[Congressional Bills 110th Congress]
[From the U.S. Government Publishing Office]
[H.R. 6365 Introduced in House (IH)]







110th CONGRESS
  2d Session
                                H. R. 6365

To amend part C of title XVIII of the Social Security Act with respect 
   to Medicare special needs plans and the alignment of Medicare and 
               Medicaid for dually eligible individuals.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             June 25, 2008

 Mr. Kind (for himself and Mr. Ramstad) introduced the following bill; 
which was referred to the Committee on Ways and Means, and in addition 
      to the Committee on Energy and Commerce, for a period to be 
subsequently determined by the Speaker, in each case for consideration 
  of such provisions as fall within the jurisdiction of the committee 
                               concerned

_______________________________________________________________________

                                 A BILL


 
To amend part C of title XVIII of the Social Security Act with respect 
   to Medicare special needs plans and the alignment of Medicare and 
               Medicaid for dually eligible individuals.

    Be it enacted by the Senate and House of 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 ``Medicare Special 
Needs Plans Extension and Amendments Act of 2008''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Extend SNP authority through December 31, 2012.
Sec. 3. Require targeting of high-risk groups; advance specialty care 
                            capabilities.
Sec. 4. Study on improving risk adjustment for high-risk, high-cost 
                            beneficiaries.
Sec. 5. Advance alignment of Medicare and Medicaid for dual eligibles.

SEC. 2. EXTEND SNP AUTHORITY THROUGH DECEMBER 31, 2012.

    Section 1859(f) of the Social Security Act (42 U.S.C. 1395w-28(f)), 
as amended by section 108 of the Medicare, Medicaid, and SCHIP 
Extension Act of 2007 (Public Law 110-173), is amended by striking 
``2010'' and inserting ``2013''.

SEC. 3. REQUIRE TARGETING OF HIGH-RISK GROUPS; ADVANCE SPECIALTY CARE 
              CAPABILITIES.

    (a) Requiring Targeting of High-Risk Groups.--
            (1) In general.--Section 1859(b)(6) of the Social Security 
        Act (42 U.S.C. 1395w-28(b)(6)) is amended--
                    (A) in subparagraph (A), by striking all that 
                follows ``means'' and inserting the following: ``an MA 
                plan--
                            ``(i) that serves special needs individuals 
                        (as defined in subparagraph (B)); and
                            ``(ii) for which--
                                    ``(I) at least 90 percent of the 
                                individuals enrolled after December 31, 
                                2008, are described in subparagraph 
                                (B)(i);
                                    ``(II) at least 90 percent of the 
                                individuals enrolled after December 31, 
                                2008, are described in subparagraph 
                                (B)(ii); or
                                    ``(III) at least 90 percent of the 
                                individuals enrolled after December 31, 
                                2008, are described in subparagraph 
                                (B)(iii) and have a severe or disabling 
                                chronic condition of the type that the 
                                plan is committed to serve.'';
                    (B) by adding at the end of subparagraph (A) the 
                following: ``For purposes of applying clause (ii), an 
                individual who is described in subparagraph (B)(i) or 
                (B)(ii) and who is enrolled in a specialized MA plan 
                for special needs individuals shall thereafter be 
                treated as continuing to be described in such 
                respective subparagraph regardless of changes in the 
                individual's circumstances so long as the individual 
                maintains continuous enrollment in such plan. Clause 
                (ii) shall not apply to a plan described in section 
                231(d) of the Medicare Prescription Drug, Improvement, 
                and Modernization Act of 2003 (Public Law 108-173) 
                which was previously operated under section 2355 of the 
                Deficit Reduction Act of 1984 (Public Law 98-369) and 
                which is operating as a specialized MA plan for special 
                needs individuals as of the date of the enactment of 
                this sentence.''; and
                    (C) in subparagraph (B)--
                            (i) in clause (i), by inserting ``under 
                        regulations in effect as of July 1, 2007'' 
                        after ``as defined by the Secretary''; and
                            (ii) by amending clause (iii) to read as 
                        follows:
                            ``(iii) has a severe or disabling chronic 
                        condition that requires complex care management 
                        capabilities, of the type described in 
                        subsection (f)(4), and specialized delivery 
                        systems to reduce medical complications and 
                        adverse health outcomes.''.
            (2) Coordinated financing for dual-eligible snps.--The 
        Secretary of Health and Human Services shall enter into 
        agreements with States (as defined for purposes of title XIX of 
        the Social Security Act) for coordinating the financing of 
        specialized MA plans for special needs individuals described in 
        section 1859(b)(6)(A)(ii)(II) of such Act for enrollees who are 
        entitled to medical assistance under State plans under such 
        title.
    (b) Advance Specialty Care Capabilities.--
            (1) In general.--Section 1859 of such Act (42 U.S.C. 1395w-
        28) is further amended--
                    (A) in subsection (b)(6)(A), as amended by 
                subsection (a)(1)--
                            (i) by striking ``and'' at the end of 
                        clause (i);
                            (ii) by striking the period at the end of 
                        clause (ii) and inserting ``; and'' ; and
                            (iii) by adding at the end the following 
                        new clause:
                            ``(iii) meets the applicable requirements 
                        specified in subsection (f) for the plan.''; 
                        and
                    (B) in subsection (f)--
                            (i) by amending the heading to read as 
                        follows: ``Requirements for Enrollment in 
                        Specialized MA Plans for Special Needs 
                        Beneficiaries'';
                            (ii) by designating the sentence beginning 
                        ``In the case of'' as paragraph (1) with the 
                        heading ``Requirements for enrollment.--'' and 
                        with appropriate indentation; and
                            (iii) by adding at the end the following 
                        new paragraphs:
            ``(2) Additional requirements for dual snps.--In the case 
        of a specialized MA plan for special needs individuals 
        described in subsection (b)(6)(A)(ii)(II), the applicable 
        requirements of this subsection include the following:
                    ``(A)(i) Subject to clause (ii), the plan has an 
                agreement with the State Medicaid agency that--
                            ``(I) includes provisions regarding 
                        cooperation on the coordination of care and the 
                        coordination of the financing of care for such 
                        individuals;
                            ``(II) includes a description of any 
                        Medicaid services to be covered by the plan for 
                        individuals enrolled in the plan eligible under 
                        such title for medical assistance;
                            ``(III) includes a description of the 
                        manner that the State Medicaid program under 
                        title XIX will fulfill its responsibilities 
                        under such title (including section 1902) with 
                        respect to payment for Medicare cost-sharing 
                        and with respect to payment for any Medicaid 
                        services not covered by Medicare for 
                        individuals enrolled in the plan eligible under 
                        such title for medical assistance; and
                            ``(IV) requires the disclosure to 
                        enrollees, including in the marketing materials 
                        of such plan, of Medicaid benefits and of those 
                        provider networks that contract with the State 
                        under the Medicaid program.
                    ``(ii) The agreement requirement of clause (i) 
                between a plan and a State Medicaid agency shall not 
                apply if the Secretary determines that the State--
                            ``(I) does not have the administrative 
                        infrastructure to enter into such agreements 
                        with such plan or to provide for coordination 
                        of benefits or payments with such plans;
                            ``(II) is unable to enter into such an 
                        agreement because of a State limitation on the 
                        number of Medicaid managed care contracts 
                        issued; or
                            ``(III) is otherwise unwilling or unable to 
                        enter into such an agreement.
                    ``(B) The out-of-pocket costs for services under 
                parts A and B that are charged to enrollees may not 
                exceed the out-of-pocket costs for same services 
                permitted for such individuals under title XIX.
            ``(3) Additional requirements for severe or disabling 
        chronic condition snps.--In the case of a specialized MA plan 
        for special needs individuals described in subsection 
        (b)(6)(A)(ii)(III), the applicable requirements of this 
        subsection include the following:
                    ``(A) The plan is designated to serve, and serves, 
                individuals described in subsection (b)(6)(1)(B)(iii).
                    ``(B) The plan meets any of the 3 following 
                criteria:
                            ``(i) The plan specializes in care of 
                        individuals who are disabled or have end-stage 
                        renal disease, including individuals who are 
                        eligible for benefits under part A through the 
                        application of section 226(b) or section 226A.
                            ``(ii) The plan specializes in care for 
                        persons who have co-morbid or complex chronic 
                        conditions that influence other aspects of 
                        health and have a high risk of hospitalization 
                        or other significant adverse health outcomes.
                            ``(iii) The plan has an average risk score 
                        under section 1853(a)(1)(C) of 1.35 or greater.
            ``(4) Complex care management capabilities for all snps.--
        The complex care management capabilities for a specialized need 
        plan shall include with respect to a special needs individual 
        enrolled under the plan the following:
                    ``(A) Conducting an initial assessment, and annual 
                reassessment, of the individual's physical, social, 
                medical, and functional needs for each individual 
                enrolled in the plan.
                    ``(B) Developing, for each such individual and with 
                input of the individual, an individualized plan of care 
                that identifies goals and objectives, including 
                measurable outcomes.
                    ``(C) Using an interdisciplinary team in management 
                of care and assuring appropriate access to specialty 
                care networks.
                    ``(D) Developing interventions based on population-
                based protocols and best practices to the extent 
                available.
                    ``(E) Assigning appropriate clinicians to meet the 
                unique needs of the population being served.
                    ``(F) Assuring coordination among clinicians and 
                other service providers involved.
                    ``(G) Assisting individuals enrolled in the plan 
                who are entitled to medical assistance under title XIX 
                in accessing and coordinating benefits and services 
                under this title and under such title.
            ``(5) Specialty care network defined.--In this subsection, 
        the term `specialty care network' means, with respect to a 
        specialized need plan, a group of health care providers under 
        contract with the plan that--
                    ``(A) includes physicians, hospitals, nursing 
                facilities, and allied health and social service 
                providers with special expertise relevant to the 
                special needs population being served;
                    ``(B) serves a common chronically ill or impaired 
                population, either at the same time or in sequence to 
                one another; and
                    ``(C) work together to improve total quality and 
                cost performance.''.
            (2) Quality standards and quality reporting.--Section 
        1852(e)(3) of such Act (42 U.S.C. 1395w-22(e)(3)) is amended--
                    (A) in subparagraph (A)(i), by adding at the end 
                the following: ``In the case of a specialized MA plan 
                for special needs individuals, the organization shall 
                provide for the reporting on quality measures developed 
                for the plan under subparagraph (C).''; and
                    (B) by adding at the end the following new 
                subparagraph:
                    ``(C) Specification of quality measurements for 
                specialized ma plans.--
                            ``(i) In general.--Notwithstanding 
                        subparagraph (B), the Secretary shall specify 
                        quality measures appropriate to meeting the 
                        needs of beneficiaries enrolled in specialized 
                        MA plans for special needs individuals 
                        (described in section 1859(b)(6)(A)). In 
                        implementing such measures, the Secretary shall 
                        take into account those HEDIS measures and 
                        structure and process measures identified that 
                        are unique to special needs individuals 
                        enrolled under such plans.
                            ``(ii) Satisfaction through current 
                        reporting requirements.--Nothing in clause (i) 
                        shall be construed as requiring the Secretary 
                        to impose on specialized MA plans for special 
                        needs individuals requirements that are in 
                        addition to the reporting requirements that are 
                        imposed on such plans as of the date of the 
                        enactment of this subparagraph. In implementing 
                        such clause, the Secretary shall not require 
                        the reporting by such plans of measures under 
                        such clause in a manner that is more burdensome 
                        to such plans than the reporting burden imposed 
                        on other MA plans.''.
    (c) Effective Date; Grandfather; Transition.--
            (1) Effective date.--
                    (A) In general.--Except as otherwise provided, the 
                amendments made by this section shall take effect for 
                enrollments occurring on or after January 1, 2010.
                    (B) Medicaid contract requirement.--Section 
                1859(f)(2)(A) of the Social Security Act, as added by 
                subsection (b)(1)(B)(iii), shall apply to plan years 
                beginning on or after the date that is 3 years after 
                the date of the enactment of this Act.
            (2) Permitting maintenance of policies and procedures for 
        current dual-eligible snps under a state integration program.--
        In the case of a specialized MA plan for special needs 
        individuals described in section 1859(b)(6)(A)(ii)(II)) of the 
        Social Security Act (42 U.S.C. 1395w-28(b)(6)(A)(ii)(II)) that 
        is offered under a State Medicaid Integrated Medicare-Medicaid 
        Program that was approved by the Administrator of the Centers 
        for Medicaid & Medicare Services before the date of the 
        enactment of this Act, and expansions of such a Program offered 
        on or after such date, the Secretary of Health and Human 
        Services shall permit the continuation of policies and 
        procedures in effect under such a Program as of the date of the 
        enactment of this Act notwithstanding the amendments made by 
        this section.
            (3) Orderly transition for certain enrollees.--The 
        Secretary of Health and Human Services shall provide for an 
        orderly transition of those specialized MA plans for special 
        needs individuals (as defined in subparagraph (A) of section 
        1859(b)(6) of the Social Security Act (42 U.S.C. 1395w-
        28(b)(6)), as of the date of the enactment of this Act), and 
        their enrollees, that no longer qualify as such plans or as 
        such individuals under such section, as amended by this 
        section.

SEC. 4. STUDY ON IMPROVING RISK ADJUSTMENT FOR HIGH-RISK, HIGH-COST 
              BENEFICIARIES.

    (a) In General.--Not later than 1 year after the date of enactment 
of this Act, the Secretary of Health and Human Services shall submit to 
Congress a report that evaluates the adequacy of the Medicare Advantage 
risk adjustment system under section 1853(a)(1)(C) of the Social 
Security Act (42 U.S.C. 1395w-23(a)(1)(C)), as well as the risk 
adjustment mechanism under section 1860D-15(c)(1)(A) of such Act (42 
U.S.C. 1395w-115(c)(1)(A)).
    (b) Particulars.--The report under subsection (a) shall include an 
evaluation of the need for improving the adequacy of the existing 
hierarchical condition categories and pharmacy risk adjustment methods 
for plans that specialize in care of high-risk beneficiaries as it 
relates to--
            (1) accurately predicting costs for beneficiaries with--
                    (A) sustained high-risk scores over multiple 
                contract periods;
                    (B) high costs;
                    (C) co-morbid chronic conditions;
                    (D) diagnoses not included in the risk-adjustment 
                methodology, including dementia and other cognitive 
                impairments;
                    (E) physical disabilities, developmental 
                disabilities, or both; and
                    (F) frailty;
            (2) including further gradations of diseases and conditions 
        to better reflect stage of condition, condition severity and 
        costs related to burden of illness;
            (3) accounting for costs of pre-existing conditions at the 
        time of initial enrollment for new entrants to the Medicare 
        program; and
            (4) enhancing coding persistency by calculating risk scores 
        using data covering at least two years.
    (c) Refinement.--The Secretary shall refine the risk-adjusted 
payment methods referred to in subsection (a) for high-risk, high-cost 
beneficiaries, consistent with the results of the study, not later than 
2 years after the date of the enactment of this Act.

SEC. 5. ADVANCE ALIGNMENT OF MEDICARE AND MEDICAID FOR DUAL ELIGIBLES.

    (a) Alignment of Medicare and Medicaid Policies and Procedures for 
SNPs Serving Dual Eligibles.--In order to increase simplicity for dual 
eligibles in accessing and coordinating Medicare and Medicaid benefits 
by enhancing coordination between CMS and State Medicaid agencies in 
the oversight of SNPs insofar as they serve dual eligibles, the 
Secretary may modify rules, policies, and procedures under titles XVIII 
and XIX of such Act in order to provide for the alignment of Medicare 
and Medicaid requirements, including marketing, enrollment, care 
coordination, auditing, reporting, quality assurance, and other 
relevant oversight functions.
    (b) Office of Medicare/Medicaid Integration.--
            (1) Establishment.--The Secretary shall establish or 
        designate an Office on Medicare/Medicaid Integration (in this 
        subsection referred to as the ``Office'') for the purpose of 
        aligning Medicare and Medicaid policies and procedures and 
        developing tools to support State integration efforts in 
        order--
                    (A) to simplify dual eligible access to Medicare 
                and Medicaid benefits and services;
                    (B) to improve care continuity and ensure safe and 
                effective care transitions;
                    (C) to eliminate cost shifting between Medicare and 
                Medicaid and among related care providers;
                    (D) to eliminate regulatory conflicts between 
                Medicare and Medicaid rules; and
                    (E) to improve total cost and quality performance.
            (2) Head.--The head of the Office who shall report to the 
        Administrator of the Centers for Medicare & Medicaid Services.
            (3) Responsibilities.--The responsibilities of the Office 
        are to develop policies and procedures--
                    (A) to support State efforts to coordinate and 
                align acute and long-term care benefits for dual 
                eligibles through a State plan option or other means;
                    (B) to provide support for coordination of State 
                and Federal contracting and oversight for dual 
                integration programs supportive of the goals described 
                in paragraph (1); and
                    (C) to align Federal rules for Medicaid managed 
                care and Medicare Advantage Plans to include methods 
                for integrating marketing, enrollment, grievances and 
                appeals, auditing, reporting, quality assurance and 
                other relevant oversight functions.
    (c) Facilitation of Alignment.--The Secretary shall--
            (1) submit to Congress a report on statutory changes needed 
        to facilitate the alignment of Medicare and Medicaid policies 
        for dual eligibles;
            (2) work with the Congressional Budget Office and the 
        Office of Management and Budget to establish a process for 
        evaluating total Medicare and Medicaid spending for 
        beneficiaries who are dually eligible for Medicare and Medicaid 
        and enrolled in plans that integrate Medicare and Medicaid 
        benefits such that the enrollment of such beneficiaries in such 
        plans is treated as ``budget neutral'' if the combined Medicare 
        and Medicaid costs under such plans do not exceed the combined 
        costs of providing Medicare and Medicaid services on a fee-for-
        service basis for a comparable risk group; and
            (3) provide States and SNPs with education and tools for 
        developing programs that align Medicare and Medicaid benefits 
        for dual eligibles.
    (d) Identification of Incentives in Support of State Integration 
Efforts.--The Secretary shall identify incentives for States to advance 
the development of integrated approaches in providing health care 
services for dual eligibles.
    (e) Definitions.--In this section:
            (1) CMS.--The term ``CMS'' means the Centers for Medicare & 
        Medicaid Services.
            (2) Dual eligible.--The term ``dual eligible'' means an MA 
        eligible individual (as defined in section 1851(a)(3) of the 
        Social Security Act, 42 U.S.C. 13195w-21(a)(3)) who is also 
        entitled to medical assistance under a State plan under title 
        XIX of the Social Security Act.
            (3) Dual eligible snp.--The term ``dual eligible SNP'' 
        means a SNP described in section 1859(b)(6)(A)(ii)(II) of the 
        Social Security Act, as amended by section 3(a).
            (4) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.
            (5) SNP.--The term ``SNP'' means a specialized MA plan for 
        special needs individuals, as defined in section 1859(b)(6)(A) 
        of the Social Security Act (42 U.S.C. 1395w-28(b)(6)(A)).
            (6) State.--The term ``State'' has the meaning given such 
        term for purposes of title XIX of the Social Security Act.
                                 <all>