Comprehensive Care for Dual Eligible Individuals Act
Bill: S.4635 | Sponsor: Sen. Brown, Sherrod (D-OH)
Policy area: Health

Summary:
Comprehensive Care for Dual Eligible Individuals Act
This bill provides states with the option to establish a separate health care program for individuals who are dually eligible for Medicare and Medicaid. Programs must provide a core package of covered benefits to address the individualized medical, behavioral, long-term care, and social needs of enrollees, including all basic Medicare and Medicaid benefits. States may receive federal matching payments in accordance with a specified formula; the bill provides funds for the Federal Coordinated Health Care Office to implement the bill.

To amend the Social Security Act to establish an optional State-
   administered program to provide fully integrated, comprehensive, 
 coordinated care for full-benefit dual eligible individuals under the 
        Medicare and Medicaid programs, and for other purposes.

    Be it enacted by the Senate and House of Representatives 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 ``Comprehensive Care 
for Dual Eligible Individuals Act''.
    (b) Table of Contents.--The table of contents for this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Establishment of All Inclusive Medicare-Medicaid Program for 
                            Full-Benefit Dual Eligible Individuals.
 ``TITLE XXII--ALL INCLUSIVE MEDICARE-MEDICAID (AIM) PROGRAM FOR FULL-
                   BENEFIT DUAL ELIGIBLE INDIVIDUALS

        ``Sec. 2201. Purpose; General requirements.
        ``Sec. 2202. Eligibility.
        ``Sec. 2203. Enrollment.
        ``Sec. 2204. Benefits.
        ``Sec. 2205. Beneficiary protections.
        ``Sec. 2206. Federal administration.
        ``Sec. 2207. Selection and role of AIM-administering entities.
        ``Sec. 2208. Program financing.
        ``Sec. 2209. Accountability and oversight.
        ``Sec. 2210. Definitions; miscellaneous provisions.
Sec. 3. MedPAC study and report.

SEC. 2. ESTABLISHMENT OF ALL INCLUSIVE MEDICARE-MEDICAID PROGRAM FOR 
              FULL-BENEFIT DUAL ELIGIBLE INDIVIDUALS.

    (a) In General.--The Social Security Act is amended by adding at 
the end the following new title:

 ``TITLE XXII--ALL INCLUSIVE MEDICARE-MEDICAID (AIM) PROGRAM FOR FULL-
                   BENEFIT DUAL ELIGIBLE INDIVIDUALS

``SEC. 2201. PURPOSE; GENERAL REQUIREMENTS.

    ``(a) Purpose.--The purpose of this title is to provide, at the 
option of a State, for a program implemented and administered by the 
State of comprehensive, coordinated care for individuals eligible for 
benefits under the Medicare program under title XVIII and for full 
benefits under the Medicaid program under title XIX in order to improve 
quality, control costs, address health disparities, and support 
independence, community participation, and quality of life.
    ``(b) Requirement for Approved AIM Program Application.--A State 
may not be approved to implement an AIM program under this title 
unless, consistent with the process specified for approval of AIM 
programs under subsection (c)--
            ``(1) the State has completed, in a pre-printed format and 
        manner specified by the Secretary, a notice of intent to 
        establish such a program not earlier than 3 years after the 
        date on which the State submits the notice of intent to the 
        Secretary, and which includes a plan for such a program (or the 
        State is working with the Federal Coordinated Health Care 
        Office to transition an integrated care program of the State 
        into an AIM program under this title); and
            ``(2) the Secretary has received assurances, satisfactory 
        to the Secretary, that the proposed State AIM program and its 
        plan (or, in the case of a State working with the Federal 
        Coordinated Health Care Office to transition an integrated care 
        program of the State into an AIM program under this title, the 
        State AIM program after such transition is completed) meet the 
        applicable requirements for such a program under this title, 
        including the requirements specified in subsection (c).
    ``(c) General Requirements.--The requirements specified in this 
subsection for an AIM program of a State are as follows:
            ``(1) Eligibility and enrollment.--The program provides for 
        eligibility and enrollment of AIMP-eligible individuals under 
        the program in accordance with sections 2202 and 2203.
            ``(2) Benefits.--The program provides for benefits for AIMP 
        enrollees under the program in accordance with section 2204.
            ``(3) Beneficiary protections.--The program provides for 
        beneficiary protections for AIMP enrollees under the program 
        that are not less than those required under section 2205.
            ``(4) Coordinating and integration of benefits.--The 
        program provides for the coordination and integration of 
        benefits by AIM-administering entities in accordance with 
        section 2205.
            ``(5) Program accountability.--The program provides for 
        accountability in administration and financing in accordance 
        with section 2208.
            ``(6) Other requirements.--The program meets such other 
        requirements as the Secretary may establish to carry out this 
        title.
    ``(d) Program Approval Process.--The Secretary shall establish a 
process for the initial approval of AIM programs of States based on the 
process used for approval of waivers under section 1115 with respect to 
title XIX. The process established under this subsection shall include 
at least the following elements:
            ``(1) Notice of intent.--
                    ``(A) In general.--Subject to subparagraph (B), the 
                State submits to the Secretary a notice of intent to 
                establish the AIMP.
                    ``(B) Conditions for transparent process.--The 
                Secretary shall not accept a notice of intent submitted 
                under subparagraph (A) unless, before the date of such 
                submission, the State--
                            ``(i) has provided a period of not less 
                        than 90 days for notice and public comment on 
                        the proposed establishment of the program in 
                        the State;
                            ``(ii) has held at least 2 public meetings 
                        regarding the establishment of the program; and
                            ``(iii) has conducted relevant consultation 
                        with any relevant tribal authorities of 
                        Federally recognized Indian tribes located in 
                        the State.
            ``(2) Federal readiness review completed.--At least 1 year 
        before the identified initial implementation date for an AIM 
        program in a State, the State has passed a review by the 
        Secretary of the State's readiness to implement the program.
            ``(3) State readiness review of aim-administering 
        entities.--After a State passes the Federal readiness review 
        under paragraph (2), the State shall conduct a review of the 
        proposed AIM-administering entities under proposed AIMP 
        contracts with the State with respect to their readiness to 
        administer the program for benefits for AIMP enrollees assigned 
        to such entities. Such review--
                    ``(A) shall include elements specified by the 
                Secretary, including a network adequacy review;
                    ``(B) may include activities such as a desk review, 
                separate network validation review, and site visit; and
                    ``(C) must be passed by an AIMP-administering 
                entity before any outreach or marketing of or by that 
                entity is permitted under a State AIM program.
    ``(e) Technical Assistance Planning Grants.--
            ``(1) Eligibility.--A State that has provided a notice of 
        intent under subsection (d)(1) to implement an AIM program is 
        eligible for funding assistance with technical planning 
        necessary to implement the program. Such funding shall be 
        provided in amounts of up to $10,000,000 per State, and under 
        such conditions as the Secretary shall specify.
            ``(2) Use of funds.--Funding made available to a State 
        under this subsection may be used to assist the State with the 
        staffing, information technology, planning and evaluation, and 
        initial implementation of the AIM program in the State for 
        expenses incurred during the 3-year period that begins on the 
        date the State submits a notice of intent under subsection 
        (d)(1).
            ``(3) Funding.--For the purpose of providing funding 
        assistance under this subsection, there is appropriated, out of 
        any money in the Treasury not otherwise appropriated, such sums 
        as may be necessary to carry out this subsection.

``SEC. 2202. ELIGIBILITY.

    ``(a) In General.--In this title, the term `AIMP-eligible 
individual' means, with respect to an AIMP-participating State, an 
individual who--
            ``(1) is 21 years of age or older;
            ``(2) is entitled (or eligible to be enrolled) under part A 
        or part B, or both, of title XVIII;
            ``(3) subject to subsection (c), is eligible for medical 
        assistance under the State plan (including a waiver thereof) 
        under title XIX as a full-benefit dual eligible individual; and
            ``(4) meets such income and asset standards as the State 
        may establish for the AIM program in accordance with subsection 
        (d) (and which shall be applied in addition to the income and 
        asset standards the individual is required to meet for purposes 
        of eligibility for medical assistance under the State plan (or 
        a waiver) under title XIX).
    ``(b) Process for Determination of Eligibility.--Except as 
otherwise provided in this title, the determination of whether an 
individual is an AIMP-eligible individual with respect to the AIM 
program of a State shall be made in accordance with the processes used 
to determine the individual's eligibility for medical assistance under 
the State plan (or waiver thereof) under title XIX of the State.
    ``(c) Flexibility Permitted.--
            ``(1) Geographic scope.--
                    ``(A) Statewide.--Except as provided in 
                subparagraph (B), an AIMP-participating State shall 
                provide for the implementation of its AIM program on a 
                statewide basis.
                    ``(B) Phase-in permitted on a time-limited basis.--
                An AIMP-participating State may provide for the 
                implementation of its AIM program not on a statewide 
                basis so long as the program is phased in 
                geographically in a manner so that it is implemented 
                statewide no later than the 4th year of implementation, 
                except that the Secretary may permit a longer phase-in 
                period due to extenuating circumstances.
            ``(2) New population phase-in permitted.--
                    ``(A) Carve-outs not permitted.--Except as provided 
                in subparagraph (B), an AIMP-participating State may 
                not deny eligibility under its AIM program to 
                subpopulations of AIMP-eligible individuals and shall 
                enroll all AIMP-eligible individuals under the program 
                without the application of any waiting lists.
                    ``(B) Time-limited exception permitted.--The 
                Secretary may allow States to phase in the enrollment 
                of certain subpopulations over a specified period, not 
                to exceed a period of 4 years.
            ``(3) Pace continuation permitted.--Nothing in this title 
        shall be construed as preventing an AIMP-participating State 
        from continuing to offer a Program of All-Inclusive Care for 
        the Elderly (PACE) under section 1894 or 1934.
    ``(d) Income and Asset Standards.--
            ``(1) Income eligibility floor.--In no case shall an AIMP-
        participating State have an income eligibility threshold under 
        its AIM program that is less than 73 percent of the official 
        poverty line (as defined by the Office of Management and 
        Budget, and revised annually in accordance with section 673(2) 
        of the Omnibus Budget Reconciliation Act of 1981) applicable to 
        a family of the size involved or, if greater, the income 
        threshold applied during the fiscal year preceding the year in 
        which this title is enacted.
            ``(2) Asset threshold floor.--In no case shall an AIMP-
        participating State apply an asset threshold for eligibility 
        for a fiscal year that is less than the following:
                    ``(A) For first fiscal year.--For the 1st fiscal 
                year (or portion of a fiscal year) in which the AIM 
                program is implemented in the State, the greater of--
                            ``(i) $2,000; and
                            ``(ii) the asset eligibility standard 
                        applied under the State plan (including a 
                        waiver thereof) under title XIX for a full-
                        benefit dual eligible individual during the 
                        fiscal year preceding the fiscal year in which 
                        this title is enacted.
                    ``(B) For subsequent fiscal year.--For a subsequent 
                fiscal year, the minimum asset threshold applied under 
                this paragraph for the previous fiscal year increased 
                (and rounded to the nearest $10) by the annual increase 
                in the consumer price index for all urban consumers 
                (United States city average).
            ``(3) Flexibility.--Nothing in this subsection shall be 
        construed as limiting the ability of an AIMP-participating 
        State to increase the income eligibility threshold, asset 
        eligibility threshold, or income or asset disregards, including 
        by allowing buy-ins or spenddowns, above the minimum levels 
        required under this subsection.
            ``(4) Eligibility threshold.--The income and asset 
        thresholds that a State establishes under this subsection shall 
        be applied under the State AIM program to determine whether an 
        individual is an AIMP-eligible individual without regard to 
        whether the individual elects to enroll, or is enrolled, in the 
        State AIM program.
    ``(e) Use of Streamlined Eligibility Determination and Enrollment 
Processes.--
            ``(1) In general.--Each AIMP-participating State shall use 
        streamlined eligibility and enrollment processes in order to 
        promote continuity and incentivize States that invest in 
        improving quality and costs, including those specified in this 
        subsection.
            ``(2) Specific streamlined eligibility required.--Each 
        AIMP-participating State shall utilize the following with 
        respect to streamlining the eligibility determination and 
        enrollment of individuals in the State's AIM program:
                    ``(A) 12-month continuous eligibility.
                    ``(B) Use of electronic data matches with trusted 
                third-party sources (such as the Social Security 
                Administration or the Supplemental Nutrition Assistance 
                Program) to verify eligibility under the State AIM 
                program both for initial eligibility applications and 
                for renewals.
                    ``(C) Streamlined eligibility recertification every 
                12 months, including--
                            ``(i) for individuals who have been 
                        determined eligible and enrolled, only 
                        requiring submission of information on any 
                        changes to their financial or disability status 
                        (instead of submitting an entire renewal 
                        application);
                            ``(ii) with respect to verification of 
                        eligibility, initially using of available 
                        information to auto-verify eligibility;
                            ``(iii) if additional information is needed 
                        for renewal of eligibility, using pre-populated 
                        forms and allowing submission of information 
                        online, in person, by telephone, fax, or mail; 
                        and
                            ``(iv) using a standard reconsideration 
                        period of 90 days from the time of termination 
                        of coverage.
            ``(3) Use of deeming.--Each AIMP-participating State shall 
        use deemed eligibility for a period of not less than 6 months.
            ``(4) Data sharing on enrollment.--Under an AIMP contract, 
        an AIMP-participating State, the Secretary, and AIM-
        administering entities shall routinely and frequently share 
        data among themselves with regard to eligibility and enrollment 
        of individuals under AIM programs. Such data sharing may 
        include monthly changes in program enrollment and eligibility, 
        beneficiary opt-out rates, and other changes specified by the 
        Secretary.
    ``(f) Rule of Construction of Continuation as a Medicare and 
Medicaid Beneficiary for Purposes Other Than Benefits.--The fact that 
an individual qualifies as an AIMP-eligible individual shall not be 
construed as removing the individual's status as an individual entitled 
to benefits under title XVIII or XIX, but insofar as the individual 
becomes an AIMP enrollee entitled to benefits under this title, such 
entitlement to benefits under titles XVIII and XIX shall be considered 
as met through the provision of benefits under this title.

``SEC. 2203. ENROLLMENT.

    ``(a) Beneficiary Choice.--In an AIMP-participating State under its 
AIM program, an AIMP-eligible individual may select (in a manner 
specified by the State consistent with this section) to receive 
benefits through any of the following:
            ``(1) The State AIM program.
            ``(2) A PACE program (if available to the individual in the 
        State).
            ``(3) A combination of Medicare fee-for-service program 
        (under parts A, B, and D, as applicable, of title XVIII) and 
        medical assistance under title XIX (whether delivered through 
        fee-for-service or managed care, as provided by the State under 
        such title).
    ``(b) Initial Assignment at Time of Program Implementation or 
Initial Enrollment.--An AIMP-participating State may provide that all 
AIMP-eligible individuals in the State who are not enrolled in a PACE 
program under section 1894 or 1934 and who do not make an affirmative 
selection under subsection (a)(3) shall be deemed to have elected to 
enroll in the AIM program of the State.
    ``(c) Coordination of Selection and Enrollment With Medicare 
Enrollment Processes.--The process for selection and enrollment of 
AIMP-eligible individuals in AIM programs shall be consistent and 
coordinated with the processes for enrollment in Medicare Advantage 
plans under part C of title XVIII during open and special enrollment 
periods. Such processes shall, consistent with section 423.38(c) of 
title 42, Code of Federal Regulations (or any successor regulation) and 
any other applicable regulations, provide--
            ``(1) a special enrollment period for individuals who--
                    ``(A) are dually eligible individuals enrolled in 
                fee-for-service Medicare when the State AIM program is 
                first established to permit such individuals to elect 
                to enroll in the State AIM program; or
                    ``(B) become AIMP-eligible individuals; and
            ``(2) for the right of an AIMP-enrolled individual to 
        disenroll from the AIM program and to otherwise to make changes 
        in the selection in enrollment described in subsection (a).
    ``(d) Assistance in Enrollment Choice.--An AIMP-participating State 
must contract with 1 or more independent enrollment brokers, at least 1 
of which is a nonprofit, community-based organization, and all of which 
are approved by the Secretary, to assist AIMP-eligible individuals in 
understanding the AIM program and making enrollment choices under this 
section in the same manner as such brokers are permitted with respect 
to enrollment of individuals under its State plan under title XIX (or 
waiver thereof), except that no individual sales commissions shall be 
permitted (including to the extent such commissions may otherwise be 
permitted by brokers and employed or captive agents under the Medicare 
Advantage program under part C of title XVIII).
    ``(e) Construction Regarding Continued Medicaid Use of Managed 
Care.--Nothing in this subsection shall be construed as affecting the 
authority of an AIMP-participating State to require, in the case of an 
AIMP-eligible individual who makes the election described in subsection 
(a)(3) (or otherwise opts-out of enrollment in the AIM program and into 
benefits under title XIX), to obtain benefits for covered services 
under title XIX through participation in a managed care plan or 
arrangement.
    ``(f) Assignment of Enrollees to AIMP-Administering Entities.--
            ``(1) In general.--An AIMP-eligible individual enrolled 
        under an AIM program shall be provided with a choice of the 
        AIMP-administering entity to which the individual is assigned 
        for purposes of obtaining benefits under the program.
            ``(2) Initial assignment at time of program implementation 
        or initial enrollment.--
                    ``(A) In general.--In the case of an AIMP-eligible 
                individual who, at the time of enrollment under an AIM 
                program, is enrolled in an integrated program for 
                individuals dually eligible for Medicare and Medicaid 
                participating in the Financial Alignment Initiative of 
                the Federal Coordinated Health Care Office, or enrolled 
                in a Medicare Advantage plan that is a highly 
                integrated dual eligible special needs plan or a fully 
                integrated dual eligible special needs plan, the State 
                AIM program may initially assign the individual to the 
                AIMP-administering entity for such Medicare Advantage 
                plan (or, in the case of an AIMP-eligible individual 
                who, at the time of enrollment under an AIM program, is 
                enrolled in an integrated program for individuals 
                dually eligible for Medicare and Medicaid participating 
                in the Financial Alignment Initiative of the Federal 
                Coordinated Health Care Office, to the AIMP-
                administering entity designated by the State), or 
                another AIMP-administering entity, if necessary if--
                            ``(i) the provider network of such entity 
                        under the AIM program is substantially similar 
                        to the network used under the plan offered by 
                        the entity that the individual is enrolled in 
                        prior to such assignment; and
                            ``(ii) the individual is provided with--
                                    ``(I) at least 1 written notice of 
                                such assignment at least 60 days in 
                                advance of the effective date of the 
                                assignment; and
                                    ``(II) at least 1 phone call 
                                notifying the individual of the 
                                assignment in advance of the effective 
                                date of the assignment.
                    ``(B) Continuity of care.--To the extent possible 
                to prevent disruption and promote continuity of care, a 
                State AIM program shall seek to ensure that individuals 
                described in subparagraph (A) are assigned to the AIMP-
                administering entity that offers the plan or program in 
                which the individual is enrolled in prior to the 
                individual's transfer to, and enrollment in, the State 
                AIM program.
                    ``(C) Conditional initial assignment for other 
                aimp-eligible individuals.--In the case of an AIMP-
                eligible individual who, at the time of enrollment 
                under a State AIM program is enrolled in a Medicare 
                Advantage plan that is operating as an AIMP-
                administering entity other than a plan described in 
                subparagraph (A), or is enrolled in a Medicaid managed 
                care plan offered by the same entity that is operating 
                as an AIMP-administering entity in the State AIM 
                Program, the State AIM program may initially assign the 
                individual to that AIMP-administering entity if--
                            ``(i) the provider network of such entity 
                        under the State AIM program is substantially 
                        similar to the network used under the Medicare 
                        Advantage plan or Medicaid managed care plan 
                        offered by the entity that the individual is 
                        enrolled in prior to such assignment; and
                            ``(ii) the individual is provided with--
                                    ``(I) at least 1 written notice of 
                                such assignment at least 60 days in 
                                advance of the effective date of the 
                                assignment; and
                                    ``(II) at least 1 phone call 
                                notifying the individual of the 
                                assignment in advance of the effective 
                                date of the assignment.
            ``(3) Rule of construction.--Nothing in this subsection 
        shall be construed as--
                    ``(A) preventing an individual from choosing to be 
                assigned to a different participating AIMP-
                administering entity;
                    ``(B) preventing an individual from changing their 
                assignment to an AIMP-administering entity or from 
                opting-out of participating in the State AIM program; 
                or
                    ``(C) constraining or changing the authority of a 
                State under the State plan under title XIX or under a 
                waiver of such plan to require a Medicaid-eligible 
                individual to enroll with a managed care entity if the 
                individual chooses not to participate in the AIM 
                Program.
            ``(4) Choice of enrollment from fee-for-service medicare.--
        An AIMP-eligible individual who, as of the date on which a 
        State first implements the State AIM program, is enrolled in 
        the Medicare fee-for-service program under title XVIII, may 
        elect to enroll in the State AIM Program through a special 
        enrollment period established for such individuals, consistent 
        with the requirements of section 423.38(c)(4) of title 42, Code 
        of Federal Regulations (or a successor regulation).
    ``(g) Effect of Enrollment on Medicare and Medicaid Payments to 
States.--Except as provided in this title, in the case of an individual 
who is enrolled as an AIMP enrollee under a State AIM program under 
this title, during the period of such enrollment payment to the State 
under this title shall be instead of the payment amounts which would 
otherwise be payable under title XVIII or XIX for items and services 
furnished to the enrollee.
    ``(h) Outreach and Enrollment Support.--
            ``(1) Funding.--For the purpose of providing funding 
        assistance to AIMP-participating States for outreach to, and 
        enrollment support of, AIMP-eligible individuals, there is 
        appropriated, out of any money in the Treasury not otherwise 
        appropriated, such sums as may be necessary for each fiscal 
        year beginning with the first fiscal year that begins on or 
        after the date of enactment of this title.
            ``(2) Use of funds.--An AIMP-participating State shall use 
        funds provided to the State under this subsection for outreach 
        to, and enrollment support of, AIMP-eligible individuals, that 
        includes the following:
                    ``(A) Distributing outreach and enrollment 
                materials printed in accessible language formats 
                (including primary languages, Braille, large print, and 
                alternative texts).
                    ``(B) Engaging community-based organizations to 
                conduct outreach to, and provide enrollment assistance 
                for, AIMP-eligible individuals.
                    ``(C) Referring AIMP-eligible individuals to the 
                State long-term care ombudsman, the qualified nonprofit 
                AIM Ombudsman selected for the AIM program under 
                section 2205(c), and other beneficiary support entities 
                for enrollment assistance and information.

``SEC. 2204. BENEFITS.

    ``(a) Covered Benefits.--
            ``(1) In general.--A State AIM program shall provide a core 
        package of covered benefits to address medical, behavioral, 
        long-term care, and social needs of AIMP enrollees in 
        accordance with an individual assessment and plan of care. Such 
        core package of available benefits shall include the following:
                    ``(A) Medicare benefits.--All benefits available 
                under parts A, B, and D of title XVIII, including with 
                respect to benefits available under such part D, 
                coverage of the 6 protected classes and 2 drugs from 
                each class.
                    ``(B) Medicaid mandatory benefits.--All benefits 
                otherwise required to be provided to AIMP-eligible 
                individuals under title XIX in the State if they were 
                not AIMP enrollees.
                    ``(C) Historic benefits.--All Medicaid services and 
                benefits offered as of 1 year prior to the enactment of 
                this title, as required by section 2204(d).
                    ``(D) Drugs.--All prescription drugs and covered 
                outpatient drugs available under the State Medicaid 
                program, including any such drugs that are available 
                under a prescription drug plan under part D of title 
                XVIII.
                    ``(E) Additional services.--An AIMP-participating 
                State may, with approval from the Federal Coordinated 
                Health Care Office, make available under the State AIM 
                program additional behavioral health, social, and 
                supportive services that enable flexibility to achieve 
                person-centered outcomes in the most cost-effective 
                setting.
            ``(2) Limitation on benefit carve-outs.--The Secretary may 
        permit a State AIM program to exclude benefits for some 
        services under paragraph (1)(C) if the Secretary determines 
        that such an exclusion is essential for the State to implement 
        the AIM program but such exclusion may not extend over a period 
        of longer than 4 years.
    ``(b) Benefit Assessment Process.--
            ``(1) Assessment tool and plan of care.--
                    ``(A) Development.--Not later than 18 months after 
                the date of the enactment of this title, the Secretary, 
                in consultation with State agencies administering State 
                plans or waivers under title XIX and with input from 
                other stakeholders, shall develop and publish a robust, 
                comprehensive standard assessment tool for use by all 
                AIM programs in evaluating the condition and needs of 
                AIMP enrollees for benefits under the program.
                    ``(B) Application to plan of care.--Each AIM 
                program shall provide for an assessment for each AIMP 
                enrollee, using such standard assessment tool, to form 
                a basis for the enrollee's plan of care under the 
                program. Such an assessment shall be conducted at least 
                annually, and when a triggering event (as defined by 
                the Secretary) affecting the enrollee's need for care 
                occurs.
                    ``(C) Application of grievance and appeals 
                procedures.--Disagreements concerning the plan of care 
                for an AIM enrollee shall be subject to grievance and 
                appeal rights under section 2205(b).
            ``(2) Standard assessment tool.--The standard assessment 
        tool under paragraph (1) shall--
                    ``(A) contain a required set of core elements, to 
                which States and AIMP-administering entities may add 
                additional requirements so long as the requirements a 
                State or AIMP administering entity uses contain at a 
                minimum the core set of elements;
                    ``(B) cover multiple domains, including medical, 
                functional, behavioral, and social domains; and
                    ``(C) be applicable to the full range of AIMP 
                enrollees, including individuals with serious mental 
                illness and with needs for assistance with activities 
                of daily living.
    ``(c) State Provision of Covered Benefits.--
            ``(1) Use of tiered-benefit model.--An AIMP-participating 
        State may establish a tiered-benefit design structure for 
        benefits so that specialized benefits may be available to meet 
        the needs of specific subpopulations of AIMP enrollees so long 
        as such tiering--
                    ``(A) only applies to benefits described in 
                subparagraph (E) of subsection (a)(1) and does not 
                limit the coverage of core covered benefits described 
                in subparagraphs (A) and (B) of such subsection; and
                    ``(B) is no more restrictive than the benefit 
                structure in place in the State under title XIX in the 
                year before the date of the enactment of this title.
            ``(2) In-lieu-thereof alternative services permitted.--An 
        AIMP-participating State may permit AIMP-administering entities 
        to cover benefits for cost-effective alternative services 
        (known as `in lieu of services') instead of benefits for 
        services otherwise included under the AIM program but in no 
        case shall an AIMP enrollee be required to use such alternative 
        services.
            ``(3) Continuity of services.--
                    ``(A) In general.--Except as provided in 
                subparagraph (B), during the first 6 months of an AIM 
                enrollee's enrollment in an AIM program (or for such 
                longer period as the AIM program may provide) an AIMP-
                participating State shall continue to provide access to 
                all medically necessary covered items and services and 
                providers (for continuity of care) that were being 
                provided at the time of enrollment.
                    ``(B) Exception.--Subparagraph (A) shall not apply 
                in cases in which it is determined by the State, and 
                agreed to by the Secretary, that the AIMP enrollee was 
                not eligible for such services at the time of 
                enrollment or was enrolled in the AIM program due to 
                error or fraud.
    ``(d) Maintenance of Effort.--As a condition for approval of an AIM 
program of a State, the State shall maintain levels of benefits for AIM 
enrollees under the program that are not less than the level of 
benefits under its State plan (including under a waiver) under title 
XIX for full-benefit dual eligible individuals as of fiscal year 2021, 
as of the fiscal year before the fiscal year in which this title is 
enacted, or as of the fiscal year before the 1st fiscal year in which 
the program is implemented in the State, whichever fiscal year has the 
highest level of benefits.
    ``(e) Administration of Benefits Through AIM-Administering 
Entities.--AIMP-participating States shall provide for the coordination 
of, and the responsibility for the delivery of covered services through 
AIM-administering entities under an AIM contract under section 2207.

``SEC. 2205. BENEFICIARY PROTECTIONS.

    ``(a) In General.--Except as otherwise provided, the beneficiary 
protections applicable to individuals enrolled under plans under parts 
C and D of title XVIII and under a State plan under title XIX shall 
apply in a manner specified by the Secretary to AIMP enrollees under an 
AIM program under this title and are in addition to beneficiary 
protections provided under this title.
    ``(b) Application of Grievances and Internal and External Appeals 
Under AIMP Contracts.--The rights of individuals with respect to 
internal and external complaints and appeals processes shall be 
specified in the contract between the AIMP-participating State and an 
AIMP-administering entity. Such processes shall, at a minimum, 
incorporate relevant rights and processes from the requirements for 
plans under parts C and D of title XVIII as well as requirements for 
Medicaid managed care organizations under title XIX.
    ``(c) Requirement for Qualified AIM Ombudsman Program.--
            ``(1) In general.--As a condition for approval of an AIM 
        program for a State under this title--
                    ``(A) the State shall have established and have 
                ready for implementation not later than 18 months prior 
                to implementing the AIM program, a qualified nonprofit 
                AIM Ombudsman program run by a community-based 
                organization for such AIM program; and
                    ``(B) the State, before implementation of its AIM 
                program, shall demonstrate to the satisfaction of the 
                Secretary (through an application of certification 
                process specified by the Secretary) that its AIM 
                Ombudsman program has the capacity to carry out its 
                functions in the State, including that the program has 
                the independence, expertise, and adequate resources in 
                place to serve AIMP-eligible individuals and AIMP 
                enrollees under the State AIM program.
            ``(2) Qualifications for qualified aim ombudsman program.--
                    ``(A) In general.--In order to be a qualified AIM 
                Ombudsman program, such program must meet the 
                requirements of this subsection for such a program.
                    ``(B) Construction.--Nothing in this subsection 
                shall be construed as preventing a qualified AIM 
                Ombudsman program from being structured as part of 
                another protection service (including those specified 
                in paragraph (3)), so long as such other protection 
                service meets the requirements of this subsection for a 
                qualified AIM Ombudsman program.
            ``(3) Coordination with other beneficiary protection 
        services.--A qualified AIM Ombudsman program shall coordinate 
        with State and Federal beneficiary protection services, 
        including the following:
                    ``(A) Demonstration Ombudsman Programs Serving 
                Medicare-Medicaid Enrollees.
                    ``(B) Managed Care Beneficiary Support Systems.
                    ``(C) Long-Term Care Ombudsman Programs.
                    ``(D) Disability Protection and Advocacy Programs.
            ``(4) Core services.--A qualified AIM Ombudsman program for 
        an AIMP-participating State shall have authority to provide the 
        following core services with respect to the AIM program in the 
        State:
                    ``(A) Individual assistance (including consumer 
                education and empowerment, assistance with and 
                representation in beneficiary appeals, fair hearings, 
                and grievances, guidance regarding plan and provider 
                selection, and support during enrollment and 
                disenrollment) for AIMP-eligible individuals 
                considering enrollment in the State AIM program and for 
                AIMP enrollees in such program.
                    ``(B) Systemic monitoring and reporting to the 
                State regarding compliance with applicable 
                requirements.
            ``(5) Providing reports to consumer advisory boards.--A 
        qualified AIM Ombudsman program for a State shall provide, on a 
        timely basis, any reports it produces to the consumer advisory 
        boards (established under subsection (e)) for the State and 
        shall make them publicly available.
            ``(6) Funding and oversight.--
                    ``(A) In general.--The Secretary shall oversee and 
                administer Federal funding directly to qualified AIM 
                Ombudsman programs established by States.
                    ``(B) Funding level.--For the purpose of providing 
                funding to qualified AIMP Ombudsman programs in each 
                State over a period of 3 fiscal years, there is 
                appropriated, out of any money in the Treasury not 
                otherwise appropriated, not less than $1,000,000, and 
                not more than $5,000,000. The Secretary shall determine 
                the funding for each such program based on the 
                estimated number of AIMP-eligible individuals in each 
                State.
                    ``(C) Supplemental funding.--Nothing in this 
                paragraph shall be construed as preventing an AIMP-
                participating State from providing supplemental funding 
                for the qualified AIM Ombudsman program for the State.
    ``(d) Beneficiary Advisory Council.--Each AIMP-participating State 
shall have in operation a Beneficiary Advisory Council to advise the 
State regarding the treatment of AIMP-eligible individuals and AIMP 
enrollees under this title. The composition and specific functions and 
authority of such a Council shall be delineated in readiness review 
requirements specified by the Secretary in carrying out paragraphs (2) 
and (3) of section 2201(d).
    ``(e) Consumer Advisory Boards.--
            ``(1) In general.--Each AIMP-participating State and each 
        AIMP-administering entity in each such State shall establish a 
        consumer advisory board that will provide regular feedback to 
        the State or governing board of the entity, respectively, on 
        issues of care of AIMP enrollees under the AIM program in that 
        State or through that entity, respectively.
            ``(2) Composition; functions.--Each such consumer advisory 
        board shall--
                    ``(A) meet at least quarterly;
                    ``(B) be comprised of members who--
                            ``(i) may be subject to approval by the 
                        Secretary and the AIMP-participating State;
                            ``(ii) are AIMP enrollees;
                            ``(iii) are family members and other 
                        caregivers for AIMP enrollees; and
                            ``(iv) are chosen in a manner that reflects 
                        the demographic diversity of the population of 
                        AIMP enrollees, including with respect to race, 
                        ethnicity, age, and urban and rural 
                        populations, and which includes individuals 
                        with disabilities;
                    ``(C) meet the requirements for member advisory 
                committees under section 438.110 of title 42, Code of 
                Federal Regulations; and
                    ``(D) file and make publicly available an annual 
                report that includes at least information on--
                            ``(i) the dates for its meetings held 
                        within the reporting year;
                            ``(ii) the names of board members invited 
                        and of those members in attendance at each such 
                        meeting; and
                            ``(iii) the agenda and minutes for each 
                        such meeting.

``SEC. 2206. FEDERAL ADMINISTRATION.

    ``(a) Primary Administration Through the Federal Coordinated Health 
Care Office.--
            ``(1) In general.--The Secretary shall carry out this title 
        through the Federal Coordinated Health Care Office, except that 
        with respect to payments under section 2208, the Secretary may 
        delegate such authority to the Administrator of the Centers for 
        Medicare & Medicaid Services.
            ``(2) Appropriations.--There are hereby appropriated to the 
        Secretary to carry out this title, out of any funds in the 
        Treasury not otherwise appropriated--
                    ``(A) for each of fiscal years 2022, 2023, and 
                2024, $100,000,000; and
                    ``(B) for each succeeding fiscal year, $30,000,000.
    ``(b) Standards and Process.--
            ``(1) Federal standards.--In carrying out this title, the 
        Secretary shall specify a minimum set of Federal standards, 
        including standards relating to access to care, quality of 
        care, beneficiary protections, marketing and enrollment, 
        grievances and appeals, and procurement.
            ``(2) Transparency in rulemaking.--In implementing the 
        provisions of this title, to the extent practical, the 
        Secretary shall utilize notice and comment rulemaking to ensure 
        transparency for stakeholders.
            ``(3) Application of knowledge gained from demonstration 
        projects and contract management teams under the financial 
        alignment initiative.--The Secretary shall carry out this title 
        taking into account the knowledge gained from the use of 
        contract management teams in demonstration projects under the 
        Financial Alignment Initiative for Medicare-Medicaid Enrollees 
        administered by the Federal Coordinated Health Care Office.
    ``(c) Direct-Hire Authority.--In carrying out this title, the 
Secretary (acting through the Federal Coordinated Health Care Office) 
shall have direct-hire authority to the extent required to implement 
and administer this title on a timely basis.

``SEC. 2207. SELECTION AND ROLE OF AIM-ADMINISTERING ENTITIES.

    ``(a) Requirements for State Selection of AIM-Administering 
Entities.--The Secretary, in consultation with States, shall develop 
(not later than 1 year after the date of the enactment of this title) a 
set of standardized requirements for the selection of qualified 
organizations to serve as AIMP-administering entities in the AIM 
programs in each AIMP-participating State.
    ``(b) Application of Criteria for the Qualification and Selection 
of AIMP-Administering Entities.--
            ``(1) In general.--Each AIM program in an AIMP-
        participating State shall be implemented through contracts 
        entered into by the AIMP-participating State and organizations 
        that qualify as AIMP-administering entities under this title. A 
        contract with an AIMP-administrating entity shall require the 
        entity to assume 2-sided financial risk in return for payment 
        for the arrangement and delivery of covered benefits to AIMP 
        enrollees assigned to the entity under the program.
            ``(2) Specification of criteria.--The Secretary and AIMP-
        participating States shall establish basic national criteria 
        for the qualification and selection of organizations to be 
        AIMP-administering entities. Such criteria shall take into 
        account the prior experience (including under both the Medicare 
        program under title XVIII and Medicaid programs under title 
        XIX) of such an organization in serving the population of AIMP-
        eligible individuals as well as other criteria, including the 
        following:
                    ``(A) The organization's experience serving AIMP-
                eligible individuals in that State (or another State), 
                including the organization's experience in providing 
                covered services described in section 2204(a)(1) 
                (including long-term services and supports and 
                behavioral health services) to such individuals, and in 
                integrating all of those services and supports for such 
                individuals in that State (or another State).
                    ``(B) The organization's performance on key quality 
                measures in providing such services, such as on 
                measures of key health outcomes and enrollee 
                satisfaction.
                    ``(C) The adequacy of the organization's provider 
                network in ensuring timely access to care.
                    ``(D) The organization's demonstrated experience in 
                implementing models of care for the full range of such 
                services, including with respect to non-medical 
                services described in section 2204(a)(1).
            ``(3) Additional state-specific criteria.--Nothing in this 
        subsection shall be construed as preventing a State, with the 
        approval of the Secretary, from applying additional criteria or 
        requirements regarding health care quality, equity, or access 
        on AIMP-administering entities specific to quality, equity, or 
        access, so long as such requirements and criteria--
                    ``(A) can be applied consistently to all AIMP-
                administering entities; and
                    ``(B) are made available for public comment prior 
                to being imposed.
            ``(4) Application of medical loss ratio requirements.--
                    ``(A) In general.--Any AIMP contract between an 
                AIMP-participating State and an AIMP-administering 
                entity to administer benefits under an AIM program 
                shall include a requirement that the medical loss ratio 
                under the AIM program shall not be not less than a 
                percentage (not less than 85 percent) specified by the 
                State and that the entity shall return to the State 
                payment amounts that result in the medical loss ratio 
                being below such percentage.
                    ``(B) Special rules.--If an administering entity 
                who is contracting with a participating State to 
                administer a program under this title is an entity 
                bearing 2-sided risk, the State shall establish with 
                the approval of the Secretary a mechanism comparable to 
                a medical loss ratio target to ensure appropriate 
                spending on services by the entity.
    ``(c) State Procurement Process for AIMP-Administering Entities.--
            ``(1) In general.--Each AIMP-participating State shall be 
        responsible for establishing and implementing a process for the 
        procurement and selection of AIMP-administering entities for 
        the State AIM program, subject to the approval of the 
        Secretary. The Secretary shall not approve such a process 
        unless the State demonstrates to the Secretary's satisfaction 
        that the process results in the selection of AIMP-administering 
        entities that meet the requirements of this title and are 
        qualified to serve the needs of AIMP enrollees in the State 
        under the State's AIM program. An AIMP-participating State may 
        add additional requirements specific to quality, equity, or 
        access that further the State's overall integrated care 
        strategy and goals, so long as such requirements are posted for 
        public comment and approved by the Federal Coordinated Health 
        Care Office.
            ``(2) Separate procurement process required for initial 
        procurement.--For the initial procurement executed to establish 
        an AIM program in an AIMP-participating State, the State shall 
        not combine its AIM administering entity procurement process 
        with a procurement process that is also used for procurement 
        under the State plan or waiver under title XIX and shall select 
        AIM administering entities through a standalone procurement 
        process.
    ``(d) Payments to AIM-Administering Entities.--Each AIMP-
participating State shall make payments to AIM-administering entities 
under a risk-adjusted payment model that--
            ``(1) reflects the risk of the population of AIMP enrollees 
        served by each entity;
            ``(2) ensures that there are appropriate resources to serve 
        the AIMP enrollees in the State; and
            ``(3) protects against any adverse selection of AIMP 
        enrollees by entities.

``SEC. 2208. PROGRAM FINANCING.

    ``(a) Payments to States With AIM Programs.--
            ``(1) For program benefits.--
                    ``(A) In general.--From the sums appropriated under 
                paragraph (3), the Secretary shall pay to each AIMP-
                participating State for each quarter in a fiscal year 
                (beginning with the first fiscal year that begins after 
                the date of enactment of this title), an amount equal 
                to the Federal AIMP matching percentage (as defined in 
                subsection (b)(1)) of the total amount expended during 
                the quarter as AIMP assistance (as defined in 
                subparagraph (B).
                    ``(B) AIMP assistance defined.--In this title, the 
                term `AIMP assistance' has the meaning given the term 
                `medical assistance' under section 1905(a), except that 
                in applying such term under this subparagraph--
                            ``(i) the services described in section 
                        2204(a)(1) shall be substituted for the 
                        services described in paragraph (1) and the 
                        subsequent paragraphs of such section 1905(a);
                            ``(ii) an AIMP enrollee shall be treated as 
                        an individual referred to in the matter in 
                        section 1905(a) before paragraph (1) of such 
                        section; and
                            ``(iii) the exclusion in the subdivision 
                        (B) following the last paragraph of the first 
                        sentence of section 1905(a) shall not apply.
            ``(2) For administrative expenses.--In addition to the 
        amount paid for each quarter in a fiscal year to an AIMP-
        participating State under paragraph (1), the Secretary shall 
        pay to each such State for each quarter in a fiscal year 
        (beginning with the first fiscal year that begins after the 
        date of enactment of this title), from the sums appropriated 
        under paragraph (3), not less than 50 percent of the total 
        amount expended during such quarter as found necessary by the 
        Secretary for the proper and efficient administration of the 
        State AIM program under this title.
            ``(3) 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, reduced by any amounts made available from the 
        Medicare trust funds under paragraph (5).
            ``(4) Relation to other payments.--Payment amounts provided 
        under this subsection are in addition to payments provided 
        under other provisions of this title.
            ``(5) Relation to medicare trust funds.--There shall be 
        made available for application under this title from the 
        Federal Hospital Insurance Trust Fund (under section 1817) and 
        from the Federal Supplementary Medical Insurance 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 
        Account that are attributable to the coverage of AIMP enrollees 
        under AIM programs under this title.
    ``(b) Federal AIMP Matching Percentage.--
            ``(1) In general.--In this section, the term `Federal AIMP 
        matching percentage' means, for an AIMP-participating State for 
        a fiscal year, 100 percent minus the State contribution 
        percentage (as defined in paragraph (2)) for the State and 
        fiscal year.
            ``(2) State contribution percentage formula.--
                    ``(A) In general.--In this section, the term `State 
                contribution percentage' means, subject to adjustment 
                under the subsequent provisions of this paragraph, with 
                respect to an AIMP-participating State for--
                            ``(i) the 1st fiscal year of the AIM 
                        program in the State, the base AIMP State 
                        percentage computed under subsection (c); or
                            ``(ii) a subsequent fiscal year, the State 
                        contribution percentage under this paragraph 
                        for the previous fiscal year adjusted in 
                        accordance with subparagraph (B) or (C), as 
                        applicable.
                    ``(B) Annual adjustment based on changes in 
                expenditures.--For an AIMP-participating State for a 
                fiscal year after such 1st fiscal year, if the 
                expenditures for AIMP assistance for which payment is 
                made under subsection (a)(1) under the State AIM 
                program for the second previous fiscal year--
                            ``(i) are not greater than 110 percent, or 
                        less than 90 percent, of the AIMP assistance 
                        expenditures for the previous fiscal year, 
                        there shall be no adjustment for the fiscal 
                        year involved under this subparagraph;
                            ``(ii) is greater than 110 percent of the 
                        AIMP assistance expenditures for the previous 
                        fiscal year, the adjustment under this 
                        subparagraph for the fiscal year involved shall 
                        be an increase in the State contribution 
                        percentage of 1 percentage point for each 
                        multiple of 10 percentage points by which such 
                        AIMP assistance expenditures exceed 110 
                        percent; or
                            ``(iii) is less than 90 percent of the AIMP 
                        assistance expenditures for the previous fiscal 
                        year, the adjustment under this subparagraph 
                        for the fiscal year involved shall be a 
                        decrease in the State contribution percentage 
                        of 1 percentage point for each multiple of 10 
                        percentage points by which such AIMP assistance 
                        expenditures is less than 90 percent.
                    ``(C) Additional adjustments for exceptions.--The 
                Secretary shall provide a process by which adjustments 
                may be made to the State contribution percentage to 
                take into account increases and decreases in AIMP 
                expenditures described in clause (ii) or (iii) of 
                subparagraph (B) in which the adjustments under such 
                clauses would not apply, such as in cases of a 
                significant increase or decrease in AIMP enrollees, a 
                declaration of a national emergency that impacts on 
                AIMP expenditures under this title, or a significant 
                cost increase beyond the control of the State, as 
                determined by the Secretary.
    ``(c) Baseline Expenditure and Percentage Computations.--
            ``(1) In general.--Using the data reported under paragraph 
        (2):
                    ``(A) Computation of base aimp percentages.--For 
                the base Federal fiscal year (as defined in paragraph 
                (3)), the Secretary shall compute and publish for each 
                State--
                            ``(i) the base AIMP State percentage (as 
                        defined in subparagraph (B)) for the State and 
                        such fiscal year; and
                            ``(ii) the Federal AIMP matching percentage 
                        for the State and such fiscal year.
                    ``(B) Base aimp state percentage defined.--In this 
                section, the `base AIMP State percentage' means the 
                amount equal to the ratio (expressed as a percentage) 
                of--
                            ``(i) the sum of--
                                    ``(I) the amount of the State share 
                                of expenditures under title XIX for 
                                medical assistance during the base 
                                Federal fiscal year attributable to 
                                full-benefit dual eligible individuals; 
                                and
                                    ``(II) the amount of the payment 
                                made to the Federal Government during 
                                the base Federal fiscal year under 
                                section 1935(c) (commonly referred to 
                                as the `part D clawback') attributable 
                                to such individuals; to
                            ``(ii) the sum of--
                                    ``(I) the total expenses paid under 
                                title XVIII that are attributable to 
                                full-benefit dual eligible individuals 
                                for services (or periods of coverage) 
                                occurring the base Federal fiscal year 
                                (as estimated by the Secretary); and
                                    ``(II) the total amount expended on 
                                items and services described in section 
                                2204(a)(1) paid under title XIX 
                                (including any waivers under title XI) 
                                for full-benefit dual eligible 
                                individuals in the base Federal fiscal 
                                year.
                    ``(C) Adjustments to base aimp percentages.--With 
                respect to the base AIMP State percentages and the 
                Federal AIMP matching percentages otherwise computed 
                under this paragraph for the base Federal fiscal year, 
                the Secretary shall adjust such percentages to take 
                into account material changes in the programs under 
                titles XVIII and XIX between the base Federal fiscal 
                year and the first fiscal year for which AIM programs 
                may be implemented under this title insofar as such 
                material changes have a direct material impact on AIMP 
                expenditures relating to AIMP-eligible individuals.
            ``(2) Data reporting for baseline computations.--Each 
        State, in its application for approval of its AIM program, 
        shall provide the Secretary (in such form and manner as the 
        Secretary may require) such financial data (including detailed 
        and aggregate, historical and projected expenditures data) on 
        its expenditures under title XIX as the Secretary may require 
        to carry out the computations required under this section. The 
        Secretary shall share with the State, in a process defined by 
        the Secretary, Medicare expenditure data (including detailed 
        and aggregate historical and projected expenditures data) for 
        services and benefits for full-benefit dual eligible 
        individuals in such State.
            ``(3) Base federal fiscal year defined.--In this section, 
        the term `base Federal fiscal year' means the Federal fiscal 
        year that is the second preceding fiscal year to the 1st fiscal 
        year for which AIM programs may be implemented under this 
        title.
    ``(d) Reinvestment of Shared Savings.--
            ``(1) In general.--
                    ``(A) In general.--If, with respect to a fiscal 
                year, an AIMP-participating State has expenditures 
                under this title for AIMP assistance that for the 
                preceding fiscal year, are less than 85 percent of the 
                expenditures for such assistance under the State AIM 
                program for the second preceding fiscal year, the 
                Secretary shall ensure that for each quarter in the 
                following fiscal year, the State spends at least the 
                shared savings amount determined for the State for the 
                fiscal year on 1 or more of the core applications 
                described in paragraph (3). Amounts expended by a State 
                to meet the requirement of the preceding sentence shall 
                not be subject to any Federal matching payments under 
                this title.
                    ``(B) Shared savings amount defined.--In this 
                subsection, the term `shared savings amount' means, 
                with respect to an AIMP-participating State for a 
                fiscal year, the amount by which the AIMP assistance 
                expenditures for the fiscal year is less than 85 
                percent of the expenditures for such assistance under 
                the State AIM program for the second preceding fiscal 
                year.
            ``(2) Application of shared savings.--The Secretary shall 
        issue guidance outlining allowable use of the shared savings 
        payments under paragraph (1). Under such guidance, the 
        Secretary shall outline the types of services and benefits for 
        which a State has the authority to apply the payments for the 
        benefit of consumers who are AIMP-eligible individuals. Such 
        guidance shall permit the use of such payments consistent with 
        the core applications described in paragraph (3) and with 
        paragraph (4), and may be used for existing State-funded health 
        programs or new health-related initiatives that serve full-
        benefit dual eligible individuals under this title.
            ``(3) Core applications.--The core applications described 
        in this paragraph for such consumers are as follows:
                    ``(A) Consumer power and choice.--To provide such 
                consumers more information and control over their 
                health care and community support options.
                    ``(B) Equity and access to care.--To improve access 
                to, and quality of, care across populations, advance 
                health equity for consumers, and reduce health 
                disparities and eliminate barriers to care.
                    ``(C) Prevention and wellness.--To strive to better 
                enable such consumers to receive individualized health 
                care that is outcomes-oriented and focused on 
                prevention, wellness, recovery and maintaining 
                independence.
                    ``(D) Pay for performance.--To employ purchasing 
                and payment methods that encourage and reward service 
                quality and cost-effectiveness by linking 
                reimbursements for services to such consumers to 
                common, evidence-based quality performance measures, 
                including patient satisfaction.
                    ``(E) Innovative advancement.--To implement 
                innovative and technological advancements that 
                facilitate such consumers remaining in the community.
                    ``(F) Service integration.--To increase integration 
                of services with social needs to improve health 
                outcomes for such consumers.
                    ``(G) State personnel.--To hire additional State 
                personnel to carry out this title.
                    ``(H) Capacity building.--To expand capacity in 
                providing services to such consumers, such as in--
                            ``(i) community-based care; and
                            ``(ii) caregiver assistance.
                    ``(I) Improve enrollment policies and process.--To 
                improve the ability to enroll in the State AIMP program 
                through streamlining enrollment policies and processes.
                    ``(J) Increase education for providers and 
                beneficiaries.--To ensure providers and beneficiaries 
                understand the State AIMP program and the choices 
                available under such program.
                    ``(K) Improve data collection regarding racial 
                disparities and health inequities.--To ensure 
                appropriate data is collected and used to determine 
                program inequities.
                    ``(L) Other services and initiatives.--Other 
                services and initiatives approved by the Secretary that 
                serve full-benefit dual eligible individuals under this 
                title.
            ``(4) Limitation on payment to aimp-administering 
        entities.--An AIMP-participating State may use payments under 
        this subsection for an AIMP-administering entity only if the 
        State demonstrates, to the satisfaction of the Secretary, that 
        the State's AIM program provides appropriate maintenance of 
        access to and quality of care based on the requirements imposed 
        by the State on the applicable AIMP-administering entities.
    ``(e) Application of Medicaid Payment Methodologies Financing 
Limitations for the Non-Federal Share of Expenditures.--
            ``(1) In general.--Except as the Secretary may otherwise 
        provide through notice and comment regulation, the following 
        provisions of title XIX (and related regulations) shall apply 
        to AIMP-participating States' expenditures in the AIM program 
        in a manner similar to the manner in which such provisions 
        apply under title XIX:
                    ``(A) Section 1903(d) (relating to estimated 
                payments, recovery of overpayments, disallowance of 
                provisions).
                    ``(B) Section 1903(w) (relating to provider-related 
                donations, health care related taxes, and broad-based 
                health care related taxes).
                    ``(C) Section 1903(w)(6) (relating to certified 
                public expenditures and intergovernmental transfers).
                    ``(D) Other provisions relating to deferral of 
                payments, preventing fraud and abuse, and ensuring 
                program integrity.
            ``(2) Processes and forms.--
                    ``(A) In general.--The Secretary shall establish 
                appropriate forms and processes (including expenditure 
                reconciliation processes) for submission of information 
                on State expenditures under this title in a manner 
                similar to the processes used for purposes of payments 
                to States under title XIX, but through the use of such 
                alternative forms as may be appropriate in implementing 
                this title.
                    ``(B) Reporting of estimated expenditures by 
                quarter.--An AIMP-participating State shall estimate 
                matchable expenditures (including both total 
                expenditures as well as the estimated Federal share of 
                those expenditures) and separately report these 
                expenditures by quarter for each fiscal year for its 
                AIM program. The Secretary shall make Federal funds 
                available based upon the State's estimate, as approved 
                by the Secretary.
                    ``(C) Reporting and reconciliation of actual 
                expenditures on a quarterly basis.--Not later than 30 
                days after the end of each quarter, each AIMP-
                participating State shall submit to the Secretary (on 
                an appropriate form) a quarterly expenditure report, 
                showing expenditures made in the quarter just ended 
                under its AIM program. The Secretary shall reconcile 
                expenditures so reported with Federal funding 
                previously made available to the State under this 
                section and include the reconciling adjustment in the 
                finalization of the grant award to the State.
            ``(3) Rule of construction.--Nothing in this title shall be 
        construed as constraining or limiting the authority of the 
        Secretary, the Administrator of the Centers for Medicare & 
        Medicaid Services, the Inspector General of the Department of 
        Health and Human Services, or the Comptroller General of the 
        United States, to conduct routine and targeted program and 
        financial management audits and other oversight activities of 
        funds expended under this title, including oversight activities 
        relating to the allowable use of funds.
    ``(f) Option for Multi-Year Investment Initiative.--The Secretary 
may specify a process by which an AIM-participating State may elect to 
participate in a multi-year investment initiative during the first 3-
year period in which the State participates in the AIM program. Under 
such option, an AIM-participating State shall be eligible for 
additional Federal financial participation (as determined by the 
Secretary) for expenditures under this title that do not exceed an 
annual budget target established for the State, based on the 
expenditures of the State used to determined the base AIMP State 
percentage under subsection (c)(1)(B), and increased for the 2d and 3rd 
years of such period, by 9.99 percent over the budget target 
established for the preceding year.

``SEC. 2209. ACCOUNTABILITY AND OVERSIGHT.

    ``(a) Quality Assessment.--To ensure that full-benefit dual 
eligible individuals receive high quality care and to encourage quality 
improvement under AIM programs, each AIM-participating State shall 
establish a quality incentive program that uses financial rewards, 
penalties, or both that are meaningful enough to influence the 
administering entity's behavior and is approved by the Federal 
Coordinated Health Care Office. Each AIM program will be expected to 
tie financial incentives to performance either in the form of quality 
withholds or incentives, such as making additional quality payments to 
an AIMP-administering entity that achieves quality or equity goals or 
the withholding of a portion of a capitation payment to an entity that 
fails to achieve such goals. Each AIM-participating State shall 
publicly post and seek comment on its proposed quality incentive 
program prior to submitting to the Federal Coordinated Health Care 
Office for approval.
    ``(b) Monitoring and Program Evaluation.--
            ``(1) Consolidated reporting requirements for aim-
        administering entities.--The Secretary and each AIMP-
        participating State shall define and specify in the contract 
        for each AIMP-administering entity under this title a 
        consolidated reporting process that ensures the provision of 
        the necessary data on diagnosis, HEDIS measures, encounter 
        reports, enrollee satisfaction, and evidence-based measures and 
        other information as may be useful in order to monitor each 
        AIMP-administering entity's performance under the AIMP 
        contract.
            ``(2) Evaluation.--The Secretary and each AIMP-
        participating State shall develop processes and protocols for 
        collecting (or ensuring that AIMP-administering entities 
        collect) and reporting to the Secretary and the State the data 
        needed for an evaluation by the Secretary to measure the impact 
        of AIMP-administering entities, the effectiveness of the 
        process in enrolling AIMP-eligible individuals under the AIM 
        program, and the effectiveness of the AIM program in reducing 
        disparities, improving quality of care, and advancing health 
        equity.
            ``(3) Collaborative evaluation.--The Secretary and AIMP-
        participating States shall collaborate on and coordinate during 
        any evaluation activity conducted under this subsection.
    ``(c) Administrative Oversight Responsibilities.--
            ``(1) State role.--Each AIMP-participating State shall be 
        responsible for day-to-day oversight of the AIMP-administering 
        entities providing services with respect to AIMP enrollees 
        under the AIMP contract with the State under its AIM program. 
        Such oversight shall include the following activities:
                    ``(A) Conducting a comprehensive readiness review 
                of each entity (as required under section 2201(d)).
                    ``(B) Monitoring compliance of the entity with the 
                terms of its AIMP contract under the AIM program, 
                including--
                            ``(i) ensuring adherence to and protection 
                        of enrollee rights as provided under this 
                        title;
                            ``(ii) monitoring the entity to ensure it 
                        authorizes, arranges, coordinates, and provides 
                        all covered and medically necessary services 
                        (as required under this title) to AIMP 
                        enrollees receiving benefits administered by 
                        the entity, in accordance with the requirements 
                        of the AIMP contract; and
                            ``(iii) ensuring compliance with applicable 
                        reporting requirements under this title.
                    ``(C) Reviewing, approving, and monitoring--
                            ``(i) the entity's network adequacy;
                            ``(ii) the outreach and orientation 
                        materials and procedures of the entity;
                            ``(iii) the complaint and appeals 
                        procedures carried out by the entity;
                            ``(iv) the utilization management functions 
                        of the entity;
                            ``(v) the entity's adherence to required 
                        continuity of care provisions under section 
                        2204(c)(3);
                            ``(vi) the entity's use of required 
                        standard assessment tool under section 2204(b);
                            ``(vii) the entity's informational 
                        materials, particularly for those individuals 
                        who will be assigned to the entity under 
                        section 2203(f); and
                            ``(viii) the entity's use of streamlined 
                        eligibility processes under this title.
                    ``(D) Conducting monthly (or more frequent) 
                performance review meetings with the entity.
                    ``(E) Conducting periodic audits of the entity, 
                including at least an annual independent external 
                review and an annual site visit.
                    ``(F) Receiving and responding to complaints about 
                the entity.
                    ``(G) Conducting annual surveys of AIMP enrollees 
                and providing the entity with written results of such 
                surveys.
                    ``(H) Applying 1 or more sanctions (such as those 
                provided under title XIX), which may include 
                termination of the contract, if the State or the 
                Secretary determines that the entity is in material 
                violation of any of the terms of the AIMP contract.
            ``(2) Federal oversight role.--
                    ``(A) In general.--The Secretary shall be 
                responsible for the oversight of AIMP-participating 
                States. Such oversight shall include activities 
                developed through engagement with stakeholders, 
                including consumer advocates, and shall include at the 
                least the following activities:
                            ``(i) Monitoring the process to select 
                        organizations to serve as AIMP-administering 
                        entities under the AIM program.
                            ``(ii) Conducting a thorough readiness 
                        review of the State (before readiness reviews 
                        for such organizations) under section 
                        2201(d)(2).
                            ``(iii) Ensuring, including through 
                        complaint tracking and secret shopping, the 
                        State creates and maintains a highly 
                        functional, dedicated AIMP Ombudsman program 
                        under section 2205(c).
                            ``(iv) Ensuring, through direct monitoring, 
                        State oversight of compliance of AIMP-
                        administering entities with the terms of their 
                        AIMP contracts under the AIM program.
                            ``(v) Reviewing eligibility and enrollment 
                        processes and procedures.
                            ``(vi) Monitoring State data systems to 
                        ensure they are sufficient for providing timely 
                        data on program performance.
                            ``(vii) Ensuring payment rates to AIMP-
                        administering entities under the AIMP contract 
                        are actuarially sound, including by 
                        establishing a rate setting process established 
                        through rulemaking whereby, at a minimum--
                                    ``(I) States and the Secretary 
                                provide AIMP-administering entities 
                                with comprehensive and timely data as 
                                part of the rate setting process and 
                                procurement, including historical 
                                Medicaid and Medicare cost and 
                                utilization data for full-benefit dual 
                                eligible individuals by region and 
                                including detailed categories of 
                                service;
                                    ``(II) States may elect to share 
                                the final rate certification package 
                                provided to the Secretary with AIMP-
                                administering entities; and
                                    ``(III) an opportunity for public 
                                input is established for annual rate 
                                setting or when rates are significantly 
                                modified whereby stakeholders, 
                                including patient advocacy groups, 
                                health care providers, and AIMP-
                                administering entities, can provide 
                                feedback to the Secretary prior to rate 
                                approval.
                            ``(viii) Coordinating periodic audits of 
                        the State with respect o its AIM program.
                            ``(ix) Conducting regular meetings with the 
                        State.
                            ``(x) Applying discretionary action, if 
                        warranted.
                            ``(xi) Ensuring regular engagement with 
                        dually eligible individuals and their 
                        caregivers.
                    ``(B) Compliance authority.--If the Secretary finds 
                with respect to a State AIM program that the State 
                failed to achieve the appropriate performance levels or 
                compliance with the activities required under 
                subparagraph (A), the Secretary shall take such action 
                as is necessary to address and correct the State 
                failures, which may include, to the extent the 
                Secretary determines appropriate, 1 or more of the 
                following:
                            ``(i) Developing in consultation with the 
                        State, a corrective compliance plan for 
                        achieving appropriate performance levels or 
                        compliance.
                            ``(ii) Remedial education and supervised 
                        training.
                            ``(iii) Imposition of penalties or 
                        sanctions.
                            ``(iv) Removal of the State from the AIM 
                        program.
            ``(3) State-federal partnership role through joint contract 
        management teams (cmt).--
                    ``(A) Establishment.--The Secretary shall, jointly 
                with each AIMP-participating State, establish a Joint 
                Contract Management Team (in this paragraph referred to 
                as a `CMT') following the model used in the 
                demonstration projects conducted under the Financial 
                Alignment Initiative for Medicare-Medicaid Enrollees 
                administered by the Federal Coordinated Health Care 
                Office.
                    ``(B) Composition and structure.--
                            ``(i) In general.--Each CMT shall include 
                        at least 1 contract officer from the Centers 
                        for Medicare & Medicaid Services and at least 1 
                        contract officer from the AIMP-participating 
                        State, each of whom is authorized and empowered 
                        to represent the Secretary and the State, 
                        respectively, about all aspects of the AIMP 
                        contract with an AIMP-administering entity 
                        under the AIM program of the State.
                            ``(ii) Lead.--The representation from the 
                        Federal Government shall be led by the 
                        individual from the Federal Coordinated Health 
                        Care Office who is assigned to work with the 
                        State, who will bring in additional 
                        individuals, as appropriate.
                            ``(iii) State lead.--The representation 
                        from the AIMP-participating State shall be led 
                        by the Director of the State Medicaid program 
                        under title XIX (or such Director's designee) 
                        who will bring in additional individual to 
                        represent the State, as appropriate.
                    ``(C) Responsibilities of cmt.--Each CMT for a 
                State shall act as a liaison among the AIMP-
                administering entity, the Secretary, and the State for 
                the duration of the AIMP contract with such entity and 
                shall serve to facilitate communications and operations 
                among the 3 parties. Each CMT shall, among other 
                functions--
                            ``(i) receive and respond to complaints;
                            ``(ii) conduct quarterly meetings among the 
                        parties;
                            ``(iii) establish a mechanism for ongoing 
                        consumer engagement;
                            ``(iv) coordinate requests for assistance 
                        from the entity and assign Federal and State 
                        staff with appropriate expertise to provide 
                        technical assistance to the entity;
                            ``(v) make best efforts to resolve any 
                        issues applicable to the parties; and
                            ``(vi) monitor any discretionary action by 
                        the State or the Secretary under the provisions 
                        of the AIMP contract.

``SEC. 2210. DEFINITIONS; MISCELLANEOUS PROVISIONS.

    ``(a) Definitions.--In this title:
            ``(1) Terms relating to aimp.--
                    ``(A) AIMP-administering entity.--The term `AIMP-
                administering entity' means an organization that has 
                been determined to meet the requirements for such an 
                entity under this title and has an AIMP contract with 
                an AIMP-participating State under this title.
                    ``(B) AIMP assistance.--The term `AIMP assistance' 
                has the meaning given such term in section 
                2208(a)(1)(B).
                    ``(C) AIMP contract.--The term `AIMP contract' is a 
                contract described in section 2207(b)(1).
                    ``(D) AIMP-eligible individual.--The term `AIMP-
                eligible individual' has the meaning given such term in 
                section 2202(a).
                    ``(E) AIMP enrollee.--The term `AIMP enrollee' 
                means an individual who is enrolled in an AIM program 
                under this title.
                    ``(F) AIMP-participating state.--The term `AIMP-
                participating State' means a State administering an AIM 
                program under this title.
                    ``(G) AIM program; aimp.--The terms `AIM program' 
                and `AIMP' mean, with respect to a State, the program 
                established by the State under this title.
            ``(2) Other definitions.--
                    ``(A) Full-benefit dual eligible individual.--The 
                term `full-benefit dual eligible individual' has the 
                meaning given such term in section 1935(c)(6) but 
                without the application of subparagraph (A)(i) of such 
                section.
                    ``(B) Federal coordinated health care office.--The 
                term `Federal Coordinated Health Care Office' means the 
                office established under section 2602 of the Patient 
                Protection and Affordable Care Act.
                    ``(C) Medicaid managed care organization.--The term 
                `medicaid managed care organization' has the meaning 
                given that term in section 1903(m)(1)(A) and includes a 
                prepaid inpatient health plan, as defined in section 
                438.2 of title 42, Code of Federal Regulations (or any 
                successor regulation) and a prepaid ambulatory health 
                plan, as defined in such section (or any successor 
                regulation).
    ``(b) Miscellaneous Provisions.--
            ``(1) Relation to other requirements.--Except as otherwise 
        provided under this title or by regulation, the requirements of 
        title XIX shall apply under an AIM program in relation to AIMP-
        eligible individuals, AIMP enrollees, and the provision of 
        benefits under an AIM program, in the same manner as such 
        requirements apply with respect to individuals eligible for 
        medical assistance who are enrolled in under a medicaid managed 
        care organization.
            ``(2) Limitation on waiver authority.--Except as provided 
        in this title, the Secretary is not authorized (under section 
        1115, 1115A, or otherwise) to waive the requirements specified 
        in this title.''.
    (b) Conforming Amendments to Medicare.--
            (1) 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 paragraph:
            ``(4) Additional enrollment option for certain full-benefit 
        dual eligible individuals.--Full-benefit dual eligible 
        individuals may also be eligible to enroll under a State AIM 
        program under title XXII.''.
            (2) Prohibition.--During the period in which an AIM program 
        is fully implemented in an AIMP-participating State under title 
        XXII, AIMP-eligible individuals in the State may not enroll in 
        a managed Medicare and other integrated duals product (other 
        than a PACE program).
    (c) Conforming Amendments to Medicaid.--
            (1) Preventing duplicate payments.--Section 1903(i) of the 
        Social Security Act (42 U.S.C. 1396(i)) is amended--
                    (A) by striking ``or'' at the end of paragraph 
                (26);
                    (B) by striking the period at the end of paragraph 
                (27) and inserting ``; or''; and
                    (C) by inserting after paragraph (27) the following 
                new paragraph:
            ``(28) with respect to any amount expended for medical 
        assistance for an individual who is an AIMP enrollee under a 
        State AIM program under title XXII, except specifically 
        permitted under such title.''.
            (2) Note: Additional conforming amendments to be provided.
    (d) Conforming Amendment.--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:
            ``(9) To be primarily responsible for the Federal 
        administration of title XXII of the Social Security Act.''.
    (e) Other Conforming Amendments.--Section 1101(a)(1) of the Social 
Security Act (42 U.S.C. 1301(a)(1)) is amended--
            (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''.

SEC. 3. MEDPAC STUDY AND REPORT.

    (a) Study.--The Medicare Payment Advisory Commission shall conduct 
a study for purposes of making recommendations regarding how to improve 
health care and other support needs of individuals who are eligible for 
and are receiving medical assistance for the payment of medicare cost-
sharing under a State Medicaid program pursuant to clause (i), (iii), 
or (iv) of section 1902(a)(10)(E) of the Social Security Act (42 U.S.C. 
1396a(a)(10)(E)).
    (b) Report.--Not later than 18 months after the date of enactment 
of this Act, the Medicare Payment Advisory Commission shall submit to 
Congress a report on the study conducted under subsection (a), together 
with recommendations for such legislation and administrative action as 
the Commission determines to be appropriate.
                                 <all>