[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3168 Introduced in House (IH)]

<DOC>






115th CONGRESS
  1st Session
                                H. R. 3168

 To amend title XVIII of the Social Security Act to provide continued 
   access to specialized Medicare Advantage plans for special needs 
                  individuals, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                              July 6, 2017

 Mr. Tiberi (for himself and Mr. Levin) 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 continued 
   access to specialized Medicare Advantage plans for special needs 
                  individuals, 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. SPECIALIZED MEDICARE ADVANTAGE PLANS FOR SPECIAL NEEDS 
              INDIVIDUALS.

    (a) Extension.--Section 1859(f)(1) of the Social Security Act (42 
U.S.C. 1395w-28(f)(1)) is amended--
            (1) by striking ``and for periods before January 1, 2019''; 
        and
            (2) by adding at the end the following new sentence: ``In 
        the case of a specialized MA plan for special needs individuals 
        described in clause (ii) or (iii) of subsection (b)(6)(B), the 
        previous sentence shall apply for periods before January 1, 
        2024.''.
    (b) Increased Integration of Dual SNPs.--
            (1) In general.--Section 1859(f) of the Social Security Act 
        (42 U.S.C. 1395w-28(f)) is amended--
                    (A) in paragraph (3), by adding at the end the 
                following new subparagraph:
                    ``(F) The plan meets the requirements applicable 
                under paragraph (8).''; and
                    (B) by adding at the end the following new 
                paragraph:
            ``(8) Increased integration of dual snps.--
                    ``(A) Designated contact.--The Secretary, acting 
                through the Federal Coordinated Health Care Office 
                established under section 2602 of Public Law 111-148, 
                shall serve as a dedicated point of contact for States 
                to address misalignments that arise with the 
                integration of specialized MA plans for special needs 
                individuals described in subsection (b)(6)(B)(ii) under 
                this paragraph and, consistent with such role, shall--
                            ``(i) establish a uniform process for 
                        disseminating to State Medicaid agencies 
                        information under this title impacting 
                        contracts between such agencies and such plans 
                        under this subsection; and
                            ``(ii) establish basic resources for States 
                        interested in exploring such plans as a 
                        platform for integration, such as a model 
                        contract or other tools to achieve those goals.
                    ``(B) Unified grievances and appeals process.--
                            ``(i) In general.--Not later than April 1, 
                        2020, the Secretary shall establish procedures, 
                        to the extent feasible as determined by the 
                        Secretary, unifying grievances and appeals 
                        procedures under sections 1852(f), 1852(g), 
                        1902(a)(3), 1902(a)(5), and 1932(b)(4) for 
                        items and services provided by specialized MA 
                        plans for special needs individuals described 
                        in subsection (b)(6)(B)(ii) under this title 
                        and title XIX. The Secretary shall solicit 
                        comment in developing such procedures from 
                        States, plans, beneficiaries and their 
                        representatives, and other relevant 
                        stakeholders. With respect to items and 
                        services described in the previous sentence, 
                        appeals procedures established under this 
                        clause shall apply in place of otherwise 
                        applicable appeals procedures.
                            ``(ii) Procedures.--The procedures 
                        established under clause (i) shall be included 
                        in the plan contract under paragraph (3)(D) and 
                        shall--
                                    ``(I) adopt the provisions for the 
                                enrollee that are most protective for 
                                the enrollee and, to the extent 
                                feasible as determined by the 
                                Secretary, are compatible with unified 
                                timeframes and consolidated access to 
                                external review under an integrated 
                                process;
                                    ``(II) take into account 
                                differences in State plans under title 
                                XIX to the extent necessary;
                                    ``(III) be easily navigable by an 
                                enrollee; and
                                    ``(IV) include the elements 
                                described in clause (iii), as 
                                applicable.
                            ``(iii) Elements described.--Both unified 
                        appeals and unified grievance procedures shall 
                        include, as applicable, the following elements 
                        described in this clause:
                                    ``(I) Single written notification 
                                of all applicable grievances and appeal 
                                rights under this title and title XIX. 
                                For purposes of this subparagraph, the 
                                Secretary may waive the requirements 
                                under section 1852(g)(1)(B) when the 
                                specialized MA plan covers items or 
                                services under this part or under title 
                                XIX.
                                    ``(II) Single pathways for 
                                resolution of any grievance or appeal 
                                related to a particular item or service 
                                provided by specialized MA plans for 
                                special needs individuals described in 
                                subsection (b)(6)(B)(ii) under this 
                                title and title XIX.
                                    ``(III) Notices written in plain 
                                language and available in a language 
                                and format that is accessible to the 
                                enrollee, including in non-English 
                                languages that are prevalent in the 
                                service area of the specialized MA 
                                plan.
                                    ``(IV) Unified timeframes for 
                                grievances and appeals processes, such 
                                as an individual's filing of a 
                                grievance or appeal, a plan's 
                                acknowledgment and resolution of a 
                                grievance or appeal, and notification 
                                of decisions with respect to a 
                                grievance or appeal.
                                    ``(V) Requirements for how the plan 
                                must process, track, and resolve 
                                grievances and appeals, to ensure 
                                beneficiaries are notified on a timely 
                                basis of decisions that are made 
                                throughout the grievance or appeals 
                                process and are able to easily 
                                determine the status of a grievance or 
                                appeal.
                            ``(iv) Continuation of benefits pending 
                        appeal.--The unified procedures under clause 
                        (i) shall, with respect to all benefits under 
                        parts A and B and title XIX subject to appeal 
                        under such procedures, incorporate provisions 
                        under current law and implementing regulations 
                        that provide continuation of benefits pending 
                        appeal under this title and title XIX.
                    ``(C) Requirement for unified grievances and 
                appeals.--For 2022 and subsequent years, the contract 
                of a specialized MA plan for special needs individuals 
                described in subsection (b)(6)(B)(ii) with a State 
                Medicaid agency under paragraph (3)(D) shall require 
                the use of unified grievances and appeals procedures as 
                described in subparagraph (B).
                    ``(D) Requirements for full integration for certain 
                dual snps.--
                            ``(i) Requirement.--For 2022 and subsequent 
                        years, a specialized MA plan for special needs 
                        individuals described in subsection 
                        (b)(6)(B)(ii) shall meet one or more of the 
                        following requirements, to the extent allowed 
                        by the State, for integration of benefits under 
                        this title and title XIX:
                                    ``(I) Meet the requirements of a 
                                fully integrated plan described in 
                                section 1853(a)(1)(B)(iv)(II) (other 
                                than the requirement that the plan have 
                                similar average levels of frailty, as 
                                determined by the Secretary, as the 
                                PACE program).
                                    ``(II) Enter into a capitated 
                                contract with the State Medicaid agency 
                                to provide long-term services and 
                                supports or behavioral health services, 
                                or both.
                                    ``(III) Enter into any other type 
                                of arrangement, as determined 
                                appropriate by the Secretary.
                            ``(ii) Sanctions.--For 2022 and subsequent 
                        years, if the Secretary determines that a 
                        specialized MA plan fails to comply with clause 
                        (i), the Secretary may provide for the 
                        application against the Medicare Advantage 
                        organization offering the plan any of the 
                        remedies described in section 1857(g)(2).''.
            (2) Conforming amendment to responsibilities of federal 
        coordinated health care office.--Section 2602(d) of Public Law 
        111-148 (42 U.S.C. 1315b(d)) is amended by adding at the end 
        the following new paragraphs:
            ``(6) To act as a designated contact for States under 
        subsection (f)(8)(A) of section 1859 of the Social Security Act 
        (42 U.S.C. 1395w-28) with respect to the integration of 
        specialized MA plans for special needs individuals described in 
        subsection (b)(6)(B)(ii) of such section.
            ``(7) To be responsible for developing regulations and 
        guidance related to the implementation of a unified grievance 
        and appeals process as described in subparagraphs (B) and (C) 
        of section 1859(f)(8) of the Social Security Act (42 U.S.C. 
        1395w-28(f)(8)).
            ``(8) To be responsible for developing regulations and 
        guidance related to the integration or alignment of policy and 
        oversight under the Medicare program under title XVIII of such 
        Act and Medicaid program under title XIX of such Act regarding 
        specialized MA plans for special needs individuals described in 
        subsection (b)(6)(B)(ii) of such section 1859.''.
    (c) Improvements to Severe or Disabling Chronic Condition SNPs.--
            (1) Care management requirements.--Section 1859(f)(5) of 
        the Social Security Act (42 U.S.C. 1395w-28(f)(5)) is amended--
                    (A) by redesignating subparagraphs (A) and (B) as 
                clauses (i) and (ii), respectively, and indenting 
                appropriately;
                    (B) in clause (ii), as redesignated by subparagraph 
                (B), by redesignating clauses (i) through (iii) as 
                subclauses (I) through (III), respectively, and 
                indenting appropriately;
                    (C) by striking ``all snps.--The requirements'' and 
                inserting ``all snps.--
                    ``(A) In general.--Subject to subparagraph (B), the 
                requirements''; and
                    (D) by adding at the end the following new 
                subparagraph:
                    ``(B) Improvements to care management requirements 
                for severe or disabling chronic condition snps.--For 
                2020 and subsequent years, in the case of a specialized 
                MA plan for special needs individuals described in 
                subsection (b)(6)(B)(iii), the requirements described 
                in this paragraph include the following:
                            ``(i) The interdisciplinary team under 
                        subparagraph (A)(ii)(III) includes a team of 
                        providers with demonstrated expertise, 
                        including training in an applicable specialty, 
                        in treating individuals similar to the targeted 
                        population of the plan.
                            ``(ii) Requirements developed by the 
                        Secretary to provide face-to-face encounters 
                        with individuals enrolled in the plan not less 
                        frequently than on an annual basis.
                            ``(iii) As part of the model of care under 
                        clause (i) of subparagraph (A), the results of 
                        the initial assessment and annual reassessment 
                        under clause (ii)(I) of such subparagraph of 
                        each individual enrolled in the plan are 
                        addressed in the individual's individualized 
                        care plan under clause (ii)(II) of such 
                        subparagraph.
                            ``(iv) As part of the annual evaluation and 
                        approval of such model of care, the Secretary 
                        shall take into account whether the plan 
                        fulfilled the previous year's goals (as 
                        required under the model of care).
                            ``(v) The Secretary shall establish a 
                        minimum benchmark for each element of the model 
                        of care of a plan. The Secretary shall only 
                        approve a plan's model of care under this 
                        paragraph if each element of the model of care 
                        meets the minimum benchmark applicable under 
                        the preceding sentence.''.
            (2) Revisions to the definition of a severe or disabling 
        chronic conditions specialized needs individual.--
                    (A) In general.--Section 1859(b)(6)(B)(iii) of the 
                Social Security Act (42 U.S.C. 1395w-28(b)(6)(B)(iii)) 
                is amended--
                            (i) by striking ``who have'' and inserting 
                        ``who--
                                    ``(I) before January 1, 2022, 
                                have'';
                            (ii) in subclause (I), as added by clause 
                        (i), by striking the period at the end and 
                        inserting ``; and''; and
                            (iii) by adding at the end the following 
                        new subclause:
                                    ``(II) on or after January 1, 2022, 
                                have one or more comorbid and medically 
                                complex chronic conditions that is life 
                                threatening or significantly limits 
                                overall health or function, have a high 
                                risk of hospitalization or other 
                                adverse health outcomes, and require 
                                intensive care coordination and that is 
                                listed under subsection (f)(9)(A).''.
                    (B) Panel of clinical advisors.--Section 1859(f) of 
                the Social Security Act (42 U.S.C. 1395w-28(f)), as 
                amended by subsection (b), is amended by adding at the 
                end the following new paragraph:
            ``(9) List of conditions for clarification of the 
        definition of a severe or disabling chronic conditions 
        specialized needs individual.--
                    ``(A) In general.--Not later than December 31, 
                2020, and every 5 years thereafter, the Secretary shall 
                convene a panel of clinical advisors to establish and 
                update a list of conditions that meet each of the 
                following criteria:
                            ``(i) Conditions that meet the definition 
                        of a severe or disabling chronic condition 
                        under subsection (b)(6)(B)(iii) on or after 
                        January 1, 2022.
                            ``(ii) Conditions that require prescription 
                        drugs, providers, and models of care that are 
                        unique to the specific population of enrollees 
                        in a specialized MA plan for special needs 
                        individuals described in such subsection on or 
                        after such date and--
                                    ``(I) as a result of such special 
                                needs individuals with such a condition 
                                having access to and being enrolled in 
                                such a plan, as compared to access to 
                                and enrollment in other Medicare 
                                Advantage plans under this part, it is 
                                projected that such individuals would 
                                improve health outcomes with respect to 
                                such condition, that such individuals 
                                would have reduced overall costs under 
                                this title, and that there would not be 
                                any increase in expenditures under this 
                                title for such individuals; or
                                    ``(II) have a low prevalence in the 
                                general population of beneficiaries 
                                under this title or a disproportionally 
                                high per-beneficiary cost under this 
                                title.
                    ``(B) GAO study on health outcomes of individuals 
                enrolled in specialized ma plans.--Not later than the 
                date that is 3 years after the date of the enactment of 
                this paragraph, the Comptroller General of the United 
                States shall conduct a study and submit to Congress a 
                report on the extent to which health outcomes can be 
                compared across specialized MA plans for special needs 
                individuals (as defined in section 1859(b)(6)) and 
                other Medicare Advantage plans under this part across 
                similar populations, using existing measures and that 
                identifies any potential limitations where new measures 
                may need to be developed for such population.''.
    (d) Quality Measurement at the Plan Level for SNPs and 
Determination of Feasability of Quality Measurement at the Plan Level 
for All MA Plans.--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 
paragraphs:
            ``(6) Quality measurement at the plan level for snps.--
                    ``(A) In general.--Subject to subparagraph (B), the 
                Secretary may require reporting of data under section 
                1852(e) for, and apply under this subsection, quality 
                measures at the plan level for specialized MA plans for 
                special needs individuals instead of at the contract 
                level.
                    ``(B) Considerations.--Prior to applying quality 
                measurement at the plan level under this paragraph, the 
                Secretary shall--
                            ``(i) take into consideration the minimum 
                        number of enrollees in a specialized MA plan 
                        for special needs individuals in order to 
                        determine if a statistically significant or 
                        valid measurement of quality at the plan level 
                        is possible under this paragraph;
                            ``(ii) if quality measures are reported at 
                        the plan level, ensure that MA plans are not 
                        required to provide duplicative information; 
                        and
                            ``(iii) ensure that such reporting does not 
                        interfere with the collection of encounter data 
                        submitted by MA organizations or the 
                        administration of any changes to the program 
                        under this part as a result of the collection 
                        of such data.
                    ``(C) Application.--If the Secretary applies 
                quality measurement at the plan level under this 
                paragraph--
                            ``(i) such quality measurement may include 
                        Medicare Health Outcomes Survey (HOS), 
                        Healthcare Effectiveness Data and Information 
                        Set (HEDIS), Consumer Assessment of Healthcare 
                        Providers and Systems (CAHPS) measures and 
                        quality measures under part D; and
                            ``(ii) the Secretary shall consider 
                        applying administrative actions, such as 
                        remedies described in section 1857(g)(2), to 
                        the plan level.
            ``(7) Determination of feasibility of quality measurement 
        at the plan level for all ma plans.--
                    ``(A) Determination of feasibility.--The Secretary 
                shall determine the feasibility of requiring reporting 
                of data under section 1852(e) for, and applying under 
                this subsection, quality measures at the plan level for 
                all MA plans under this part.
                    ``(B) Consideration of change.--After making a 
                determination under subparagraph (A), the Secretary 
                shall consider requiring such reporting and applying 
                such quality measures at the plan level as described in 
                such subparagraph.''.
    (e) GAO Study and Report on State-Level Integration Between Dual 
SNPs and Medicaid.--
            (1) Study.--The Comptroller General of the United States 
        (in this paragraph referred to as the ``Comptroller General'') 
        shall conduct a study on State-level integration between 
        specialized MA plans for special needs individuals described in 
        subsection (b)(6)(B)(ii) of section 1859 of the Social Security 
        Act (42 U.S.C. 1395w-28) and the Medicaid program under title 
        XIX of such Act (42 U.S.C. 1396 et seq.). Such study shall 
        include an analysis of the following:
                    (A) The characteristics of States in which the 
                State agency responsible for administering the State 
                plan under such title XIX has a contract with such a 
                specialized MA plan and that delivers long-term 
                services and supports under the State plan under such 
                title XIX through a managed care program, including the 
                requirements under such State plan with respect to 
                long-term services and supports.
                    (B) The types of such specialized MA plans, which 
                may include the following:
                            (i) A plan described in section 
                        1853(a)(1)(B)(iv)(II) of such Act (42 U.S.C. 
                        1395w-23(a)(1)(B)(iv)(II)).
                            (ii) A plan that meets the requirements 
                        described in subsection (f)(3)(D) of such 
                        section 1859.
                            (iii) A plan described in clause (ii) that 
                        also meets additional requirements established 
                        by the State.
                    (C) The characteristics of individuals enrolled in 
                such specialized MA plans.
                    (D) As practicable, the following with respect to 
                State programs for the delivery of long-term services 
                and supports under such title XIX through a managed 
                care program:
                            (i) Which populations of individuals are 
                        eligible to receive such services and supports.
                            (ii) Whether all such services and supports 
                        are provided on a capitated basis or if any of 
                        such services and supports are carved out and 
                        provided through fee-for-service.
                    (E) As, practicable, how the availability and 
                variation of integration arrangements of such 
                specialized MA plans offered in States affects 
                spending, service delivery options, access to 
                community-based care, and utilization of care.
                    (F) Barriers and opportunities for making further 
                progress on dual integration, as well as recommend 
                legislation to expedite or refine pathways toward fully 
                integrated care.
            (2) Report.--Not later than 2 years after the date of the 
        enactment of this Act, the Comptroller General shall submit to 
        Congress a report containing the results of the study conducted 
        under paragraph (1), together with recommendations for such 
        legislation and administrative action as the Comptroller 
        General determines appropriate.

SEC. 2. EXPANDING SUPPLEMENTAL BENEFITS TO MEET THE NEEDS OF 
              CHRONICALLY ILL MEDICARE ADVANTAGE ENROLLEES.

    (a) In General.--Section 1852(a)(3) of the Social Security Act (42 
U.S.C. 1395w-22(a)(3)) is amended--
            (1) in subparagraph (A), by striking ``Each'' and inserting 
        ``Subject to subparagraph (D), each''; and
            (2) by adding at the end the following new subparagraph:
                    ``(D) Expanding supplemental benefits to meet the 
                needs of chronically ill enrollees.--
                            ``(i) In general.--For plan year 2020 and 
                        subsequent plan years, in addition to any 
                        supplemental health care benefits otherwise 
                        provided under this paragraph, an MA plan, 
                        including a specialized MA plan for special 
                        needs individuals described in subsection 
                        (b)(6) of section 1859, may provide 
                        supplemental benefits described in clause (ii) 
                        to a chronically ill enrollee (as defined in 
                        clause (iii)).
                            ``(ii) Supplemental benefits described.--
                                    ``(I) In general.--Supplemental 
                                benefits described in this clause are 
                                supplemental benefits that, with 
                                respect to a chronically ill enrollee, 
                                have a reasonable expectation of 
                                improving or maintaining the health or 
                                overall function of the chronically ill 
                                enrollee and may not be limited to 
                                being primarily health related 
                                benefits.
                                    ``(II) Authority to waive 
                                uniformity requirements.--The Secretary 
                                may, with respect to supplemental 
                                benefits provided to a chronically ill 
                                enrollee under this subparagraph, waive 
                                the uniformity requirement, as 
                                determined appropriate by the 
                                Secretary.
                            ``(iii) Chronically ill enrollee defined.--
                        In this subparagraph, the term `chronically ill 
                        enrollee' means an enrollee in an MA plan that 
                        the Secretary determines--
                                    ``(I) has one or more comorbid and 
                                medically complex chronic conditions 
                                that is life threatening or 
                                significantly limits the overall health 
                                or function of the enrollee;
                                    ``(II) has a high risk of 
                                hospitalization or other adverse health 
                                outcomes; or
                                    ``(III) requires intensive care 
                                coordination.''.
    (b) GAO Study and Report.--
            (1) Study.--The Comptroller General of the United States 
        (in this subsection referred to as the ``Comptroller General'') 
        shall conduct a study on supplemental benefits provided to 
        enrollees in Medicare Advantage plans under part C of title 
        XVIII of the Social Security Act, including specialized MA 
        plans for special needs individuals described in section 
        1859(b)(6) of such Act (42 U.S.C. 1395w-28(b)(6)). Such study 
        shall be conducted in consultation with the Centers for 
        Medicare & Medicaid Services and Medicare Advantage plans as 
        necessary and, to the extent data is available, shall include 
        an analysis of the following:
                    (A) The type of supplemental benefits provided to 
                such enrollees, the total number of enrollees receiving 
                each supplemental benefit, and whether the supplemental 
                benefit is covered by the standard benchmark cost of 
                the benefit or with an additional premium.
                    (B) The frequency in which supplemental benefits 
                are utilized by such enrollees.
                    (C) The impact supplemental benefits have on--
                            (i) indicators of the quality of care 
                        received by such enrollees, including overall 
                        health and function of the enrollees;
                            (ii) the utilization of items and services 
                        for which benefits are available under the 
                        original Medicare fee-for-service program 
                        option under parts A and B of such title XVIII 
                        by such enrollees; and
                            (iii) the amount of the bids submitted by 
                        Medicare Advantage Organizations for Medicare 
                        Advantage plans under such part C.
            (2) Report.--Not later than 5 years after the date of the 
        enactment of this Act, the Comptroller General shall submit to 
        Congress a report containing the results of the study conducted 
        under paragraph (1), together with recommendations for such 
        legislation and administrative action as the Comptroller 
        General determines appropriate.
                                 <all>