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[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4484 Introduced in House (IH)]

113th CONGRESS
  2d Session
                                H. R. 4484

To amend title XVIII of the Social Security Act to provide improvements 
  for Medicare Advantage special needs plans, and for other purposes.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                             April 10, 2014

Ms. Sinema (for herself, Mr. Gibson, Mr. Barber, Mr. Bilirakis, and Mr. 
Murphy of Florida) introduced the following bill; which was referred to 
 the Committee on Ways and Means, and in addition to the Committee on 
Energy and Commerce, 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 amend title XVIII of the Social Security Act to provide improvements 
  for Medicare Advantage special needs plans, and for other purposes.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Strengthening Healthcare Options for 
Vulnerable Populations Act''.

SEC. 2. REAUTHORIZATION OF CERTAIN MEDICARE ADVANTAGE SPECIAL NEEDS 
              PLANS.

    (a) Permanent Extension of Medicare Advantage Dual Special Needs 
Plans Authority.--Section 1859(f)(1) of the Social Security Act (42 
U.S.C. 1395w-28(f)(1)) is amended by inserting ``, in the case of a 
specialized MA plan for special needs individuals who are not described 
in section 1859(b)(6)(B)(ii),'' before ``for periods before January 1, 
2015''.
    (b) Medicare Advantage Dual Special Needs Plans Required To Provide 
Integrated Care.--Section 1859(f)(3) of the Social Security Act (42 
U.S.C. 1395w-28(f)(3)) is amended by adding at the end the following 
new subparagraph:
                    ``(F) Not later than December 31, 2018, the plan is 
                fully integrated with capitated contracts with States 
                for any Medicaid benefits, including long-term care and 
                behavioral health, to the extent State law permits 
                capitation of such services under such plan.''.
    (c) Clearly Defined Role of State Medicaid Agency.--Section 
1852(a)(1)(B) of the Social Security Act (42 U.S.C. 1395w-22(a)(1)(B)) 
is amended by adding at the end the following new clause:
                            ``(vi) Defined role of state medicaid 
                        agencies with respect to fully integrated dual 
                        special needs plans.--The Secretary, in 
                        coordination with State Medicaid Directors, 
                        shall develop a clearly defined role for State 
                        Medicaid agencies in contracting and oversight 
                        of plans described in clause (v)(II).''.

SEC. 3. IMPROVEMENTS TO MEDICARE ADVANTAGE 5-STAR QUALITY RATING SYSTEM 
              FOR PLANS WITH PREDOMINATELY DUAL ELIGIBLE ENROLLEES.

    (a) Treatment of Plans With Disproportionately High Dual Eligible 
Enrollees.--Section 1853(o) of the Social Security Act (42 U.S.C. 
1395w-23(o)) is amended by adding at the end the following new 
paragraph:
            ``(6) Treatment of plans with disproportionately high dual 
        eligible enrollees.--
                    ``(A) In general.--In implementing this subsection, 
                the Secretary shall take such steps as are necessary to 
                ensure that the quality rating for a plan--
                            ``(i) does not disadvantage such a plan 
                        that enrolls--
                                    ``(I) full-benefit dual eligible 
                                individual (as defined in section 
                                1935(c)(6));
                                    ``(II) qualified Medicare 
                                beneficiaries (as defined in section 
                                1905(p)(1)); or
                                    ``(III) individuals with complex 
                                health care needs, such as individuals 
                                with multiple conditions or individuals 
                                who require chronic care or 
                                institutional care; and
                            ``(ii) accounts for differences in 
                        socioeconomic and demographic characteristics 
                        of enrollees of such a plan that result in 
                        significant variation in health outcomes.
                    ``(B) Specific steps.--The steps described in 
                subparagraph (A) shall include at least the following:
                            ``(i) Comparing specialized MA plans for 
                        special needs individuals (as defined in 
                        section 1859(b)(6)) for special needs 
                        individuals who are described in subparagraph 
                        (B)(ii) of such section only against other 
                        plans with the same types of enrollment.
                            ``(ii) Developing a methodology specific to 
                        specialized MA plans for special needs 
                        individuals (as defined in section 1859(b)(6)) 
                        for special needs individuals who are described 
                        in subparagraph (B)(ii) of such section for 
                        determining a quality rating under this 
                        subsection for such plans.
                            ``(iii) Developing appropriate case mix 
                        adjustment to Healthcare Effectiveness Data and 
                        Information Set (HEDIS) and Health Outcomes 
                        Survey (HOS) measures for specialized MA plans 
                        for special needs individuals (as defined in 
                        section 1859(b)(6)) for special needs 
                        individuals who are described in subparagraph 
                        (B)(ii) of such section that account for 
                        factors beyond the control of the health 
                        system, such as the management of conditions.
                            ``(iv) Identifying and implementing those 
                        quality measures that are appropriate for 
                        evaluating the performance of specialized MA 
                        plans for special needs individuals (as defined 
                        in section 1859(b)(6)) for special needs 
                        individuals who are described in subparagraph 
                        (B)(ii) of such section.
                            ``(v) Eliminating duplicative or 
                        substantially similar measures applied under 
                        this title or title XIX with respect to 
                        specialized MA plans.''.
    (b) Temporary Treatment of Certain Dual Special Needs Plans.--
Section 1853(o) of the Social Security Act (42 U.S.C. 1395w-23(o)), as 
amended by subsection (a), is further amended by adding at the end the 
following new paragraph:
            ``(7) Temporary treatment of certain dual special needs 
        plans.--In implementing this subsection during the period 
        beginning on the date of the enactment of this paragraph and 
        ending one year after the date on which the Secretary has taken 
        such steps as are required under paragraph (6), the Secretary 
        may increase the quality rating that a specialized MA plans for 
        special needs individuals (as defined in section 1859(b)(6)) 
        for special needs individuals who are described in subparagraph 
        (B)(ii) of such section would otherwise receive under this 
        subsection for a year by 0.5 stars if the plan demonstrates to 
        the satisfaction of the Secretary that the quality rating the 
        plan would have otherwise received is predominately 
        attributable to socio-economic, demographic, or pre-existing 
        complex health care needs of the population enrolled in such 
        plan with respect to such year instead of the performance of 
        the plan with respect to such year.''.
    (c) GAO Report.--Not later than one year after the date on which 
the Secretary of Health and Human Services has taken such steps as are 
required under paragraph (6) of section 1853(o) of the Social Security 
Act (42 U.S.C. 1395w-23(o)), as added by subsection (a), and annually 
thereafter for the following four years, the Comptroller General of the 
United States shall submit to Congress a report that includes a 
comprehensive review of the effectiveness of, and recommendations to 
improve, such steps so taken for improving health outcomes, cost 
controls, and beneficiary satisfaction.

SEC. 4. ADDITIONAL IMPROVEMENTS TO THE OVERSIGHT AND OPERATION OF 
              MEDICARE ADVANTAGE DUAL SPECIAL NEEDS PLANS BY THE 
              FEDERAL COORDINATED HEALTH CARE OFFICE.

    (a) Dedicated Point of Contact for Assisting States With 
Administration.--Section 2602(d) of the Patient Protection and 
Affordable Care Act (42 U.S.C. 1315b(d)) is amended by adding at the 
end the following new paragraph:
            ``(6) Serving as the dedicated point of contact within the 
        Centers for Medicare & Medicaid Services to assist States with 
        ongoing issues related to the administration of specialized MA 
        plans for special needs individuals (as defined in section 
        1859(b)(6) of the Social Security Act) for special needs 
        individuals who are described in subparagraph (B)(ii) of such 
        section, including--
                    ``(A) addressing any misalignment between the 
                contracting timelines, processes, and deadlines under 
                title XVIII of such Act, with respect to such plans for 
                such individuals and contracting timelines, processes, 
                and deadlines under title XIX of such Act, with respect 
                to such plans and individuals; and
                    ``(B) streamlining the flow of information to dual 
                eligible individuals and establishing a single set of 
                rules for outreach and marketing to such 
                individuals.''.
    (b) Authority To Waive Certain Requirements.--
            (1) In general.--Subject to paragraph (2), the Secretary of 
        Health and Human Services, through the Federal Coordinated 
        Health Care Office established under section 2602 of the 
        Patient Protection and Affordable Care Act (42 U.S.C. 1315b) 
        and in coordination with the appropriate State Medicaid agency, 
        may waive the application of requirements under title XVIII of 
        the Social Security Act to promote the integration, alignment, 
        and delivery of items and services under the Medicare program 
        under title XVIII of such Act and the Medicaid program under 
        title XIX of such Act, with respect to dual eligible 
        individuals (as defined in section 2602(f) of the Patient 
        Protection and Affordable Care Act (42 U.S.C. 1315b(f)), and to 
        ensure the seamless delivery of patient-centered services 
        across the continuum of care with respect to such individuals.
            (2) Public notice requirement.--The Secretary may not waive 
        the application of a requirement pursuant to paragraph (1) 
        unless the Secretary makes such waiver publicly available 
        (whether on the public Internet website of Department of Health 
        and Human Services, or otherwise) at least 30 days before the 
        effective date of such waiver.

SEC. 5. IMPROVEMENTS TO DISPUTE RESOLUTION FOR CLAIMS AND APPEALS UNDER 
              MEDICARE ADVANTAGE DUAL SPECIAL NEEDS PLANS.

    (a) Medicare Advantage Dual Special Needs Plans Required To Provide 
Coverage During Appeals Process.--Section 1859(f)(3) of the Social 
Security Act (42 U.S.C. 1395w-28(f)(3)), as amended by section 2(b), is 
further amended by adding at the end the following new subparagraph:
                    ``(G) For plan years beginning after December 31, 
                2015, coverage under this title and title XIX of an 
                individual enrolled under such respective title shall 
                continue during any determination, reconsideration, or 
                appeals proceeding described in section 1852(g), with 
                respect to such individual.''.
    (b) Streamlined Pathway for Dispute Resolution.--Not later than 
December 31, 2015, the Secretary of Health and Human Services shall 
establish a streamlined process for dispute resolution for claims and 
appeals, with respect items and services furnished to special needs 
individuals described in section 1859(b)(6)(B)(ii) of the Social 
Security Act (42 U.S.C. 1395w-28(b)(6)(B)(ii)), to align such process 
under the Medicare program under title XVIII of the Social Security Act 
with such process under the Medicaid program under title XIX of such 
Act. Such streamlined process shall take into account various State 
requirements and promote a pathway that would be the most beneficial 
for individuals entitled to benefits under part A of title XVIII of 
such Act or enrolled under part B of such Act and to individuals 
enrolled under a State plan under title XIX of such Act.

SEC. 6. REPORT ON IMPLEMENTATION OF CERTAIN MEDICARE AND MEDICAID FRAUD 
              DETECTION AND PROGRAM INTEGRITY PROVISIONS.

    Section 1128J(a)(1)(A) of the Social Security Act (42 U.S.C. 1320a-
7k(a)(1)(A)) is amended by adding at the end the following new clause:
                            ``(iii) Report on integrated data 
                        repository and one program integrity system.--
                        Not later than six months after the date of 
                        enactment of this clause, the Secretary shall 
                        submit to the appropriate Congressional 
                        committees a report on the following:
                                    ``(I) Integrated data repository.--
                                Efforts to finalize plans and schedules 
                                for fully implementing and expanding 
                                the use of the Integrated Data 
                                Repository, including actions taken to 
                                finalize, implement, and manage plans 
                                for incorporating data into the 
                                Integrated Data Repository and actions 
                                taken to define measurable financial 
                                benefits expected from the 
                                implementation of the Integrated Data 
                                Repository.
                                    ``(II) One program integrity 
                                system.--Actions taken to plan, 
                                schedule, and conduct training on the 
                                One Program Integrity System, a Web-
                                based portal and suite of software 
                                tools used to analyze and extract data 
                                from the Integrated Data Repository, 
                                and actions taken to define measurable 
                                financial benefits expected from the 
                                use of the One Program Integrity 
                                System.''.
                                 <all>
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