I 

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. 

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. 

4 This Act may be cited as the ‘‘Strengthening 

5 Healthcare Options for Vulnerable Populations Act’’. 


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1 SEC. 2. REAUTHORIZATION OF CERTAIN MEDICARE ADVAN2 TAGE SPECIAL NEEDS PLANS. 

3 (a) PERMANENT EXTENSION OF MEDICARE ADVAN4 TAGE DUAL SPECIAL NEEDS PLANS AUTHORITY.—Sec5 tion 1859(f)(1) of the Social Security Act (42 U.S.C. 

6 1395w–28(f)(1)) is amended by inserting ‘‘, in the case 

7 of a specialized MA plan for special needs individuals who 

8 are not described in section 1859(b)(6)(B)(ii),’’ before 

9 ‘‘for periods before January 1, 2015’’. 

10 (b) MEDICARE ADVANTAGE DUAL SPECIAL NEEDS

11 PLANS REQUIRED TO PROVIDE INTEGRATED CARE.— 

12 Section 1859(f)(3) of the Social Security Act (42 U.S.C. 

13 1395w–28(f)(3)) is amended by adding at the end the fol14 lowing new subparagraph: 

15 ‘‘(F) Not later than December 31, 2018, 

16 the plan is fully integrated with capitated con17 tracts with States for any Medicaid benefits, in18 cluding long-term care and behavioral health, to 

19 the extent State law permits capitation of such 

20 services under such plan.’’. 

21 (c) CLEARLY DEFINED ROLE OF STATE MEDICAID

22 AGENCY.—Section 1852(a)(1)(B) of the Social Security 

23 Act (42 U.S.C. 1395w–22(a)(1)(B)) is amended by adding 

24 at the end the following new clause: 

25 ‘‘(vi) DEFINED ROLE OF STATE MED26 ICAID AGENCIES WITH RESPECT TO FULLY


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1 INTEGRATED DUAL SPECIAL NEEDS

2 PLANS.—The Secretary, in coordination 

3 with State Medicaid Directors, shall de4 velop a clearly defined role for State Med5 icaid agencies in contracting and oversight 

6 of plans described in clause (v)(II).’’. 

7 SEC. 3. IMPROVEMENTS TO MEDICARE ADVANTAGE 5–STAR 

8 QUALITY RATING SYSTEM FOR PLANS WITH 

9 PREDOMINATELY DUAL ELIGIBLE ENROLL10 EES. 

11 (a) TREATMENT OF PLANS WITH DISPROPORTION12 ATELY HIGH DUAL ELIGIBLE ENROLLEES.—Section 

13 1853(o) of the Social Security Act (42 U.S.C. 1395w– 

14 23(o)) is amended by adding at the end the following new 

15 paragraph: 

16 ‘‘(6) TREATMENT OF PLANS WITH DISPROPOR17 TIONATELY HIGH DUAL ELIGIBLE ENROLLEES.— 

18 ‘‘(A) IN GENERAL.—In implementing this 

19 subsection, the Secretary shall take such steps 

20 as are necessary to ensure that the quality rat21 ing for a plan— 

22 ‘‘(i) does not disadvantage such a plan 

23 that enrolls— 


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1 ‘‘(I) full-benefit dual eligible indi2 vidual (as defined in section 

3 1935(c)(6)); 

4 ‘‘(II) qualified Medicare bene5 ficiaries (as defined in section 

6 1905(p)(1)); or 

7 ‘‘(III) individuals with complex 

8 health care needs, such as individuals 

9 with multiple conditions or individuals 

10 who require chronic care or institu11 tional care; and 

12 ‘‘(ii) accounts for differences in socio13 economic and demographic characteristics 

14 of enrollees of such a plan that result in 

15 significant variation in health outcomes. 

16 ‘‘(B) SPECIFIC STEPS.—The steps de17 scribed in subparagraph (A) shall include at 

18 least the following: 

19 ‘‘(i) Comparing specialized MA plans 

20 for special needs individuals (as defined in 

21 section 1859(b)(6)) for special needs indi22 viduals who are described in subparagraph 

23 (B)(ii) of such section only against other 

24 plans with the same types of enrollment. 


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1 ‘‘(ii) Developing a methodology spe2 cific to specialized MA plans for special 

3 needs individuals (as defined in section 

4 1859(b)(6)) for special needs individuals 

5 who are described in subparagraph (B)(ii) 

6 of such section for determining a quality 

7 rating under this subsection for such 

8 plans. 

9 ‘‘(iii) Developing appropriate case mix 

10 adjustment to Healthcare Effectiveness 

11 Data and Information Set (HEDIS) and 

12 Health Outcomes Survey (HOS) measures 

13 for specialized MA plans for special needs 

14 individuals (as defined in section 

15 1859(b)(6)) for special needs individuals 

16 who are described in subparagraph (B)(ii) 

17 of such section that account for factors be18 yond the control of the health system, such 

19 as the management of conditions. 

20 ‘‘(iv) Identifying and implementing 

21 those quality measures that are appro22 priate for evaluating the performance of 

23 specialized MA plans for special needs indi24 viduals (as defined in section 1859(b)(6)) 

25 for special needs individuals who are deVerDate Mar 15 2010 00:23 Apr 16, 2014 Jkt 039200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H4484.IH H4484

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1 scribed in subparagraph (B)(ii) of such 

2 section. 

3 ‘‘(v) Eliminating duplicative or sub4 stantially similar measures applied under 

5 this title or title XIX with respect to spe6 cialized MA plans.’’. 

7 (b) TEMPORARY TREATMENT OF CERTAIN DUAL

8 SPECIAL NEEDS PLANS.—Section 1853(o) of the Social 

9 Security Act (42 U.S.C. 1395w–23(o)), as amended by 

10 subsection (a), is further amended by adding at the end 

11 the following new paragraph: 

12 ‘‘(7) TEMPORARY TREATMENT OF CERTAIN

13 DUAL SPECIAL NEEDS PLANS.—In implementing this 

14 subsection during the period beginning on the date 

15 of the enactment of this paragraph and ending one 

16 year after the date on which the Secretary has taken 

17 such steps as are required under paragraph (6), the 

18 Secretary may increase the quality rating that a spe19 cialized MA plans for special needs individuals (as 

20 defined in section 1859(b)(6)) for special needs indi21 viduals who are described in subparagraph (B)(ii) of 

22 such section would otherwise receive under this sub23 section for a year by 0.5 stars if the plan dem24 onstrates to the satisfaction of the Secretary that 

25 the quality rating the plan would have otherwise reVerDate Mar 15 2010 00:23 Apr 16, 2014 Jkt 039200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H4484.IH H4484

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1 ceived is predominately attributable to socio-eco2 nomic, demographic, or pre-existing complex health 

3 care needs of the population enrolled in such plan 

4 with respect to such year instead of the performance 

5 of the plan with respect to such year.’’. 

6 (c) GAO REPORT.—Not later than one year after the 

7 date on which the Secretary of Health and Human Serv8 ices has taken such steps as are required under paragraph 

9 (6) of section 1853(o) of the Social Security Act (42 

10 U.S.C. 1395w–23(o)), as added by subsection (a), and an11 nually thereafter for the following four years, the Comp12 troller General of the United States shall submit to Con13 gress a report that includes a comprehensive review of the 

14 effectiveness of, and recommendations to improve, such 

15 steps so taken for improving health outcomes, cost con16 trols, and beneficiary satisfaction. 

17 SEC. 4. ADDITIONAL IMPROVEMENTS TO THE OVERSIGHT 

18 AND OPERATION OF MEDICARE ADVANTAGE 

19 DUAL SPECIAL NEEDS PLANS BY THE FED20 ERAL COORDINATED HEALTH CARE OFFICE. 

21 (a) DEDICATED POINT OF CONTACT FOR ASSISTING

22 STATES WITH ADMINISTRATION.—Section 2602(d) of the 

23 Patient Protection and Affordable Care Act (42 U.S.C. 

24 1315b(d)) is amended by adding at the end the following 

25 new paragraph: 


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1 ‘‘(6) Serving as the dedicated point of contact 

2 within the Centers for Medicare & Medicaid Services 

3 to assist States with ongoing issues related to the 

4 administration of specialized MA plans for special 

5 needs individuals (as defined in section 1859(b)(6) 

6 of the Social Security Act) for special needs individ7 uals who are described in subparagraph (B)(ii) of 

8 such section, including— 

9 ‘‘(A) addressing any misalignment between 

10 the contracting timelines, processes, and dead11 lines under title XVIII of such Act, with respect 

12 to such plans for such individuals and con13 tracting timelines, processes, and deadlines 

14 under title XIX of such Act, with respect to 

15 such plans and individuals; and 

16 ‘‘(B) streamlining the flow of information 

17 to dual eligible individuals and establishing a 

18 single set of rules for outreach and marketing 

19 to such individuals.’’. 

20 (b) AUTHORITY TO WAIVE CERTAIN REQUIRE21 MENTS.— 

22 (1) IN GENERAL.—Subject to paragraph (2), 

23 the Secretary of Health and Human Services, 

24 through the Federal Coordinated Health Care Office 

25 established under section 2602 of the Patient ProVerDate Mar 15 2010 00:23 Apr 16, 2014 Jkt 039200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H4484.IH H4484

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1 tection and Affordable Care Act (42 U.S.C. 1315b) 

2 and in coordination with the appropriate State Med3 icaid agency, may waive the application of require4 ments under title XVIII of the Social Security Act 

5 to promote the integration, alignment, and delivery 

6 of items and services under the Medicare program 

7 under title XVIII of such Act and the Medicaid pro8 gram under title XIX of such Act, with respect to 

9 dual eligible individuals (as defined in section 

10 2602(f) of the Patient Protection and Affordable 

11 Care Act (42 U.S.C. 1315b(f)), and to ensure the 

12 seamless delivery of patient-centered services across 

13 the continuum of care with respect to such individ14 uals. 

15 (2) PUBLIC NOTICE REQUIREMENT.—The Sec16 retary may not waive the application of a require17 ment pursuant to paragraph (1) unless the Sec18 retary makes such waiver publicly available (whether 

19 on the public Internet website of Department of 

20 Health and Human Services, or otherwise) at least 

21 30 days before the effective date of such waiver. 


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1 SEC. 5. IMPROVEMENTS TO DISPUTE RESOLUTION FOR 

2 CLAIMS AND APPEALS UNDER MEDICARE AD3 VANTAGE DUAL SPECIAL NEEDS PLANS. 

4 (a) MEDICARE ADVANTAGE DUAL SPECIAL NEEDS

5 PLANS REQUIRED TO PROVIDE COVERAGE DURING AP6 PEALS PROCESS.—Section 1859(f)(3) of the Social Secu7 rity Act (42 U.S.C. 1395w–28(f)(3)), as amended by sec8 tion 2(b), is further amended by adding at the end the 

9 following new subparagraph: 

10 ‘‘(G) For plan years beginning after De11 cember 31, 2015, coverage under this title and 

12 title XIX of an individual enrolled under such 

13 respective title shall continue during any deter14 mination, reconsideration, or appeals proceeding 

15 described in section 1852(g), with respect to 

16 such individual.’’. 

17 (b) STREAMLINED PATHWAY FOR DISPUTE RESOLU18 TION.—Not later than December 31, 2015, the Secretary 

19 of Health and Human Services shall establish a stream20 lined process for dispute resolution for claims and appeals, 

21 with respect items and services furnished to special needs 

22 individuals described in section 1859(b)(6)(B)(ii) of the 

23 Social Security Act (42 U.S.C. 1395w–28(b)(6)(B)(ii)), to 

24 align such process under the Medicare program under title 

25 XVIII of the Social Security Act with such process under 

26 the Medicaid program under title XIX of such Act. Such 


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1 streamlined process shall take into account various State 

2 requirements and promote a pathway that would be the 

3 most beneficial for individuals entitled to benefits under 

4 part A of title XVIII of such Act or enrolled under part 

5 B of such Act and to individuals enrolled under a State 

6 plan under title XIX of such Act. 

7 SEC. 6. REPORT ON IMPLEMENTATION OF CERTAIN MEDI8 CARE AND MEDICAID FRAUD DETECTION 

9 AND PROGRAM INTEGRITY PROVISIONS. 

10 Section 1128J(a)(1)(A) of the Social Security Act 

11 (42 U.S.C. 1320a–7k(a)(1)(A)) is amended by adding at 

12 the end the following new clause: 

13 ‘‘(iii) REPORT ON INTEGRATED DATA

14 REPOSITORY AND ONE PROGRAM INTEG15 RITY SYSTEM.—Not later than six months 

16 after the date of enactment of this clause, 

17 the Secretary shall submit to the appro18 priate Congressional committees a report 

19 on the following: 

20 ‘‘(I) INTEGRATED DATA REPOSI21 TORY.—Efforts to finalize plans and 

22 schedules for fully implementing and 

23 expanding the use of the Integrated 

24 Data Repository, including actions 

25 taken to finalize, implement, and 


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1 manage plans for incorporating data 

2 into the Integrated Data Repository 

3 and actions taken to define measur4 able financial benefits expected from 

5 the implementation of the Integrated 

6 Data Repository. 

7 ‘‘(II) ONE PROGRAM INTEGRITY

8 SYSTEM.—Actions taken to plan, 

9 schedule, and conduct training on the 

10 One Program Integrity System, a 

11 Web-based portal and suite of soft12 ware tools used to analyze and extract 

13 data from the Integrated Data Repos14 itory, and actions taken to define 

15 measurable financial benefits expected 

16 from the use of the One Program In17 tegrity System.’’. 

Æ 


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