1.Short title; table of
contents
(a)This Act may be cited
as the Medicare Specialty Care
Improvement and Protection Act of 2009
.
(b)The table of contents of this Act is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Extension of SNP authority.
Sec. 3. Improve risk adjustment for high-risk, high-cost
beneficiaries.
Sec. 4. Additional enhancements to ensure payment equity for
specialized MA plans.
Sec. 5. Advance alignment of Medicare and Medicaid for dual
eligibles.
Sec. 6. Medicaid presumptive eligibility option.
Sec. 7. Extension of prescription drug discounts to enrollees
of Medicaid managed care organizations.
Sec. 8. Definitions.
2.Extension of SNP
authoritySection 1859(f)(1)
of the Social Security Act (42 U.S.C. 1395w–28(f)(1)), as amended by section
164(a) of the Medicare Improvements for Patients and Providers Act of 2008
(Public Law 110–275), is amended—
(1)by striking 2011
and
inserting 2014
; and
(2)by adding at the
end the following new sentence: In the case of a specialized MA plan for
special needs individuals that is designated as a Fully Integrated Dual
Eligible Special Needs Plan under section 5(a)(1) of the
Medicare Specialty Care Improvement and
Protection Act of 2009, the preceding sentence shall be applied
by substituting 2016
for 2014
.
.
3.Improve risk
adjustment for high-risk, high-cost beneficiaries
(a)
(1)The Secretary shall
evaluate the Medicare Advantage risk adjustment payment mechanism under section
1853(a)(1)(C) of the Social Security Act (42 U.S.C. 1395w–23(a)(1)(C)) and the
risk adjustment payment mechanism under section 1860D–15(c)(1)(A) of such Act
(42 U.S.C. 1395w–115(c)(1)(A)) in order to resolve plan payment inequities
relative to Medicare fee-for-service payments for beneficiaries identified
under paragraph (2).
(2)The evaluation conducted under paragraph
(1) shall address the need for improving the adequacy of the existing
hierarchical condition categories and pharmacy risk adjustment methods for
Medicare Advantage plans that exclusively or disproportionately serve high-risk
beneficiaries as it relates to—
(A)accurately
predicting costs relative to Medicare fee-for-service for beneficiaries
with—
(i)sustained
high-risk scores over multiple contract periods;
(ii)sustained high
costs over multiple contract periods;
(iii)co-morbid chronic
conditions;
(iv)diagnoses not included in the
risk-adjustment methodology, including dementia and other cognitive
impairments;
(v)physical
disabilities, developmental disabilities, or both; and
(vi)frailty;
(B)accurately
predicting costs relative to Medicare fee-for-service for beneficiaries near
the end of life;
(C)accurately
predicting costs relative to Medicare fee-for-service for other conditions for
which the current risk adjustment methodology underpays in relation to Medicare
fee-for-service, as determined by the Secretary;
(D)further gradations
of diseases and conditions to better reflect stage of condition, condition
severity, and costs related to burden of illness;
(E)accounting for
costs of pre-existing conditions at the time of initial enrollment for new
entrants into Medicare; and
(F)enhancing coding
persistency by calculating risk scores using data covering at least 2
years.
(b)Use of the
results of the study for refinements
(1)
(A)Beginning with plan
year 2011, the Secretary, using the results of the evaluation conducted under
subsection (a)(1), shall refine the risk adjustment payment mechanisms referred
to in subsection (a)(1) for beneficiaries identified under subsection (a)(2).
The Secretary shall make additional refinements, as appropriate, for subsequent
plan years.
(B)To
the extent that the Secretary determines that the risk adjustment payment
mechanisms referred to in subsection (a)(1) do not accurately pay for Medicare
beneficiaries identified under subsection (a)(2), the Secretary shall ensure
that a Medicare Advantage plan that exclusively or disproportionately serves
high-risk beneficiaries is not paid less, in the aggregate, than 100 percent of
Medicare fee-for-service payment rates (as determined under section
1853(c)(1)(D)(i)).
(C)Beginning
with plan year 2011, the Secretary shall recalibrate the risk adjustment
payment mechanisms referred to in subsection (a)(1) so that the overall
predicted costs for all Medicare beneficiaries are identical to what they would
have been in the absence of the new risk adjustment payment mechanism.
(2)Budget neutral
adjustmentsIf the Secretary determines that the application of
paragraph (1) results in expenditures under title XVIII of the Social Security
Act that exceed the expenditures under such title that would have been made
without such application, the Secretary shall provide for an appropriate
adjustment to payment rates under part C of such title for beneficiaries for
whom the risk adjustment payment mechanism overpays in relation to Medicare
fee-for-service in order to eliminate such excess.
4.Additional
enhancements to ensure payment equity for specialized MA plans
(a)Accounting for
added regulatory costsFor plan year 2011 and subsequent plan
years, the Secretary shall provide bonus payments to account for added SNP
costs associated with additional benefit, care management, reporting, and other
requirements established by Congress and the Secretary in excess of other
Medicare Advantage plans.
(b)Ensuring fair
bidding practicesFor plan year 2011 and subsequent plan years,
the Secretary shall take into account the following factors with respect to the
bid structure for SNPs:
(1)Dual
eligibility.
(2)Geographic cost
differences.
(3)Population
characteristics.
(4)The differences
in plan requirements, including differences in additional benefits, care
management, and reporting requirements.
(5)The differences
between community-based and regional or nationally based plans.
(c)Authority To
apply PACE rulesFor plan year 2011 and subsequent plan years,
the Secretary may apply the payment rules under section 1894(d) of the Social
Security Act (42 U.S.C. 1395eee(d)) to Fully Integrated Dual Eligible Special
Needs Plans rather than the payment rules that would otherwise apply to such
plans under part C.
(d)Budget neutral
adjustmentsIf the Secretary determines that the application of
subsections (a), (b), and (c) result in expenditures under title XVIII of the
Social Security Act that exceed the expenditures under such title that would
have been made without such application, the Secretary shall provide for an
appropriate adjustment to payment rates under part C of such title for
beneficiaries for whom the risk adjustment payment mechanism overpays in
relation to Medicare fee-for-service in order to eliminate such excess.
5.Advance
alignment of Medicare and Medicaid for dual eligibles
(a)Medicare and
Medicaid integration programs
(1)
(A)For plan year 2011 and subsequent plan years, the
Secretary shall have in place a process under which the Secretary designates
dual eligible SNPs as Fully Integrated Dual Eligible Special Needs Plans for
the purpose of advancing fully integrated Medicare and Medicaid benefits and
services for dual beneficiaries, including State designated Dual
subsets.
(B)In order to be designated as a Fully Integrated Dual
Eligible Special Needs Plan, the dual eligible SNP shall meet the following
requirements:
(i)The
dual eligible SNP provides dual eligibles with access to Medicare and Medicaid
benefits specified by the State for Medicaid beneficiaries enrolled in
integrated programs under a single managed care organization (MCO).
(ii)The dual
eligible SNP has a contract in place with a State Medicaid agency that includes
coverage of specified primary, acute, and long-term care benefits and services,
consistent with State policy, under risk-based financing.
(iii)The dual
eligible SNP coordinates the delivery of covered Medicare and Medicaid health
and long-term care services, consistent with State policy, using aligned care
management and specialty care network methods for high-risk
beneficiaries.
(iv)The dual
eligible SNP employs policies and procedures approved by the Secretary and the
State to coordinate or integrate enrollment, member materials, communications,
grievance and appeals, and quality assurance.
(v)The dual eligible
SNP provides advanced person-centered, integrated care for the full array of
primary, acute, and residential and home and community-based long-term care
services, using a robust advanced medical home model that—
(I)empowers dual
eligibles with serious chronic conditions and their family caregivers to
optimize their health and well-being;
(II)provides a
comprehensive array of patient-centered benefits and services designed to meet
the unique needs of dual eligibles;
(III)helps dual
eligibles and their family caregivers to access the right care, at the right
time, in the right place, given the nature of their condition;
(IV)aligns the
incentives of related care providers to improve transitions and care
continuity; and
(V)optimizes total
quality and cost performance across time, place, and profession.
(2)In order to increase simplicity for dual eligibles in
accessing and coordinating Medicare and Medicaid benefits, the Secretary,
working in conjunction with States, on a State by State basis, consistent with
existing statutory authority, is encouraged to establish a single
administrative structure and process under titles XVIII and XIX for Fully
Integrated Dual Eligible Special Needs Plans, under a three-way contract or
Memorandum of Understanding, among CMS, the State, and related plans,
for—
(A)the enrollment of
dual eligibles;
(B)member materials
and related communications;
(C)care management
and model of care requirements;
(D)reporting,
auditing, and performance evaluation;
(E)grievance and
appeals procedures; and
(F)payment
methods.
(3)Alignment of
Medicare and Medicaid policies and procedures for SNPs serving dual
eligiblesIn 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, working in collaboration with State Medicaid agencies, 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.
(4)
(A)Not later than December 31, 2013, the Secretary shall
submit to Congress an interim report on the impact of integrating Medicare and
Medicaid benefits and services on total quality and cost performance in serving
dual eligibles.
(B)Not later than December 31, 2015, the Secretary shall
submit to Congress a final report on the impact of integrating Medicare and
Medicaid benefits and services on total quality and cost performance in serving
dual eligibles.
(C)A
report under subparagraph (A) and (B) shall include recommendations for such
legislative and administrative actions as the Secretary determines appropriate
to further advance Medicare and Medicaid integration, including options for
integrating Medicare and Medicaid funding, to facilitate ongoing improvements
in total quality and cost performance in care of dual eligibles.
(D)Quality and
cost performanceNot later than 6 months after the date of the
enactment of this Act, the Secretary, working in consultation with consumers,
plans, and States, shall identify the measures and benchmarks to be used for
evaluating cost and quality performance for purposes of subparagraph
(C).
(b)Office of
Medicare/Medicaid Integration
(1)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 to—
(A)simplify dual eligible access to Medicare
and Medicaid benefits and services;
(B)improve care
continuity and ensure safe and effective care transitions;
(C)eliminate cost
shifting between Medicare and Medicaid and among related care providers;
(D)eliminate
regulatory conflicts between Medicare and Medicaid rules; and
(E)improve total cost
and quality performance.
(2)The responsibilities of the Office are to
develop policies and procedures to—
(A)oversee the
designation, implementation, and oversight of Fully Integrated Dual Eligible
Special Needs Plans under subsection (a)(1) in collaboration with the States,
with authority to effectively align Medicare and Medicaid policy for dual
eligibles;
(B)provide State
Medicaid agencies with training, materials, technical assistance, and other
resources in support of advancing Medicare and Medicaid integration in States
where Fully Integrated Dual Eligible Special Needs Plans have been designated
and other integration initiatives are being advanced to coordinate and align
primary, acute, and long-term care benefits for dual eligibles through a State
plan option or other means;
(C)identify
incentives for States to advance the integration of Medicare and Medicaid to
improve total cost and quality performance, including shared cost savings among
consumers, plans, and Federal and State governments with respect to State
initiatives for advancing Medicare and Medicaid integration;
(D)support State efforts to coordinate and
align acute and long-term care benefits for dual eligibles through a State plan
option or other means;
(E)provide support for
coordination of State and Federal contracting and oversight for dual
integration programs supportive of the goals described in paragraph (1);
(F)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;
(G)serve as a
liaison between CMS central and regional offices to ensure consistent
application of CMS rules, policies, and auditing practices as such rules,
policies, and auditing practices pertain to dual eligibles;
(H)monitor total
combined Medicare and Medicaid costs in serving dual eligibles and make
recommendations for optimizing total quality and cost performance across both
programs; and
(I)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
dual eligibles who are enrolled in Fully Integrated Dual Eligible Special Needs
Plans such that the enrollment of such dual eligibles 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.
(3)
(A)For purposes of funding for the Office, there shall be
made available for each of fiscal years 2010 through 2014, $2,000,000 from the
savings described in subparagraph (B).
(B)The
savings described in this subparagraph are the average per capita savings
described in paragraphs (3)(C) and (4)(C) of section 1854(b) for which monthly
rebates are provided under section 1854(b)(1)(C) in the fiscal year
involved.
(C)Funds
made available under this paragraph shall be transferred to the Secretary from
the Federal Hospital Insurance Trust Fund under section 1817 of the Social
Security Act (42 U.S.C. 1395i) and the Federal Supplementary Insurance Trust
Fund under section 1841 of such Act (42 U.S.C. 1395t) in the proportion
specified in section 1853(f) of such Act (42 U.S.C. 1395w–23(f)).
6.Medicaid
presumptive eligibility option
(a)Section 1902(e) of
the Social Security Act (42 U.S.C. 1396a(e)) is amended by adding at the end
the following:
(14)At the option of the State, the plan
may provide for a period of presumptive eligibility for an individual who has
attained age 65, who has 12 or more consecutive months of eligibility under
this title, and who the State has reason to believe will be determined to be a
full-benefit dual eligible individual (as defined in section 1935(c)(6)), but
only if the State—
(A)agrees to randomly conducted
eligibility audits by the Secretary; and
(B)ensures that any individual enrolled
under the State plan who is determined to be ineligible for medical assistance
as a result of such an audit (and, if such individual is enrolled in a
specialized MA plan for special needs individuals under part C of title XVIII,
ensures that the organization offering such plan) is notified at least 30 days
prior to the date on which the individual is disenrolled from the State
plan.
.
(b)The amendment made by
subsection (a) takes effect on January 1, 2010.
7.Extension of
prescription drug discounts to enrollees of Medicaid managed care
organizations
(a)Section 1903(m)(2)(A) of the Social Security Act (42
U.S.C. 1396b(m)(2)(A)) is amended—
(1)in clause (xi),
by striking and
at the end;
(2)in clause (xii),
by striking the period at the end and inserting ; and
;
and
(3)by adding at the
end the following:
(xiii)such contract
provides that (I) payment for covered outpatient drugs dispensed to individuals
eligible for medical assistance who are enrolled with the entity shall be
subject to the same rebate required by the agreement entered into under section
1927 as the State is subject to, and (II) capitation rates paid to the entity
shall be based on actual cost experience related to rebates and subject to the
Federal regulations requiring actuarially sound
rates.
.
(b)Section 1927 of the Social Security Act (42 U.S.C.
1396r–8) is amended—
(1)in subsection
(d)—
(A)in paragraph (1),
by adding at the end the following:
(C)Notwithstanding
the subparagraphs (A) and (B)—
(i)a
Medicaid managed care organization with a contract under section 1903(m) may
exclude or otherwise restrict coverage of a covered outpatient drug on the
basis of policies or practices of the organization, such as those affecting
utilization management, formulary adherence, and cost sharing or dispute
resolution, in lieu of any State policies or practices relating to the
exclusion or restriction of coverage of such drugs, provided, however, that any
such exclusions and restrictions of coverage shall be subject to any
contractual requirements and oversight by the State as contained in the
Medicaid managed care organization's contract with the State, and the State
shall maintain approval authority over the formulary used by the Medicaid
managed care organization; and
(ii)nothing in this
section or paragraph (2)(A)(xiii) of section 1903(m) shall be construed as
requiring a Medicaid managed care organization with a contract under such
section to maintain the same such policies and practices as those established
by the State for purposes of individuals who receive medical assistance for
covered outpatient drugs on a fee-for-service
basis.
;
and
(B)in paragraph (4),
by inserting after subparagraph (E) the following:
(F)Notwithstanding
the preceding subparagraphs of this paragraph, any formulary established by
Medicaid managed care organization with a contract under section 1903(m) may be
based on positive inclusion of drugs selected by a formulary committee
consisting of physicians, pharmacists, and other individuals with appropriate
clinical experience as long as drugs excluded from the formulary are available
through prior authorization, as described in paragraph
(5).
;
and
(2)in subsection
(j), by striking paragraph (1) and inserting the following:
(1)Covered
outpatients drugs are not subject to the requirements of this section if such
drugs are—
(A)dispensed by
health maintenance organizations, including Medicaid managed care organizations
that contract under section 1903(m); and
(B)subject to
discounts under section 340B of the Public Health Service
Act.
.
(c)Each
State with a contract with a Medicaid managed care organization under section
1903(m) of the Social Security Act (42 U.S.C. 1396b(m)) shall report to the
Secretary on a quarterly basis the total amount of rebates in dollars and
volume received from manufacturers (as defined in section 1927(k)(5) of such
Act (42 U.S.C. 1396r–8(k)(5)) for drugs provided to individuals enrolled with
such an organization as a result of the amendments made by this section for
both brand-name and generic drugs. The Secretary shall review the reports
submitted by States under this subsection and, after such review, make
publically available the aggregate data contained in such reports.
(d)This section and the amendments made by this section take
effect on the date of enactment of this Act and apply to rebate agreements
entered into or renewed under section 1927 of the Social Security Act (42
U.S.C. 1396r–8) on or after such date.
8.In this Act:
(1)The
term CMS means the Centers for Medicare & Medicaid
Services.
(2)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)The term dual
eligible SNP means a SNP described in section 1859(b)(6)(A)(ii) of the
Social Security Act.
(4)The
term Medicaid
means the program under title XIX of the Social
Security Act.
(5)The
term Medicare
means the program under title XVIII of the Social
Security Act.
(6)The term Medicare fee-for-service
means the original Medicare fee-for-service program under parts A and B of
title XVIII of the Social Security Act.
(7)The
term Secretary means the Secretary of Health and Human
Services.
(8)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)).
(9)The term State has the meaning
given such term for purposes of title XIX of the Social Security Act.