I 
110TH CONGRESS 
2D SESSION 
H. R. 6365 
To amend part C of title XVIII of the Social Security Act with respect 
to Medicare special needs plans and the alignment of Medicare and 
Medicaid for dually eligible individuals. 
IN THE HOUSE OF REPRESENTATIVES 
JUNE 25, 2008 
Mr. KIND (for himself and Mr. RAMSTAD) 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 part C of title XVIII of the Social Security Act 
with respect to Medicare special needs plans and the 
alignment of Medicare and Medicaid for dually eligible 
individuals. 
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 
‘‘Medicare Special Needs Plans Extension and Amend-
ments Act of 2008’’. 
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(b) TABLE OF CONTENTS.—The table of contents of 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
Sec. 2. Extend SNP authority through December 31, 2012. 
Sec. 3. Require targeting of high-risk groups; advance specialty care capabili-
ties. 
Sec. 4. Study on improving risk adjustment for high-risk, high-cost bene-
ficiaries. 
Sec. 5. Advance alignment of Medicare and Medicaid for dual eligibles. 
SEC. 2. EXTEND SNP AUTHORITY THROUGH DECEMBER 31, 
2012. 
Section 1859(f) of the Social Security Act (42 U.S.C. 
1395w–28(f)), as amended by section 108 of the Medicare, 
Medicaid, and SCHIP Extension Act of 2007 (Public Law 
110–173), is amended by striking ‘‘2010’’ and inserting 
‘‘2013’’. 
SEC. 3. REQUIRE TARGETING OF HIGH-RISK GROUPS; AD-
VANCE SPECIALTY CARE CAPABILITIES. 
(a) 
REQUIRING
TARGETING
OF
HIGH-RISK 
GROUPS.— 
(1) IN GENERAL.—Section 1859(b)(6) of the 
Social Security Act (42 U.S.C. 1395w–28(b)(6)) is 
amended— 
(A) in subparagraph (A), by striking all 
that follows ‘‘means’’ and inserting the fol-
lowing: ‘‘an MA plan— 
‘‘(i) that serves special needs individ-
uals (as defined in subparagraph (B)); and 
‘‘(ii) for which— 
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‘‘(I) at least 90 percent of the in-
dividuals enrolled after December 31, 
2008, are described in subparagraph 
(B)(i); 
‘‘(II) at least 90 percent of the 
individuals enrolled after December 
31, 2008, are described in subpara-
graph (B)(ii); or 
‘‘(III) at least 90 percent of the 
individuals enrolled after December 
31, 2008, are described in subpara-
graph (B)(iii) and have a severe or 
disabling chronic condition of the type 
that the plan is committed to serve.’’; 
(B) by adding at the end of subparagraph 
(A) the following: ‘‘For purposes of applying 
clause (ii), an individual who is described in 
subparagraph (B)(i) or (B)(ii) and who is en-
rolled in a specialized MA plan for special needs 
individuals shall thereafter be treated as con-
tinuing to be described in such respective sub-
paragraph regardless of changes in the individ-
ual’s circumstances so long as the individual 
maintains continuous enrollment in such plan. 
Clause (ii) shall not apply to a plan described 
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in section 231(d) of the Medicare Prescription 
Drug, Improvement, and Modernization Act of 
2003 (Public Law 108–173) which was pre-
viously operated under section 2355 of the Def-
icit Reduction Act of 1984 (Public Law 98– 
369) and which is operating as a specialized 
MA plan for special needs individuals as of the 
date of the enactment of this sentence.’’; and 
(C) in subparagraph (B)— 
(i) in clause (i), by inserting ‘‘under 
regulations in effect as of July 1, 2007’’ 
after ‘‘as defined by the Secretary’’; and 
(ii) by amending clause (iii) to read as 
follows: 
‘‘(iii) has a severe or disabling chronic 
condition that requires complex care man-
agement capabilities, of the type described 
in subsection (f)(4), and specialized deliv-
ery systems to reduce medical complica-
tions and adverse health outcomes.’’. 
(2) COORDINATED FINANCING FOR DUAL-ELIGI-
BLE SNPS.—The Secretary of Health and Human 
Services shall enter into agreements with States (as 
defined for purposes of title XIX of the Social Secu-
rity Act) for coordinating the financing of special-
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ized MA plans for special needs individuals described 
in section 1859(b)(6)(A)(ii)(II) of such Act for en-
rollees who are entitled to medical assistance under 
State plans under such title. 
(b) ADVANCE SPECIALTY CARE CAPABILITIES.— 
(1) IN GENERAL.—Section 1859 of such Act 
(42 U.S.C. 1395w–28) is further amended— 
(A) in subsection (b)(6)(A), as amended by 
subsection (a)(1)— 
(i) by striking ‘‘and’’ at the end of 
clause (i); 
(ii) by striking the period at the end 
of clause (ii) and inserting ‘‘; and’’ ; and 
(iii) by adding at the end the fol-
lowing new clause: 
‘‘(iii) meets the applicable require-
ments specified in subsection (f) for the 
plan.’’; and 
(B) in subsection (f)— 
(i) by amending the heading to read 
as follows: ‘‘REQUIREMENTS FOR ENROLL-
MENT
IN SPECIALIZED MA PLANS
FOR 
SPECIAL NEEDS BENEFICIARIES’’; 
(ii) by designating the sentence begin-
ning ‘‘In the case of’’ as paragraph (1) 
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with the heading ‘‘REQUIREMENTS
FOR 
ENROLLMENT.—’’ and with appropriate in-
dentation; and 
(iii) by adding at the end the fol-
lowing new paragraphs: 
‘‘(2) ADDITIONAL
REQUIREMENTS
FOR
DUAL 
SNPS.—In the case of a specialized MA plan for spe-
cial needs individuals described in subsection 
(b)(6)(A)(ii)(II), the applicable requirements of this 
subsection include the following: 
‘‘(A)(i) Subject to clause (ii), the plan has 
an agreement with the State Medicaid agency 
that— 
‘‘(I) includes provisions regarding co-
operation on the coordination of care and 
the coordination of the financing of care 
for such individuals; 
‘‘(II) includes a description of any 
Medicaid services to be covered by the plan 
for individuals enrolled in the plan eligible 
under such title for medical assistance; 
‘‘(III) includes a description of the 
manner that the State Medicaid program 
under title XIX will fulfill its responsibil-
ities under such title (including section 
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1902) with respect to payment for Medi-
care cost-sharing and with respect to pay-
ment for any Medicaid services not covered 
by Medicare for individuals enrolled in the 
plan eligible under such title for medical 
assistance; and 
‘‘(IV) requires the disclosure to enroll-
ees, including in the marketing materials 
of such plan, of Medicaid benefits and of 
those provider networks that contract with 
the State under the Medicaid program. 
‘‘(ii) The agreement requirement of clause 
(i) between a plan and a State Medicaid agency 
shall not apply if the Secretary determines that 
the State— 
‘‘(I) does not have the administrative 
infrastructure to enter into such agree-
ments with such plan or to provide for co-
ordination of benefits or payments with 
such plans; 
‘‘(II) is unable to enter into such an 
agreement because of a State limitation on 
the number of Medicaid managed care con-
tracts issued; or 
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‘‘(III) is otherwise unwilling or unable 
to enter into such an agreement. 
‘‘(B) The out-of-pocket costs for services 
under parts A and B that are charged to enroll-
ees may not exceed the out-of-pocket costs for 
same services permitted for such individuals 
under title XIX. 
‘‘(3) ADDITIONAL REQUIREMENTS FOR SEVERE 
OR DISABLING CHRONIC CONDITION SNPS.—In the 
case of a specialized MA plan for special needs indi-
viduals described in subsection (b)(6)(A)(ii)(III), the 
applicable requirements of this subsection include 
the following: 
‘‘(A) The plan is designated to serve, and 
serves, individuals described in subsection 
(b)(6)(1)(B)(iii). 
‘‘(B) The plan meets any of the 3 following 
criteria: 
‘‘(i) The plan specializes in care of in-
dividuals who are disabled or have end- 
stage renal disease, including individuals 
who are eligible for benefits under part A 
through the application of section 226(b) 
or section 226A. 
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‘‘(ii) The plan specializes in care for 
persons who have co-morbid or complex 
chronic conditions that influence other as-
pects of health and have a high risk of hos-
pitalization or other significant adverse 
health outcomes. 
‘‘(iii) The plan has an average risk 
score under section 1853(a)(1)(C) of 1.35 
or greater. 
‘‘(4) COMPLEX CARE MANAGEMENT CAPABILI-
TIES FOR ALL SNPS.—The complex care manage-
ment capabilities for a specialized need plan shall in-
clude with respect to a special needs individual en-
rolled under the plan the following: 
‘‘(A) Conducting an initial assessment, and 
annual reassessment, of the individual’s phys-
ical, social, medical, and functional needs for 
each individual enrolled in the plan. 
‘‘(B) Developing, for each such individual 
and with input of the individual, an individual-
ized plan of care that identifies goals and objec-
tives, including measurable outcomes. 
‘‘(C) Using an interdisciplinary team in 
management of care and assuring appropriate 
access to specialty care networks. 
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‘‘(D) Developing interventions based on 
population-based protocols and best practices to 
the extent available. 
‘‘(E) Assigning appropriate clinicians to 
meet the unique needs of the population being 
served. 
‘‘(F) Assuring coordination among clini-
cians and other service providers involved. 
‘‘(G) Assisting individuals enrolled in the 
plan who are entitled to medical assistance 
under title XIX in accessing and coordinating 
benefits and services under this title and under 
such title. 
‘‘(5) SPECIALTY CARE NETWORK DEFINED.—In 
this subsection, the term ‘specialty care network’ 
means, with respect to a specialized need plan, a 
group of health care providers under contract with 
the plan that— 
‘‘(A) includes physicians, hospitals, nursing 
facilities, and allied health and social service 
providers with special expertise relevant to the 
special needs population being served; 
‘‘(B) serves a common chronically ill or im-
paired population, either at the same time or in 
sequence to one another; and 
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‘‘(C) work together to improve total quality 
and cost performance.’’. 
(2) QUALITY
STANDARDS
AND
QUALITY
RE-
PORTING.—Section 1852(e)(3) of such Act (42 
U.S.C. 1395w–22(e)(3)) is amended— 
(A) in subparagraph (A)(i), by adding at 
the end the following: ‘‘In the case of a special-
ized MA plan for special needs individuals, the 
organization shall provide for the reporting on 
quality measures developed for the plan under 
subparagraph (C).’’; and 
(B) by adding at the end the following new 
subparagraph: 
‘‘(C) SPECIFICATION
OF
QUALITY
MEAS-
UREMENTS FOR SPECIALIZED MA PLANS.— 
‘‘(i) IN
GENERAL.—Notwithstanding 
subparagraph (B), the Secretary shall 
specify quality measures appropriate to 
meeting the needs of beneficiaries enrolled 
in specialized MA plans for special needs 
individuals 
(described 
in 
section 
1859(b)(6)(A)). 
In 
implementing 
such 
measures, the Secretary shall take into ac-
count those HEDIS measures and struc-
ture and process measures identified that 
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are unique to special needs individuals en-
rolled under such plans. 
‘‘(ii) SATISFACTION
THROUGH
CUR-
RENT REPORTING REQUIREMENTS.—Noth-
ing in clause (i) shall be construed as re-
quiring the Secretary to impose on special-
ized MA plans for special needs individuals 
requirements that are in addition to the re-
porting requirements that are imposed on 
such plans as of the date of the enactment 
of this subparagraph. In implementing 
such clause, the Secretary shall not require 
the reporting by such plans of measures 
under such clause in a manner that is 
more burdensome to such plans than the 
reporting burden imposed on other MA 
plans.’’. 
(c) EFFECTIVE
DATE; GRANDFATHER; TRANSI-
TION.— 
(1) EFFECTIVE DATE.— 
(A) IN
GENERAL.—Except as otherwise 
provided, the amendments made by this section 
shall take effect for enrollments occurring on or 
after January 1, 2010. 
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(B) 
MEDICAID
CONTRACT
REQUIRE-
MENT.—Section 1859(f)(2)(A) of the Social Se-
curity 
Act, 
as 
added 
by 
subsection 
(b)(1)(B)(iii), shall apply to plan years begin-
ning on or after the date that is 3 years after 
the date of the enactment of this Act. 
(2) PERMITTING
MAINTENANCE
OF
POLICIES 
AND
PROCEDURES
FOR
CURRENT
DUAL-ELIGIBLE 
SNPS UNDER A STATE INTEGRATION PROGRAM.—In 
the case of a specialized MA plan for special needs 
individuals 
described 
in 
section 
1859(b)(6)(A)(ii)(II)) of the Social Security Act (42 
U.S.C. 1395w–28(b)(6)(A)(ii)(II)) that is offered 
under a State Medicaid Integrated Medicare-Med-
icaid Program that was approved by the Adminis-
trator of the Centers for Medicaid & Medicare Serv-
ices before the date of the enactment of this Act, 
and expansions of such a Program offered on or 
after such date, the Secretary of Health and Human 
Services shall permit the continuation of policies and 
procedures in effect under such a Program as of the 
date of the enactment of this Act notwithstanding 
the amendments made by this section. 
(3) ORDERLY TRANSITION FOR CERTAIN EN-
ROLLEES.—The Secretary of Health and Human 
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Services shall provide for an orderly transition of 
those specialized MA plans for special needs individ-
uals (as defined in subparagraph (A) of section 
1859(b)(6) of the Social Security Act (42 U.S.C. 
1395w–28(b)(6)), as of the date of the enactment of 
this Act), and their enrollees, that no longer qualify 
as such plans or as such individuals under such sec-
tion, as amended by this section. 
SEC. 4. STUDY ON IMPROVING RISK ADJUSTMENT FOR 
HIGH-RISK, HIGH-COST BENEFICIARIES. 
(a) IN GENERAL.—Not later than 1 year after the 
date of enactment of this Act, the Secretary of Health and 
Human Services shall submit to Congress a report that 
evaluates the adequacy of the Medicare Advantage risk ad-
justment system under section 1853(a)(1)(C) of the Social 
Security Act (42 U.S.C. 1395w–23(a)(1)(C)), as well as 
the risk adjustment mechanism under section 1860D– 
15(c)(1)(A) of such Act (42 U.S.C. 1395w–115(c)(1)(A)). 
(b) PARTICULARS.—The report under subsection (a) 
shall include an evaluation of the need for improving the 
adequacy of the existing hierarchical condition categories 
and pharmacy risk adjustment methods for plans that spe-
cialize in care of high-risk beneficiaries as it relates to— 
(1) accurately predicting costs for beneficiaries 
with— 
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(A) sustained high-risk scores over mul-
tiple contract periods; 
(B) high costs; 
(C) co-morbid chronic conditions; 
(D) diagnoses not included in the risk-ad-
justment methodology, including dementia and 
other cognitive impairments; 
(E) physical disabilities, developmental dis-
abilities, or both; and 
(F) frailty; 
(2) including further gradations of diseases and 
conditions to better reflect stage of condition, condi-
tion severity and costs related to burden of illness; 
(3) accounting for costs of pre-existing condi-
tions at the time of initial enrollment for new en-
trants to the Medicare program; and 
(4) enhancing coding persistency by calculating 
risk scores using data covering at least two years. 
(c) REFINEMENT.—The Secretary shall refine the 
risk-adjusted payment methods referred to in subsection 
(a) for high-risk, high-cost beneficiaries, consistent with 
the results of the study, not later than 2 years after the 
date of the enactment of this Act. 
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