I 113th CONGRESS 2d Session H. R. 4484 IN THE HOUSE OF REPRESENTATIVES April 10, 2014 Ms. Sinema (for herself, Mr. Gibson , Mr. Barber , Mr. Bilirakis , and Mr. Murphy of Florida ) introduced the following bill; which was referred to the Committee on Ways and Means , and in addition to the Committee on Energy and Commerce , for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To amend title XVIII of the Social Security Act to provide improvements for Medicare Advantage special needs plans, and for other purposes.

1. Short title This Act may be cited as the Strengthening Healthcare Options for Vulnerable Populations Act . 2. Reauthorization of certain Medicare Advantage Special Needs Plans (a) Permanent extension of Medicare Advantage Dual Special Needs Plans authority Section 1859(f)(1) of the Social Security Act ( 42 U.S.C. 1395w–28(f)(1) ) is amended by inserting , in the case of a specialized MA plan for special needs individuals who are not described in section 1859(b)(6)(B)(ii), before for periods before January 1, 2015 . (b) Medicare Advantage Dual Special Needs Plans required To provide integrated care Section 1859(f)(3) of the Social Security Act ( 42 U.S.C. 1395w–28(f)(3) ) is amended by adding at the end the following new subparagraph: (F) Not later than December 31, 2018, the plan is fully integrated with capitated contracts with States for any Medicaid benefits, including long-term care and behavioral health, to the extent State law permits capitation of such services under such plan. . (c) Clearly defined role of State Medicaid agency Section 1852(a)(1)(B) of the Social Security Act ( 42 U.S.C. 1395w–22(a)(1)(B) ) is amended by adding at the end the following new clause: (vi) Defined role of State Medicaid agencies with respect to fully integrated dual special needs plans The Secretary, in coordination with State Medicaid Directors, shall develop a clearly defined role for State Medicaid agencies in contracting and oversight of plans described in clause (v)(II). . 3. Improvements to Medicare Advantage 5–Star Quality Rating System for plans with predominately Dual Eligible enrollees (a) Treatment of plans with disproportionately high dual eligible enrollees Section 1853(o) of the Social Security Act ( 42 U.S.C. 1395w–23(o) ) is amended by adding at the end the following new paragraph: (6) Treatment of plans with disproportionately high dual eligible enrollees (A) In general In implementing this subsection, the Secretary shall take such steps as are necessary to ensure that the quality rating for a plan— (i) does not disadvantage such a plan that enrolls— (I) full-benefit dual eligible individual (as defined in section 1935(c)(6)); (II) qualified Medicare beneficiaries (as defined in section 1905(p)(1)); or (III) individuals with complex health care needs, such as individuals with multiple conditions or individuals who require chronic care or institutional care; and (ii) accounts for differences in socioeconomic and demographic characteristics of enrollees of such a plan that result in significant variation in health outcomes. (B) Specific steps The steps described in subparagraph (A) shall include at least the following: (i) Comparing specialized MA plans for special needs individuals (as defined in section 1859(b)(6)) for special needs individuals who are described in subparagraph (B)(ii) of such section only against other plans with the same types of enrollment. (ii) Developing a methodology specific to specialized MA plans for special needs individuals (as defined in section 1859(b)(6)) for special needs individuals who are described in subparagraph (B)(ii) of such section for determining a quality rating under this subsection for such plans. (iii) Developing appropriate case mix adjustment to Healthcare Effectiveness Data and Information Set (HEDIS) and Health Outcomes Survey (HOS) measures for specialized MA plans for special needs individuals (as defined in section 1859(b)(6)) for special needs individuals who are described in subparagraph (B)(ii) of such section that account for factors beyond the control of the health system, such as the management of conditions. (iv) Identifying and implementing those quality measures that are appropriate for evaluating the performance of specialized MA plans for special needs individuals (as defined in section 1859(b)(6)) for special needs individuals who are described in subparagraph (B)(ii) of such section. (v) Eliminating duplicative or substantially similar measures applied under this title or title XIX with respect to specialized MA plans. . (b) Temporary treatment of certain dual special needs plans Section 1853(o) of the Social Security Act ( 42 U.S.C. 1395w–23(o) ), as amended by subsection (a), is further amended by adding at the end the following new paragraph: (7) Temporary treatment of certain dual special needs plans In implementing this subsection during the period beginning on the date of the enactment of this paragraph and ending one year after the date on which the Secretary has taken such steps as are required under paragraph (6), the Secretary may increase the quality rating that a specialized MA plans for special needs individuals (as defined in section 1859(b)(6)) for special needs individuals who are described in subparagraph (B)(ii) of such section would otherwise receive under this subsection for a year by 0.5 stars if the plan demonstrates to the satisfaction of the Secretary that the quality rating the plan would have otherwise received is predominately attributable to socio-economic, demographic, or pre-existing complex health care needs of the population enrolled in such plan with respect to such year instead of the performance of the plan with respect to such year. . (c) GAO report Not later than one year after the date on which the Secretary of Health and Human Services has taken such steps as are required under paragraph (6) of section 1853(o) of the Social Security Act ( 42 U.S.C. 1395w–23(o) ), as added by subsection (a), and annually thereafter for the following four years, the Comptroller General of the United States shall submit to Congress a report that includes a comprehensive review of the effectiveness of, and recommendations to improve, such steps so taken for improving health outcomes, cost controls, and beneficiary satisfaction. 4. Additional improvements to the oversight and operation of Medicare Advantage Dual Special Needs Plans by the Federal Coordinated Health Care Office (a) Dedicated point of contact for assisting States with administration Section 2602(d) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 1315b(d) ) is amended by adding at the end the following new paragraph: (6) Serving as the dedicated point of contact within the Centers for Medicare & Medicaid Services to assist States with ongoing issues related to the administration of specialized MA plans for special needs individuals (as defined in section 1859(b)(6) of the Social Security Act) for special needs individuals who are described in subparagraph (B)(ii) of such section, including— (A) addressing any misalignment between the contracting timelines, processes, and deadlines under title XVIII of such Act, with respect to such plans for such individuals and contracting timelines, processes, and deadlines under title XIX of such Act, with respect to such plans and individuals; and (B) streamlining the flow of information to dual eligible individuals and establishing a single set of rules for outreach and marketing to such individuals. . (b) Authority To waive certain requirements (1) In general Subject to paragraph (2), the Secretary of Health and Human Services, through the Federal Coordinated Health Care Office established under section 2602 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 1315b ) and in coordination with the appropriate State Medicaid agency, may waive the application of requirements under title XVIII of the Social Security Act to promote the integration, alignment, and delivery of items and services under the Medicare program under title XVIII of such Act and the Medicaid program under title XIX of such Act, with respect to dual eligible individuals (as defined in section 2602(f) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 1315b(f) ), and to ensure the seamless delivery of patient-centered services across the continuum of care with respect to such individuals. (2) Public notice requirement The Secretary may not waive the application of a requirement pursuant to paragraph (1) unless the Secretary makes such waiver publicly available (whether on the public Internet website of Department of Health and Human Services, or otherwise) at least 30 days before the effective date of such waiver. 5. Improvements to dispute resolution for claims and appeals under Medicare Advantage Dual Special Needs Plans (a) Medicare Advantage Dual Special Needs Plans required To provide coverage during appeals process Section 1859(f)(3) of the Social Security Act ( 42 U.S.C. 1395w–28(f)(3) ), as amended by section 2(b), is further amended by adding at the end the following new subparagraph: (G) For plan years beginning after December 31, 2015, coverage under this title and title XIX of an individual enrolled under such respective title shall continue during any determination, reconsideration, or appeals proceeding described in section 1852(g), with respect to such individual. . (b) Streamlined pathway for dispute resolution Not later than December 31, 2015, the Secretary of Health and Human Services shall establish a streamlined process for dispute resolution for claims and appeals, with respect items and services furnished to special needs individuals described in section 1859(b)(6)(B)(ii) of the Social Security Act (42 U.S.C. 1395w–28(b)(6)(B)(ii)), to align such process under the Medicare program under title XVIII of the Social Security Act with such process under the Medicaid program under title XIX of such Act. Such streamlined process shall take into account various State requirements and promote a pathway that would be the most beneficial for individuals entitled to benefits under part A of title XVIII of such Act or enrolled under part B of such Act and to individuals enrolled under a State plan under title XIX of such Act. 6. Report on implementation of certain Medicare and Medicaid fraud detection and program integrity provisions Section 1128J(a)(1)(A) of the Social Security Act (42 U.S.C. 1320a–7k(a)(1)(A)) is amended by adding at the end the following new clause: (iii) Report on integrated data repository and one program integrity system Not later than six months after the date of enactment of this clause, the Secretary shall submit to the appropriate Congressional committees a report on the following: (I) Integrated data repository Efforts to finalize plans and schedules for fully implementing and expanding the use of the Integrated Data Repository, including actions taken to finalize, implement, and manage plans for incorporating data into the Integrated Data Repository and actions taken to define measurable financial benefits expected from the implementation of the Integrated Data Repository. (II) One program integrity system Actions taken to plan, schedule, and conduct training on the One Program Integrity System, a Web-based portal and suite of software tools used to analyze and extract data from the Integrated Data Repository, and actions taken to define measurable financial benefits expected from the use of the One Program Integrity System. .