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 with-
in 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. 
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 ‘‘Strengthening 
Healthcare Options for Vulnerable Populations Act’’. 
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SEC. 2. REAUTHORIZATION OF CERTAIN MEDICARE ADVAN-
TAGE SPECIAL NEEDS PLANS. 
(a) PERMANENT EXTENSION OF MEDICARE ADVAN-
TAGE DUAL SPECIAL NEEDS PLANS AUTHORITY.—Sec-
tion 1859(f)(1) of the Social Security Act (42 U.S.C. 
1395w–28(f)(1)) is amended by inserting ‘‘, in the case 
of a specialized MA plan for special needs individuals who 
are not described in section 1859(b)(6)(B)(ii),’’ before 
‘‘for periods before January 1, 2015’’. 
(b) MEDICARE ADVANTAGE DUAL SPECIAL NEEDS 
PLANS REQUIRED TO PROVIDE INTEGRATED CARE.— 
Section 1859(f)(3) of the Social Security Act (42 U.S.C. 
1395w–28(f)(3)) is amended by adding at the end the fol-
lowing new subparagraph: 
‘‘(F) Not later than December 31, 2018, 
the plan is fully integrated with capitated con-
tracts with States for any Medicaid benefits, in-
cluding long-term care and behavioral health, to 
the extent State law permits capitation of such 
services under such plan.’’. 
(c) CLEARLY DEFINED ROLE OF STATE MEDICAID 
AGENCY.—Section 1852(a)(1)(B) of the Social Security 
Act (42 U.S.C. 1395w–22(a)(1)(B)) is amended by adding 
at the end the following new clause: 
‘‘(vi) DEFINED ROLE OF STATE MED-
ICAID AGENCIES WITH RESPECT TO FULLY 
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INTEGRATED
DUAL
SPECIAL
NEEDS 
PLANS.—The Secretary, in coordination 
with State Medicaid Directors, shall de-
velop a clearly defined role for State Med-
icaid agencies in contracting and oversight 
of plans described in clause (v)(II).’’. 
SEC. 3. IMPROVEMENTS TO MEDICARE ADVANTAGE 5–STAR 
QUALITY RATING SYSTEM FOR PLANS WITH 
PREDOMINATELY DUAL ELIGIBLE ENROLL-
EES. 
(a) TREATMENT OF PLANS WITH DISPROPORTION-
ATELY
HIGH
DUAL
ELIGIBLE
ENROLLEES.—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 
paragraph: 
‘‘(6) TREATMENT OF PLANS WITH DISPROPOR-
TIONATELY HIGH DUAL ELIGIBLE ENROLLEES.— 
‘‘(A) IN GENERAL.—In implementing this 
subsection, the Secretary shall take such steps 
as are necessary to ensure that the quality rat-
ing for a plan— 
‘‘(i) does not disadvantage such a plan 
that enrolls— 
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‘‘(I) full-benefit dual eligible indi-
vidual 
(as 
defined 
in 
section 
1935(c)(6)); 
‘‘(II) qualified Medicare bene-
ficiaries 
(as 
defined 
in 
section 
1905(p)(1)); or 
‘‘(III) individuals with complex 
health care needs, such as individuals 
with multiple conditions or individuals 
who require chronic care or institu-
tional care; and 
‘‘(ii) accounts for differences in socio-
economic and demographic characteristics 
of enrollees of such a plan that result in 
significant variation in health outcomes. 
‘‘(B) SPECIFIC
STEPS.—The steps de-
scribed in subparagraph (A) shall include at 
least the following: 
‘‘(i) Comparing specialized MA plans 
for special needs individuals (as defined in 
section 1859(b)(6)) for special needs indi-
viduals who are described in subparagraph 
(B)(ii) of such section only against other 
plans with the same types of enrollment. 
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‘‘(ii) Developing a methodology spe-
cific to specialized MA plans for special 
needs individuals (as defined in section 
1859(b)(6)) for special needs individuals 
who are described in subparagraph (B)(ii) 
of such section for determining a quality 
rating under this subsection for such 
plans. 
‘‘(iii) Developing appropriate case mix 
adjustment to Healthcare Effectiveness 
Data and Information Set (HEDIS) and 
Health Outcomes Survey (HOS) measures 
for specialized MA plans for special needs 
individuals 
(as 
defined 
in 
section 
1859(b)(6)) for special needs individuals 
who are described in subparagraph (B)(ii) 
of such section that account for factors be-
yond the control of the health system, such 
as the management of conditions. 
‘‘(iv) Identifying and implementing 
those quality measures that are appro-
priate for evaluating the performance of 
specialized MA plans for special needs indi-
viduals (as defined in section 1859(b)(6)) 
for special needs individuals who are de-
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scribed in subparagraph (B)(ii) of such 
section. 
‘‘(v) Eliminating duplicative or sub-
stantially similar measures applied under 
this title or title XIX with respect to spe-
cialized MA plans.’’. 
(b) TEMPORARY TREATMENT
OF CERTAIN DUAL 
SPECIAL NEEDS PLANS.—Section 1853(o) of the Social 
Security Act (42 U.S.C. 1395w–23(o)), as amended by 
subsection (a), is further amended by adding at the end 
the following new paragraph: 
‘‘(7) TEMPORARY
TREATMENT
OF
CERTAIN 
DUAL SPECIAL NEEDS PLANS.—In implementing this 
subsection during the period beginning on the date 
of the enactment of this paragraph and ending one 
year after the date on which the Secretary has taken 
such steps as are required under paragraph (6), the 
Secretary may increase the quality rating that a spe-
cialized MA plans for special needs individuals (as 
defined in section 1859(b)(6)) for special needs indi-
viduals who are described in subparagraph (B)(ii) of 
such section would otherwise receive under this sub-
section for a year by 0.5 stars if the plan dem-
onstrates to the satisfaction of the Secretary that 
the quality rating the plan would have otherwise re-
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ceived is predominately attributable to socio-eco-
nomic, demographic, or pre-existing complex health 
care needs of the population enrolled in such plan 
with respect to such year instead of the performance 
of the plan with respect to such year.’’. 
(c) GAO REPORT.—Not later than one year after the 
date on which the Secretary of Health and Human Serv-
ices has taken such steps as are required under paragraph 
(6) of section 1853(o) of the Social Security Act (42 
U.S.C. 1395w–23(o)), as added by subsection (a), and an-
nually thereafter for the following four years, the Comp-
troller General of the United States shall submit to Con-
gress a report that includes a comprehensive review of the 
effectiveness of, and recommendations to improve, such 
steps so taken for improving health outcomes, cost con-
trols, and beneficiary satisfaction. 
SEC. 4. ADDITIONAL IMPROVEMENTS TO THE OVERSIGHT 
AND OPERATION OF MEDICARE ADVANTAGE 
DUAL SPECIAL NEEDS PLANS BY THE FED-
ERAL COORDINATED HEALTH CARE OFFICE. 
(a) DEDICATED POINT OF CONTACT FOR ASSISTING 
STATES WITH ADMINISTRATION.—Section 2602(d) of the 
Patient Protection and Affordable Care Act (42 U.S.C. 
1315b(d)) is amended by adding at the end the following 
new paragraph: 
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‘‘(6) Serving as the dedicated point of contact 
within the Centers for Medicare & Medicaid Services 
to assist States with ongoing issues related to the 
administration of specialized MA plans for special 
needs individuals (as defined in section 1859(b)(6) 
of the Social Security Act) for special needs individ-
uals who are described in subparagraph (B)(ii) of 
such section, including— 
‘‘(A) addressing any misalignment between 
the contracting timelines, processes, and dead-
lines under title XVIII of such Act, with respect 
to such plans for such individuals and con-
tracting timelines, processes, and deadlines 
under title XIX of such Act, with respect to 
such plans and individuals; and 
‘‘(B) streamlining the flow of information 
to dual eligible individuals and establishing a 
single set of rules for outreach and marketing 
to such individuals.’’. 
(b) AUTHORITY
TO
WAIVE
CERTAIN
REQUIRE-
MENTS.— 
(1) IN GENERAL.—Subject to paragraph (2), 
the Secretary of Health and Human Services, 
through the Federal Coordinated Health Care Office 
established under section 2602 of the Patient Pro-
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tection and Affordable Care Act (42 U.S.C. 1315b) 
and in coordination with the appropriate State Med-
icaid agency, may waive the application of require-
ments under title XVIII of the Social Security Act 
to promote the integration, alignment, and delivery 
of items and services under the Medicare program 
under title XVIII of such Act and the Medicaid pro-
gram under title XIX of such Act, with respect to 
dual eligible individuals (as defined in section 
2602(f) of the Patient Protection and Affordable 
Care Act (42 U.S.C. 1315b(f)), and to ensure the 
seamless delivery of patient-centered services across 
the continuum of care with respect to such individ-
uals. 
(2) PUBLIC NOTICE REQUIREMENT.—The Sec-
retary may not waive the application of a require-
ment pursuant to paragraph (1) unless the Sec-
retary makes such waiver publicly available (whether 
on the public Internet website of Department of 
Health and Human Services, or otherwise) at least 
30 days before the effective date of such waiver. 
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SEC. 5. IMPROVEMENTS TO DISPUTE RESOLUTION FOR 
CLAIMS AND APPEALS UNDER MEDICARE AD-
VANTAGE DUAL SPECIAL NEEDS PLANS. 
(a) MEDICARE ADVANTAGE DUAL SPECIAL NEEDS 
PLANS REQUIRED TO PROVIDE COVERAGE DURING AP-
PEALS PROCESS.—Section 1859(f)(3) of the Social Secu-
rity Act (42 U.S.C. 1395w–28(f)(3)), as amended by sec-
tion 2(b), is further amended by adding at the end the 
following new subparagraph: 
‘‘(G) For plan years beginning after De-
cember 31, 2015, coverage under this title and 
title XIX of an individual enrolled under such 
respective title shall continue during any deter-
mination, reconsideration, or appeals proceeding 
described in section 1852(g), with respect to 
such individual.’’. 
(b) STREAMLINED PATHWAY FOR DISPUTE RESOLU-
TION.—Not later than December 31, 2015, the Secretary 
of Health and Human Services shall establish a stream-
lined process for dispute resolution for claims and appeals, 
with respect items and services furnished to special needs 
individuals described in section 1859(b)(6)(B)(ii) of the 
Social Security Act (42 U.S.C. 1395w–28(b)(6)(B)(ii)), to 
align such process under the Medicare program under title 
XVIII of the Social Security Act with such process under 
the Medicaid program under title XIX of such Act. Such 
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streamlined process shall take into account various State 
requirements and promote a pathway that would be the 
most beneficial for individuals entitled to benefits under 
part A of title XVIII of such Act or enrolled under part 
B of such Act and to individuals enrolled under a State 
plan under title XIX of such Act. 
SEC. 6. REPORT ON IMPLEMENTATION OF CERTAIN MEDI-
CARE AND MEDICAID FRAUD DETECTION 
AND PROGRAM INTEGRITY PROVISIONS. 
Section 1128J(a)(1)(A) of the Social Security Act 
(42 U.S.C. 1320a–7k(a)(1)(A)) is amended by adding at 
the end the following new clause: 
‘‘(iii) REPORT ON INTEGRATED DATA 
REPOSITORY
AND
ONE
PROGRAM
INTEG-
RITY SYSTEM.—Not later than six months 
after the date of enactment of this clause, 
the Secretary shall submit to the appro-
priate Congressional committees a report 
on the following: 
‘‘(I) INTEGRATED DATA REPOSI-
TORY.—Efforts to finalize plans and 
schedules for fully implementing and 
expanding the use of the Integrated 
Data Repository, including actions 
taken to finalize, implement, and 
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manage plans for incorporating data 
into the Integrated Data Repository 
and actions taken to define measur-
able financial benefits expected from 
the implementation of the Integrated 
Data Repository. 
‘‘(II) ONE PROGRAM INTEGRITY 
SYSTEM.—Actions 
taken 
to 
plan, 
schedule, and conduct training on the 
One Program Integrity System, a 
Web-based portal and suite of soft-
ware tools used to analyze and extract 
data from the Integrated Data Repos-
itory, and actions taken to define 
measurable financial benefits expected 
from the use of the One Program In-
tegrity System.’’. 
Æ 
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