Helping States Integrate Medicare and Medicaid Act

To amend title XIX of the Social Security Act to provide States with resources to support efforts to integrate or coordinate Medicare and Medicaid benefits for individuals that are eligible for both programs. 1. Short title This Act may be cited as the Helping States Integrate Medicare and Medicaid Act 2. Supporting State efforts to integrate Medicare and Medicaid benefits for full-benefit dual eligible individuals (a) In general Section 1902 of the Social Security Act ( 42 U.S.C. 1396a (1) in subsection (a)— (A) by striking and (B) by striking the period at the end of paragraph (87) and inserting ; and (C) by inserting after paragraph (87) the following new paragraph: (88) in the case of a State that is 1 of the 50 States or the District of Columbia, provide that the State will carry out activities to coordinate and integrate benefits for full-benefit dual eligible individuals (as defined in section 1935(c)(6)) in accordance with a Dual Coordination and Integration Plan approved by the Secretary under subsection (uu). ; and (2) by adding at the end the following new subsection: (uu) Supporting State efforts To integrate Medicare and Medicaid benefits for full-Benefit dual eligible individuals (1) Definitions In this subsection: (A) Full-benefit dual eligible individual The term full-benefit dual eligible individual (B) Medicaid The term Medicaid (C) Medicare The term Medicare (D) Medicare and Medicaid benefits The term Medicare and Medicaid benefits (E) Medicare-Medicaid Coordination Office The term Medicare-Medicaid Coordination Office (F) Relevant stakeholders The term relevant stakeholders (i) Full-benefit dual eligible individuals and their representatives. (ii) Beneficiary advocates. (iii) Health plans. (iv) Health care providers, such as physicians, hospitals, and nursing homes. (v) PACE providers. (vi) Community-based organizations. (vii) Other interested individuals or groups as determined by the Secretary or the State. (2) Planning grants (A) In general Not later than 1 year after the date of enactment of this subsection, from the amount reserved under paragraph (8)(B), the Secretary shall award a planning grant to each State to carry out planning activities to develop and submit to the Secretary a Dual Coordination and Integration Plan described in paragraph (3). (B) Limitation The Secretary shall award planning grants to States under this paragraph in such amounts as the Secretary shall determine except that in no case shall a grant awarded under this paragraph exceed $5,000,000. (C) Use of funds A State may only use grant funds awarded under this paragraph for the planning activities described in subparagraph (A), except that, if a State does not use all of the grant funds and receives approval for a Dual Coordination and Integration Plan described in paragraph (3), the State may use any remaining funds to carry out activities described in paragraph (4) that are in accordance with such plan. (3) Dual Coordination and Integration Plan (A) In general As a condition of receiving a payment under this subsection, a State shall submit to the Secretary for approval a Dual Coordination and Integration Plan (to be developed by the State with input from relevant stakeholders) describing the State's strategy for integrating and coordinating health benefits coverage for full-benefit dual eligible individuals that includes detailed descriptions of the following components: (i) A description of the activities described in paragraph (4) that will be carried out under the plan. (ii) The integration and coordination approaches selected by the State. (iii) The eligibility requirements and benefits available under such strategy. (iv) The education, enrollment, and outreach strategy for participation by full-benefit dual eligible individuals. (v) Beneficiary protections intended to preserve and strengthen beneficiary choice and access to care. (vi) The plan for collecting data analytics and measuring the quality of care provided under such strategy. (vii) Structures to promote health equity. (viii) The coordination and integration of mental health benefits with other benefits and services available under Medicare and Medicaid for full-benefit dual eligible individuals under such strategy. (ix) Such other components as the Secretary may require. (B) Development and submission In order to meet the requirements of this subsection, a Dual Coordination and Integration Plan shall— (i) be submitted for approval by the Secretary not later than 24 months after the date on which the State was awarded a planning grant under paragraph (2); and (ii) be made publicly available in the final version submitted to the Secretary on a State internet website. (C) Approval; publication (i) In general The Secretary shall approve a Dual Coordination and Integration Plan submitted by a State under this paragraph if— (I) the plan contains each of the components required under subparagraph (A); and (II) the State provides assurances to the satisfaction of the Secretary that the State will carry out the Dual Coordination and Integration Plan as it is written. (ii) Regular reviews and updates The State regularly shall review and update a Dual Coordination and Integration Plan approved under this subparagraph at such times and in accordance with such requirements as the Secretary shall specify. (4) Medicare and Medicaid coordination and integration activities (A) In general The activities described in this paragraph are the following: (i) Activities to recruit or retain expert capacity at the State agency responsible for administering the State plan under this title to inform the integration of Medicare and Medicaid for full-benefit dual eligible individuals. (ii) Training for staff at such State agency to develop expertise to inform the integration of Medicare and Medicaid benefits for full-benefit dual eligible individuals. (iii) Support for development of payment rates and alternative payment models. (iv) Development of information technology infrastructure to— (I) support data sharing among health plans, providers, PACE providers, community-based organizations, and Federal, State, and local government agencies; and (II) transfer Medicare and Medicaid eligibility and enrollment data. (v) Advancement of a unified Medicare and Medicaid grievance and appeals structure for determinations made by integrated agencies (as permissible under the rules and regulations of the Centers for Medicare & Medicaid Services). (vi) Development of, or enhancements to, enrollment, outreach, and education supports for full-benefit dual eligible individuals. (vii) Development of, or enhancements to, administration, monitoring, and oversight systems and protocols for all entities that provide coordinated or integrated Medicare and Medicaid benefits to full-benefit dual eligible individuals. (viii) Development of, or enhancements to, administration of quality measurement and improvement programs for services furnished to full-benefit dual eligible individuals. (ix) Stakeholder engagement processes, including— (I) the establishment and maintenance of a Consumer Advisory Council comprised of full-benefit dual eligible individuals, as well as beneficiary advocates, and their representatives that is reflective of the local population in terms of status for dual eligible qualification as well as race, ethnicity, sexual orientation, and other characteristics determined by the State; and (II) the establishment and maintenance of a stakeholder engagement group that regularly solicits and incorporates into the State's Medicare and Medicaid coordination or integration strategy input from the Consumer Advisory Council and other relevant stakeholders (as defined in paragraph (1)) in the State. (x) Development of a workforce needs assessment to identify the needs of the full-benefit dually eligible population, including strategies to ensure adequate compensation for the workforce. (B) Limitations No payment may be made under this subsection for expenditures on an activity that the State carried out before the date of enactment of this subsection. (5) Payments to States (A) In general Subject to subparagraph (B), for each fiscal quarter during which a State has in effect a Dual Coordination and Integration Plan approved under paragraph (3), the Secretary shall pay to the State an amount equal to 50 percent (or, during the first 20 full fiscal quarters during which the plan is in effect, 80 percent) of the amounts expended by the State during the quarter on activities described in paragraph (4) that are in accordance with such plan. (B) Limitations (i) Use of planning grant funds A State shall not be eligible for a payment under this paragraph until the State has expended the full amount of the planning grant awarded to the State under paragraph (2). (ii) Non-duplication of payment; application of higher rates No payment shall be made under this paragraph with respect to State expenditures of funds made available from Federal sources, and to the extent that a State expenditure is eligible for a Federal payment under both subparagraph (A) and another provision of this title or any other law, payment shall only be made under the provision that results in the State receiving the higher payment. (C) Manner of payment Payment to a State under this subsection shall be made in the same manner as payments for State expenditures for the proper and efficient administration of the State plan described in section 1903(a)(7). (6) Evaluation of plan implementation; reporting requirement (A) Evaluation benchmarks The Secretary shall establish benchmarks for evaluating whether a State's use of payments received under this subsection is in alignment with the State's Dual Coordination and Integration Plan (as approved under paragraph (3)). (B) Annual report As a condition of payment under this subsection— (i) a State shall submit to the Secretary an annual report detailing how the State is using payments received under this subsection; and (ii) the Secretary shall certify, based on such report, that the State's use of such payments is in alignment with the State's Dual Coordination and Integration Plan (as approved under paragraph (3)). (7) Administration In carrying out this subsection, the Secretary shall coordinate with the Medicare-Medicaid Coordination Office and other Federal agencies as appropriate. (8) Funding (A) In general Out of any funds in the Treasury not otherwise appropriated, there is appropriated to the Secretary $300,000,000 for fiscal year 2025 to carry out this subsection, to remain available until expended. (B) Reservation for planning grants Of the amount appropriated under subparagraph (A), $150,000,000 is reserved to award planning grants under paragraph (2). (C) Technical assistance and guidance Of the amount appropriated under subparagraph (A), $150,000,000 is reserved for issuing guidance and providing technical assistance to States in— (i) developing and implementing Dual Coordination and Integration Plans under this subsection; and (ii) completing the annual reports required under paragraph (6). . (b) Effective date (1) In general Except as provided in paragraph (2), the amendments made by this section shall take effect on the date of enactment of this Act. (2) Delay if State legislation needed In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirements imposed by the amendments made by the section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these additional requirements before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature.

Summary: Helping States Integrate Medicare and Medicaid Act This bill requires state Medicaid programs to integrate and coordinate Medicaid and Medicare coverage for individuals who are dually eligible for both, including with respect to enrollment, quality measures, and access to care. The bill provides funds for FY2025 for planning grants and related implementation.