I 
118TH CONGRESS 
2D SESSION 
H. R. 8503 
To provide States with support to establish integrated care programs for 
individuals who are dually eligible for Medicare and Medicaid, and for 
other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 22, 2024 
Mr. KELLY of Pennsylvania (for himself and Mr. BERA) introduced the fol-
lowing bill; which was referred to the Committee on Energy and Com-
merce, and in addition to the Committee on Ways and Means, for a pe-
riod to be subsequently determined by the Speaker, in each case for con-
sideration of such provisions as fall within the jurisdiction of the com-
mittee concerned 
A BILL 
To provide States with support to establish integrated care 
programs for individuals who are dually eligible for Medi-
care and Medicaid, 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; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Delivering Unified Access to Lifesaving Services Act of 
2024’’ or the ‘‘DUALS Act of 2024’’. 
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(b) TABLE OF CONTENTS.—The table of contents for 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
TITLE I—STATE INTEGRATED CARE PROGRAMS FOR DUAL 
ELIGIBLE INDIVIDUALS 
Sec. 101. State implementation. 
‘‘TITLE XXII—STATE INTEGRATED CARE PROGRAMS FOR DUAL 
ELIGIBLE INDIVIDUALS 
‘‘Sec. 2201. Definitions. 
‘‘Sec. 2202. State selection of program models, development, and imple-
mentation. 
‘‘Sec. 2203. Enrollment in integrated care plans. 
‘‘Sec. 2204. Plan requirements and payments. 
‘‘Sec. 2205. Data collection and reporting. 
‘‘Sec. 2206. State ombudsman. 
‘‘Sec. 2207. Funding. 
‘‘Sec. 2208. Federal administration through the Federal Coordinated 
Health Care Office. 
Sec. 102. Providing Federal Coordinated Health Care Office authority over 
dual snps. 
Sec. 103. Additional conforming amendments. 
TITLE II—IMPROVING ELIGIBILITY DETERMINATIONS, ENROLL-
MENT PROCESSES, AND QUALITY OF CARE FOR DUAL ELIGI-
BLE INDIVIDUALS 
Sec. 201. Identifying opportunities for State coordination with respect to eligi-
bility determinations. 
Sec. 202. Alignment of bidding, reporting, and other dates and deadlines for in-
tegrated care plans. 
Sec. 203. Grants to State and local community organizations for outreach and 
enrollment. 
Sec. 204. Application of model standards to information requirements for inte-
grated care plans. 
Sec. 205. Enrollment through independent brokers. 
Sec. 206. Reducing threshold for look-alike D–SNP plans under Medicare Ad-
vantage. 
Sec. 207. Requiring regular update of provider directories. 
Sec. 208. Review of hospital quality star rating system. 
Sec. 209. Requirement for FCHCO and State Medicaid agencies to develop 
maximum staffing ratios for care coordinators. 
Sec. 210. CMMI testing of coverage of partial benefit dual eligible individuals 
through State Integrated Care Programs. 
TITLE III—ADMINISTRATION 
Sec. 301. Alignment of billing codes under titles XVIII, XIX, and XXII. 
TITLE IV—PACE 
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Sec. 401. Requiring States to offer PACE program services to eligible individ-
uals. 
Sec. 402. Enrollment of PACE beneficiaries at any time. 
Sec. 403. Extending eligibility for PACE to medicare-eligible individuals under 
the age of 55. 
Sec. 404. Removal of quarterly restrictions for submission of a new PACE or-
ganization application, and removal of quarterly restrictions for 
applications in a new service area. 
Sec. 405. Ensuring Medicare-only PACE program enrollees have a choice of 
prescription drug plans under Medicare part D. 
TITLE 
I—STATE 
INTEGRATED 
CARE PROGRAMS FOR DUAL 
ELIGIBLE INDIVIDUALS 
SEC. 101. STATE IMPLEMENTATION. 
The Social Security Act is amended by adding at the 
end the following new title: 
‘‘TITLE 
XXII—STATE 
INTE-
GRATED 
CARE 
PROGRAMS 
FOR DUAL ELIGIBLE INDIVID-
UALS 
‘‘SEC. 2201. DEFINITIONS. 
‘‘In this title: 
‘‘(1) DIRECTOR.—The term ‘Director’ means 
the Director of the Federal Coordinated Health Care 
Office of the Centers for Medicare & Medicaid Serv-
ices. 
‘‘(2) DUAL ELIGIBLE INDIVIDUAL.—The term 
‘dual eligible individual’ means an individual who is 
entitled to, or enrolled for, benefits under part A of 
title XVIII, or enrolled for benefits under part B of 
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title XVIII, and is eligible for medical assistance for 
full 
benefits 
under 
title 
XIX 
under 
section 
1902(a)(10)(A) or 1902(a)(10)(C), by reason of sec-
tion 1902(f), or under any other category of eligi-
bility for medical assistance for full benefits under 
such title, as determined by the Secretary. 
‘‘(3) INTEGRATED CARE PLAN.—The term ‘in-
tegrated care plan’ means an entity or organization 
that is selected by a State under section 2202(a) to 
provide fully integrated care for a dual eligible indi-
vidual in accordance with the requirements of this 
title and related Federal and State regulations. Such 
term shall not include a PACE program (as defined 
in sections 1894(a)(2) and 1934(a)(2)). 
‘‘SEC. 2202. STATE SELECTION OF PROGRAM MODELS, DE-
VELOPMENT, AND IMPLEMENTATION. 
‘‘(a) STATE SELECTION OF PROGRAM MODELS.— 
Not later than 1 year after the date on which the Director 
first publishes the range of program models for providing 
integrated care for dual eligible individuals required by 
section 2208(b)(1), each State shall select from such pub-
lished models, and shall work with the Director to imple-
ment such models in the State in accordance with the re-
quirements of this title a program model to provide com-
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members of the council shall include representatives 
of a wide range of stakeholders relevant to the provi-
sion of integrated care for dual eligible individuals. 
‘‘(2) DUTIES.—The implementation council 
shall provide advice and counsel to the State with re-
spect to the implementation of the models selected 
by the State under subsection (a). 
‘‘SEC. 2203. ENROLLMENT IN INTEGRATED CARE PLANS. 
‘‘(a) 
PASSIVE
ENROLLMENT; 
OPT-OUT
PER-
MITTED.— 
‘‘(1) PASSIVE ENROLLMENT AND NOTICE RE-
QUIREMENTS.—A State shall automatically enroll a 
dual eligible individual with an integrated care plan 
under a contract with the State provided that the 
State notifies the individual that the individual will 
be enrolled with such plan at least 60 days (90 days, 
in the case of the first time the individual is pro-
vided such notice) prior to the effective date of such 
enrollment. Notice provided to a dual eligible indi-
vidual under this paragraph shall include the fol-
lowing: 
‘‘(A) The name and contact information 
for the integrated care plan. 
‘‘(B) The date on which the enrollment 
takes effect and, if applicable, whether the 
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State has elected the option for a 12-month 
continuous eligibility period under paragraph 
(4). 
‘‘(C) A summary of the benefits to be pro-
vided by the plan. 
‘‘(D) Information regarding the provider 
network of the plan. 
‘‘(E) Information regarding how the dual 
eligible individual may elect to opt-out of enroll-
ment with the plan within 60 days (90 days, in 
the case of the first time the individual is pro-
vided such notice). 
‘‘(2) ENROLLMENT
IN
PLAN
WITH
IN-NET-
WORK, PARTICIPATING PRIMARY CARE PROVIDER RE-
QUIRED.—A State shall not passively enroll a dual 
eligible individual in an integrated care plan unless 
the individual’s primary care physician is an in-net-
work, participating provider for the plan. 
‘‘(3) VOLUNTARY ENROLLMENT.—A State shall 
offer a dual eligible individual the option to enroll in 
an integrated care plan without regard to meeting 
the requirement of paragraph (2). 
‘‘(4) STATE OPTION FOR CONTINUOUS ELIGI-
BILITY AND ENROLLMENT.—A State may elect for a 
dual eligible individual who is determined to be eligi-
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ble for medical assistance under the State plan 
under title XIX or under a waiver of such plan and 
who is enrolled with an integrated care plan under 
a contract with the State to remain eligible for med-
ical assistance and enrolled with such plan until the 
earlier of— 
‘‘(A) the end of the 12-month period begin-
ning on the date of such determination; or 
‘‘(B) the date that such individual ceases 
to be a resident of such State. 
‘‘(b) CHANGE OF ENROLLMENT.—A State shall per-
mit a dual eligible individual to change enrollment in an 
integrated care plan— 
‘‘(1) on a monthly basis if the individual is 
electing to enroll in another integrated care plan; 
‘‘(2) during the general enrollment period appli-
cable under section 1837, if the individual is electing 
to disenroll from an integrated care plan and not en-
roll in another integrated care plan; and 
‘‘(3) during the 60-day period beginning on the 
date the individual receives notice from the State 
that the individual has been determined to no longer 
be eligible for treatment as a dual eligible individual, 
if the individual is no longer eligible to enroll in an 
integrated care plan. 
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‘‘(c) CONTACT BY PLAN CARE COORDINATOR PER-
MITTED PRIOR TO EFFECTIVE DATE OF ENROLLMENT.— 
A care coordinator for an integrated care plan may contact 
a dual eligible individual who has been passively enrolled 
in the plan prior to the effective date of the enrollment. 
‘‘SEC. 2204. PLAN REQUIREMENTS AND PAYMENTS. 
‘‘(a) IN GENERAL.—A contract between a State, an 
offeror of an integrated care plan, and the Director shall 
not be considered to meet the requirements of this title 
unless— 
‘‘(1) in the case of a dual eligible individual en-
rolled with the plan who changes enrollment to an-
other integrated care plan for which the individual’s 
primary care provider is not a participating, in-net-
work provider, or who disenrolls from the plan and 
does not enroll in another integrated care plan, the 
offeror of the plan will, during the 30-day period 
that begins on the date on which the individual’s 
disenrollment from the plan takes effect— 
‘‘(A) allow the individual to continue to be 
treated by the individual’s primary care pro-
vider; and 
‘‘(B) cover any treatment provided to the 
individual by such provider as if the individual 
were still enrolled with the plan; 
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‘‘(2) the offeror of the plan administers a 
health risk assessment to each dual eligible indi-
vidual enrolled with the plan within 90 days of the 
effective date of the individual’s enrollment in ac-
cordance with the requirements of subsection (c) and 
shall affirm that there are no changes in the infor-
mation provided at least every 12 months thereafter; 
‘‘(3) the offeror of the plan provides benefits for 
a dual eligible individual under a comprehensive care 
plan in accordance with the requirements of sub-
sections (d) and (f); 
‘‘(4) the offeror of the plan assigns a care coor-
dinator to each dual eligible individual enrolled with 
the plan in accordance with the requirements of sub-
section (e) and notifies such individual in a timely 
and accessible manner when a new care coordinator 
is assigned; and 
‘‘(5) the contract provides for payment to the 
offeror for benefits provided to dual eligible individ-
uals enrolled with the plan using a financing struc-
ture that satisfies the requirements of section 
2208(c). 
‘‘(b) DISREGARD
OF
CERTAIN
DISENROLLMENT 
DATA FOR RATINGS PURPOSES.—The disenrollment of a 
dual eligible individual from an integrated care plan who 
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was passively enrolled in the plan under section 2203 shall 
be disregarded for purposes of any data used for rating 
of the plan for such plan year. 
‘‘(c) HEALTH RISK ASSESSMENT.—An offeror of an 
integrated care plan shall administer a health risk assess-
ment to each dual eligible individual enrolled with the plan 
using the standardized health risk assessment question-
naire developed by the Director under section 2208(b)(3) 
and in accordance with such additional requirements as 
the State may establish. An integrated care plan may rely 
on the results of a previously administered health risk as-
sessment of a dual eligible individual if such results are 
accessible to the plan and the dual eligible individual af-
firms that there are no changes in the information pre-
viously provided. 
‘‘(d) BENEFITS.— 
‘‘(1) IN
GENERAL.—An integrated care plan 
shall provide benefits under the plan in accordance 
with requirements established by the Director and 
the State, and which shall include the following: 
‘‘(A) Clinical health services. 
‘‘(B) Behavioral health services. 
‘‘(C) Long-term services and supports. 
‘‘(2) CARVE-OUT
EXCEPTIONS.—The Director 
may permit a State and integrated care plan to sep-
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arately contract for the provision of services or sup-
ports required under paragraph (1) but only if the 
State demonstrates to the Director that— 
‘‘(A) the level of care provided for a dual 
eligible individual under the separate contract 
with respect to such services or supports is not 
less than the level of care that would be pro-
vided without the exception; and 
‘‘(B) the dual eligible individual will not be 
subject to any unreasonable administrative re-
quirements to access the services or supports, 
as determined by the Secretary. 
‘‘(3) SUPPLEMENTAL
BENEFITS.—An inte-
grated care plan may provide customized, supple-
mental benefits to a dual eligible individual enrolled 
with the plan, including supplemental health care 
benefits described in section 1852(a)(3), other pri-
marily health-related benefits offered by Medicare 
Advantage plans and benefits permitted by the Sec-
retary to be offered as Special Supplemental Bene-
fits for the Chronically Ill (SSBCI), without regard 
to whether the dual eligible individual has a requisite 
condition or diagnosis, so long as the plan dem-
onstrates to the Director and the State that the of-
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fering of such benefits has a positive impact on pa-
tient health. 
‘‘(e) CARE COORDINATOR REQUIREMENTS.—A care 
coordinator assigned to a dual eligible individual enrolled 
in an integrated care plan shall— 
‘‘(1) serve as the single point of contact be-
tween the individual and the plan; 
‘‘(2) be responsible for helping the individual 
and the individual’s caregivers and family make ben-
efit and service decisions; 
‘‘(3) design a beneficiary-focused comprehensive 
care plan for the individual that meets the require-
ments of subsection (f); and 
‘‘(4) connect and coordinate acute, subacute, 
social, primary, and specialty care for the individual 
and the provision of long-term services and supports 
for the individual. 
‘‘(f) 
COMPREHENSIVE
CARE
PLAN
REQUIRE-
MENTS.—The comprehensive care plan for a dual eligible 
individual enrolled in an integrated care plan shall be— 
‘‘(1) designed to address the totality of the indi-
vidual’s medical, functional, behavioral, social, and 
caregiving needs and goals, and to the extent prac-
ticable, to apply to multiple years; 
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‘‘(2) be based on the health risk assessment of 
the individual required by subsection (c); 
‘‘(3) be implemented by an interdisciplinary 
care team that includes relevant specialists to ensure 
access to all aspects of care that are required for the 
individual; 
‘‘(4) be approved by the individual (or by an 
authorized caregiver or guardian) prior to implemen-
tation; and 
‘‘(5) be reviewed at least annually and within 
30 days of a major health event, such as hospitaliza-
tion or an emergency room visit. 
‘‘(g) CONTINUITY OF CARE REQUIREMENT.—An in-
tegrated care plan shall provide a dual eligible individual 
enrolled in the plan with a minimum 90-day transition pe-
riod for any active course of treatment when the individual 
has enrolled in an integrated care plan after starting a 
course of treatment, even if the service is furnished by 
an out-of-network provider. This includes enrollees new to 
a plan and enrollees new to Medicare. The integrated care 
plan must not disrupt or require reauthorization for an 
active course of treatment for new plan enrollees for a pe-
riod of at least 90 days. An integrated care plan may pro-
vide for a longer transition period than 90 days at the 
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option of the plan. For purposes of this subsection the 
following definitions apply: 
‘‘(1) The term ‘course of treatment’ means as 
a prescribed order or ordered course of treatment 
for a specific individual with a specific condition is 
outlined and decided upon ahead of time with the 
patient and provider. A course of treatment may but 
is not required to be part of a treatment plan. 
‘‘(2) The term ‘active course of treatment’ 
means a course of treatment in which a patient is 
actively seeing the provider and following the course 
of treatment. 
‘‘(h) AUTHORITY TO APPLY FRAILTY ADJUSTMENT 
FACTOR
TO PLAN PAYMENTS.—A contract between a 
State, an integrated care plan, and the Director under this 
title may apply a frailty adjustment factor with respect 
to dual eligible individuals enrolled in the plan in the same 
manner as is permitted under section 1853(a)(1)(B)(iv), 
but without regard to requiring the plan to demonstrate 
enrollment of a high concentration of frail individuals. 
‘‘SEC. 2205. DATA COLLECTION AND REPORTING. 
‘‘(a) ANNUAL COLLECTION
AND REPORTING
BY 
STATES AND INTEGRATED CARE PLANS.—Each State, 
and each integrated care plan with a contract with a State 
under this title, annually shall collect and report informa-
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tion and data to the Director in accordance with the re-
quirements of this section and guidance and regulations 
issued under section 2208(b)(7) that includes data col-
lected by such States and plans with respect to a plan 
year regarding age, gender, disability (including specific 
disability statuses required to be reported by the Direc-
tor), smoking status, mobility, employment status, edu-
cation, race and ethnicity, and zip code, of dual eligible 
individuals enrolled in the plan. 
‘‘(b) COLLECTION AND REPORTING OF ADDITIONAL 
DATA AND INFORMATION PERMITTED.—A State may re-
quire an integrated care plan with a contract with the 
State under this title to collect and report to the State 
additional data and information. 
‘‘SEC. 2206. STATE OMBUDSMAN. 
‘‘(a) IN GENERAL.—Each State shall establish and 
operate an Office of the Ombudsman for Integrated Care 
Plans for Dual Eligible Individuals (in this section re-
ferred to as the ‘Office’). The Office may operate inde-
pendently of, or in connection with, the State agency re-
sponsible for administering the Medicaid program under 
title XIX. 
‘‘(b) OMBUDSMAN.—The Office shall be headed by an 
individual, to be known as the State Integrated Care for 
Dual Eligible Individuals Ombudsman, who shall be se-
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lected from among individuals with expertise in and expe-
rience with integrated care models for dual eligible individ-
uals, the Medicare program under title XVIII, and the 
Medicaid program under title XIX. The Ombudsman shall 
be responsible for the management, including the fiscal 
management, of the Office. 
‘‘(c) REQUIREMENTS.— 
‘‘(1) IN GENERAL.—The primary responsibility 
of the Office shall be to provide support and feed-
back for dual eligible individuals enrolled in inte-
grated care plans under this title and caregivers or 
family members of such individuals who need assist-
ance. 
‘‘(2) MINIMUM STAFFING RATIO.—The Office 
shall have a minimum staffing ratio of one employee 
for every 2,000 dual eligible individuals in the State. 
‘‘(d) FUNDING.— 
‘‘(1) INITIAL
FUNDING.—During the first 2 
years in which a State operates the Office, the Sec-
retary shall pay to the State for each such year for 
expenditures necessary to establish and operate the 
Office, from amounts appropriated under section 
2207(c), an amount equal to $50,000,000 multiplied 
by the ratio of— 
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‘‘(A) the number of dual eligible individ-
uals in the State; to 
‘‘(B) the number of dual eligible individ-
uals in all States. 
‘‘(2) SUBSEQUENT FUNDING.—Beginning with 
the third year of the Office’s operation, expenditures 
necessary to operate the Office shall be considered, 
for purposes of section 1903(a)(7), to be necessary 
for the proper and efficient administration of the 
State plan under title XIX and reimbursed to a 
State in accordance with that section. 
‘‘SEC. 2207. FUNDING. 
‘‘(a) TREATMENT OF STATE PAYMENTS TO INTE-
GRATED
CARE
PLANS
AS
MEDICAL
ASSISTANCE.— 
Amounts expended by a State for payments to an inte-
grated care plan for the Medicaid component of the capita-
tion payment described in section 2208(c) shall be treated 
as medical assistance for which payment is made under 
section 1903(a). Nothing in this title shall prevent a State 
from providing medical assistance under title XIX to a 
dual eligible individual for services for which coverage is 
not provided under the integrated care plan with which 
the individual is enrolled or from receiving payment under 
section 1903(a) with respect to expenditures attributable 
to providing such medical assistance. 
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‘‘(b) PAYMENTS TO STATES.—From the sums appro-
priated under subsection (c), the Secretary shall pay to 
each State for each calendar year (beginning January 1 
of the first full calendar year in which this title is imple-
mented in the State), an amount equal to the sum of the 
following: 
‘‘(1) 
SHARED
SAVINGS
COMPONENT.—The 
shared savings payment applicable to the State and 
the year, as determined in accordance with section 
2208(b)(6)(D). 
‘‘(2) GENERAL ADMINISTRATIVE EXPENSES.— 
For administrative expenses to carry out this title, 
other than section 2205, an amount that bears the 
same proportion to $50,000,000 as the number of 
dual eligible individuals in the State bears to the 
number of dual eligible individuals in all States, as 
determined by the Secretary. 
‘‘(3) DATA COLLECTION AND REPORTING.—For 
data collection and reporting expenses under section 
2205, an amount that bears the same proportion to 
$50,000,000 as the number of dual eligible individ-
uals in the State bears to the number of dual eligible 
individuals in all States, as determined by the Sec-
retary. 
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‘‘(c) APPROPRIATION.—There is appropriated, out of 
any money in the Treasury not otherwise appropriated, 
such amounts as may be required to provide payments to 
States under this section, for each calendar year (begin-
ning January 1 of the first full calendar year in which 
this title is implemented in any State), reduced by any 
amounts made available from the Medicare trust funds 
under subsection (d). 
‘‘(d) RELATION
TO MEDICARE TRUST FUNDS.— 
There shall be made available for carrying out this title, 
and the Secretary shall provide for the transfer from the 
Federal Hospital Insurance Trust Fund (under section 
1817) and from the Federal Supplementary Medical In-
surance Trust Fund (under section 1841) (and from the 
Medicare Prescription Drug Account (under section 
1860D–16) within such Trust Fund) such amounts as the 
Secretary determines appropriate, taking into account the 
reductions in payments from such Trust Funds and Ac-
count that are attributable to the enrollment of dual eligi-
ble individuals in integrated care plans under this title, 
for each calendar year (beginning January 1 of the first 
full calendar year in which this title is implemented in any 
State). 
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‘‘(e) RELATION TO OTHER PAYMENTS.—Payments 
provided under this section to a State are in addition to 
payments provided under section 2208. 
‘‘SEC. 2208. FEDERAL ADMINISTRATION THROUGH THE 
FEDERAL COORDINATED HEALTH CARE OF-
FICE. 
‘‘(a) IN GENERAL.—The Director shall have primary 
authority for implementing and carrying out responsibil-
ities of the Federal Government under this title. 
‘‘(b) RESPONSIBILITIES OF THE FCHCO.—In car-
rying out this title, the Director shall have the following 
responsibilities: 
‘‘(1) DEVELOPMENT AND PUBLICATION OF IN-
TEGRATED
CARE
PROGRAM
MODELS.—Subject to 
subsection (c), to develop and, not later than 180 
days after the date of enactment of this paragraph, 
publish, a range of program models (including but 
not limited to Medicare-Medicaid plans, accountable 
care organizations, and dual eligible special needs 
plans) for providing integrated care for dual eligible 
individuals from which States shall select to develop 
and administer integrated care programs for dual el-
igible individuals in accordance with this title. 
‘‘(2) UNIFIED APPEALS PROCESS.—To develop 
and, not later than 1 year after the date of enact-
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ment of this paragraph, publish a unified adminis-
trative appeals process for State integrated care pro-
grams for dual eligible individuals under this title to 
use in lieu of other administrative appeals processes 
involving Medicare and Medicaid. 
‘‘(3) HEALTH RISK ASSESSMENT.—To develop 
a standardized health risk assessment questionnaire 
for dual eligible individuals that collects standard de-
mographic data and information relating to food in-
security, access to transportation, internet access, 
utility difficulty, interpersonal safety, and housing 
instability. 
‘‘(4) SUPPLEMENTAL
BENEFITS
STANDARDS 
AND
REPORTING
REQUIREMENTS.—To establish 
standards for reporting by States and integrated 
care plans under title XXII information relating to 
the offering and provision of supplemental benefits 
under section 2204(d)(3), including data relating to 
enrollment, utilization, and outcomes, to annually 
publish a report regarding the offering and utiliza-
tion of such benefits, and to study and report to the 
Secretary on whether to cap the actuarial dollar 
value allowed for such benefits under titles XVIII, 
XIX, and XXII. 
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‘‘(5) CARE
COORDINATOR
REQUIREMENTS.— 
To— 
‘‘(A) establish a formula based on patient 
chronic conditions, activities of daily living 
standards, geographic, and such other factors 
as the Director determines are necessary for 
States and integrated care plans to use to de-
termine the maximum staffing ratio for assign-
ing care coordinators to dual eligible individuals 
enrolled with integrated care plans under this 
title; and 
‘‘(B) develop online training and profes-
sional development materials relating to the 
statutory and administrative requirements for 
providing integrated care for care coordinators 
for dual eligible individuals enrolled with inte-
grated care plans under this title. 
‘‘(6) ADMINISTRATION AND OVERSIGHT OF IN-
TEGRATED CARE PLANS FOR DUAL ELIGIBLE INDI-
VIDUALS.—To— 
‘‘(A) develop and issue guidance and regu-
lations related to the alignment of policy and 
operational process under the Medicare pro-
gram under title XVIII and the Medicaid pro-
gram under title XIX, necessary for implemen-
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models that do not rely on traditional 
time and distance standards, such as 
the use of telehealth; and 
‘‘(iii) the establishment and applica-
tion of targeted, streamlined model-of-care 
requirements for such plans that include 
an integrated audit process, with shared 
responsibilities between the Director and 
States, and that requires the Director to 
share the results of such audits with State 
Medicaid programs. To the extent prac-
ticable, such requirements also shall be de-
signed to be integrated with model of care 
requirements applicable to Medicaid man-
aged care organizations; 
‘‘(C) develop contract management teams, 
consisting of representatives from integrated 
care plans with contracts with States under this 
title, State agencies responsible for admin-
istering the State plan under title XIX or a 
waiver of such plan, and the Federal Coordi-
nated Health Care Office, to oversee compliance 
and performance of integrated care plans under 
this title; 
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‘‘(D) develop and implement a shared sav-
ings payment for States to receive a share of 
savings to Federal spending in the Medicaid 
program under title XIX as a result of the im-
plementation and operation of integrated care 
plans for dual eligible individuals under this 
title; and 
‘‘(E) develop a new star rating system for 
integrated care plans for dual eligible individ-
uals under this title that rates the performance 
of each plan type separately, with State-specific 
measures and tied to single contracts, instead 
of the collective performance of all of the 
offeror’s plans under contract with the State 
under that title, that include measures which 
directly reflect enrollee satisfaction, and that 
awards higher star ratings to plans based on 
their ability to retain enrollees. 
‘‘(7) DATA COLLECTION AND REPORTING.—To 
establish data and information collection and report-
ing requirements for States and integrated care 
plans under section 2205, including required report-
ing of specific disability statuses and safeguards to 
protect patient privacy, and to annually publish not 
later than April 30 of any year, the data and infor-
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mation collected and reported to the Director under 
such section for the preceding year. 
‘‘(8) QUALITY MEASURES.—To develop quality 
measures for the population of dual eligible individ-
uals that are designed to be uniformly implemented 
across all platforms and health benefits plans that 
provide integrated care for such individuals under 
this title. Such measures shall include measures re-
lating to patient satisfaction, quality of life, rates of 
emergency room use, institutionalization for long- 
term care, hospital admission and readmission rates, 
and medication errors. The Director shall regularly 
review and update such measures as necessary and 
may develop outcome-based quality measures for de-
termining payments to health benefits plans that 
provide integrated care for dual eligible individuals 
under this title. 
‘‘(9) BEST PRACTICES.—To not less than annu-
ally publish best practices under this title for States 
and integrated care plans, including with respect to 
improving outreach to beneficiaries, improving com-
prehensive care plans and health risk assessments 
for dual eligible individuals, and developing a work-
force that provides culturally intelligent and respect-
ful care. 
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‘‘(10) TRAINING PROGRAMS.—To develop train-
ing programs related to integrated care plans under 
this title for— 
‘‘(A) providers of care, services, and sup-
ports under such plans with respect to issues 
such as coordination of benefits, data sharing 
barriers, quality ratings, and provider incen-
tives; 
‘‘(B) State employees to increase Medicare 
expertise at State agencies responsible for ad-
ministering Medicaid plans and waivers and 
contracting with integrated care plans under 
this title; and 
‘‘(C) insurance brokers and local coun-
selors who help enroll individuals in Medicare, 
Medicaid, and integrated care plans under this 
title. 
‘‘(c) CAPITATED PAYMENT STRUCTURE FOR INTE-
GRATED CARE PROGRAM MODELS.— 
‘‘(1) IN GENERAL.—Each program model that 
is designed by the Director under subsection (b)(1) 
shall provide that payments shall be made to an in-
tegrated care plan for benefits provided under a con-
tract under this title using a capitated payment 
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structure under which, for each month that the inte-
grated care plan provides such benefits— 
‘‘(A) the State shall pay the integrated 
care plan an amount equal to the Medicaid 
component payment determined for the month; 
and 
‘‘(B) the Secretary shall pay the integrated 
care plan an amount equal to the Medicare 
component payment determined for the month. 
‘‘(2) DETERMINATION
OF
MEDICAID
COMPO-
NENT PAYMENT.—For purposes of paragraph (1), 
the Medicaid component payment payable to an inte-
grated care plan for a month shall be an amount 
equal to the sum of the products of— 
‘‘(A) for each category of beneficiary, the 
Medicaid capitation rate applicable to the cat-
egory of beneficiary (as determined by the Sec-
retary and specified in the contract between the 
State, the Secretary, and the offeror of the 
plan); and 
‘‘(B) the number of beneficiaries in such 
category enrolled with the plan for the month. 
‘‘(3) DETERMINATION
OF
MEDICARE
COMPO-
NENT PAYMENT.—For purposes of paragraph (1), 
the Medicare component payment payable to an inte-
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grated care plan for a month shall be an amount 
equal to the sum of the products of— 
‘‘(A) for each category of beneficiary, the 
Medicare capitation rate applicable to the cat-
egory of beneficiary (as determined by the Sec-
retary and specified in the contract between the 
State, the Secretary, and the offeror of the 
plan); and 
‘‘(B) the number of beneficiaries in such 
category enrolled with the plan for the month. 
‘‘(4) APPLICATION
OF
RISK
ADJUSTMENT 
MODEL TO CAPITATION RATES.—The Medicaid and 
Medicare capitation rates for each category of bene-
ficiary specified in a contract between a State, the 
Secretary, and the offeror of an integrated care plan 
shall be determined using the risk adjustment pay-
ment model developed under subsection (d). 
‘‘(d) RISK ADJUSTMENT PAYMENT MODEL FOR PRO-
VIDING HEALTH BENEFITS COVERAGE FOR DUAL ELIGI-
BLE INDIVIDUALS.—Not later than 1 year after the date 
of enactment of this subsection, the Director shall enter 
into a contract or other agreement with an independent 
entity to develop a risk adjustment payment model for 
dual eligible individuals that— 
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‘‘(1) is designed to be uniformly implemented 
across all platforms and health benefits plans that 
provide integrated care for such individuals under 
title XXII of the Social Security Act; 
‘‘(2) includes factors based on the health status 
of such individuals; and 
‘‘(3) allows plan payments to be made and up-
dated on a monthly basis. 
‘‘(e) ADDITIONAL RESPONSIBILITIES WITH RESPECT 
TO INTEGRATED CARE PLANS.— 
‘‘(1) OUTREACH
TO
MEDICAID
PROVIDERS.— 
Not later than 180 days after the date of enactment 
of this subsection, the Director, in consultation with 
State Medicaid programs, shall develop outreach 
plans for such programs to use to contact providers 
of health benefits, services, or supports for dual eli-
gible individuals and provide information and edu-
cation regarding the State Integrated Care Pro-
grams for Dual Eligible Individuals established 
under this title, how such program will operate in 
the State where such providers offer health benefits, 
services or supports for such individuals, and the im-
pact of such program on such providers. 
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‘‘(2) COLLECTION OF DATA ON QUALITY MEAS-
URES FROM INTEGRATED CARE PLANS UNDER MED-
ICAID AND MEDICARE.— 
‘‘(A) IN
GENERAL.—Not later than 180 
days after the date of enactment of this sub-
section, the Director, in consultation with the 
Administrator of the Centers for Medicare & 
Medicaid Services and State Medicaid pro-
grams, shall establish a plan for collecting data 
on quality measures from health benefits plans 
that provide integrated care for dual eligible in-
dividuals under Medicare or Medicaid. Such 
data shall include, at a minimum, data relating 
to provider network availability in both Medi-
care and Medicaid, providers in-network who 
are accepting new Medicare and Medicaid pa-
tients, spending on supplemental benefits, and 
claims denials. 
‘‘(B) AUTHORITY
TO
COLLECT
ADDI-
TIONAL
DATA
AND
INFORMATION; PUBLICA-
TION.—The Director may— 
‘‘(i) collect additional data and infor-
mation relating to the quality of care pro-
vided for dual eligible individuals by health 
benefits plans that provide integrated care 
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for such individuals under Medicare or 
Medicaid; and 
‘‘(ii) make the data and information 
collected in accordance with this paragraph 
publicly available. 
‘‘(3) DEVELOPMENT OF AN ALIGNED PROGRAM 
FOR INSTITUTIONAL SPECIAL NEEDS PLANS UNDER 
MEDICAID.—Not later than 180 days after the date 
of enactment of this subsection, the Director, in con-
sultation with the Administrator of the Centers for 
Medicare & Medicaid Services and State Medicaid 
programs, shall develop an aligned program for of-
fering Institutional Special Needs Plans under Med-
icaid that has one entity financially responsible for 
providing health benefits, services, and supports for 
dual eligible individuals. 
‘‘(4) ASSESSMENT OF NEED FOR CRITERIA TO 
REGULATE AND EXPAND UTILIZATION OF INSTITU-
TIONAL SPECIAL NEEDS PLANS.—Not later than 180 
days after the date of enactment of this subsection, 
the Director, in consultation with the Administrator 
of the Centers for Medicare & Medicaid Services, 
shall assess the adequacy of regulations and over-
sight of Institutional Special Needs Plan to deter-
mine whether new, or additional requirements should 
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be established to improve the utilization, perform-
ance, and oversight of such plans and how such 
plans may be offered under State Integrated Care 
Programs for Dual Eligible Individuals established 
under this title. 
‘‘(f) APPROPRIATIONS.—There are hereby appro-
priated, out of any funds in the Treasury not otherwise 
appropriated, for the first fiscal year that begins after the 
date of enactment of this title, and for each fiscal year 
thereafter, such sums as are necessary to carry out this 
title. 
‘‘(g) DIRECT-HIRE AUTHORITY.—In carrying out 
this title, the Director shall have direct-hire authority to 
the extent required to implement and administer this title 
on a timely basis.’’. 
SEC. 102. PROVIDING FEDERAL COORDINATED HEALTH 
CARE OFFICE AUTHORITY OVER DUAL SNPS. 
(a) IN GENERAL.—Section 1859(f)(8) of the Social 
Security Act (42 U.S.C. 1395w–28(f)(8)) is amended by 
adding at the end the following new subparagraph: 
‘‘(F) AUTHORITY
OF
FEDERAL
COORDI-
NATED HEALTH CARE OFFICE.—For plan years 
beginning on or after January 1, 2025, the 
Federal Coordinated Health Care Office estab-
lished under section 2602 of Public Law 111– 
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148 shall have primary authority for imple-
menting and carrying out responsibilities of the 
Secretary with respect to the integration of spe-
cialized MA plans for special needs individuals 
described in subsection (b)(6)(B)(ii) under this 
subsection.’’. 
(b) CONFORMING AMENDMENT.—Section 2602(d)(6) 
of the Patient Protection and Affordable Care Act (42 
U.S.C. 1315b(d)(6)) is amended by inserting the following 
before the period: ‘‘and, for plan years beginning on or 
after January 1, 2025, to carry out subsection (f)(8)(F) 
of such section’’. 
SEC. 103. ADDITIONAL CONFORMING AMENDMENTS. 
(a) DEFINITION OF STATE.—Section 1101(a)(1) of 
the Social Security Act (42 U.S.C. 1301(a)(1)) is amend-
ed— 
(1) by striking ‘‘XIX, and XXI’’ and inserting 
‘‘XIX, XXI, and XXII’’; and 
(2) by striking ‘‘XIX and XXI’’ and inserting 
‘‘XIX, XXI, and XXII’’. 
(b) MEDICARE ENROLLMENT.—Section 1851(a) of 
the Social Security Act (42 U.S.C. 1395w–21(a)) is 
amended by adding at the end the following new para-
graph: 
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