I 

118TH CONGRESS 

2D SESSION H. R. 8503 

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 HOUSE OF REPRESENTATIVES 

MAY 22, 2024 

Mr. KELLY of Pennsylvania (for himself and Mr. BERA) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

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. 

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 ‘‘Delivering Unified Access to Lifesaving Services Act of 

6 2024’’ or the ‘‘DUALS Act of 2024’’. 


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

2 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 


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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 of 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. 

1 TITLE I—STATE INTEGRATED 

2 CARE PROGRAMS FOR DUAL 

3 ELIGIBLE INDIVIDUALS 

4 SEC. 101. STATE IMPLEMENTATION. 

5 The Social Security Act is amended by adding at the 

6 end the following new title: 

7 ‘‘TITLE XXII—STATE INTE8 GRATED CARE PROGRAMS 

9 FOR DUAL ELIGIBLE INDIVID10 UALS 

11 ‘‘SEC. 2201. DEFINITIONS. 

12 ‘‘In this title: 

13 ‘‘(1) DIRECTOR.—The term ‘Director’ means 

14 the Director of the Federal Coordinated Health Care 

15 Office of the Centers for Medicare & Medicaid Serv16 ices. 

17 ‘‘(2) DUAL ELIGIBLE INDIVIDUAL.—The term 

18 ‘dual eligible individual’ means an individual who is 

19 entitled to, or enrolled for, benefits under part A of 

20 title XVIII, or enrolled for benefits under part B of 


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1 title XVIII, and is eligible for medical assistance for 

2 full benefits under title XIX under section 

3 1902(a)(10)(A) or 1902(a)(10)(C), by reason of sec4 tion 1902(f), or under any other category of eligi5 bility for medical assistance for full benefits under 

6 such title, as determined by the Secretary. 

7 ‘‘(3) INTEGRATED CARE PLAN.—The term ‘in8 tegrated care plan’ means an entity or organization 

9 that is selected by a State under section 2202(a) to 

10 provide fully integrated care for a dual eligible indi11 vidual in accordance with the requirements of this 

12 title and related Federal and State regulations. Such 

13 term shall not include a PACE program (as defined 

14 in sections 1894(a)(2) and 1934(a)(2)). 

15 ‘‘SEC. 2202. STATE SELECTION OF PROGRAM MODELS, DE16 VELOPMENT, AND IMPLEMENTATION. 

17 ‘‘(a) STATE SELECTION OF PROGRAM MODELS.— 

18 Not later than 1 year after the date on which the Director 

19 first publishes the range of program models for providing 

20 integrated care for dual eligible individuals required by 

21 section 2208(b)(1), each State shall select from such pub22 lished models, and shall work with the Director to imple23 ment such models in the State in accordance with the re24 quirements of this title a program model to provide comVerDate Sep 11 2014 19:31 Jul 08, 2024 Jkt 049200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H8503.IH H8503

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1 prehensive, fully integrated care for dual eligible individ2 uals. 

3 ‘‘(b) TIMING.—Each State shall work with the Direc4 tor to implement the models selected by the State under 

5 subsection (a) so that, to the extent practicable, the State 

6 may begin to enroll dual eligible individuals in the pro7 gram models selected during the fourth year that occurs 

8 after the year in which the State makes such selection and, 

9 by the end of such fourth year, the models are fully imple10 mented and operated in accordance with the requirements 

11 of this title and related Federal and State regulations. 

12 Nothing in this subsection shall prohibit a State from en13 rolling dual eligible individuals in such program models 

14 earlier than the end of such fourth year if the models are 

15 fully implemented and operated in accordance with the re16 quirements of this title and related Federal and State reg17 ulations. 

18 ‘‘(c) ADJUSTMENT AUTHORITY.—The Director may 

19 modify the timing required by subsections (a) and (b) as 

20 appropriate to account for the particular needs or cir21 cumstances of a State. 

22 ‘‘(d) IMPLEMENTATION COUNCIL.— 

23 ‘‘(1) IN GENERAL.—A State shall establish an 

24 implementation council in accordance with such re25 quirements as the Secretary shall establish. The 


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1 members of the council shall include representatives 

2 of a wide range of stakeholders relevant to the provi3 sion of integrated care for dual eligible individuals. 

4 ‘‘(2) DUTIES.—The implementation council 

5 shall provide advice and counsel to the State with re6 spect to the implementation of the models selected 

7 by the State under subsection (a). 

8 ‘‘SEC. 2203. ENROLLMENT IN INTEGRATED CARE PLANS. 

9 ‘‘(a) PASSIVE ENROLLMENT; OPT-OUT PER10 MITTED.— 

11 ‘‘(1) PASSIVE ENROLLMENT AND NOTICE RE12 QUIREMENTS.—A State shall automatically enroll a 

13 dual eligible individual with an integrated care plan 

14 under a contract with the State provided that the 

15 State notifies the individual that the individual will 

16 be enrolled with such plan at least 60 days (90 days, 

17 in the case of the first time the individual is pro18 vided such notice) prior to the effective date of such 

19 enrollment. Notice provided to a dual eligible indi20 vidual under this paragraph shall include the fol21 lowing: 

22 ‘‘(A) The name and contact information 

23 for the integrated care plan. 

24 ‘‘(B) The date on which the enrollment 

25 takes effect and, if applicable, whether the 


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1 State has elected the option for a 12-month 

2 continuous eligibility period under paragraph 

3 (4). 

4 ‘‘(C) A summary of the benefits to be pro5 vided by the plan. 

6 ‘‘(D) Information regarding the provider 

7 network of the plan. 

8 ‘‘(E) Information regarding how the dual 

9 eligible individual may elect to opt-out of enroll10 ment with the plan within 60 days (90 days, in 

11 the case of the first time the individual is pro12 vided such notice). 

13 ‘‘(2) ENROLLMENT IN PLAN WITH IN-NET14 WORK, PARTICIPATING PRIMARY CARE PROVIDER RE15 QUIRED.—A State shall not passively enroll a dual 

16 eligible individual in an integrated care plan unless 

17 the individual’s primary care physician is an in-net18 work, participating provider for the plan. 

19 ‘‘(3) VOLUNTARY ENROLLMENT.—A State shall 

20 offer a dual eligible individual the option to enroll in 

21 an integrated care plan without regard to meeting 

22 the requirement of paragraph (2). 

23 ‘‘(4) STATE OPTION FOR CONTINUOUS ELIGI24 BILITY AND ENROLLMENT.—A State may elect for a 

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1 ble for medical assistance under the State plan 

2 under title XIX or under a waiver of such plan and 

3 who is enrolled with an integrated care plan under 

4 a contract with the State to remain eligible for med5 ical assistance and enrolled with such plan until the 

6 earlier of— 

7 ‘‘(A) the end of the 12-month period begin8 ning on the date of such determination; or 

9 ‘‘(B) the date that such individual ceases 

10 to be a resident of such State. 

11 ‘‘(b) CHANGE OF ENROLLMENT.—A State shall per12 mit a dual eligible individual to change enrollment in an 

13 integrated care plan— 

14 ‘‘(1) on a monthly basis if the individual is 

15 electing to enroll in another integrated care plan; 

16 ‘‘(2) during the general enrollment period appli17 cable under section 1837, if the individual is electing 

18 to disenroll from an integrated care plan and not en19 roll in another integrated care plan; and 

20 ‘‘(3) during the 60-day period beginning on the 

21 date the individual receives notice from the State 

22 that the individual has been determined to no longer 

23 be eligible for treatment as a dual eligible individual, 

24 if the individual is no longer eligible to enroll in an 

25 integrated care plan. 


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1 ‘‘(c) CONTACT BY PLAN CARE COORDINATOR PER2 MITTED PRIOR TO EFFECTIVE DATE OF ENROLLMENT.— 

3 A care coordinator for an integrated care plan may contact 

4 a dual eligible individual who has been passively enrolled 

5 in the plan prior to the effective date of the enrollment. 

6 ‘‘SEC. 2204. PLAN REQUIREMENTS AND PAYMENTS. 

7 ‘‘(a) IN GENERAL.—A contract between a State, an 

8 offeror of an integrated care plan, and the Director shall 

9 not be considered to meet the requirements of this title 

10 unless— 

11 ‘‘(1) in the case of a dual eligible individual en12 rolled with the plan who changes enrollment to an13 other integrated care plan for which the individual’s 

14 primary care provider is not a participating, in-net15 work provider, or who disenrolls from the plan and 

16 does not enroll in another integrated care plan, the 

17 offeror of the plan will, during the 30-day period 

18 that begins on the date on which the individual’s 

19 disenrollment from the plan takes effect— 

20 ‘‘(A) allow the individual to continue to be 

21 treated by the individual’s primary care pro22 vider; and 

23 ‘‘(B) cover any treatment provided to the 

24 individual by such provider as if the individual 

25 were still enrolled with the plan; 


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1 ‘‘(2) the offeror of the plan administers a 

2 health risk assessment to each dual eligible indi3 vidual enrolled with the plan within 90 days of the 

4 effective date of the individual’s enrollment in ac5 cordance with the requirements of subsection (c) and 

6 shall affirm that there are no changes in the infor7 mation provided at least every 12 months thereafter; 

8 ‘‘(3) the offeror of the plan provides benefits for 

9 a dual eligible individual under a comprehensive care 

10 plan in accordance with the requirements of sub11 sections (d) and (f); 

12 ‘‘(4) the offeror of the plan assigns a care coor13 dinator to each dual eligible individual enrolled with 

14 the plan in accordance with the requirements of sub15 section (e) and notifies such individual in a timely 

16 and accessible manner when a new care coordinator 

17 is assigned; and 

18 ‘‘(5) the contract provides for payment to the 

19 offeror for benefits provided to dual eligible individ20 uals enrolled with the plan using a financing struc21 ture that satisfies the requirements of section 

22 2208(c). 

23 ‘‘(b) DISREGARD OF CERTAIN DISENROLLMENT

24 DATA FOR RATINGS PURPOSES.—The disenrollment of a 

25 dual eligible individual from an integrated care plan who 


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1 was passively enrolled in the plan under section 2203 shall 

2 be disregarded for purposes of any data used for rating 

3 of the plan for such plan year. 

4 ‘‘(c) HEALTH RISK ASSESSMENT.—An offeror of an 

5 integrated care plan shall administer a health risk assess6 ment to each dual eligible individual enrolled with the plan 

7 using the standardized health risk assessment question8 naire developed by the Director under section 2208(b)(3) 

9 and in accordance with such additional requirements as 

10 the State may establish. An integrated care plan may rely 

11 on the results of a previously administered health risk as12 sessment of a dual eligible individual if such results are 

13 accessible to the plan and the dual eligible individual af14 firms that there are no changes in the information pre15 viously provided. 

16 ‘‘(d) BENEFITS.— 

17 ‘‘(1) IN GENERAL.—An integrated care plan 

18 shall provide benefits under the plan in accordance 

19 with requirements established by the Director and 

20 the State, and which shall include the following: 

21 ‘‘(A) Clinical health services. 

22 ‘‘(B) Behavioral health services. 

23 ‘‘(C) Long-term services and supports. 

24 ‘‘(2) CARVE-OUT EXCEPTIONS.—The Director 

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1 arately contract for the provision of services or sup2 ports required under paragraph (1) but only if the 

3 State demonstrates to the Director that— 

4 ‘‘(A) the level of care provided for a dual 

5 eligible individual under the separate contract 

6 with respect to such services or supports is not 

7 less than the level of care that would be pro8 vided without the exception; and 

9 ‘‘(B) the dual eligible individual will not be 

10 subject to any unreasonable administrative re11 quirements to access the services or supports, 

12 as determined by the Secretary. 

13 ‘‘(3) SUPPLEMENTAL BENEFITS.—An inte14 grated care plan may provide customized, supple15 mental benefits to a dual eligible individual enrolled 

16 with the plan, including supplemental health care 

17 benefits described in section 1852(a)(3), other pri18 marily health-related benefits offered by Medicare 

19 Advantage plans and benefits permitted by the Sec20 retary to be offered as Special Supplemental Bene21 fits for the Chronically Ill (SSBCI), without regard 

22 to whether the dual eligible individual has a requisite 

23 condition or diagnosis, so long as the plan dem24 onstrates to the Director and the State that the ofVerDate Sep 11 2014 19:31 Jul 08, 2024 Jkt 049200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\H8503.IH H8503

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1 fering of such benefits has a positive impact on pa2 tient health. 

3 ‘‘(e) CARE COORDINATOR REQUIREMENTS.—A care 

4 coordinator assigned to a dual eligible individual enrolled 

5 in an integrated care plan shall— 

6 ‘‘(1) serve as the single point of contact be7 tween the individual and the plan; 

8 ‘‘(2) be responsible for helping the individual 

9 and the individual’s caregivers and family make ben10 efit and service decisions; 

11 ‘‘(3) design a beneficiary-focused comprehensive 

12 care plan for the individual that meets the require13 ments of subsection (f); and 

14 ‘‘(4) connect and coordinate acute, subacute, 

15 social, primary, and specialty care for the individual 

16 and the provision of long-term services and supports 

17 for the individual. 

18 ‘‘(f) COMPREHENSIVE CARE PLAN REQUIRE19 MENTS.—The comprehensive care plan for a dual eligible 

20 individual enrolled in an integrated care plan shall be— 

21 ‘‘(1) designed to address the totality of the indi22 vidual’s medical, functional, behavioral, social, and 

23 caregiving needs and goals, and to the extent prac24 ticable, to apply to multiple years; 


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1 ‘‘(2) be based on the health risk assessment of 

2 the individual required by subsection (c); 

3 ‘‘(3) be implemented by an interdisciplinary 

4 care team that includes relevant specialists to ensure 

5 access to all aspects of care that are required for the 

6 individual; 

7 ‘‘(4) be approved by the individual (or by an 

8 authorized caregiver or guardian) prior to implemen9 tation; and 

10 ‘‘(5) be reviewed at least annually and within 

11 30 days of a major health event, such as hospitaliza12 tion or an emergency room visit. 

13 ‘‘(g) CONTINUITY OF CARE REQUIREMENT.—An in14 tegrated care plan shall provide a dual eligible individual 

15 enrolled in the plan with a minimum 90-day transition pe16 riod for any active course of treatment when the individual 

17 has enrolled in an integrated care plan after starting a 

18 course of treatment, even if the service is furnished by 

19 an out-of-network provider. This includes enrollees new to 

20 a plan and enrollees new to Medicare. The integrated care 

21 plan must not disrupt or require reauthorization for an 

22 active course of treatment for new plan enrollees for a pe23 riod of at least 90 days. An integrated care plan may pro24 vide for a longer transition period than 90 days at the 


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1 option of the plan. For purposes of this subsection the 

2 following definitions apply: 

3 ‘‘(1) The term ‘course of treatment’ means as 

4 a prescribed order or ordered course of treatment 

5 for a specific individual with a specific condition is 

6 outlined and decided upon ahead of time with the 

7 patient and provider. A course of treatment may but 

8 is not required to be part of a treatment plan. 

9 ‘‘(2) The term ‘active course of treatment’ 

10 means a course of treatment in which a patient is 

11 actively seeing the provider and following the course 

12 of treatment. 

13 ‘‘(h) AUTHORITY TO APPLY FRAILTY ADJUSTMENT

14 FACTOR TO PLAN PAYMENTS.—A contract between a 

15 State, an integrated care plan, and the Director under this 

16 title may apply a frailty adjustment factor with respect 

17 to dual eligible individuals enrolled in the plan in the same 

18 manner as is permitted under section 1853(a)(1)(B)(iv), 

19 but without regard to requiring the plan to demonstrate 

20 enrollment of a high concentration of frail individuals. 

21 ‘‘SEC. 2205. DATA COLLECTION AND REPORTING. 

22 ‘‘(a) ANNUAL COLLECTION AND REPORTING BY

23 STATES AND INTEGRATED CARE PLANS.—Each State, 

24 and each integrated care plan with a contract with a State 

25 under this title, annually shall collect and report informaVerDate Sep 11 2014 19:31 Jul 08, 2024 Jkt 049200 PO 00000 Frm 00015 Fmt 6652 Sfmt 6201 E:\BILLS\H8503.IH H8503

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1 tion and data to the Director in accordance with the re2 quirements of this section and guidance and regulations 

3 issued under section 2208(b)(7) that includes data col4 lected by such States and plans with respect to a plan 

5 year regarding age, gender, disability (including specific 

6 disability statuses required to be reported by the Direc7 tor), smoking status, mobility, employment status, edu8 cation, race and ethnicity, and zip code, of dual eligible 

9 individuals enrolled in the plan. 

10 ‘‘(b) COLLECTION AND REPORTING OF ADDITIONAL

11 DATA AND INFORMATION PERMITTED.—A State may re12 quire an integrated care plan with a contract with the 

13 State under this title to collect and report to the State 

14 additional data and information. 

15 ‘‘SEC. 2206. STATE OMBUDSMAN. 

16 ‘‘(a) IN GENERAL.—Each State shall establish and 

17 operate an Office of the Ombudsman for Integrated Care 

18 Plans for Dual Eligible Individuals (in this section re19 ferred to as the ‘Office’). The Office may operate inde20 pendently of, or in connection with, the State agency re21 sponsible for administering the Medicaid program under 

22 title XIX. 

23 ‘‘(b) OMBUDSMAN.—The Office shall be headed by an 

24 individual, to be known as the State Integrated Care for 

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1 lected from among individuals with expertise in and expe2 rience with integrated care models for dual eligible individ3 uals, the Medicare program under title XVIII, and the 

4 Medicaid program under title XIX. The Ombudsman shall 

5 be responsible for the management, including the fiscal 

6 management, of the Office. 

7 ‘‘(c) REQUIREMENTS.— 

8 ‘‘(1) IN GENERAL.—The primary responsibility 

9 of the Office shall be to provide support and feed10 back for dual eligible individuals enrolled in inte11 grated care plans under this title and caregivers or 

12 family members of such individuals who need assist13 ance. 

14 ‘‘(2) MINIMUM STAFFING RATIO.—The Office 

15 shall have a minimum staffing ratio of one employee 

16 for every 2,000 dual eligible individuals in the State. 

17 ‘‘(d) FUNDING.— 

18 ‘‘(1) INITIAL FUNDING.—During the first 2 

19 years in which a State operates the Office, the Sec20 retary shall pay to the State for each such year for 

21 expenditures necessary to establish and operate the 

22 Office, from amounts appropriated under section 

23 2207(c), an amount equal to $50,000,000 multiplied 

24 by the ratio of— 


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1 ‘‘(A) the number of dual eligible individ2 uals in the State; to 

3 ‘‘(B) the number of dual eligible individ4 uals in all States. 

5 ‘‘(2) SUBSEQUENT FUNDING.—Beginning with 

6 the third year of the Office’s operation, expenditures 

7 necessary to operate the Office shall be considered, 

8 for purposes of section 1903(a)(7), to be necessary 

9 for the proper and efficient administration of the 

10 State plan under title XIX and reimbursed to a 

11 State in accordance with that section. 

12 ‘‘SEC. 2207. FUNDING. 

13 ‘‘(a) TREATMENT OF STATE PAYMENTS TO INTE14 GRATED CARE PLANS AS MEDICAL ASSISTANCE.— 

15 Amounts expended by a State for payments to an inte16 grated care plan for the Medicaid component of the capita17 tion payment described in section 2208(c) shall be treated 

18 as medical assistance for which payment is made under 

19 section 1903(a). Nothing in this title shall prevent a State 

20 from providing medical assistance under title XIX to a 

21 dual eligible individual for services for which coverage is 

22 not provided under the integrated care plan with which 

23 the individual is enrolled or from receiving payment under 

24 section 1903(a) with respect to expenditures attributable 

25 to providing such medical assistance. 


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1 ‘‘(b) PAYMENTS TO STATES.—From the sums appro2 priated under subsection (c), the Secretary shall pay to 

3 each State for each calendar year (beginning January 1 

4 of the first full calendar year in which this title is imple5 mented in the State), an amount equal to the sum of the 

6 following: 

7 ‘‘(1) SHARED SAVINGS COMPONENT.—The 

8 shared savings payment applicable to the State and 

9 the year, as determined in accordance with section 

10 2208(b)(6)(D). 

11 ‘‘(2) GENERAL ADMINISTRATIVE EXPENSES.— 

12 For administrative expenses to carry out this title, 

13 other than section 2205, an amount that bears the 

14 same proportion to $50,000,000 as the number of 

15 dual eligible individuals in the State bears to the 

16 number of dual eligible individuals in all States, as 

17 determined by the Secretary. 

18 ‘‘(3) DATA COLLECTION AND REPORTING.—For 

19 data collection and reporting expenses under section 

20 2205, an amount that bears the same proportion to 

21 $50,000,000 as the number of dual eligible individ22 uals in the State bears to the number of dual eligible 

23 individuals in all States, as determined by the Sec24 retary. 


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1 ‘‘(c) APPROPRIATION.—There is appropriated, out of 

2 any money in the Treasury not otherwise appropriated, 

3 such amounts as may be required to provide payments to 

4 States under this section, for each calendar year (begin5 ning January 1 of the first full calendar year in which 

6 this title is implemented in any State), reduced by any 

7 amounts made available from the Medicare trust funds 

8 under subsection (d). 

9 ‘‘(d) RELATION TO MEDICARE TRUST FUNDS.— 

10 There shall be made available for carrying out this title, 

11 and the Secretary shall provide for the transfer from the 

12 Federal Hospital Insurance Trust Fund (under section 

13 1817) and from the Federal Supplementary Medical In14 surance Trust Fund (under section 1841) (and from the 

15 Medicare Prescription Drug Account (under section 

16 1860D–16) within such Trust Fund) such amounts as the 

17 Secretary determines appropriate, taking into account the 

18 reductions in payments from such Trust Funds and Ac19 count that are attributable to the enrollment of dual eligi20 ble individuals in integrated care plans under this title, 

21 for each calendar year (beginning January 1 of the first 

22 full calendar year in which this title is implemented in any 

23 State). 


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1 ‘‘(e) RELATION TO OTHER PAYMENTS.—Payments 

2 provided under this section to a State are in addition to 

3 payments provided under section 2208. 

4 ‘‘SEC. 2208. FEDERAL ADMINISTRATION THROUGH THE 

5 FEDERAL COORDINATED HEALTH CARE OF6 FICE. 

7 ‘‘(a) IN GENERAL.—The Director shall have primary 

8 authority for implementing and carrying out responsibil9 ities of the Federal Government under this title. 

10 ‘‘(b) RESPONSIBILITIES OF THE FCHCO.—In car11 rying out this title, the Director shall have the following 

12 responsibilities: 

13 ‘‘(1) DEVELOPMENT AND PUBLICATION OF IN14 TEGRATED CARE PROGRAM MODELS.—Subject to 

15 subsection (c), to develop and, not later than 180 

16 days after the date of enactment of this paragraph, 

17 publish, a range of program models (including but 

18 not limited to Medicare-Medicaid plans, accountable 

19 care organizations, and dual eligible special needs 

20 plans) for providing integrated care for dual eligible 

21 individuals from which States shall select to develop 

22 and administer integrated care programs for dual el23 igible individuals in accordance with this title. 

24 ‘‘(2) UNIFIED APPEALS PROCESS.—To develop 

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1 ment of this paragraph, publish a unified adminis2 trative appeals process for State integrated care pro3 grams for dual eligible individuals under this title to 

4 use in lieu of other administrative appeals processes 

5 involving Medicare and Medicaid. 

6 ‘‘(3) HEALTH RISK ASSESSMENT.—To develop 

7 a standardized health risk assessment questionnaire 

8 for dual eligible individuals that collects standard de9 mographic data and information relating to food in10 security, access to transportation, internet access, 

11 utility difficulty, interpersonal safety, and housing 

12 instability. 

13 ‘‘(4) SUPPLEMENTAL BENEFITS STANDARDS

14 AND REPORTING REQUIREMENTS.—To establish 

15 standards for reporting by States and integrated 

16 care plans under title XXII information relating to 

17 the offering and provision of supplemental benefits 

18 under section 2204(d)(3), including data relating to 

19 enrollment, utilization, and outcomes, to annually 

20 publish a report regarding the offering and utiliza21 tion of such benefits, and to study and report to the 

22 Secretary on whether to cap the actuarial dollar 

23 value allowed for such benefits under titles XVIII, 

24 XIX, and XXII. 


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1 ‘‘(5) CARE COORDINATOR REQUIREMENTS.— 

2 To— 

3 ‘‘(A) establish a formula based on patient 

4 chronic conditions, activities of daily living 

5 standards, geographic, and such other factors 

6 as the Director determines are necessary for 

7 States and integrated care plans to use to de8 termine the maximum staffing ratio for assign9 ing care coordinators to dual eligible individuals 

10 enrolled with integrated care plans under this 

11 title; and 

12 ‘‘(B) develop online training and profes13 sional development materials relating to the 

14 statutory and administrative requirements for 

15 providing integrated care for care coordinators 

16 for dual eligible individuals enrolled with inte17 grated care plans under this title. 

18 ‘‘(6) ADMINISTRATION AND OVERSIGHT OF IN19 TEGRATED CARE PLANS FOR DUAL ELIGIBLE INDI20 VIDUALS.—To— 

21 ‘‘(A) develop and issue guidance and regu22 lations related to the alignment of policy and 

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1 tation, administration, and oversight of inte2 grated care plans for dual eligible individuals 

3 under this title; and 

4 ‘‘(B) administer and provide oversight of 

5 integrated care plans for dual eligible individ6 uals under this title, including with respect to— 

7 ‘‘(i) the development and application 

8 of an integrated medical loss ratio for such 

9 plans, in lieu of compliance with separate 

10 medical loss ratio requirements under titles 

11 XVIII and XIX; 

12 ‘‘(ii) the establishment and application 

13 of network adequacy standards for such 

14 plans that— 

15 ‘‘(I) apply only with respect to 

16 such plans; 

17 ‘‘(II) allow the Director to waive 

18 compliance with such standards for 

19 integrated care plans that cannot 

20 meet the requirements in certain 

21 areas, but must operate statewide to 

22 meet a State’s selective contracting 

23 requirements; and 

24 ‘‘(III) allow the Director to con25 sider flexibilities to support innovative 


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1 models that do not rely on traditional 

2 time and distance standards, such as 

3 the use of telehealth; and 

4 ‘‘(iii) the establishment and applica5 tion of targeted, streamlined model-of-care 

6 requirements for such plans that include 

7 an integrated audit process, with shared 

8 responsibilities between the Director and 

9 States, and that requires the Director to 

10 share the results of such audits with State 

11 Medicaid programs. To the extent prac12 ticable, such requirements also shall be de13 signed to be integrated with model of care 

14 requirements applicable to Medicaid man15 aged care organizations; 

16 ‘‘(C) develop contract management teams, 

17 consisting of representatives from integrated 

18 care plans with contracts with States under this 

19 title, State agencies responsible for admin20 istering the State plan under title XIX or a 

21 waiver of such plan, and the Federal Coordi22 nated Health Care Office, to oversee compliance 

23 and performance of integrated care plans under 

24 this title; 


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1 ‘‘(D) develop and implement a shared sav2 ings payment for States to receive a share of 

3 savings to Federal spending in the Medicaid 

4 program under title XIX as a result of the im5 plementation and operation of integrated care 

6 plans for dual eligible individuals under this 

7 title; and 

8 ‘‘(E) develop a new star rating system for 

9 integrated care plans for dual eligible individ10 uals under this title that rates the performance 

11 of each plan type separately, with State-specific 

12 measures and tied to single contracts, instead 

13 of the collective performance of all of the 

14 offeror’s plans under contract with the State 

15 under that title, that include measures which 

16 directly reflect enrollee satisfaction, and that 

17 awards higher star ratings to plans based on 

18 their ability to retain enrollees. 

19 ‘‘(7) DATA COLLECTION AND REPORTING.—To 

20 establish data and information collection and report21 ing requirements for States and integrated care 

22 plans under section 2205, including required report23 ing of specific disability statuses and safeguards to 

24 protect patient privacy, and to annually publish not 

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1 mation collected and reported to the Director under 

2 such section for the preceding year. 

3 ‘‘(8) QUALITY MEASURES.—To develop quality 

4 measures for the population of dual eligible individ5 uals that are designed to be uniformly implemented 

6 across all platforms and health benefits plans that 

7 provide integrated care for such individuals under 

8 this title. Such measures shall include measures re9 lating to patient satisfaction, quality of life, rates of 

10 emergency room use, institutionalization for long11 term care, hospital admission and readmission rates, 

12 and medication errors. The Director shall regularly 

13 review and update such measures as necessary and 

14 may develop outcome-based quality measures for de15 termining payments to health benefits plans that 

16 provide integrated care for dual eligible individuals 

17 under this title. 

18 ‘‘(9) BEST PRACTICES.—To not less than annu19 ally publish best practices under this title for States 

20 and integrated care plans, including with respect to 

21 improving outreach to beneficiaries, improving com22 prehensive care plans and health risk assessments 

23 for dual eligible individuals, and developing a work24 force that provides culturally intelligent and respect25 ful care. 


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1 ‘‘(10) TRAINING PROGRAMS.—To develop train2 ing programs related to integrated care plans under 

3 this title for— 

4 ‘‘(A) providers of care, services, and sup5 ports under such plans with respect to issues 

6 such as coordination of benefits, data sharing 

7 barriers, quality ratings, and provider incen8 tives; 

9 ‘‘(B) State employees to increase Medicare 

10 expertise at State agencies responsible for ad11 ministering Medicaid plans and waivers and 

12 contracting with integrated care plans under 

13 this title; and 

14 ‘‘(C) insurance brokers and local coun15 selors who help enroll individuals in Medicare, 

16 Medicaid, and integrated care plans under this 

17 title. 

18 ‘‘(c) CAPITATED PAYMENT STRUCTURE FOR INTE19 GRATED CARE PROGRAM MODELS.— 

20 ‘‘(1) IN GENERAL.—Each program model that 

21 is designed by the Director under subsection (b)(1) 

22 shall provide that payments shall be made to an in23 tegrated care plan for benefits provided under a con24 tract under this title using a capitated payment 


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1 structure under which, for each month that the inte2 grated care plan provides such benefits— 

3 ‘‘(A) the State shall pay the integrated 

4 care plan an amount equal to the Medicaid 

5 component payment determined for the month; 

6 and 

7 ‘‘(B) the Secretary shall pay the integrated 

8 care plan an amount equal to the Medicare 

9 component payment determined for the month. 

10 ‘‘(2) DETERMINATION OF MEDICAID COMPO11 NENT PAYMENT.—For purposes of paragraph (1), 

12 the Medicaid component payment payable to an inte13 grated care plan for a month shall be an amount 

14 equal to the sum of the products of— 

15 ‘‘(A) for each category of beneficiary, the 

16 Medicaid capitation rate applicable to the cat17 egory of beneficiary (as determined by the Sec18 retary and specified in the contract between the 

19 State, the Secretary, and the offeror of the 

20 plan); and 

21 ‘‘(B) the number of beneficiaries in such 

22 category enrolled with the plan for the month. 

23 ‘‘(3) DETERMINATION OF MEDICARE COMPO24 NENT PAYMENT.—For purposes of paragraph (1), 

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1 grated care plan for a month shall be an amount 

2 equal to the sum of the products of— 

3 ‘‘(A) for each category of beneficiary, the 

4 Medicare capitation rate applicable to the cat5 egory of beneficiary (as determined by the Sec6 retary and specified in the contract between the 

7 State, the Secretary, and the offeror of the 

8 plan); and 

9 ‘‘(B) the number of beneficiaries in such 

10 category enrolled with the plan for the month. 

11 ‘‘(4) APPLICATION OF RISK ADJUSTMENT

12 MODEL TO CAPITATION RATES.—The Medicaid and 

13 Medicare capitation rates for each category of bene14 ficiary specified in a contract between a State, the 

15 Secretary, and the offeror of an integrated care plan 

16 shall be determined using the risk adjustment pay17 ment model developed under subsection (d). 

18 ‘‘(d) RISK ADJUSTMENT PAYMENT MODEL FOR PRO19 VIDING HEALTH BENEFITS COVERAGE FOR DUAL ELIGI20 BLE INDIVIDUALS.—Not later than 1 year after the date 

21 of enactment of this subsection, the Director shall enter 

22 into a contract or other agreement with an independent 

23 entity to develop a risk adjustment payment model for 

24 dual eligible individuals that— 


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1 ‘‘(1) is designed to be uniformly implemented 

2 across all platforms and health benefits plans that 

3 provide integrated care for such individuals under 

4 title XXII of the Social Security Act; 

5 ‘‘(2) includes factors based on the health status 

6 of such individuals; and 

7 ‘‘(3) allows plan payments to be made and up8 dated on a monthly basis. 

9 ‘‘(e) ADDITIONAL RESPONSIBILITIES WITH RESPECT

10 TO INTEGRATED CARE PLANS.— 

11 ‘‘(1) OUTREACH TO MEDICAID PROVIDERS.— 

12 Not later than 180 days after the date of enactment 

13 of this subsection, the Director, in consultation with 

14 State Medicaid programs, shall develop outreach 

15 plans for such programs to use to contact providers 

16 of health benefits, services, or supports for dual eli17 gible individuals and provide information and edu18 cation regarding the State Integrated Care Pro19 grams for Dual Eligible Individuals established 

20 under this title, how such program will operate in 

21 the State where such providers offer health benefits, 

22 services or supports for such individuals, and the im23 pact of such program on such providers. 


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1 ‘‘(2) COLLECTION OF DATA ON QUALITY MEAS2 URES FROM INTEGRATED CARE PLANS UNDER MED3 ICAID AND MEDICARE.— 

4 ‘‘(A) IN GENERAL.—Not later than 180 

5 days after the date of enactment of this sub6 section, the Director, in consultation with the 

7 Administrator of the Centers for Medicare & 

8 Medicaid Services and State Medicaid pro9 grams, shall establish a plan for collecting data 

10 on quality measures from health benefits plans 

11 that provide integrated care for dual eligible in12 dividuals under Medicare or Medicaid. Such 

13 data shall include, at a minimum, data relating 

14 to provider network availability in both Medi15 care and Medicaid, providers in-network who 

16 are accepting new Medicare and Medicaid pa17 tients, spending on supplemental benefits, and 

18 claims denials. 

19 ‘‘(B) AUTHORITY TO COLLECT ADDI20 TIONAL DATA AND INFORMATION; PUBLICA21 TION.—The Director may— 

22 ‘‘(i) collect additional data and infor23 mation relating to the quality of care pro24 vided for dual eligible individuals by health 

25 benefits plans that provide integrated care 


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1 for such individuals under Medicare or 

2 Medicaid; and 

3 ‘‘(ii) make the data and information 

4 collected in accordance with this paragraph 

5 publicly available. 

6 ‘‘(3) DEVELOPMENT OF AN ALIGNED PROGRAM

7 FOR INSTITUTIONAL SPECIAL NEEDS PLANS UNDER

8 MEDICAID.—Not later than 180 days after the date 

9 of enactment of this subsection, the Director, in con10 sultation with the Administrator of the Centers for 

11 Medicare & Medicaid Services and State Medicaid 

12 programs, shall develop an aligned program for of13 fering Institutional Special Needs Plans under Med14 icaid that has one entity financially responsible for 

15 providing health benefits, services, and supports for 

16 dual eligible individuals. 

17 ‘‘(4) ASSESSMENT OF NEED FOR CRITERIA TO

18 REGULATE AND EXPAND UTILIZATION OF INSTITU19 TIONAL SPECIAL NEEDS PLANS.—Not later than 180 

20 days after the date of enactment of this subsection, 

21 the Director, in consultation with the Administrator 

22 of the Centers for Medicare & Medicaid Services, 

23 shall assess the adequacy of regulations and over24 sight of Institutional Special Needs Plan to deter25 mine whether new, or additional requirements should 


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1 be established to improve the utilization, perform2 ance, and oversight of such plans and how such 

3 plans may be offered under State Integrated Care 

4 Programs for Dual Eligible Individuals established 

5 under this title. 

6 ‘‘(f) APPROPRIATIONS.—There are hereby appro7 priated, out of any funds in the Treasury not otherwise 

8 appropriated, for the first fiscal year that begins after the 

9 date of enactment of this title, and for each fiscal year 

10 thereafter, such sums as are necessary to carry out this 

11 title. 

12 ‘‘(g) DIRECT-HIRE AUTHORITY.—In carrying out 

13 this title, the Director shall have direct-hire authority to 

14 the extent required to implement and administer this title 

15 on a timely basis.’’. 

16 SEC. 102. PROVIDING FEDERAL COORDINATED HEALTH 

17 CARE OFFICE AUTHORITY OVER DUAL SNPS. 

18 (a) IN GENERAL.—Section 1859(f)(8) of the Social 

19 Security Act (42 U.S.C. 1395w–28(f)(8)) is amended by 

20 adding at the end the following new subparagraph: 

21 ‘‘(F) AUTHORITY OF FEDERAL COORDI22 NATED HEALTH CARE OFFICE.—For plan years 

23 beginning on or after January 1, 2025, the 

24 Federal Coordinated Health Care Office estab25 lished under section 2602 of Public Law 111– 


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1 148 shall have primary authority for imple2 menting and carrying out responsibilities of the 

3 Secretary with respect to the integration of spe4 cialized MA plans for special needs individuals 

5 described in subsection (b)(6)(B)(ii) under this 

6 subsection.’’. 

7 (b) CONFORMING AMENDMENT.—Section 2602(d)(6) 

8 of the Patient Protection and Affordable Care Act (42 

9 U.S.C. 1315b(d)(6)) is amended by inserting the following 

10 before the period: ‘‘and, for plan years beginning on or 

11 after January 1, 2025, to carry out subsection (f)(8)(F) 

12 of such section’’. 

13 SEC. 103. ADDITIONAL CONFORMING AMENDMENTS. 

14 (a) DEFINITION OF STATE.—Section 1101(a)(1) of 

15 the Social Security Act (42 U.S.C. 1301(a)(1)) is amend16 ed— 

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

18 ‘‘XIX, XXI, and XXII’’; and 

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

20 ‘‘XIX, XXI, and XXII’’. 

21 (b) MEDICARE ENROLLMENT.—Section 1851(a) of 

22 the Social Security Act (42 U.S.C. 1395w–21(a)) is 

23 amended by adding at the end the following new para24 graph: 


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1 ‘‘(4) ADDITIONAL ENROLLMENT OPTION FOR

2 DUAL ELIGIBLE INDIVIDUALS.—Dual eligible individ3 uals (as defined in section 2201) may also be eligible 

4 to enroll in an integrated care plan under title 

5 XXII.’’. 

6 (c) PREVENTING DUPLICATE PAYMENTS UNDER

7 MEDICAID.—Section 1903(i) of the Social Security Act 

8 (42 U.S.C. 1396b(i)) is amended— 

9 (1) by striking ‘‘or’’ at the end of paragraph 

10 (26); 

11 (2) by striking the period at the end of para12 graph (27) and inserting ‘‘; or’’; 

13 (3) by inserting after paragraph (27) the fol14 lowing new paragraph: 

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

16 medical assistance for a dual eligible individual (as 

17 defined in section 2201) enrolled in an integrated 

18 care plan under title XXII, except as specifically 

19 permitted under such title.’’; and 

20 (4) in the third sentence, by striking ‘‘, and 

21 (18)’’ and inserting ‘‘, (18), and (28)’’. 


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1 TITLE II—IMPROVING ELIGI2 BILITY DETERMINATIONS, EN3 ROLLMENT PROCESSES, AND 

4 QUALITY OF CARE FOR DUAL 

5 ELIGIBLE INDIVIDUALS 

6 SEC. 201. IDENTIFYING OPPORTUNITIES FOR STATE CO7 ORDINATION WITH RESPECT TO ELIGIBILITY 

8 DETERMINATIONS. 

9 Not later than 1 year after the date of enactment 

10 of this Act, the Secretary of Health and Human Services, 

11 in consultation with States, shall— 

12 (1) review State processes for determining 

13 whether an individual is a full-benefit dual individual 

14 (as defined in section 1935(c)(6) of the Social Secu15 rity Act (42 U.S.C. 1396u–5(c)(6)) but without the 

16 application of subparagraph (A)(i) of such section) 

17 and whether an individual is eligible for the low-in18 come subsidy program under section 1860D–14 of 

19 the Social Security Act (42 U.S.C. 1395w–114) and 

20 the Medicare Savings Program (as defined in section 

21 1144(c)(7) of such Act (42 U.S.C. 1320b– 

22 14(c)(7))); and 

23 (2) issue guidance for States that identifies op24 portunities for better coordination of such processes 

25 between the States and the Federal government. 


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1 SEC. 202. ALIGNMENT OF BIDDING, REPORTING, AND 

2 OTHER DATES AND DEADLINES FOR INTE3 GRATED CARE PLANS. 

4 Not later than 180 days after the date of enactment 

5 of this Act, the Director of the Federal Coordinated 

6 Health Care Office of the Centers for Medicare & Med7 icaid Services and the Administrator of the Centers for 

8 Medicare & Medicaid Services shall— 

9 (1) review bidding, reporting, and other signifi10 cant dates and deadlines applicable to integrated 

11 care plans under the Medicare program, the Med12 icaid program, and State Integrated Care Programs 

13 for Dual Eligible Individuals under title XXII of the 

14 Social Security Act; and 

15 (2) identify such administrative and legislative 

16 changes as are needed to ensure that all such dates 

17 and deadlines are aligned and consistent under all 

18 such programs. 

19 SEC. 203. GRANTS TO STATE AND LOCAL COMMUNITY OR20 GANIZATIONS FOR OUTREACH AND ENROLL21 MENT. 

22 (a) IN GENERAL.—From the amounts appropriated 

23 under subsection (c) for a fiscal year, the Secretary of 

24 Health and Human Services (in this section referred to 

25 as the ‘‘Secretary’’) shall award grants to State and local 

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1 ment efforts that are designed to increase the enrollment 

2 of dual eligible individuals (as defined in section 2201 of 

3 the Social Security Act) in health benefits plans that pro4 vide integrated care for such individuals under State Inte5 grated Care Programs for Dual Eligible Individuals estab6 lished under XXII of the Social Security Act. 

7 (b) MODEL STANDARDS.—The Secretary, in con8 sultation with the Administrator of the Administration for 

9 Community Living and States, shall develop and issue 

10 model standards for outreach and education conducted by 

11 State and local community organizations awarded grants 

12 under this section that include the following: 

13 (1) Information and education support is avail14 able for individuals in a range of languages, and on15 line, over the phone, and in person. 

16 (2) Materials presented are easy to read, writ17 ten in as low a reading comprehension level as pos18 sible, and are in the proper language for the indi19 vidual involved. 

20 (3) Information presented online is accessible 

21 for individuals with disabilities. 

22 (4) Information is presented in a manner that 

23 takes into consideration the accessibility needs of the 

24 individual, such as language access requirements 

25 and the health literacy level of the individual. 


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1 (c) APPROPRIATION.—There is appropriated, out of 

2 any money in the Treasury not otherwise appropriated, 

3 for the first fiscal year that begins after the date of enact4 ment of this Act, and for each fiscal year thereafter, 

5 $50,000,000 to carry out this section. 

6 SEC. 204. APPLICATION OF MODEL STANDARDS TO INFOR7 MATION REQUIREMENTS FOR INTEGRATED 

8 CARE PLANS. 

9 Not later than 1 year after the date of enactment 

10 of this Act, the Director of the Federal Coordinated 

11 Health Care Office of the Centers for Medicare & Med12 icaid Services and the Administrator of the Centers for 

13 Medicare & Medicaid Services jointly shall issue guidance 

14 or regulations requiring that any notice or informational 

15 materials provided to a dual eligible individual (as defined 

16 in section 2201 of the Social Security Act) by such Direc17 tor, Administrator, States, or health benefits plans that 

18 provide integrated care for such individuals under the 

19 Medicare program, the Medicaid program, or under State 

20 Integrated Care Programs for Dual Eligible Individuals 

21 established under XXII of the Social Security Act com22 plies with the model standards issued under section 

23 203(b). 


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1 SEC. 205. ENROLLMENT THROUGH INDEPENDENT BRO2 KERS. 

3 Not later than 1 year after the date of enactment 

4 of this Act, the Director of the Federal Coordinated 

5 Health Care Office of the Centers for Medicare & Med6 icaid Services and the Administrator of the Centers for 

7 Medicare & Medicaid Services jointly shall issue guidance 

8 or regulations providing that— 

9 (1) a dual eligible individual (as defined in sec10 tion 2201 of the Social Security Act) may not be en11 rolled in a health benefits plan that provides inte12 grated care for such individual under title XXII of 

13 the Social Security Act through a broker unless the 

14 broker is an independent broker (as defined under 

15 such guidance or regulations); 

16 (2) an independent broker may receive a com17 mission for the initial enrollment of a dual eligible 

18 individual in such a plan, but no commission shall 

19 be available to any broker for any subsequent enroll20 ment of such individual in any such plan; 

21 (3) if a broker disenrolls a dual eligible indi22 vidual from any such health benefits plan to a plan 

23 that provides partial or no integrated care, the 

24 broker, in accordance with the model standards 

25 issued under section 204(b), shall inform the indi26 vidual— 


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1 (A) of the health benefits plan the indi2 vidual is being disenrolled from; and 

3 (B) that the individual is being enrolled in 

4 a health benefits plan that provides partial or 

5 no integrated care and the potential implica6 tions of such disenrollment and enrollment on 

7 the individual’s care. 

8 SEC. 206. REDUCING THRESHOLD FOR LOOK-ALIKE D–SNP 

9 PLANS UNDER MEDICARE ADVANTAGE. 

10 For the first full plan year that begins on or after 

11 the date that is 1 year after the date of enactment of this 

12 Act, and each subsequent plan year, the Secretary of 

13 Health and Human Services— 

14 (1) shall implement section 422.514(d)(1)(ii) of 

15 title 42, Code of Federal Regulations (or any suc16 cessor regulations) by substituting ‘‘50 percent’’ for 

17 ‘‘80 percent’’; and 

18 (2) shall only count full-benefit dual eligible in19 dividuals (as defined in section 1935(c)(6) of the So20 cial Security Act (42 U.S.C. 1396u–5(c)(6))) for 

21 purposes of applying the threshold under such sec22 tion. 


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1 SEC. 207. REQUIRING REGULAR UPDATE OF PROVIDER DI2 RECTORIES. 

3 Not later than 1 year after the date of enactment 

4 of this Act, the Director of the Federal Coordinated 

5 Health Care Office of the Centers for Medicare & Med6 icaid Services and the Administrator of the Centers for 

7 Medicare & Medicaid Services shall promulgate regula8 tions that— 

9 (1) require Medicare Advantage plans under 

10 part C of title XVIII of the Social Security Act (42 

11 U.S.C. 1395w–21) and integrated care plans under 

12 title XXII of such Act to regularly update provider 

13 directories; and 

14 (2) include a measure relating to provider direc15 tor currency rating on star rating systems for Medi16 care Advantage plans under section 1853(o) of the 

17 Social Security Act (42 U.S.C. 1395w–23(o)) and 

18 integrated care plans under title XXII of such Act. 

19 SEC. 208. REVIEW OF HOSPITAL QUALITY STAR RATING 

20 SYSTEM. 

21 Not later than 180 days after the date of enactment 

22 of this Act, the Administrator of the Centers for Medicare 

23 & Medicaid Services shall— 

24 (1) review the hospital quality star rating sys25 tem under the Medicare program under title XVIII 


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1 of the Social Security Act (42 U.S.C. 1395 et seq.); 

2 and 

3 (2) identify such administrative and legislative 

4 changes as are needed to ensure that sufficient in5 formation is collected under such system regarding 

6 hospitals to effectively measure hospital quality. 

7 SEC. 209. REQUIREMENT FOR FCHCO AND STATE MEDICAID 

8 AGENCIES TO DEVELOP MAXIMUM STAFFING 

9 RATIOS FOR CARE COORDINATORS. 

10 (a) IN GENERAL.—The Director of the Federal Co11 ordinated Health Care Office, in consultation with State 

12 Medicaid agencies, shall develop model Federal legislation 

13 that would establish a process for determining a maximum 

14 care coordinator-to-patient ratio for integrated care plans 

15 providing care to dual eligible individuals under an inte16 grated care model under title XXII of the Social Security 

17 Act. Such process shall take into account the varying 

18 needs required by different categories of patients. 

19 (b) SUBMISSION OF MODEL LEGISLATION.—Not 

20 later than 180 days after the date of enactment of this 

21 Act, the Director of the Federal Coordinated Health Care 

22 Office shall submit the model legislation developed under 

23 subsection (a) to— 

24 (1) the Secretary of Health and Human Serv25 ices; 


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1 (2) the Committee on Finance of the Senate; 

2 (3) the Committee on Energy and Commerce of 

3 the House of Representatives; and 

4 (4) the Committee on Ways and Means of the 

5 House of Representatives. 

6 SEC. 210. CMMI TESTING OF COVERAGE OF PARTIAL BEN7 EFIT DUAL ELIGIBLE INDIVIDUALS THROUGH 

8 STATE INTEGRATED CARE PROGRAMS. 

9 Section 1115A of the Social Security Act (42 U.S.C. 

10 1315a) is amended— 

11 (1) in subsection (b)(2)(A), by adding at the 

12 end the following new sentence: ‘‘The models se13 lected under this subparagraph shall include the 

14 testing of the model described in subsection (h)(1).’’; 

15 and 

16 (2) by adding at the end the following new sub17 section: 

18 ‘‘(h) TESTING OF MODEL FOR PROVIDING COVERAGE

19 OF PARTIAL BENEFIT DUAL ELIGIBLE INDIVIDUALS

20 THROUGH PARTIALLY INTEGRATED CARE PLANS UNDER

21 STATE INTEGRATED CARE PROGRAMS.— 

22 ‘‘(1) IN GENERAL.—The model described in this 

23 paragraph is a model under which States may offer 

24 coverage to partial benefit dual eligible individuals 

25 through partially integrated care plans under State 


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1 Integrated Care Programs established under title 

2 XXII. 

3 ‘‘(2) PARTIAL BENEFIT DUAL ELIGIBLE INDI4 VIDUAL.—For purposes of this subsection, the term 

5 ‘partial benefit dual eligible individual’ means an in6 dividual who— 

7 ‘‘(A) is eligible for the low-income subsidy 

8 program under section 1860D–14, the Medicare 

9 Savings Program (as defined in section 

10 1144(c)(7)), or both; and 

11 ‘‘(B) is not a full-benefit dual eligible indi12 vidual (as such term is defined in section 

13 1935(c)(6), but without the application of sub14 paragraph (A)(i) of such section).’’. 

15 TITLE III—ADMINISTRATION 

16 SEC. 301. ALIGNMENT OF BILLING CODES UNDER TITLES 

17 XVIII, XIX, AND XXII. 

18 Not later than 180 days after the date of enactment 

19 of this Act, the Director of the Federal Coordinated 

20 Health Care Office of the Centers for Medicare & Med21 icaid Services and the Administrator of the Centers for 

22 Medicare & Medicaid Services shall— 

23 (1) review billing codes under the Medicare pro24 gram, the Medicaid program, and State Integrated 


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1 Care Programs for Dual Eligible Individuals under 

2 XXII of the Social Security Act; 

3 (2) conduct at least one listening session open 

4 to the public on the alignment of billing under the 

5 programs identified in paragraph (1); and 

6 (3) identify such administrative and legislative 

7 changes as are needed to ensure that all such billing 

8 codes are aligned and consistent under all such pro9 grams. 

10 TITLE IV—PACE 

11 SEC. 401. REQUIRING STATES TO OFFER PACE PROGRAM 

12 SERVICES TO ELIGIBLE INDIVIDUALS. 

13 (a) IN GENERAL.—Section 1934 of the Social Secu14 rity Act (42 U.S.C. 1396u–4) is amended— 

15 (1) in subsection (a)(1)— 

16 (A) by striking ‘‘A State may elect to pro17 vide’’ and inserting ‘‘A State shall provide’’; 

18 and 

19 (B) by striking ‘‘A State may establish a 

20 numerical limit on the number of individuals 

21 who may be enrolled in a PACE program under 

22 a PACE program agreement.’’; 

23 (2) in subsection (e)— 

24 (A) in paragraph (1)— 


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1 (i) by striking ‘‘(A) IN GENERAL.— 

2 The Secretary’’ and inserting ‘‘The Sec3 retary’’; and 

4 (ii) by striking subparagraph (B); 

5 (B) in paragraph (2)(A)(ii); and 

6 (3) in subsection (h)(2)— 

7 (A) by striking ‘‘(A) IN GENERAL.—Except 

8 as provided under subparagraph (B), and’’ and 

9 inserting ‘‘Except as provided under’’; and 

10 (B) by striking subparagraph (B). 

11 (b) STATE PLAN REQUIREMENT.—Section 1902(a) 

12 of the Social Security Act (42 U.S.C. 1396a(a)) is amend13 ed— 

14 (1) in paragraph (86), by striking ‘‘; and’’ and 

15 inserting a semicolon; 

16 (2) in paragraph (87)(D), by striking the period 

17 at the end and inserting ‘‘; and’’; and 

18 (3) by inserting after paragraph (87) the fol19 lowing new paragraph; 

20 ‘‘(88) provide, in accordance with section 1934, 

21 that the State shall provide medical assistance with 

22 respect to PACE program services to PACE pro23 gram eligible individuals who are eligible for medical 

24 assistance under the State plan and who are enrolled 


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1 in a PACE program under a PACE program agree2 ment.’’. 

3 (c) EFFECTIVE DATE.—The amendments made by 

4 this section shall take effect on the date that is 180 days 

5 after the date of enactment of this Act. 

6 SEC. 402. ENROLLMENT OF PACE BENEFICIARIES AT ANY 

7 TIME. 

8 (a) IN GENERAL.—Sections 1894(d)(5)(A) and 

9 1934(d)(5)(A) (42 U.S.C. 1395eee(d)(5)(A), 1396u– 

10 4(d)(5)(A)) are each amended— 

11 (1) in the subparagraph header, by inserting 

12 ‘‘ENROLLMENT OR’’; 

13 (2) by inserting ‘‘PACE program eligible indi14 viduals to enroll in a PACE program at any time 

15 and’’ after ‘‘shall permit’’; and 

16 (3) by adding at the end the following sentence: 

17 ‘‘The amount of any capitated payment made to a 

18 PACE provider under subsection (d)(1) may be ad19 justed to account for any PACE program eligible in20 dividuals who enroll after the first day of a month 

21 (with the amount of such payment adjustment being 

22 proportional to the portion of such month for which 

23 the individual is enrolled)’’. 


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1 (b) EFFECTIVE DATE.—The amendments made by 

2 this section shall take effect on the date that is 180 days 

3 after the date of enactment of this Act. 

4 SEC. 403. EXTENDING ELIGIBILITY FOR PACE TO MEDI5 CARE-ELIGIBLE INDIVIDUALS UNDER THE 

6 AGE OF 55. 

7 (a) IN GENERAL.—Sections 1894(a)(5)(A) and 

8 1934(a)(5)(A) of the Social Security Act (42 U.S.C. 

9 1395eee(a)(5), 1396u–4(a)(5)) are each amended by in10 serting ‘‘(or any age in the case of an individual who is 

11 eligible for benefits under part A, or enrolled under part 

12 B, of title XVIII)’’ after ‘‘is 55 years of age or older’’. 

13 (b) EFFECTIVE DATE.—The amendments made by 

14 this section shall take effect on the date that is 180 days 

15 after the date of enactment of this Act. 

16 SEC. 404. REMOVAL OF QUARTERLY RESTRICTIONS FOR 

17 SUBMISSION OF A NEW PACE ORGANIZATION 

18 APPLICATION, AND REMOVAL OF QUARTERLY 

19 RESTRICTIONS FOR APPLICATIONS IN A NEW 

20 SERVICE AREA. 

21 (a) IN GENERAL.—Sections 1894(e) and 1934(e) of 

22 the Social Security Act (42 U.S.C. 1395eee(e), 1396u– 

23 4(e)) are each amended by adding at the end the following 

24 new paragraph: 


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1 ‘‘(9) NO QUARTERLY OR GEOGRAPHIC LIMITA2 TIONS ON APPLICATIONS FOR PACE PROVIDER STA3 TUS.—The Secretary shall not prohibit an entity 

4 that meets the requirements for a PACE provider 

5 under this section from— 

6 ‘‘(A) submitting multiple applications in 

7 the same quarter; or 

8 ‘‘(B) submitting multiple applications to 

9 operate a PACE program in the same service 

10 area.’’. 

11 (b) EFFECTIVE DATE.—The amendments made by 

12 this section shall take effect on the date that is 180 days 

13 after the date of enactment of this Act. 

14 SEC. 405. ENSURING MEDICARE-ONLY PACE PROGRAM EN15 ROLLEES HAVE A CHOICE OF PRESCRIPTION 

16 DRUG PLANS UNDER MEDICARE PART D. 

17 Section 1860D–21(f) of the Social Security Act (42 

18 U.S.C. 1395w–131(f)) is amended— 

19 (1) in paragraph (1), by striking ‘‘and (3)’’ and 

20 inserting ‘‘(3), and (4)’’; and 

21 (2) by adding at the end the following new 

22 paragraph: 

23 ‘‘(4) ENSURING CHOICE OF PRESCRIPTION

24 DRUG PLANS.— 


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1 ‘‘(A) IN GENERAL.—For plan years begin2 ning on or after January 1, 2024, subject to 

3 the succeeding provisions of this paragraph, an 

4 applicable PACE program enrollee may elect to 

5 enroll in a qualified standalone prescription 

6 drug plan, in accordance with rules established 

7 by the Secretary pursuant to this paragraph, 

8 while enrolled under a PACE program. 

9 ‘‘(B) DEFINITION OF APPLICABLE PACE

10 PROGRAM ENROLLEE; QUALIFIED STANDALONE

11 PRESCRIPTION DRUG PLAN.—In this paragraph: 

12 ‘‘(i) APPLICABLE PACE PROGRAM EN13 ROLLEE.—The term ‘applicable PACE pro14 gram enrollee’ means a part D eligible in15 dividual who— 

16 ‘‘(I) is not entitled to medical as17 sistance under title XIX; and 

18 ‘‘(II) is enrolled under a PACE 

19 program offered by a PACE provider. 

20 ‘‘(ii) QUALIFIED STANDALONE PRE21 SCRIPTION DRUG PLAN.—The term ‘quali22 fied standalone prescription drug plan’ 

23 means, with respect to an applicable PACE 

24 program enrollee, a prescription drug 

25 plan— 


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1 ‘‘(I) that is not an MA–PD plan; 

2 ‘‘(II) that is not operated by the 

3 PACE program under which the indi4 vidual is enrolled; and 

5 ‘‘(III) for which the Secretary de6 termines, with respect to the applica7 ble PACE program enrollees enrolled 

8 in a PACE program offered by such 

9 PACE provider, that— 

10 ‘‘(aa) the estimated bene11 ficiary out-of-pocket costs (as de12 fined in clause (iii)) for the plan 

13 year for qualified prescription 

14 drug coverage under the plan is 

15 equal to or less than the esti16 mated out-of-pocket costs for 

17 such coverage under the prescrip18 tion drug plan offered by the 

19 PACE program in which the ap20 plicable PACE program enrollee 

21 is enrolled; and 

22 ‘‘(bb) the estimated total 

23 amount of Federal subsidies for 

24 the plan year for qualified pre25 scription drug coverage under the 


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1 plan (which may be estimated 

2 using data from the previous 

3 plan year) is equal to or less than 

4 the estimated subsidy amount for 

5 such coverage under the prescrip6 tion drug plan offered by the 

7 PACE program in which the ap8 plicable PACE program enrollee 

9 is enrolled. 

10 ‘‘(iii) OUT-OF-POCKET COSTS DE11 FINED.—In this paragraph, the term ‘out12 of-pocket costs’ includes premiums imposed 

13 under a prescription drug plan and, in the 

14 case of coverage under a qualified stand15 alone prescription drug plan, deductibles, 

16 copayments, coinsurance, and other cost17 sharing. 

18 ‘‘(C) OUT-OF-POCKET COSTS.—In the case 

19 where an applicable PACE program enrollee 

20 elects to enroll in a qualified standalone pre21 scription drug plan pursuant to this paragraph, 

22 the individual shall be responsible for any out23 of-pocket costs imposed under the plan (includ24 ing costs for nonformulary drugs) after the ap25 plication of any subsidies under section 1860D– 


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1 14 for an applicable PACE program enrollee 

2 who is a subsidy eligible individual (as defined 

3 in section 1860D–14(a)(3)). 

4 ‘‘(D) REQUIREMENTS FOR PACE PRO5 GRAMS.— 

6 ‘‘(i) EDUCATING AND HELPING EN7 ROLL BENEFICIARIES INTO A PART D PLAN

8 OPTION.—A PACE program shall be re9 quired to provide— 

10 ‘‘(I) information to all applicable 

11 PACE program enrollees who are en12 rolled under the PACE program re13 garding the option to enroll in a quali14 fied standalone prescription drug plan 

15 under this paragraph; and 

16 ‘‘(II) upon request of an applica17 ble PACE program enrollee, coun18 seling and coordination to assist appli19 cable PACE program enrollees in 

20 making decisions regarding the selec21 tion of qualified standalone prescrip22 tion drug plans available to them. 

23 ‘‘(ii) MONITORING DRUG UTILIZATION, 

24 ADHERENCE, AND SPEND.—A PACE pro25 gram shall be required to monitor drug 


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1 utilization, medication adherence, and drug 

2 spending (through claims data shared pur3 suant to subparagraph (F) and otherwise) 

4 throughout the year with respect to any 

5 applicable PACE program enrollee who 

6 elects to enroll in a qualified standalone 

7 prescription drug plan under this para8 graph in order to coordinate with the PDP 

9 sponsor of such plan regarding the drug 

10 benefits offered by the plan, including 

11 upon request of an applicable PACE pro12 gram enrollee the filing of any grievances 

13 or appeals with the plan on behalf of the 

14 applicable PACE program enrollee. 

15 ‘‘(E) DISENROLLMENT.—An applicable 

16 PACE program enrollee may disenroll from the 

17 qualified standalone prescription drug plan 

18 elected by such applicable PACE program en19 rollee under subparagraph (A) if the enrollee 

20 changes medication during the plan year or can 

21 demonstrate an unexpected increase in out-of22 pocket costs post enrollment. 

23 ‘‘(F) CLAIMS SHARING.—In the case where 

24 an applicable PACE program enrollee enrolls in 

25 a qualified standalone prescription drug plan, 


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1 the PACE program in which the individual is 

2 enrolled and the PDP sponsor of the qualified 

3 standalone prescription drug plan shall share 

4 claims data with each other with respect to the 

5 applicable PACE program enrollee as needed to 

6 support care management for the applicable 

7 PACE program enrollee (including for purposes 

8 of monitoring and coordination required under 

9 subparagraph (D)(ii)) and for purposes of com10 prehensive risk adjustment under section 

11 1894(d). Such data shall be shared without the 

12 need for any formal or informal request of the 

13 PACE program in which the individual is en14 rolled or the PDP sponsor of the qualified 

15 standalone prescription drug plan in which the 

16 applicable PACE program enrollee is enrolled. 

17 ‘‘(G) RULE OF CONSTRUCTION.—The au18 thority established under this paragraph for an 

19 applicable PACE program enrollee to elect to 

20 enroll in a qualified standalone prescription 

21 drug plan shall not be construed as permitting 

22 an applicable PACE program enrollee to enroll 

23 in a prescription drug plan that is not a quali24 fied standalone prescription drug plan. 

25 ‘‘(H) RELATION TO PACE STATUTES.— 


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1 ‘‘(i) IN GENERAL.—The authority pro2 vided under this paragraph for an applica3 ble PACE program enrollee to elect to en4 roll in a qualified standalone prescription 

5 drug plan shall apply notwithstanding sub6 section (a)(1)(B)(1) of section 1894 and 

7 such other provisions of sections 1894 and 

8 1934 as the Secretary determines may con9 flict with the authority provided for under 

10 this paragraph, including subsections 

11 (a)(2)(B), (b)(1)(A)(i), (b)(1)(C), 

12 (f)(2)(B)(ii), and (f)(2)(B)(v) of such sec13 tions. 

14 ‘‘(ii) CLARIFICATION ON PAYMENT

15 FOR PART D DRUG COVERAGE.—Insofar as 

16 an applicable PACE program enrollee is 

17 enrolled in a qualified standalone prescrip18 tion drug plan under this paragraph, the 

19 PACE program shall not be entitled to 

20 payment under section 1894(d) for the 

21 provision of qualified prescription drug 

22 coverage under such standalone prescrip23 tion drug plan with respect to such appli24 cable PACE program enrollee.’’. 

Æ 


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