‘‘(L) Managing and facilitating the transi-
tion to other care arrangements in preparation
for termination of the disease management en-
rollment.
‘‘(M) Such other services for which pay-
ment would not otherwise be made under this
title, as the Secretary shall determine to be ap-
propriate.
‘‘(2) VARIATIONS IN SERVICE PACKAGES.—The
type and combinations of disease management serv-
ices furnished under agreements under this section
may vary (as permitted or required by the Sec-
retary) according to the types of diagnoses, condi-
tions, patient profiles being managed, expertise of
the disease management organization, geographic
isolation, and other factors the Secretary finds ap-
propriate.
‘‘(h) ENROLLMENT
OF INDIVIDUALS
IN DISEASE
MANAGEMENT PROGRAMS.—
‘‘(1) EFFECTIVE
DATE
AND
DURATION.—En-
rollment of an individual in the program under this
section shall remain in effect for a period to be de-
termined by the Secretary and shall be automatically
renewed for additional periods, unless terminated in
accordance with such procedures as the Secretary
shall establish by regulation.
‘‘(2) LIMITATION
OF
REENROLLMENT.—The
Secretary may establish limits on an individual’s eli-
gibility to reenroll in the program under this section
if the individual has disenrolled more than once dur-
ing a specified time period.
‘‘(i) DISEASE MANAGEMENT REQUIREMENT.—Not-
withstanding any other provision of this title, the Sec-
retary may provide that an individual enrolled in the pro-
gram under this section may be entitled to payment under
this title for any specified health care items or services
only if the items or services have been furnished by the
disease management organization, or coordinated through
the disease management services program. Under such
provision, the Secretary shall prescribe exceptions for
emergency medical services as described in section
1852(d)(3), and other exceptions determined by the Sec-
retary for the delivery of timely and needed care.
‘‘(j) AGREEMENT
WITH
DISEASE
MANAGEMENT
PROVIDERS.—
‘‘(1) ENTITIES ELIGIBLE.—Entities qualified to
enter into agreements with the Secretary for the
provision of disease management services under this
section include entities that have demonstrated the
ability to meet the performance standards and other
criteria established by the Secretary with respect
to—
‘‘(A) the management of each diagnosis
and condition with respect to which the entity,
if designated, would furnish disease manage-
ment services under this section; and
‘‘(B) the implementation of each disease
management approach that the entity, if des-
ignated, would implement under this section.
‘‘(2) CONDITIONS OF PARTICIPATION.—In order
to be eligible to provide disease management services
under this section, an entity shall—
‘‘(A) have in effect an agreement with the
Secretary setting forth such obligations of the
entity as a disease management organization
under this section as the Secretary shall pre-
scribe;
‘‘(B) meet the standards established by the
Secretary under subsection (k); and
‘‘(C) meet such other conditions as the
Secretary may establish.
‘‘(3) SECRETARY’S OPTION FOR NONCOMPETI-
TIVE DESIGNATION.—The Secretary may designate
an entity to provide disease management services
under this section without regard to the require-
ments of section 5 of title 41, United States Code.
‘‘(k) QUALITY STANDARDS.—The Secretary shall es-
tablish standards for, and procedures for assessing, the
quality of care provided by disease management organiza-
tions under this section, which shall include—
‘‘(1) performance standards with respect to the
processes or outcomes of health care or the health
status of enrolled individuals, including procedures
for establishing a baseline and measuring changes in
health care processes or health outcomes with re-
spect to managed diseases or health conditions;
‘‘(2) a requirement that the organization meet
such licensure and other accreditation standards as
the Secretary may find appropriate; and
‘‘(3) such other quality standards, including pa-
tient satisfaction, as the Secretary may find appro-
priate.
‘‘(l) PAYMENT.—The Secretary may negotiate or oth-
erwise establish payment terms and rates for the provision
of services under the program under this section, and
shall, to the extent practicable, base such payment terms
and rates methodology on payment methodologies estab-
lished under this title.
‘‘(m) DEFINITION
OF SERIOUS
AND DISABLING
CHRONIC ILLNESS.—In this section, the term ‘‘serious
and disabling chronic condition’ means one or more bio-
logical or physical conditions which are likely to last for
an unspecified period of time, or for the duration of a per-
son’s life, for which there is no known cure, and which
may affect an individual’s ability to carry out basic activi-
ties of daily living, instrumental activities of daily living,
or both. Such conditions include the following:
‘‘(1) Alzheimer’s Disease and related disorders.
‘‘(2) Arthritis.
‘‘(3) Cancer.
‘‘(4) Cerebrovascular disease.
‘‘(5) Diabetes.
‘‘(6) Emphysema and bronchitis (including
chronic obstructive pulmonary disease.
‘‘(7) Hypertension.
‘‘(8) Ischemic heart disease.
‘‘(9) Multiple sclerosis.
‘‘(10) Parkinson’s disease.
‘‘(11) Peripheral vascular disease.
‘‘(12) Renal disease.’’.
(b) COVERAGE OF DISEASE MANAGEMENT SERVICES
AS A PART B MEDICAL SERVICE.—
(1) IN GENERAL.—Section 1861(s) of the So-
cial Security Act (42 U.S.C. 1395x(s)), as amended
by section 201, is further amended—
(A) by redesignating paragraphs (17) and
(18) as paragraphs (18) and (19), respectively;
(B) by striking ‘‘and’’ at the end of para-
graph (15);
(C) by striking the period at the end of
paragraph (16) and inserting ‘‘and’’; and
(D) by inserting after paragraph (16) the
following new paragraph:
‘‘(17) disease management services furnished in
accordance with section 1889.’’.
(2) PART
B
COINSURANCE
AND
DEDUCTIBLE
NOT APPLICABLE TO DISEASE MANAGEMENT SERV-
ICES.—
(A) COINSURANCE.—Section 1833(a)(1) of
the Social Security Act (42 U.S.C. 1395l(a)(1))
is amended—
(i) by striking ‘‘and’’ before ‘‘(S)’’;
and
(ii) by inserting before the semicolon
at the end the following: ‘‘, and (T) with
respect to disease management services de-
scribed 
in 
section 
1861(s)(16), 
the
amounts paid shall be 100 percent of the
payment amounts established under section
1889’’.
(B) DEDUCTIBLE.—The first sentence of
section 1833(b) of the Social Security Act (42
U.S.C. 1395l(b)) is amended—
(i) by striking ‘‘and’’ before ‘‘(6)’’;
and
(ii) by inserting before the period the
following: ‘‘, and (7) such deductible shall
not apply with respect to disease manage-
ment services (as described in section
1861(s)(16))’’.
(3) 
CONFORMING
AMENDMENTS.—Sections
1864(a), 1902(a)(9)(C), and 1915(a)(1)(B)(ii)(I) of
the Social Security Act (42 U.S.C. 1395aa(a),
1396a(a)(9)(C), 
and 
1396n(a)(1)(B)(ii)(I)), 
as
amended by section 201(a)(2), are each further
amended by striking ‘‘paragraphs (17) and (18)’’
each place it appears and inserting ‘‘paragraphs
(18) and (19)’’.
(c) ENROLLMENT.—
(1) IN GENERAL.—To carry out the provisions
of section 1889 of the Social Security Act, as added
by subsection (a), the Secretary of Health and
Human Services shall carry out a national public re-
lations and enrollment effort aimed at both providers
and consumers of health care to ensure widespread
awareness of the importance of serious and disabling
chronic illness management and the services avail-
able under section 1889 to initiate—
(A) in 2002, the National Diabetes Pilot
Initiative to Improve Chronic Illness Care and
the National Alzheimer’s Disease Pilot Initia-
tive to Improve Chronic Illness Care, estab-
lished in subsection (a)(2) of such section; and
(B) in 2006, the National Initiative to Im-
prove Chronic Illness Care, established in sub-
section (a)(3) of such section.
(2) AUTHORIZATION
OF
APPROPRIATIONS.—
There are authorized to be appropriated to the Sec-
retary of Health and Human Services in appropriate
part from the Federal Hospital Insurance and Fed-
eral Supplementary Medical Insurance Trust Funds
such sums as are necessary to carry out the enroll-
ment effort under paragraph (1).
TITLE IV—INTEGRATING MEDI-
CARE 
AND 
MEDICAID 
FOR
DUAL ELIGIBLES
SEC. 401. PROVISION OF WAIVER AUTHORITY TO SERVE
DUAL ELIGIBLES MORE EFFICIENTLY.
(a) MEDICARE FEE-FOR-SERVICE.—
(1) IN GENERAL.—Title XVIII of the Social Se-
curity Act is amended by adding at the end the fol-
lowing new section:
‘‘CLARIFICATION OF WAIVER AUTHORITY TO COORDINATE
AND
INTEGRATE
SERVICES
AND
ADMINISTRATION
UNDER THIS TITLE AND TITLE XIX
‘‘SEC. 1897. (a) IN GENERAL.—A State, health plan,
or provider may submit to the Secretary a request to waive
requirements of this title to permit States to enhance the
coordination and integration of items and services and ad-
ministration provided under this title with items and serv-
ices provided under title XIX.
‘‘(b) DEADLINE FOR ACTION ON WAIVER.—The Sec-
retary shall approve, deny, or request additional informa-
tion for a request for waiver submitted under subsection
(a) by not later than 90 days after the receipt of such
submission.
‘‘(c) COORDINATION AND INTEGRATION OF ITEMS
AND SERVICES DESCRIBED.—The coordination and inte-
gration of items and services referred to in subsection (a)
may include the following:
‘‘(1) A process for unified enrollment under
both titles.
‘‘(2) A unified quality improvement program.
‘‘(3) A unified grievance and appeals process.
‘‘(4) Unified provider and payer reporting re-
quirements.
‘‘(5) Alternative payment methodologies under
this title, including modified risk adjusters and risk
sharing approaches.
‘‘(d) LIMITATION.—
‘‘(1) IN
GENERAL.—The Secretary shall not
grant a waiver under this section unless the Sec-
retary determines that services furnished under the
waiver—
‘‘(A) are offered to an individual for which
coverage for items and services is provided for
under this title and title XIX; and
‘‘(B) are cost effective.
‘‘(2) COST
EFFECTIVE
DEFINED.—For pur-
poses of paragraph (1), the term ‘cost effective’
means that services offered under a waiver granted
by the Secretary under this section do not result, in
the aggregate, in greater combined payments under
this title and title XIX for such services than the
combined payments that would have been made
under such titles on a fee-for-service basis to an ac-
tuarially equivalent population group.’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) shall take effect January 1, 2001.
(b) MEDICAID.—
(1) IN GENERAL.—Section 1915(a) of the So-
cial 
Security 
Act 
(42 
U.S.C. 
1396n(a)) 
is
amended—
(A) by striking ‘‘or’’ at the end of para-
graph (1);
(B) by striking the period at the end of
paragraph (2) and adding ‘‘or’’; and
(C) by adding at the end the following new
paragraph:
‘‘(3) consistent with the provisions of subsection
(i) has entered into a contract with an organization
to provide care and services, which may include care
and services in addition to those offered under the
State plan, to individuals—
‘‘(A) who are eligible for medical assist-
ance,
‘‘(B) who elect to obtain such care and
services from such organization, and
‘‘(C) who are at least 65 years of age or
have a disability or a serious and disabling
chronic illness, including individuals who are
also eligible for health insurance benefits under
title XVIII.’’.
(2) REQUIREMENTS.—Section 1915 of the So-
cial Security Act (42 U.S.C. 1396n) is amended by
adding at the end the following new subsection:
‘‘(i) For purposes of contracts entered into under
subsection (a)(3), the following provisions apply:
‘‘(1) For purposes of payments to States for
medical assistance under this title, individuals who
are eligible to receive care and services under sub-
section (a)(3) and who meet the income and re-
source eligibility requirements of individuals who are
eligible 
for 
medical 
assistance 
under 
section
1902(a)(10)(II)(ii)(VI) shall be treated as individ-
uals described in such section during enrollment
with an organization under such subsection.
‘‘(2) Section 1924 applies to individuals receiv-
ing care and services under subsection (a)(3), and in
applying such section under subsection (a)(3), the
term ‘institutionalized spouse’ means an individual—
‘‘(A) who is in a medical institution or
nursing facility or who (at the option of the
State) 
is 
described 
in 
section
1902(a)(10)(II)(ii)(VI), and
‘‘(B) whose spouse is not in a medical in-
stitution or nursing facility.
‘‘(3) A State may seek a waiver under title
XVIII, to integrate care and services furnished
under this title with items and services furnished
under title XVIII.
‘‘(4) Care and services provided under sub-
section (a)(3) shall be cost effective, determined as
follows:
‘‘(A) In the case of a program imple-
mented under subsection (a)(3) with no cor-
responding waiver under title XVIII, the aggre-
gate medical assistance payments to the organi-
zation for a defined scope of care and services
furnished to beneficiaries may not exceed the
medical assistance costs of providing those
same services on a fee-for-service basis to an
actuarially equivalent population.
‘‘(B) In the case of a program imple-
mented under subsection (a)(3) with a waiver
under title XVIII, services offered do not result,
in the aggregate, in greater combined payments
under this title and title XVIII for such services
than the combined payments that would have
been made under such titles on a fee-for-service
basis to an actuarially equivalent population
group.’’.
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