I 
115TH CONGRESS 
1ST SESSION H. R. 3168 
To amend title XVIII of the Social Security Act to provide continued access 
to specialized Medicare Advantage plans for special needs individuals, 
and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JULY 6, 2017 
Mr. TIBERI (for himself and Mr. LEVIN) 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 provi-
sions as fall within the jurisdiction of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to provide 
continued access to specialized Medicare Advantage plans 
for special needs individuals, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SPECIALIZED MEDICARE ADVANTAGE PLANS 
FOR SPECIAL NEEDS INDIVIDUALS. 
(a) EXTENSION.—Section 1859(f)(1) of the Social 
Security Act (42 U.S.C. 1395w–28(f)(1)) is amended— 
(1) by striking ‘‘and for periods before January 
1, 2019’’; and 
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(2) by adding at the end the following new sen-
tence: ‘‘In the case of a specialized MA plan for spe-
cial needs individuals described in clause (ii) or (iii) 
of subsection (b)(6)(B), the previous sentence shall 
apply for periods before January 1, 2024.’’. 
(b) INCREASED INTEGRATION OF DUAL SNPS.— 
(1) IN GENERAL.—Section 1859(f) of the Social 
Security Act (42 U.S.C. 1395w–28(f)) is amended— 
(A) in paragraph (3), by adding at the end 
the following new subparagraph: 
‘‘(F) The plan meets the requirements ap-
plicable under paragraph (8).’’; and 
(B) by adding at the end the following new 
paragraph: 
‘‘(8) 
INCREASED
INTEGRATION
OF
DUAL 
SNPS.— 
‘‘(A) DESIGNATED
CONTACT.—The Sec-
retary, acting through the Federal Coordinated 
Health Care Office established under section 
2602 of Public Law 111–148, shall serve as a 
dedicated point of contact for States to address 
misalignments that arise with the integration of 
specialized MA plans for special needs individ-
uals described in subsection (b)(6)(B)(ii) under 
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this paragraph and, consistent with such role, 
shall— 
‘‘(i) establish a uniform process for 
disseminating to State Medicaid agencies 
information under this title impacting con-
tracts between such agencies and such 
plans under this subsection; and 
‘‘(ii) establish basic resources for 
States interested in exploring such plans 
as a platform for integration, such as a 
model contract or other tools to achieve 
those goals. 
‘‘(B) UNIFIED GRIEVANCES AND APPEALS 
PROCESS.— 
‘‘(i) IN
GENERAL.—Not later than 
April 1, 2020, the Secretary shall establish 
procedures, to the extent feasible as deter-
mined by the Secretary, unifying griev-
ances and appeals procedures under sec-
tions 
1852(f), 
1852(g), 
1902(a)(3), 
1902(a)(5), and 1932(b)(4) for items and 
services provided by specialized MA plans 
for special needs individuals described in 
subsection (b)(6)(B)(ii) under this title 
and title XIX. The Secretary shall solicit 
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comment in developing such procedures 
from States, plans, beneficiaries and their 
representatives, and other relevant stake-
holders. With respect to items and services 
described in the previous sentence, appeals 
procedures established under this clause 
shall apply in place of otherwise applicable 
appeals procedures. 
‘‘(ii) PROCEDURES.—The procedures 
established under clause (i) shall be in-
cluded in the plan contract under para-
graph (3)(D) and shall— 
‘‘(I) adopt the provisions for the 
enrollee that are most protective for 
the enrollee and, to the extent feasible 
as determined by the Secretary, are 
compatible with unified timeframes 
and consolidated access to external re-
view under an integrated process; 
‘‘(II) take into account dif-
ferences in State plans under title 
XIX to the extent necessary; 
‘‘(III) be easily navigable by an 
enrollee; and 
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‘‘(IV) include the elements de-
scribed in clause (iii), as applicable. 
‘‘(iii) ELEMENTS
DESCRIBED.—Both 
unified appeals and unified grievance pro-
cedures shall include, as applicable, the fol-
lowing elements described in this clause: 
‘‘(I) Single written notification of 
all applicable grievances and appeal 
rights under this title and title XIX. 
For purposes of this subparagraph, 
the Secretary may waive the require-
ments under section 1852(g)(1)(B) 
when the specialized MA plan covers 
items or services under this part or 
under title XIX. 
‘‘(II) Single pathways for resolu-
tion of any grievance or appeal related 
to a particular item or service pro-
vided by specialized MA plans for spe-
cial needs individuals described in 
subsection (b)(6)(B)(ii) under this 
title and title XIX. 
‘‘(III) Notices written in plain 
language and available in a language 
and format that is accessible to the 
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law and implementing regulations that pro-
vide continuation of benefits pending ap-
peal under this title and title XIX. 
‘‘(C) REQUIREMENT FOR UNIFIED GRIEV-
ANCES AND APPEALS.—For 2022 and subse-
quent years, the contract of a specialized MA 
plan for special needs individuals described in 
subsection (b)(6)(B)(ii) with a State Medicaid 
agency under paragraph (3)(D) shall require 
the use of unified grievances and appeals proce-
dures as described in subparagraph (B). 
‘‘(D) REQUIREMENTS FOR FULL INTEGRA-
TION FOR CERTAIN DUAL SNPS.— 
‘‘(i) REQUIREMENT.—For 2022 and 
subsequent years, a specialized MA plan 
for special needs individuals described in 
subsection (b)(6)(B)(ii) shall meet one or 
more of the following requirements, to the 
extent allowed by the State, for integration 
of benefits under this title and title XIX: 
‘‘(I) Meet the requirements of a 
fully integrated plan described in sec-
tion 1853(a)(1)(B)(iv)(II) (other than 
the requirement that the plan have 
similar average levels of frailty, as de-
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termined by the Secretary, as the 
PACE program). 
‘‘(II) Enter into a capitated con-
tract with the State Medicaid agency 
to provide long-term services and sup-
ports or behavioral health services, or 
both. 
‘‘(III) Enter into any other type 
of arrangement, as determined appro-
priate by the Secretary. 
‘‘(ii) SANCTIONS.—For 2022 and sub-
sequent years, if the Secretary determines 
that a specialized MA plan fails to comply 
with clause (i), the Secretary may provide 
for the application against the Medicare 
Advantage organization offering the plan 
any of the remedies described in section 
1857(g)(2).’’. 
(2) CONFORMING
AMENDMENT
TO
RESPON-
SIBILITIES
OF
FEDERAL
COORDINATED
HEALTH 
CARE OFFICE.—Section 2602(d) of Public Law 111– 
148 (42 U.S.C. 1315b(d)) is amended by adding at 
the end the following new paragraphs: 
‘‘(6) To act as a designated contact for States 
under subsection (f)(8)(A) of section 1859 of the So-
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cial Security Act (42 U.S.C. 1395w–28) with respect 
to the integration of specialized MA plans for special 
needs 
individuals 
described 
in 
subsection 
(b)(6)(B)(ii) of such section. 
‘‘(7) To be responsible for developing regula-
tions and guidance related to the implementation of 
a unified grievance and appeals process as described 
in subparagraphs (B) and (C) of section 1859(f)(8) 
of the Social Security Act (42 U.S.C. 1395w– 
28(f)(8)). 
‘‘(8) To be responsible for developing regula-
tions and guidance related to the integration or 
alignment of policy and oversight under the Medi-
care program under title XVIII of such Act and 
Medicaid program under title XIX of such Act re-
garding specialized MA plans for special needs indi-
viduals described in subsection (b)(6)(B)(ii) of such 
section 1859.’’. 
(c) IMPROVEMENTS
TO
SEVERE
OR
DISABLING 
CHRONIC CONDITION SNPS.— 
(1) CARE MANAGEMENT REQUIREMENTS.—Sec-
tion 1859(f)(5) of the Social Security Act (42 
U.S.C. 1395w–28(f)(5)) is amended— 
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(A) by redesignating subparagraphs (A) 
and (B) as clauses (i) and (ii), respectively, and 
indenting appropriately; 
(B) in clause (ii), as redesignated by sub-
paragraph (B), by redesignating clauses (i) 
through (iii) as subclauses (I) through (III), re-
spectively, and indenting appropriately; 
(C) by striking ‘‘ALL SNPS.—The require-
ments’’ and inserting ‘‘ALL SNPS.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), the requirements’’; and 
(D) by adding at the end the following new 
subparagraph: 
‘‘(B) IMPROVEMENTS
TO
CARE
MANAGE-
MENT
REQUIREMENTS
FOR
SEVERE
OR
DIS-
ABLING CHRONIC CONDITION SNPS.—For 2020 
and subsequent years, in the case of a special-
ized MA plan for special needs individuals de-
scribed in subsection (b)(6)(B)(iii), the require-
ments described in this paragraph include the 
following: 
‘‘(i) The interdisciplinary team under 
subparagraph (A)(ii)(III) includes a team 
of providers with demonstrated expertise, 
including training in an applicable spe-
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cialty, in treating individuals similar to the 
targeted population of the plan. 
‘‘(ii) Requirements developed by the 
Secretary to provide face-to-face encoun-
ters with individuals enrolled in the plan 
not less frequently than on an annual 
basis. 
‘‘(iii) As part of the model of care 
under clause (i) of subparagraph (A), the 
results of the initial assessment and an-
nual reassessment under clause (ii)(I) of 
such subparagraph of each individual en-
rolled in the plan are addressed in the indi-
vidual’s individualized care plan under 
clause (ii)(II) of such subparagraph. 
‘‘(iv) As part of the annual evaluation 
and approval of such model of care, the 
Secretary shall take into account whether 
the plan fulfilled the previous year’s goals 
(as required under the model of care). 
‘‘(v) The Secretary shall establish a 
minimum benchmark for each element of 
the model of care of a plan. The Secretary 
shall only approve a plan’s model of care 
under this paragraph if each element of 
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the model of care meets the minimum 
benchmark applicable under the preceding 
sentence.’’. 
(2) REVISIONS TO THE DEFINITION OF A SE-
VERE OR DISABLING CHRONIC CONDITIONS SPECIAL-
IZED NEEDS INDIVIDUAL.— 
(A) 
IN
GENERAL.—Section 
1859(b)(6)(B)(iii) of the Social Security Act 
(42 U.S.C. 1395w–28(b)(6)(B)(iii)) is amend-
ed— 
(i) by striking ‘‘who have’’ and insert-
ing ‘‘who— 
‘‘(I) before January 1, 2022, 
have’’; 
(ii) in subclause (I), as added by 
clause (i), by striking the period at the end 
and inserting ‘‘; and’’; and 
(iii) by adding at the end the fol-
lowing new subclause: 
‘‘(II) on or after January 1, 
2022, have one or more comorbid and 
medically complex chronic conditions 
that is life threatening or significantly 
limits overall health or function, have 
a high risk of hospitalization or other 
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