IB 
Union Calendar No. 353 
115TH CONGRESS 
1ST SESSION H. R. 3168 
[Report No. 115–478, Part I] 
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 
DECEMBER 21, 2017 
Reported from the Committee on Ways and Means with an amendment 
[Strike out all after the enacting clause and insert the part printed in italic] 
DECEMBER 21, 2017 
The Committee on Energy and Commerce discharged; committed to the Com-
mittee of the Whole House on the State of the Union and ordered to be 
printed 
[For text of introduced bill, see copy of bill as introduced on July 6, 2017] 
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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. 
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Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Special Needs Plans Re-
authorization Act of 2017’’ or the ‘‘SNP Reauthorization 
Act of 2017’’. 
SEC. 2. SPECIALIZED MEDICARE ADVANTAGE PLANS FOR 
SPECIAL NEEDS INDIVIDUALS. 
(a) EXTENSION.—Section 1859(f)(1) of the Social Se-
curity Act (42 U.S.C. 1395w–28(f)(1)) is amended— 
(1) by striking ‘‘and for periods before January 
1, 2019’’; and 
(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 
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(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 
this paragraph and, consistent with such role, 
shall— 
‘‘(i) establish a uniform process for dis-
seminating to State Medicaid agencies in-
formation 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 plat-
form for integration, such as a model con-
tract or other tools to achieve those goals. 
‘‘(B) UNIFIED
GRIEVANCES
AND
APPEALS 
PROCESS.— 
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‘‘(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 grievances 
and appeals procedures under sections 
1852(f), 1852(g), 1902(a)(3), 1902(a)(5), 
and 1932(b)(4) for items and services pro-
vided 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 comment in de-
veloping such procedures from States, plans, 
beneficiaries and their representatives, and 
other relevant stakeholders. 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 
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determined by the Secretary, are com-
patible with unified timeframes and 
consolidated access to external review 
under an integrated process; 
‘‘(II) take into account differences 
in State plans under title XIX to the 
extent necessary; 
‘‘(III) be easily navigable by an 
enrollee; and 
‘‘(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 requirements 
under section 1852(g)(1)(B) when the 
specialized MA plan covers items or 
services under this part or under title 
XIX. 
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‘‘(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 sub-
section (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 en-
rollee, including in non-English lan-
guages that are prevalent in the service 
area of the specialized MA plan. 
‘‘(IV) 
Unified 
timeframes 
for 
grievances and appeals processes, such 
as an individual’s filing of a grievance 
or appeal, a plan’s acknowledgment 
and resolution of a grievance or ap-
peal, and notification of decisions with 
respect to a grievance or appeal. 
‘‘(V) Requirements for how the 
plan must process, track, and resolve 
grievances and appeals, to ensure bene-
ficiaries are notified on a timely basis 
of decisions that are made throughout 
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the grievance or appeals process and 
are able to easily determine the status 
of a grievance or appeal. 
‘‘(iv) CONTINUATION
OF
BENEFITS 
PENDING APPEAL.—The unified procedures 
under clause (i) shall, with respect to all 
benefits under parts A and B and title XIX 
subject to appeal under such procedures, in-
corporate provisions under current law and 
implementing regulations that provide con-
tinuation of benefits pending appeal under 
this title and title XIX. 
‘‘(C) REQUIREMENT
FOR
UNIFIED
GRIEV-
ANCES AND APPEALS.—For 2022 and subsequent 
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 procedures as de-
scribed in subparagraph (B). 
‘‘(D) REQUIREMENTS FOR FULL INTEGRA-
TION FOR CERTAIN DUAL SNPS.— 
‘‘(i) REQUIREMENT.—For 2021 and 
subsequent years, a specialized MA plan for 
special needs individuals described in sub-
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section (b)(6)(B)(ii) shall meet one or more 
of the following requirements 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-
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) To the extent the State does 
not allow for or require such a special-
ized MA plan to enter into a capitated 
contract described in subclause (II), 
enter into another type of integration 
arrangement, as determined appro-
priate by the Secretary after consulta-
tion with stakeholders, such as by— 
‘‘(aa) entering into a con-
tract with the State that requires 
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notifying the State in a timely 
manner of hospitalizations, emer-
gency room visits, and hospital or 
nursing home discharges of enroll-
ees or otherwise requires sharing 
data that would benefit the co-
ordination of items and services 
under this title and the State plan 
under title XIX; or 
‘‘(bb) offering, by a parent 
organization, a Medicaid man-
aged care plan that provides long 
term services and supports or be-
havioral health services to the 
same enrollees as under such spe-
cialized MA plan. 
‘‘(ii) SANCTIONS.—For 2021 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).’’. 
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(2) CONFORMING AMENDMENT TO RESPONSIBIL-
ITIES OF FEDERAL COORDINATED HEALTH CARE OF-
FICE.—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-
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 regulations 
and guidance related to the implementation of a uni-
fied 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 regulations 
and guidance related to the integration or alignment 
of policy and oversight under the Medicare program 
under title XVIII of such Act and Medicaid program 
under title XIX of such Act regarding specialized MA 
plans for special needs individuals described in sub-
section (b)(6)(B)(ii) of such section 1859.’’. 
(c) IMPROVEMENTS TO SEVERE OR DISABLING CHRON-
IC CONDITION SNPS.— 
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(1) CARE
MANAGEMENT
REQUIREMENTS.—Sec-
tion 1859(f)(5) of the Social Security Act (42 U.S.C. 
1395w–28(f)(5)) is amended— 
(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 (A), 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 specialized 
MA plan for special needs individuals described 
in subsection (b)(6)(B)(iii), the requirements de-
scribed in this paragraph include the following: 
‘‘(i) The interdisciplinary team under 
subparagraph (A)(ii)(III) includes a team 
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this paragraph if each element of the model 
of care meets the minimum benchmark ap-
plicable under the preceding sentence.’’. 
(2) REVISIONS TO THE DEFINITION OF A SEVERE 
OR
DISABLING
CHRONIC
CONDITIONS
SPECIALIZED 
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 amended— 
(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 following 
new subclause: 
‘‘(II) on or after January 1, 2022, 
have one or more comorbid and medi-
cally complex chronic conditions that 
is life threatening or significantly lim-
its overall health or function, have a 
high risk of hospitalization or other 
adverse health outcomes, and require 
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intensive care coordination and that is 
listed under subsection (f)(9)(A).’’. 
(B) PANEL OF CLINICAL ADVISORS.—Sec-
tion 1859(f) of the Social Security Act (42 
U.S.C. 1395w–28(f)), as amended by subsection 
(b), is amended by adding at the end the fol-
lowing new paragraph: 
‘‘(9) LIST OF CONDITIONS FOR CLARIFICATION OF 
THE DEFINITION OF A SEVERE OR DISABLING CHRON-
IC CONDITIONS SPECIALIZED NEEDS INDIVIDUAL.— 
‘‘(A) IN GENERAL.—Not later than Decem-
ber 31, 2020, and every 5 years thereafter, the 
Secretary shall convene a panel of clinical advi-
sors to establish and update a list of conditions 
that meet each of the following criteria: 
‘‘(i) Conditions that meet the defini-
tion of a severe or disabling chronic condi-
tion under subsection (b)(6)(B)(iii) on or 
after January 1, 2022. 
‘‘(ii) Conditions that require prescrip-
tion drugs, providers, and models of care 
that are unique to the specific population of 
enrollees in a specialized MA plan for spe-
cial needs individuals described in such sub-
section on or after such date and— 
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‘‘(I) as a result of such special 
needs individuals with such a condi-
tion having access to and being en-
rolled in such a plan, as compared to 
access to and enrollment in other Medi-
care Advantage plans under this part, 
it is projected that such individuals 
would improve health outcomes with 
respect to such condition, that such in-
dividuals would have reduced overall 
costs under this title, and that there 
would not be any increase in expendi-
tures under this title for such individ-
uals; or 
‘‘(II) have a low prevalence in the 
general population of beneficiaries 
under this title or a disproportionally 
high per-beneficiary cost under this 
title. 
‘‘(B) GAO STUDY ON HEALTH OUTCOMES 
OF INDIVIDUALS ENROLLED IN SPECIALIZED MA 
PLANS.—Not later than the date that is 3 years 
after the date of the enactment of this paragraph, 
the Comptroller General of the United States 
shall conduct a study and submit to Congress a 
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report on the extent to which health outcomes 
can be compared across specialized MA plans for 
special needs individuals (as defined in section 
1859(b)(6)) and other Medicare Advantage plans 
under this part across similar populations, using 
existing measures and that identifies any poten-
tial limitations where new measures may need to 
be developed for such population.’’. 
(d) QUALITY MEASUREMENT AT THE PLAN LEVEL FOR 
SNPS AND DETERMINATION OF FEASABILITY OF QUALITY 
MEASUREMENT
AT
THE
PLAN
LEVEL
FOR
ALL
MA 
PLANS.—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 paragraphs: 
‘‘(6) QUALITY
MEASUREMENT
AT
THE
PLAN 
LEVEL FOR SNPS.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), the Secretary may require reporting 
of data under section 1852(e) for, and apply 
under this subsection, quality measures at the 
plan level for specialized MA plans for special 
needs individuals instead of at the contract level. 
‘‘(B) CONSIDERATIONS.—Prior to applying 
quality measurement at the plan level under this 
paragraph, the Secretary shall— 
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‘‘(i) take into consideration the min-
imum number of enrollees in a specialized 
MA plan for special needs individuals in 
order to determine if a statistically signifi-
cant or valid measurement of quality at the 
plan level is possible under this paragraph; 
‘‘(ii) if quality measures are reported 
at the plan level, ensure that MA plans are 
not required to provide duplicative informa-
tion; and 
‘‘(iii) ensure that such reporting does 
not interfere with the collection of encounter 
data submitted by MA organizations or the 
administration of any changes to the pro-
gram under this part as a result of the col-
lection of such data. 
‘‘(C) APPLICATION.—If the Secretary ap-
plies quality measurement at the plan level 
under this paragraph— 
‘‘(i) such quality measurement may in-
clude Medicare Health Outcomes Survey 
(HOS), Healthcare Effectiveness Data and 
Information Set (HEDIS), Consumer As-
sessment of Healthcare Providers and Sys-
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tems (CAHPS) measures and quality meas-
ures under part D; and 
‘‘(ii) the Secretary shall consider ap-
plying administrative actions, such as rem-
edies described in section 1857(g)(2), to the 
plan level. 
‘‘(7) DETERMINATION OF FEASIBILITY OF QUAL-
ITY MEASUREMENT AT THE PLAN LEVEL FOR ALL MA 
PLANS.— 
‘‘(A) DETERMINATION
OF
FEASIBILITY.— 
The Secretary shall determine the feasibility of 
requiring reporting of data under section 1852(e) 
for, and applying under this subsection, quality 
measures at the plan level for all MA plans 
under this part. 
‘‘(B) CONSIDERATION
OF
CHANGE.—After 
making a determination under subparagraph 
(A), the Secretary shall consider requiring such 
reporting and applying such quality measures at 
the plan level as described in such subpara-
graph.’’. 
(e) GAO STUDY AND REPORT ON STATE-LEVEL INTE-
GRATION BETWEEN DUAL SNPS AND MEDICAID.— 
(1) STUDY.—The Comptroller General of the 
United States (in this paragraph referred to as the 
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‘‘Comptroller General’’) shall conduct a study on 
State-level integration between specialized MA plans 
for special needs individuals described in subsection 
(b)(6)(B)(ii) of section 1859 of the Social Security 
Act (42 U.S.C. 1395w–28) and the Medicaid program 
under title XIX of such Act (42 U.S.C. 1396 et seq.). 
Such study shall include an analysis of the following: 
(A) The characteristics of States in which 
the State agency responsible for administering 
the State plan under such title XIX has a con-
tract with such a specialized MA plan and that 
delivers long term services and supports under 
the State plan under such title XIX through a 
managed care program, including the require-
ments under such State plan with respect to long 
term services and supports. 
(B) The types of such specialized MA plans, 
which may include the following: 
(i) 
A 
plan 
described 
in 
section 
1853(a)(1)(B)(iv)(II) of such Act (42 U.S.C. 
1395w–23(a)(1)(B)(iv)(II)). 
(ii) A plan that meets the requirements 
described in subsection (f)(3)(D) of such sec-
tion 1859. 
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(iii) A plan described in clause (ii) 
that also meets additional requirements es-
tablished by the State. 
(C) The characteristics of individuals en-
rolled in such specialized MA plans. 
(D) As practicable, the following with re-
spect to State programs for the delivery of long 
term services and supports under such title XIX 
through a managed care program: 
(i) Which populations of individuals 
are eligible to receive such services and sup-
ports. 
(ii) Whether all such services and sup-
ports are provided on a capitated basis or 
if any of such services and supports are 
carved out and provided through fee-for- 
service. 
(E) As, practicable, how the availability 
and variation of integration arrangements of 
such specialized MA plans offered in States af-
fects spending, service delivery options, access to 
community-based care, and utilization of care. 
(F) Barriers and opportunities for making 
further progress on dual integration, as well as 
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recommend legislation to expedite or refine path-
ways toward fully integrated care. 
(2) REPORT.—Not later than 2 years after the 
date of the enactment of this Act, the Comptroller 
General shall submit to Congress a report containing 
the results of the study conducted under paragraph 
(1), together with recommendations for such legisla-
tion and administrative action as the Comptroller 
General determines appropriate. 
SEC. 3. EXPANDING SUPPLEMENTAL BENEFITS TO MEET 
THE NEEDS OF CHRONICALLY ILL MEDICARE 
ADVANTAGE ENROLLEES. 
(a) IN GENERAL.—Section 1852(a)(3) of the Social Se-
curity Act (42 U.S.C. 1395w–22(a)(3)) is amended— 
(1) in subparagraph (A), by striking ‘‘Each’’ 
and inserting ‘‘Subject to subparagraph (D), each’’; 
and 
(2) by adding at the end the following new sub-
paragraph: 
‘‘(D) EXPANDING SUPPLEMENTAL BENEFITS 
TO MEET THE NEEDS OF CHRONICALLY ILL EN-
ROLLEES.— 
‘‘(i) IN GENERAL.—For plan year 2020 
and subsequent plan years, in addition to 
any supplemental health care benefits other-
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wise provided under this paragraph, an MA 
plan, including a specialized MA plan for 
special needs individuals described in sub-
section (b)(6) of section 1859, may provide 
supplemental benefits described in clause 
(ii) to a chronically ill enrollee (as defined 
in clause (iii)). 
‘‘(ii) SUPPLEMENTAL
BENEFITS
DE-
SCRIBED.— 
‘‘(I) IN GENERAL.—Supplemental 
benefits described in this clause are 
supplemental benefits that, with respect 
to a chronically ill enrollee, have a rea-
sonable expectation of improving or 
maintaining the health or overall func-
tion of the chronically ill enrollee and 
may not be limited to being primarily 
health related benefits. 
‘‘(II) AUTHORITY TO WAIVE UNI-
FORMITY
REQUIREMENTS.—The Sec-
retary may, with respect to supple-
mental benefits provided to a chron-
ically ill enrollee under this subpara-
graph, waive the uniformity require-
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ment, as determined appropriate by 
the Secretary. 
‘‘(iii) CHRONICALLY
ILL
ENROLLEE 
DEFINED.—In this subparagraph, the term 
‘chronically ill enrollee’ means an enrollee 
in an MA plan that the Secretary deter-
mines— 
‘‘(I) has one or more comorbid 
and medically complex chronic condi-
tions that is life threatening or signifi-
cantly limits the overall health or func-
tion of the enrollee; 
‘‘(II) has a high risk of hos-
pitalization or other adverse health 
outcomes; or 
‘‘(III) requires intensive care co-
ordination.’’. 
(b) GAO STUDY AND REPORT.— 
(1) STUDY.—The Comptroller General of the 
United States (in this subsection referred to as the 
‘‘Comptroller General’’) shall conduct a study on sup-
plemental benefits provided to enrollees in Medicare 
Advantage plans under part C of title XVIII of the 
Social Security Act, including specialized MA plans 
for special needs individuals described in section 
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1859(b)(6) of such Act (42 U.S.C. 1395w–28(b)(6)). 
Such study shall be conducted in consultation with 
the Centers for Medicare & Medicaid Services and 
Medicare Advantage plans as necessary and, to the 
extent data is available, shall include an analysis of 
the following: 
(A) The type of supplemental benefits pro-
vided to such enrollees, the total number of en-
rollees receiving each supplemental benefit, and 
whether the supplemental benefit is covered by 
the standard benchmark cost of the benefit or 
with an additional premium. 
(B) The frequency in which supplemental 
benefits are utilized by such enrollees. 
(C) The impact supplemental benefits have 
on— 
(i) indicators of the quality of care re-
ceived by such enrollees, including overall 
health and function of the enrollees; 
(ii) the utilization of items and serv-
ices for which benefits are available under 
the original Medicare fee-for-service pro-
gram option under parts A and B of such 
title XVIII by such enrollees; and 
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(iii) the amount of the bids submitted 
by Medicare Advantage Organizations for 
Medicare Advantage plans under such part 
C. 
(2) REPORT.—Not later than 5 years after the 
date of the enactment of this Act, the Comptroller 
General shall submit to Congress a report containing 
the results of the study conducted under paragraph 
(1), together with recommendations for such legisla-
tion and administrative action as the Comptroller 
General determines appropriate. 
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Union Calendar No. 353 
115TH CONGRESS 
1ST SESSION 
H. R. 3168 
[Report No. 115–478, Part I] 
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. 
DECEMBER 21, 2017 
Reported from the Committee on Ways and Means with 
an amendment 
DECEMBER 21, 2017 
The Committee on Energy and Commerce discharged; 
committed to the Committee of the Whole House on 
the State of the Union and ordered to be printed 
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