) COMPUTATION OF BASE AIMP PER4 CENTAGES.—For the base Federal fiscal year 

5 (as defined in paragraph (3)), the Secretary 

6 shall compute and publish for each State— 

7 ‘‘(i) the base AIMP State percentage 

8 (as defined in subparagraph (B)) for the 

9 State and such fiscal year; and 

10 ‘‘(ii) the Federal AIMP matching per11 centage for the State and such fiscal year. 

12 ‘‘(B) BASE AIMP STATE PERCENTAGE DE13 FINED.—In this section, the ‘base AIMP State 

14 percentage’ means the amount equal to the 

15 ratio (expressed as a percentage) of— 

16 ‘‘(i) the sum of— 

17 ‘‘(I) the amount of the State 

18 share of expenditures under title XIX 

19 for medical assistance during the base 

20 Federal fiscal year attributable to full21 benefit dual eligible individuals; and 

22 ‘‘(II) the amount of the payment 

23 made to the Federal Government dur24 ing the base Federal fiscal year under 

25 section 1935(c) (commonly referred to 


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1 as the ‘part D clawback’) attributable 

2 to such individuals; to 

3 ‘‘(ii) the sum of— 

4 ‘‘(I) the total expenses paid 

5 under title XVIII that are attributable 

6 to full-benefit dual eligible individuals 

7 for services (or periods of coverage) 

8 occurring the base Federal fiscal year 

9 (as estimated by the Secretary); and 

10 ‘‘(II) the total amount expended 

11 on items and services described in sec12 tion 2204(a)(1) paid under title XIX 

13 (including any waivers under title XI) 

14 for full-benefit dual eligible individuals 

15 in the base Federal fiscal year. 

16 ‘‘(C) ADJUSTMENTS TO BASE AIMP PER17 CENTAGES.—With respect to the base AIMP 

18 State percentages and the Federal AIMP 

19 matching percentages otherwise computed 

20 under this paragraph for the base Federal fiscal 

21 year, the Secretary shall adjust such percent22 ages to take into account material changes in 

23 the programs under titles XVIII and XIX be24 tween the base Federal fiscal year and the first 

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1 plemented under this title insofar as such mate2 rial changes have a direct material impact on 

3 AIMP expenditures relating to AIMP-eligible 

4 individuals. 

5 ‘‘(2) DATA REPORTING FOR BASELINE COM6 PUTATIONS.—Each State, in its application for ap7 proval of its AIM program, shall provide the Sec8 retary (in such form and manner as the Secretary 

9 may require) such financial data (including detailed 

10 and aggregate, historical and projected expenditures 

11 data) on its expenditures under title XIX as the Sec12 retary may require to carry out the computations re13 quired under this section. The Secretary shall share 

14 with the State, in a process defined by the Sec15 retary, Medicare expenditure data (including de16 tailed and aggregate historical and projected expend17 itures data) for services and benefits for full-benefit 

18 dual eligible individuals in such State. 

19 ‘‘(3) BASE FEDERAL FISCAL YEAR DEFINED.— 

20 In this section, the term ‘base Federal fiscal year’ 

21 means the Federal fiscal year that is the second pre22 ceding fiscal year to the 1st fiscal year for which 

23 AIM programs may be implemented under this title. 

24 ‘‘(d) REINVESTMENT OF SHARED SAVINGS.— 

25 ‘‘(1) IN GENERAL.— 


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1 ‘‘(A) IN GENERAL.—If, with respect to a 

2 fiscal year, an AIMP-participating State has ex3 penditures under this title for AIMP assistance 

4 that for the preceding fiscal year, are less than 

5 85 percent of the expenditures for such assist6 ance under the State AIM program for the sec7 ond preceding fiscal year, the Secretary shall 

8 ensure that for each quarter in the following 

9 fiscal year, the State spends at least the shared 

10 savings amount determined for the State for 

11 the fiscal year on 1 or more of the core applica12 tions described in paragraph (3). Amounts ex13 pended by a State to meet the requirement of 

14 the preceding sentence shall not be subject to 

15 any Federal matching payments under this 

16 title. 

17 ‘‘(B) SHARED SAVINGS AMOUNT DE18 FINED.—In this subsection, the term ‘shared 

19 savings amount’ means, with respect to an 

20 AIMP-participating State for a fiscal year, the 

21 amount by which the AIMP assistance expendi22 tures for the fiscal year is less than 85 percent 

23 of the expenditures for such assistance under 

24 the State AIM program for the second pre25 ceding fiscal year. 


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1 ‘‘(2) APPLICATION OF SHARED SAVINGS.—The 

2 Secretary shall issue guidance outlining allowable 

3 use of the shared savings payments under paragraph 

4 (1). Under such guidance, the Secretary shall outline 

5 the types of services and benefits for which a State 

6 has the authority to apply the payments for the ben7 efit of consumers who are AIMP-eligible individuals. 

8 Such guidance shall permit the use of such pay9 ments consistent with the core applications described 

10 in paragraph (3) and with paragraph (4), and may 

11 be used for existing State-funded health programs or 

12 new health-related initiatives that serve full-benefit 

13 dual eligible individuals under this title. 

14 ‘‘(3) CORE APPLICATIONS.—The core applica15 tions described in this paragraph for such consumers 

16 are as follows: 

17 ‘‘(A) CONSUMER POWER AND CHOICE.—To 

18 provide such consumers more information and 

19 control over their health care and community 

20 support options. 

21 ‘‘(B) EQUITY AND ACCESS TO CARE.—To 

22 improve access to, and quality of, care across 

23 populations, advance health equity for con24 sumers, and reduce health disparities and elimi25 nate barriers to care. 


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1 ‘‘(C) PREVENTION AND WELLNESS.—To 

2 strive to better enable such consumers to re3 ceive individualized health care that is out4 comes-oriented and focused on prevention, 

5 wellness, recovery and maintaining independ6 ence. 

7 ‘‘(D) PAY FOR PERFORMANCE.—To employ 

8 purchasing and payment methods that encour9 age and reward service quality and cost-effec10 tiveness by linking reimbursements for services 

11 to such consumers to common, evidence-based 

12 quality performance measures, including patient 

13 satisfaction. 

14 ‘‘(E) INNOVATIVE ADVANCEMENT.—To im15 plement innovative and technological advance16 ments that facilitate such consumers remaining 

17 in the community. 

18 ‘‘(F) SERVICE INTEGRATION.—To increase 

19 integration of services with social needs to im20 prove health outcomes for such consumers. 

21 ‘‘(G) STATE PERSONNEL.—To hire addi22 tional State personnel to carry out this title. 

23 ‘‘(H) CAPACITY BUILDING.—To expand ca24 pacity in providing services to such consumers, 

25 such as in— 


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1 ‘‘(i) community-based care; and 

2 ‘‘(ii) caregiver assistance. 

3 ‘‘(I) IMPROVE ENROLLMENT POLICIES AND

4 PROCESS.—To improve the ability to enroll in 

5 the State AIMP program through streamlining 

6 enrollment policies and processes. 

7 ‘‘(J) INCREASE EDUCATION FOR PRO8 VIDERS AND BENEFICIARIES.—To ensure pro9 viders and beneficiaries understand the State 

10 AIMP program and the choices available under 

11 such program. 

12 ‘‘(K) IMPROVE DATA COLLECTION RE13 GARDING RACIAL DISPARITIES AND HEALTH IN14 EQUITIES.—To ensure appropriate data is col15 lected and used to determine program inequi16 ties. 

17 ‘‘(L) OTHER SERVICES AND INITIA18 TIVES.—Other services and initiatives approved 

19 by the Secretary that serve full-benefit dual eli20 gible individuals under this title. 

21 ‘‘(4) LIMITATION ON PAYMENT TO AIMP-ADMIN22 ISTERING ENTITIES.—An AIMP-participating State 

23 may use payments under this subsection for an 

24 AIMP-administering entity only if the State dem25 onstrates, to the satisfaction of the Secretary, that 


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1 the State’s AIM program provides appropriate main2 tenance of access to and quality of care based on the 

3 requirements imposed by the State on the applicable 

4 AIMP-administering entities. 

5 ‘‘(e) APPLICATION OF MEDICAID PAYMENT METH6 ODOLOGIES FINANCING LIMITATIONS FOR THE NON-FED7 ERAL SHARE OF EXPENDITURES.— 

8 ‘‘(1) IN GENERAL.—Except as the Secretary 

9 may otherwise provide through notice and comment 

10 regulation, the following provisions of title XIX (and 

11 related regulations) shall apply to AIMP-partici12 pating States’ expenditures in the AIM program in 

13 a manner similar to the manner in which such provi14 sions apply under title XIX: 

15 ‘‘(A) Section 1903(d) (relating to esti16 mated payments, recovery of overpayments, dis17 allowance of provisions). 

18 ‘‘(B) Section 1903(w) (relating to pro19 vider-related donations, health care related 

20 taxes, and broad-based health care related 

21 taxes). 

22 ‘‘(C) Section 1903(w)(6) (relating to cer23 tified public expenditures and intergovern24 mental transfers). 


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1 ‘‘(D) Other provisions relating to deferral 

2 of payments, preventing fraud and abuse, and 

3 ensuring program integrity. 

4 ‘‘(2) PROCESSES AND FORMS.— 

5 ‘‘(A) IN GENERAL.—The Secretary shall 

6 establish appropriate forms and processes (in7 cluding expenditure reconciliation processes) for 

8 submission of information on State expendi9 tures under this title in a manner similar to the 

10 processes used for purposes of payments to 

11 States under title XIX, but through the use of 

12 such alternative forms as may be appropriate in 

13 implementing this title. 

14 ‘‘(B) REPORTING OF ESTIMATED EXPENDI15 TURES BY QUARTER.—An AIMP-participating 

16 State shall estimate matchable expenditures (in17 cluding both total expenditures as well as the 

18 estimated Federal share of those expenditures) 

19 and separately report these expenditures by 

20 quarter for each fiscal year for its AIM pro21 gram. The Secretary shall make Federal funds 

22 available based upon the State’s estimate, as 

23 approved by the Secretary. 

24 ‘‘(C) REPORTING AND RECONCILIATION OF

25 ACTUAL EXPENDITURES ON A QUARTERLY


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1 BASIS.—Not later than 30 days after the end of 

2 each quarter, each AIMP-participating State 

3 shall submit to the Secretary (on an appro4 priate form) a quarterly expenditure report, 

5 showing expenditures made in the quarter just 

6 ended under its AIM program. The Secretary 

7 shall reconcile expenditures so reported with 

8 Federal funding previously made available to 

9 the State under this section and include the 

10 reconciling adjustment in the finalization of the 

11 grant award to the State. 

12 ‘‘(3) RULE OF CONSTRUCTION.—Nothing in 

13 this title shall be construed as constraining or lim14 iting the authority of the Secretary, the Adminis15 trator of the Centers for Medicare & Medicaid Serv16 ices, the Inspector General of the Department of 

17 Health and Human Services, or the Comptroller 

18 General of the United States, to conduct routine and 

19 targeted program and financial management audits 

20 and other oversight activities of funds expended 

21 under this title, including oversight activities relating 

22 to the allowable use of funds. 

23 ‘‘(f) OPTION FOR MULTI-YEAR INVESTMENT INITIA24 TIVE.—The Secretary may specify a process by which an 

25 AIM-participating State may elect to participate in a 


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1 multi-year investment initiative during the first 3-year pe2 riod in which the State participates in the AIM program. 

3 Under such option, an AIM-participating State shall be 

4 eligible for additional Federal financial participation (as 

5 determined by the Secretary) for expenditures under this 

6 title that do not exceed an annual budget target estab7 lished for the State, based on the expenditures of the State 

8 used to determined the base AIMP State percentage under 

9 subsection (c)(1)(B), and increased for the 2d and 3rd 

10 years of such period, by 9.99 percent over the budget tar11 get established for the preceding year. 

12 ‘‘SEC. 2209. ACCOUNTABILITY AND OVERSIGHT. 

13 ‘‘(a) QUALITY ASSESSMENT.—To ensure that full14 benefit dual eligible individuals receive high quality care 

15 and to encourage quality improvement under AIM pro16 grams, each AIM-participating State shall establish a 

17 quality incentive program that uses financial rewards, 

18 penalties, or both that are meaningful enough to influence 

19 the administering entity’s behavior and is approved by the 

20 Federal Coordinated Health Care Office. Each AIM pro21 gram will be expected to tie financial incentives to per22 formance either in the form of quality withholds or incen23 tives, such as making additional quality payments to an 

24 AIMP-administering entity that achieves quality or equity 

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1 ment to an entity that fails to achieve such goals. Each 

2 AIM-participating State shall publicly post and seek com3 ment on its proposed quality incentive program prior to 

4 submitting to the Federal Coordinated Health Care Office 

5 for approval. 

6 ‘‘(b) MONITORING AND PROGRAM EVALUATION.— 

7 ‘‘(1) CONSOLIDATED REPORTING REQUIRE8 MENTS FOR AIM-ADMINISTERING ENTITIES.—The 

9 Secretary and each AIMP-participating State shall 

10 define and specify in the contract for each AIMP-ad11 ministering entity under this title a consolidated re12 porting process that ensures the provision of the 

13 necessary data on diagnosis, HEDIS measures, en14 counter reports, enrollee satisfaction, and evidence15 based measures and other information as may be 

16 useful in order to monitor each AIMP-administering 

17 entity’s performance under the AIMP contract. 

18 ‘‘(2) EVALUATION.—The Secretary and each 

19 AIMP-participating State shall develop processes 

20 and protocols for collecting (or ensuring that AIMP21 administering entities collect) and reporting to the 

22 Secretary and the State the data needed for an eval23 uation by the Secretary to measure the impact of 

24 AIMP-administering entities, the effectiveness of the 

25 process in enrolling AIMP-eligible individuals under 


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1 the AIM program, and the effectiveness of the AIM 

2 program in reducing disparities, improving quality of 

3 care, and advancing health equity. 

4 ‘‘(3) COLLABORATIVE EVALUATION.—The Sec5 retary and AIMP-participating States shall collabo6 rate on and coordinate during any evaluation activ7 ity conducted under this subsection. 

8 ‘‘(c) ADMINISTRATIVE OVERSIGHT RESPONSIBIL9 ITIES.— 

10 ‘‘(1) STATE ROLE.—Each AIMP-participating 

11 State shall be responsible for day-to-day oversight of 

12 the AIMP-administering entities providing services 

13 with respect to AIMP enrollees under the AIMP 

14 contract with the State under its AIM program. 

15 Such oversight shall include the following activities: 

16 ‘‘(A) Conducting a comprehensive readi17 ness review of each entity (as required under 

18 section 2201(d)). 

19 ‘‘(B) Monitoring compliance of the entity 

20 with the terms of its AIMP contract under the 

21 AIM program, including— 

22 ‘‘(i) ensuring adherence to and protec23 tion of enrollee rights as provided under 

24 this title; 


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1 ‘‘(ii) monitoring the entity to ensure it 

2 authorizes, arranges, coordinates, and pro3 vides all covered and medically necessary 

4 services (as required under this title) to 

5 AIMP enrollees receiving benefits adminis6 tered by the entity, in accordance with the 

7 requirements of the AIMP contract; and 

8 ‘‘(iii) ensuring compliance with appli9 cable reporting requirements under this 

10 title. 

11 ‘‘(C) Reviewing, approving, and moni12 toring— 

13 ‘‘(i) the entity’s network adequacy; 

14 ‘‘(ii) the outreach and orientation ma15 terials and procedures of the entity; 

16 ‘‘(iii) the complaint and appeals pro17 cedures carried out by the entity; 

18 ‘‘(iv) the utilization management func19 tions of the entity; 

20 ‘‘(v) the entity’s adherence to required 

21 continuity of care provisions under section 

22 2204(c)(3); 

23 ‘‘(vi) the entity’s use of required 

24 standard assessment tool under section 

25 2204(b); 


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1 ‘‘(vii) the entity’s informational mate2 rials, particularly for those individuals who 

3 will be assigned to the entity under section 

4 2203(f); and 

5 ‘‘(viii) the entity’s use of streamlined 

6 eligibility processes under this title. 

7 ‘‘(D) Conducting monthly (or more fre8 quent) performance review meetings with the 

9 entity. 

10 ‘‘(E) Conducting periodic audits of the en11 tity, including at least an annual independent 

12 external review and an annual site visit. 

13 ‘‘(F) Receiving and responding to com14 plaints about the entity. 

15 ‘‘(G) Conducting annual surveys of AIMP 

16 enrollees and providing the entity with written 

17 results of such surveys. 

18 ‘‘(H) Applying 1 or more sanctions (such 

19 as those provided under title XIX), which may 

20 include termination of the contract, if the State 

21 or the Secretary determines that the entity is in 

22 material violation of any of the terms of the 

23 AIMP contract. 

24 ‘‘(2) FEDERAL OVERSIGHT ROLE.— 


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1 ‘‘(A) IN GENERAL.—The Secretary shall be 

2 responsible for the oversight of AIMP-partici3 pating States. Such oversight shall include ac4 tivities developed through engagement with 

5 stakeholders, including consumer advocates, 

6 and shall include at the least the following ac7 tivities: 

8 ‘‘(i) Monitoring the process to select 

9 organizations to serve as AIMP-admin10 istering entities under the AIM program. 

11 ‘‘(ii) Conducting a thorough readiness 

12 review of the State (before readiness re13 views for such organizations) under section 

14 2201(d)(2). 

15 ‘‘(iii) Ensuring, including through 

16 complaint tracking and secret shopping, 

17 the State creates and maintains a highly 

18 functional, dedicated AIMP Ombudsman 

19 program under section 2205(c). 

20 ‘‘(iv) Ensuring, through direct moni21 toring, State oversight of compliance of 

22 AIMP-administering entities with the 

23 terms of their AIMP contracts under the 

24 AIM program. 


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1 ‘‘(v) Reviewing eligibility and enroll2 ment processes and procedures. 

3 ‘‘(vi) Monitoring State data systems 

4 to ensure they are sufficient for providing 

5 timely data on program performance. 

6 ‘‘(vii) Ensuring payment rates to 

7 AIMP-administering entities under the 

8 AIMP contract are actuarially sound, in9 cluding by establishing a rate setting proc10 ess established through rulemaking where11 by, at a minimum— 

12 ‘‘(I) States and the Secretary 

13 provide AIMP-administering entities 

14 with comprehensive and timely data 

15 as part of the rate setting process and 

16 procurement, including historical 

17 Medicaid and Medicare cost and utili18 zation data for full-benefit dual eligi19 ble individuals by region and including 

20 detailed categories of service; 

21 ‘‘(II) States may elect to share 

22 the final rate certification package 

23 provided to the Secretary with AIMP24 administering entities; and 


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1 ‘‘(III) an opportunity for public 

2 input is established for annual rate 

3 setting or when rates are significantly 

4 modified whereby stakeholders, includ5 ing patient advocacy groups, health 

6 care providers, and AIMP-admin7 istering entities, can provide feedback 

8 to the Secretary prior to rate ap9 proval. 

10 ‘‘(viii) Coordinating periodic audits of 

11 the State with respect o its AIM program. 

12 ‘‘(ix) Conducting regular meetings 

13 with the State. 

14 ‘‘(x) Applying discretionary action, if 

15 warranted. 

16 ‘‘(xi) Ensuring regular engagement 

17 with dually eligible individuals and their 

18 caregivers. 

19 ‘‘(B) COMPLIANCE AUTHORITY.—If the 

20 Secretary finds with respect to a State AIM 

21 program that the State failed to achieve the ap22 propriate performance levels or compliance with 

23 the activities required under subparagraph (A), 

24 the Secretary shall take such action as is nec25 essary to address and correct the State failures, 


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1 which may include, to the extent the Secretary 

2 determines appropriate, 1 or more of the fol3 lowing: 

4 ‘‘(i) Developing in consultation with 

5 the State, a corrective compliance plan for 

6 achieving appropriate performance levels or 

7 compliance. 

8 ‘‘(ii) Remedial education and super9 vised training. 

10 ‘‘(iii) Imposition of penalties or sanc11 tions. 

12 ‘‘(iv) Removal of the State from the 

13 AIM program. 

14 ‘‘(3) STATE-FEDERAL PARTNERSHIP ROLE

15 THROUGH JOINT CONTRACT MANAGEMENT TEAMS

16 (CMT).— 

17 ‘‘(A) ESTABLISHMENT.—The Secretary 

18 shall, jointly with each AIMP-participating 

19 State, establish a Joint Contract Management 

20 Team (in this paragraph referred to as a 

21 ‘CMT’) following the model used in the dem22 onstration projects conducted under the Finan23 cial Alignment Initiative for Medicare-Medicaid 

24 Enrollees administered by the Federal Coordi25 nated Health Care Office. 


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1 ‘‘(B) COMPOSITION AND STRUCTURE.— 

2 ‘‘(i) IN GENERAL.—Each CMT shall 

3 include at least 1 contract officer from the 

4 Centers for Medicare & Medicaid Services 

5 and at least 1 contract officer from the 

6 AIMP-participating State, each of whom is 

7 authorized and empowered to represent the 

8 Secretary and the State, respectively, 

9 about all aspects of the AIMP contract 

10 with an AIMP-administering entity under 

11 the AIM program of the State. 

12 ‘‘(ii) LEAD.—The representation from 

13 the Federal Government shall be led by the 

14 individual from the Federal Coordinated 

15 Health Care Office who is assigned to 

16 work with the State, who will bring in ad17 ditional individuals, as appropriate. 

18 ‘‘(iii) STATE LEAD.—The representa19 tion from the AIMP-participating State 

20 shall be led by the Director of the State 

21 Medicaid program under title XIX (or such 

22 Director’s designee) who will bring in addi23 tional individual to represent the State, as 

24 appropriate. 


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1 ‘‘(C) RESPONSIBILITIES OF CMT.—Each 

2 CMT for a State shall act as a liaison among 

3 the AIMP-administering entity, the Secretary, 

4 and the State for the duration of the AIMP 

5 contract with such entity and shall serve to fa6 cilitate communications and operations among 

7 the 3 parties. Each CMT shall, among other 

8 functions— 

9 ‘‘(i) receive and respond to com10 plaints; 

11 ‘‘(ii) conduct quarterly meetings 

12 among the parties; 

13 ‘‘(iii) establish a mechanism for ongo14 ing consumer engagement; 

15 ‘‘(iv) coordinate requests for assist16 ance from the entity and assign Federal 

17 and State staff with appropriate expertise 

18 to provide technical assistance to the enti19 ty; 

20 ‘‘(v) make best efforts to resolve any 

21 issues applicable to the parties; and 

22 ‘‘(vi) monitor any discretionary action 

23 by the State or the Secretary under the 

24 provisions of the AIMP contract. 


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1 ‘‘SEC. 2210. DEFINITIONS; MISCELLANEOUS PROVISIONS. 

2 ‘‘(a) DEFINITIONS.—In this title: 

3 ‘‘(1) TERMS RELATING TO AIMP.— 

4 ‘‘(A) AIMP-ADMINISTERING ENTITY.—The 

5 term ‘AIMP-administering entity’ means an or6 ganization that has been determined to meet 

7 the requirements for such an entity under this 

8 title and has an AIMP contract with an AIMP9 participating State under this title. 

10 ‘‘(B) AIMP ASSISTANCE.—The term 

11 ‘AIMP assistance’ has the meaning given such 

12 term in section 2208(a)(1)(B). 

13 ‘‘(C) AIMP CONTRACT.—The term ‘AIMP 

14 contract’ is a contract described in section 

15 2207(b)(1). 

16 ‘‘(D) AIMP-ELIGIBLE INDIVIDUAL.—The 

17 term ‘AIMP-eligible individual’ has the meaning 

18 given such term in section 2202(a). 

19 ‘‘(E) AIMP ENROLLEE.—The term ‘AIMP 

20 enrollee’ means an individual who is enrolled in 

21 an AIM program under this title. 

22 ‘‘(F) AIMP-PARTICIPATING STATE.—The 

23 term ‘AIMP-participating State’ means a State 

24 administering an AIM program under this title. 

25 ‘‘(G) AIM PROGRAM; AIMP.—The terms 

26 ‘AIM program’ and ‘AIMP’ mean, with respect 


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1 to a State, the program established by the State 

2 under this title. 

3 ‘‘(2) OTHER DEFINITIONS.— 

4 ‘‘(A) FULL-BENEFIT DUAL ELIGIBLE INDI5 VIDUAL.—The term ‘full-benefit dual eligible in6 dividual’ has the meaning given such term in 

7 section 1935(c)(6) but without the application 

8 of subparagraph (A)(i) of such section. 

9 ‘‘(B) FEDERAL COORDINATED HEALTH

10 CARE OFFICE.—The term ‘Federal Coordinated 

11 Health Care Office’ means the office established 

12 under section 2602 of the Patient Protection 

13 and Affordable Care Act. 

14 ‘‘(C) MEDICAID MANAGED CARE ORGANI15 ZATION.—The term ‘medicaid managed care or16 ganization’ has the meaning given that term in 

17 section 1903(m)(1)(A) and includes a prepaid 

18 inpatient health plan, as defined in section 

19 438.2 of title 42, Code of Federal Regulations 

20 (or any successor regulation) and a prepaid am21 bulatory health plan, as defined in such section 

22 (or any successor regulation). 

23 ‘‘(b) MISCELLANEOUS PROVISIONS.— 

24 ‘‘(1) RELATION TO OTHER REQUIREMENTS.— 

25 Except as otherwise provided under this title or by 


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1 regulation, the requirements of title XIX shall apply 

2 under an AIM program in relation to AIMP-eligible 

3 individuals, AIMP enrollees, and the provision of 

4 benefits under an AIM program, in the same man5 ner as such requirements apply with respect to indi6 viduals eligible for medical assistance who are en7 rolled in under a medicaid managed care organiza8 tion. 

9 ‘‘(2) LIMITATION ON WAIVER AUTHORITY.—Ex10 cept as provided in this title, the Secretary is not 

11 authorized (under section 1115, 1115A, or other12 wise) to waive the requirements specified in this 

13 title.’’. 

14 (b) CONFORMING AMENDMENTS TO MEDICARE.— 

15 (1) ENROLLMENT.—Section 1851(a) of the So16 cial Security Act (42 U.S.C. 1395w–21(a)) is 

17 amended by adding at the end the following new 

18 paragraph: 

19 ‘‘(4) ADDITIONAL ENROLLMENT OPTION FOR

20 CERTAIN FULL-BENEFIT DUAL ELIGIBLE INDIVID21 UALS.—Full-benefit dual eligible individuals may 

22 also be eligible to enroll under a State AIM program 

23 under title XXII.’’. 

24 (2) PROHIBITION.—During the period in which 

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1 participating State under title XXII, AIMP-eligible 

2 individuals in the State may not enroll in a managed 

3 Medicare and other integrated duals product (other 

4 than a PACE program). 

5 (c) CONFORMING AMENDMENTS TO MEDICAID.— 

6 (1) PREVENTING DUPLICATE PAYMENTS.—Sec7 tion 1903(i) of the Social Security Act (42 U.S.C. 

8 1396(i)) is amended— 

9 (A) by striking ‘‘or’’ at the end of para10 graph (26); 

11 (B) by striking the period at the end of 

12 paragraph (27) and inserting ‘‘; or’’; and 

13 (C) by inserting after paragraph (27) the 

14 following new paragraph: 

15 ‘‘(28) with respect to any amount expended for 

16 medical assistance for an individual who is an AIMP 

17 enrollee under a State AIM program under title 

18 XXII, except specifically permitted under such 

19 title.’’. 

20 (2) Note: Additional conforming amendments to 

21 be provided. 

22 (d) CONFORMING AMENDMENT.—Section 2602(d) of 

23 the Patient Protection and Affordable Care Act (42 

24 U.S.C. 1315b(d)) is amended by adding at the end the 

25 following: 


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1 ‘‘(9) To be primarily responsible for the Federal 

2 administration of title XXII of the Social Security 

3 Act.’’. 

4 (e) OTHER CONFORMING AMENDMENTS.—Section 

5 1101(a)(1) of the Social Security Act (42 U.S.C. 

6 1301(a)(1)) is amended— 

7 (1) by striking ‘‘XIX, and XXI’’ and inserting 

8 ‘‘XIX, XXI, and XXII’’; and 

9 (2) by striking ‘‘XIX and XXI’’ and inserting 

10 ‘‘XIX, XXI, and XXII’’. 

11 SEC. 3. MEDPAC STUDY AND REPORT. 

12 (a) STUDY.—The Medicare Payment Advisory Com13 mission shall conduct a study for purposes of making rec14 ommendations regarding how to improve health care and 

15 other support needs of individuals who are eligible for and 

16 are receiving medical assistance for the payment of medi17 care cost-sharing under a State Medicaid program pursu18 ant to clause (i), (iii), or (iv) of section 1902(a)(10)(E) 

19 of the Social Security Act (42 U.S.C. 1396a(a)(10)(E)). 

20 (b) REPORT.—Not later than 18 months after the 

21 date of enactment of this Act, the Medicare Payment Ad22 visory Commission shall submit to Congress a report on 

23 the study conducted under subsection (a), together with 


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1 recommendations for such legislation and administrative 

2 action as the Commission determines to be appropriate. 

Æ 


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