117 S4635 IS: Comprehensive Care for Dual Eligible Individuals Act
U.S. Senate
2022-07-27
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EN
Pursuant to Title 17 Section 105 of the United States Code, this file is not subject to copyright protection and is in the public domain.
1.Short title; table of contents(a)This Act may be cited as the Comprehensive Care for Dual Eligible Individuals Act
.(b)The table of contents for this Act is as follows:Sec. 1. Short title; table of contents.Sec. 2. Establishment of All Inclusive Medicare-Medicaid Program for Full-Benefit Dual Eligible Individuals.TITLE XXII—All Inclusive Medicare-Medicaid (AIM) Program for Full-Benefit Dual Eligible IndividualsSec. 2201. Purpose; General requirements.Sec. 2202. Eligibility.Sec. 2203. Enrollment.Sec. 2204. Benefits.Sec. 2205. Beneficiary protections.Sec. 2206. Federal administration.Sec. 2207. Selection and role of AIM-administering entities.Sec. 2208. Program financing.Sec. 2209. Accountability and oversight.Sec. 2210. Definitions; miscellaneous provisions.Sec. 3. MedPAC study and report.2.Establishment of All Inclusive Medicare-Medicaid Program for Full-Benefit Dual Eligible Individuals(a)The Social Security Act is amended by adding at the end the following new title:<enum>XXII</enum><header>All Inclusive Medicare-Medicaid (AIM) Program for Full-Benefit Dual Eligible Individuals</header><section id="id71b2a9db02d24d97962fad8d0f2c4304"><enum>2201.</enum><header>Purpose; General requirements</header><subsection id="idba2e4f69de674c7e8add28fd4446523b"><enum>(a)</enum><header>Purpose</header><text>The purpose of this title is to provide, at the option of a State, for a program implemented and administered by the State of comprehensive, coordinated care for individuals eligible for benefits under the Medicare program under title XVIII and for full benefits under the Medicaid program under title XIX in order to improve quality, control costs, address health disparities, and support independence, community participation, and quality of life.</text></subsection><subsection id="idf7f3e2710b6c45848429aeb2241d7939"><enum>(b)</enum><header>Requirement for approved AIM program application</header><text>A State may not be approved to implement an AIM program under this title unless, consistent with the process specified for approval of AIM programs under subsection (c)—</text><paragraph id="idfc01a4d58e7d479692c7504111951af2"><enum>(1)</enum><text>the State has completed, in a pre-printed format and manner specified by the Secretary, a notice of intent to establish such a program not earlier than 3 years after the date on which the State submits the notice of intent to the Secretary, and which includes a plan for such a program (or the State is working with the Federal Coordinated Health Care Office to transition an integrated care program of the State into an AIM program under this title); and</text></paragraph><paragraph id="id7e6119131b524480822969de7ee0d66d"><enum>(2)</enum><text>the Secretary has received assurances, satisfactory to the Secretary, that the proposed State AIM program and its plan (or, in the case of a State working with the Federal Coordinated Health Care Office to transition an integrated care program of the State into an AIM program under this title, the State AIM program after such transition is completed) meet the applicable requirements for such a program under this title, including the requirements specified in subsection (c).</text></paragraph></subsection><subsection id="id274d927aefc24203baffa1fe88d129ce"><enum>(c)</enum><header>General requirements</header><text>The requirements specified in this subsection for an AIM program of a State are as follows:</text><paragraph id="idfcd363040b7d4af39dd45105b65754a5"><enum>(1)</enum><header>Eligibility and enrollment</header><text>The program provides for eligibility and enrollment of AIMP-eligible individuals under the program in accordance with sections 2202 and 2203.</text></paragraph><paragraph id="idd22f4b534ea34937a36a4d3a8817942b"><enum>(2)</enum><header>Benefits</header><text>The program provides for benefits for AIMP enrollees under the program in accordance with section 2204.</text></paragraph><paragraph id="id0a48feaf40d843139fbc7cf0fc7a1eb9"><enum>(3)</enum><header>Beneficiary protections</header><text>The program provides for beneficiary protections for AIMP enrollees under the program that are not less than those required under section 2205.</text></paragraph><paragraph id="idb36c72c699914588b5d5dbf5b86976f2"><enum>(4)</enum><header>Coordinating and integration of benefits</header><text>The program provides for the coordination and integration of benefits by AIM-administering entities in accordance with section 2205.</text></paragraph><paragraph id="idbe2d2ab83a4348f2bf70f6c1d3b794b1"><enum>(5)</enum><header>Program accountability</header><text>The program provides for accountability in administration and financing in accordance with section 2208.</text></paragraph><paragraph id="id39f5036fe4ce46338d234c86e140e512"><enum>(6)</enum><header>Other requirements</header><text>The program meets such other requirements as the Secretary may establish to carry out this title.</text></paragraph></subsection><subsection id="idee80944a01604f1e9ece64401f12a4b6"><enum>(d)</enum><header>Program approval process</header><text>The Secretary shall establish a process for the initial approval of AIM programs of States based on the process used for approval of waivers under section 1115 with respect to title XIX. The process established under this subsection shall include at least the following elements:</text><paragraph id="iddab69ae6bd04416cba04ee98c2c7bdc8"><enum>(1)</enum><header>Notice of intent</header><subparagraph id="id668ac776b5fd4d28b007992e150752c7"><enum>(A)</enum><header>In general</header><text>Subject to subparagraph (B), the State submits to the Secretary a notice of intent to establish the AIMP.</text></subparagraph><subparagraph id="id31a33af4ab504f7988b7b0d8f952240f"><enum>(B)</enum><header>Conditions for transparent process</header><text>The Secretary shall not accept a notice of intent submitted under subparagraph (A) unless, before the date of such submission, the State—</text><clause id="id348e475a60864c4d8b21f61fe3b0a3a7"><enum>(i)</enum><text>has provided a period of not less than 90 days for notice and public comment on the proposed establishment of the program in the State;</text></clause><clause id="ida8b89f5e800e4918a469778fa5bdc7db"><enum>(ii)</enum><text>has held at least 2 public meetings regarding the establishment of the program; and</text></clause><clause id="id80481d3b210a4951bcc15517ba640903"><enum>(iii)</enum><text>has conducted relevant consultation with any relevant tribal authorities of Federally recognized Indian tribes located in the State.</text></clause></subparagraph></paragraph><paragraph id="id591f14d2f15b4ab6ac622132795c2910"><enum>(2)</enum><header>Federal readiness review completed</header><text>At least 1 year before the identified initial implementation date for an AIM program in a State, the State has passed a review by the Secretary of the State’s readiness to implement the program.</text></paragraph><paragraph id="idc418e74f2506443185e0535fe03dcbd5"><enum>(3)</enum><header>State readiness review of aim-administering entities</header><text>After a State passes the Federal readiness review under paragraph (2), the State shall conduct a review of the proposed AIM-administering entities under proposed AIMP contracts with the State with respect to their readiness to administer the program for benefits for AIMP enrollees assigned to such entities. Such review—</text><subparagraph id="id0f02f7f930ca477ab6dc125ab8ce45e1"><enum>(A)</enum><text>shall include elements specified by the Secretary, including a network adequacy review; </text></subparagraph><subparagraph id="id82bb9eb354764875987b907568fab76c"><enum>(B)</enum><text>may include activities such as a desk review, separate network validation review, and site visit; and</text></subparagraph><subparagraph id="id9097bcbc70a2403c884690ad815bf069"><enum>(C)</enum><text>must be passed by an AIMP-administering entity before any outreach or marketing of or by that entity is permitted under a State AIM program.</text></subparagraph></paragraph></subsection><subsection id="idb47d208e3db54e2e8aed51e88345a68e"><enum>(e)</enum><header>Technical assistance planning grants</header><paragraph id="id41384b0df69e4a50a2f9b90bb2cc0c93"><enum>(1)</enum><header>Eligibility</header><text>A State that has provided a notice of intent under subsection (d)(1) to implement an AIM program is eligible for funding assistance with technical planning necessary to implement the program. Such funding shall be provided in amounts of up to $10,000,000 per State, and under such conditions as the Secretary shall specify. </text></paragraph><paragraph id="id8581a090760646b49554bcf4ea51e9aa"><enum>(2)</enum><header>Use of funds</header><text>Funding made available to a State under this subsection may be used to assist the State with the staffing, information technology, planning and evaluation, and initial implementation of the AIM program in the State for expenses incurred during the 3-year period that begins on the date the State submits a notice of intent under subsection (d)(1). </text></paragraph><paragraph id="idEB5923D2100A4DBCA00B140993EA602B"><enum>(3)</enum><header>Funding</header><text>For the purpose of providing funding assistance under this subsection, there is appropriated, out of any money in the Treasury not otherwise appropriated, such sums as may be necessary to carry out this subsection.</text></paragraph></subsection></section><section id="id2389f01e4779404d9a4aedcc38d2c115"><enum>2202.</enum><header>Eligibility</header><subsection id="id8770c5dcc80c4e37b2f5c5475cc68416"><enum>(a)</enum><header>In general</header><text>In this title, the term <term>AIMP-eligible individual</term> means, with respect to an AIMP-participating State, an individual who—</text><paragraph id="idb0245ea660ed4ddfa19e313dc376b8ec"><enum>(1)</enum><text>is 21 years of age or older;</text></paragraph><paragraph id="id1aba6e4c68f94d63adc2e133bda9154f"><enum>(2)</enum><text>is entitled (or eligible to be enrolled) under part A or part B, or both, of title XVIII; </text></paragraph><paragraph id="idbbaae02d2ae0497faa2522c40df4ba45"><enum>(3)</enum><text>subject to subsection (c), is eligible for medical assistance under the State plan (including a waiver thereof) under title XIX as a full-benefit dual eligible individual; and</text></paragraph><paragraph id="idD29D184EB08E435FAC2EE95910F71F81" commented="no"><enum>(4)</enum><text>meets such income and asset standards as the State may establish for the AIM program in accordance with subsection (d) (and which shall be applied in addition to the income and asset standards the individual is required to meet for purposes of eligibility for medical assistance under the State plan (or a waiver) under title XIX).</text></paragraph></subsection><subsection id="id2087c44d517240eb81de5d86b5d17a1b"><enum>(b)</enum><header>Process for determination of eligibility</header><text>Except as otherwise provided in this title, the determination of whether an individual is an AIMP-eligible individual with respect to the AIM program of a State shall be made in accordance with the processes used to determine the individual’s eligibility for medical assistance under the State plan (or waiver thereof) under title XIX of the State.</text></subsection><subsection id="id894e68a6e9ce4b5fb23ad52c1daffa0c"><enum>(c)</enum><header>Flexibility permitted</header><paragraph id="id9754886f44a04c32a5f0ea12b87cdc76"><enum>(1)</enum><header>Geographic scope</header><subparagraph id="idc564cf00495f4f8691f64ada641ef26f"><enum>(A)</enum><header>Statewide</header><text>Except as provided in subparagraph (B), an AIMP-participating State shall provide for the implementation of its AIM program on a statewide basis.</text></subparagraph><subparagraph id="id3c8594bf5e474fc0b541ba7be8d1e979"><enum>(B)</enum><header>Phase-in permitted on a time-limited basis</header><text>An AIMP-participating State may provide for the implementation of its AIM program not on a statewide basis so long as the program is phased in geographically in a manner so that it is implemented statewide no later than the 4th year of implementation, except that the Secretary may permit a longer phase-in period due to extenuating circumstances.</text></subparagraph></paragraph><paragraph id="id8edaa4c3716940a4b4bbacd56387f9d6"><enum>(2)</enum><header>New population phase-in permitted</header><subparagraph id="id27dcb1a29b044ba5a5d8a4660e5b2138"><enum>(A)</enum><header>Carve-outs not permitted</header><text>Except as provided in subparagraph (B), an AIMP-participating State may not deny eligibility under its AIM program to subpopulations of AIMP-eligible individuals and shall enroll all AIMP-eligible individuals under the program without the application of any waiting lists.</text></subparagraph><subparagraph id="id86a410ef3c8b4744843c74849b8f314d"><enum>(B)</enum><header>Time-limited exception permitted</header><text>The Secretary may allow States to phase in the enrollment of certain subpopulations over a specified period, not to exceed a period of 4 years.</text></subparagraph></paragraph><paragraph id="id9c06913836504ac89e5f47cdec805eeb"><enum>(3)</enum><header>Pace continuation permitted</header><text>Nothing in this title shall be construed as preventing an AIMP-participating State from continuing to offer a Program of All-Inclusive Care for the Elderly (PACE) under section 1894 or 1934.</text></paragraph></subsection><subsection id="id28c68fb088f3498c8662a48070ad77b2"><enum>(d)</enum><header>Income and asset standards</header><paragraph id="idaccebf16effb4629a48d88ce665e4510"><enum>(1)</enum><header>Income eligibility floor</header><text>In no case shall an AIMP-participating State have an income eligibility threshold under its AIM program that is less than 73 percent of the official poverty line (as defined by the Office of Management and Budget, and revised annually in accordance with section 673(2) of the Omnibus Budget Reconciliation Act of 1981) applicable to a family of the size involved or, if greater, the income threshold applied during the fiscal year preceding the year in which this title is enacted.</text></paragraph><paragraph id="id16f9c5dd696c4d3bad74679478963aaf"><enum>(2)</enum><header>Asset threshold floor</header><text>In no case shall an AIMP-participating State apply an asset threshold for eligibility for a fiscal year that is less than the following:</text><subparagraph id="idd0d0a72c00d04dbd89373d89c83c2fdb"><enum>(A)</enum><header>For first fiscal year</header><text>For the 1st fiscal year (or portion of a fiscal year) in which the AIM program is implemented in the State, the greater of—</text><clause id="idB5F4EDDA50F64A44A299640A2623B8FA"><enum>(i)</enum><text>$2,000; and</text></clause><clause id="id7F03E3FFD27D49A4A4E7754191886DFA"><enum>(ii)</enum><text>the asset eligibility standard applied under the State plan (including a waiver thereof) under title XIX for a full-benefit dual eligible individual during the fiscal year preceding the fiscal year in which this title is enacted.</text></clause></subparagraph><subparagraph id="id93377c32717642e1b6a73454f732ba13"><enum>(B)</enum><header>For subsequent fiscal year</header><text>For a subsequent fiscal year, the minimum asset threshold applied under this paragraph for the previous fiscal year increased (and rounded to the nearest $10) by the annual increase in the consumer price index for all urban consumers (United States city average).</text></subparagraph></paragraph><paragraph id="id8d9fec0549594abdb17c94d349681b53"><enum>(3)</enum><header>Flexibility</header><text>Nothing in this subsection shall be construed as limiting the ability of an AIMP-participating State to increase the income eligibility threshold, asset eligibility threshold, or income or asset disregards, including by allowing buy-ins or spenddowns, above the minimum levels required under this subsection.</text></paragraph><paragraph id="id1560afa780244001a473fb06380c6731"><enum>(4)</enum><header>Eligibility threshold</header><text>The income and asset thresholds that a State establishes under this subsection shall be applied under the State AIM program to determine whether an individual is an AIMP-eligible individual without regard to whether the individual elects to enroll, or is enrolled, in the State AIM program. </text></paragraph></subsection><subsection id="id7630ea7bf6854276bd4aa4e42d672f40"><enum>(e)</enum><header>Use of streamlined eligibility determination and enrollment processes</header><paragraph id="id05d5ac44c2284c4db2186c8a2cc0b2bf"><enum>(1)</enum><header>In general</header><text>Each AIMP-participating State shall use streamlined eligibility and enrollment processes in order to promote continuity and incentivize States that invest in improving quality and costs, including those specified in this subsection.</text></paragraph><paragraph id="idca1ed54d44d442ae913eed816352cfa0"><enum>(2)</enum><header>Specific streamlined eligibility required</header><text>Each AIMP-participating State shall utilize the following with respect to streamlining the eligibility determination and enrollment of individuals in the State's AIM program:</text><subparagraph id="idd59c7bd1a08e45139e59239a7823634a"><enum>(A)</enum><text>12-month continuous eligibility.</text></subparagraph><subparagraph id="idf85eec8d2d784d928197e31eace859ca"><enum>(B)</enum><text>Use of electronic data matches with trusted third-party sources (such as the Social Security Administration or the Supplemental Nutrition Assistance Program) to verify eligibility under the State AIM program both for initial eligibility applications and for renewals.</text></subparagraph><subparagraph id="idf2390f4a57fc4980851d2d04b4099256"><enum>(C)</enum><text>Streamlined eligibility recertification every 12 months, including—</text><clause id="id88263811eb1f487087cc99023fc43a48"><enum>(i)</enum><text>for individuals who have been determined eligible and enrolled, only requiring submission of information on any changes to their financial or disability status (instead of submitting an entire renewal application);</text></clause><clause id="id62fd869f96dd48bdb4101b75c2ba3d72"><enum>(ii)</enum><text>with respect to verification of eligibility, initially using of available information to auto-verify eligibility;</text></clause><clause id="id4c359793ab5445c280f185da200dd844"><enum>(iii)</enum><text>if additional information is needed for renewal of eligibility, using pre-populated forms and allowing submission of information online, in person, by telephone, fax, or mail; and</text></clause><clause id="id7ced0e3a9a8d472b8608847fb1d14dea"><enum>(iv)</enum><text>using a standard reconsideration period of 90 days from the time of termination of coverage.</text></clause></subparagraph></paragraph><paragraph id="id2bc31a3579aa45a58dbaa2a9a1b9b5ee"><enum>(3)</enum><header>Use of deeming</header><text>Each AIMP-participating State shall use deemed eligibility for a period of not less than 6 months.</text></paragraph><paragraph id="id5cf58a31eb0a4ad6a66283e84476f05a"><enum>(4)</enum><header>Data sharing on enrollment</header><text>Under an AIMP contract, an AIMP-participating State, the Secretary, and AIM-administering entities shall routinely and frequently share data among themselves with regard to eligibility and enrollment of individuals under AIM programs. Such data sharing may include monthly changes in program enrollment and eligibility, beneficiary opt-out rates, and other changes specified by the Secretary. </text></paragraph></subsection><subsection id="id63a24c7c27ea46239eb186ff1f53a7ca"><enum>(f)</enum><header>Rule of construction of continuation as a medicare and medicaid beneficiary for purposes other than benefits</header><text>The fact that an individual qualifies as an AIMP-eligible individual shall not be construed as removing the individual’s status as an individual entitled to benefits under title XVIII or XIX, but insofar as the individual becomes an AIMP enrollee entitled to benefits under this title, such entitlement to benefits under titles XVIII and XIX shall be considered as met through the provision of benefits under this title.</text></subsection></section><section id="idb17f96ac739f4ad08ed2c6bf147ea0f1"><enum>2203.</enum><header>Enrollment</header><subsection id="ided1174c566ed4d88938825325bde9f14"><enum>(a)</enum><header>Beneficiary choice</header><text>In an AIMP-participating State under its AIM program, an AIMP-eligible individual may select (in a manner specified by the State consistent with this section) to receive benefits through any of the following:</text><paragraph id="id0d450348fae947b0b37207ec06ee57fa"><enum>(1)</enum><text>The State AIM program.</text></paragraph><paragraph id="idecd1095d03324640b25483c809c27107"><enum>(2)</enum><text>A PACE program (if available to the individual in the State).</text></paragraph><paragraph id="idc4dd44c27cf54afa9769ffb8c2865d55"><enum>(3)</enum><text>A combination of Medicare fee-for-service program (under parts A, B, and D, as applicable, of title XVIII) and medical assistance under title XIX (whether delivered through fee-for-service or managed care, as provided by the State under such title).</text></paragraph></subsection><subsection id="idacaef559344649e289914c0591426c15"><enum>(b)</enum><header>Initial assignment at time of program implementation or initial enrollment</header><text>An AIMP-participating State may provide that all AIMP-eligible individuals in the State who are not enrolled in a PACE program under section 1894 or 1934 and who do not make an affirmative selection under subsection (a)(3) shall be deemed to have elected to enroll in the AIM program of the State.</text></subsection><subsection id="id6ffb91b51397486f9d880944b6b58401"><enum>(c)</enum><header>Coordination of selection and enrollment with medicare enrollment processes</header><text>The process for selection and enrollment of AIMP-eligible individuals in AIM programs shall be consistent and coordinated with the processes for enrollment in Medicare Advantage plans under part C of title XVIII during open and special enrollment periods. Such processes shall, consistent with section 423.38(c) of title 42, Code of Federal Regulations (or any successor regulation) and any other applicable regulations, provide— </text><paragraph id="id7162E9147A4B49C79A790469FAD6031C"><enum>(1)</enum><text>a special enrollment period for individuals who—</text><subparagraph id="idDAD07A61ADD24C7C9333A6267CBD1A52"><enum>(A)</enum><text> are dually eligible individuals enrolled in fee-for-service Medicare when the State AIM program is first established to permit such individuals to elect to enroll in the State AIM program; or</text></subparagraph><subparagraph id="id06748D506F9F46E5ADC6988A4C2D3F65"><enum>(B)</enum><text> become AIMP-eligible individuals; and</text></subparagraph></paragraph><paragraph id="idb66006a960d84036be84e70dbf1b0ae9"><enum>(2)</enum><text>for the right of an AIMP-enrolled individual to disenroll from the AIM program and to otherwise to make changes in the selection in enrollment described in subsection (a).</text></paragraph></subsection><subsection id="id8d445e1ad8f1493998e31948abb34ae6"><enum>(d)</enum><header>Assistance in enrollment choice</header><text>An AIMP-participating State must contract with 1 or more independent enrollment brokers, at least 1 of which is a nonprofit, community-based organization, and all of which are approved by the Secretary, to assist AIMP-eligible individuals in understanding the AIM program and making enrollment choices under this section in the same manner as such brokers are permitted with respect to enrollment of individuals under its State plan under title XIX (or waiver thereof), except that no individual sales commissions shall be permitted (including to the extent such commissions may otherwise be permitted by brokers and employed or captive agents under the Medicare Advantage program under part C of title XVIII). </text></subsection><subsection id="id77daf1de854e48aeb2f5cb1166a6e403"><enum>(e)</enum><header>Construction regarding continued medicaid use of managed care</header><text>Nothing in this subsection shall be construed as affecting the authority of an AIMP-participating State to require, in the case of an AIMP-eligible individual who makes the election described in subsection (a)(3) (or otherwise opts-out of enrollment in the AIM program and into benefits under title XIX), to obtain benefits for covered services under title XIX through participation in a managed care plan or arrangement.</text></subsection><subsection id="idf5f78aa6627f46b98f5ff040b975b2a8"><enum>(f)</enum><header>Assignment of enrollees to AIMP-Administering entities</header><paragraph id="id1af49786cba34786a6892bee822d37bf"><enum>(1)</enum><header>In general</header><text>An AIMP-eligible individual enrolled under an AIM program shall be provided with a choice of the AIMP-administering entity to which the individual is assigned for purposes of obtaining benefits under the program.</text></paragraph><paragraph id="id9cefba6794494038a268d8a438d0acca"><enum>(2)</enum><header>Initial assignment at time of program implementation or initial enrollment</header><subparagraph id="id6444B5ADD7A54B54BB3CBF5F0392F409"><enum>(A)</enum><header>In general</header><text>In the case of an AIMP-eligible individual who, at the time of enrollment under an AIM program, is enrolled in an integrated program for individuals dually eligible for Medicare and Medicaid participating in the Financial Alignment Initiative of the Federal Coordinated Health Care Office, or enrolled in a Medicare Advantage plan that is a highly integrated dual eligible special needs plan or a fully integrated dual eligible special needs plan, the State AIM program may initially assign the individual to the AIMP-administering entity for such Medicare Advantage plan (or, in the case of an AIMP-eligible individual who, at the time of enrollment under an AIM program, is enrolled in an integrated program for individuals dually eligible for Medicare and Medicaid participating in the Financial Alignment Initiative of the Federal Coordinated Health Care Office, to the AIMP-administering entity designated by the State), or another AIMP-administering entity, if necessary if— </text><clause id="id8446d56196354eed94301fc1f82deade"><enum>(i)</enum><text>the provider network of such entity under the AIM program is substantially similar to the network used under the plan offered by the entity that the individual is enrolled in prior to such assignment; and</text></clause><clause id="id1b4067f632914dd2b48038f280585bfb"><enum>(ii)</enum><text>the individual is provided with—</text><subclause id="id7330977A13C64894BE4885F3C7E311C4"><enum>(I)</enum><text>at least 1 written notice of such assignment at least 60 days in advance of the effective date of the assignment; and</text></subclause><subclause id="idE466BE3882DD4E0EA495AF419259D32D"><enum>(II)</enum><text>at least 1 phone call notifying the individual of the assignment in advance of the effective date of the assignment. </text></subclause></clause></subparagraph><subparagraph id="idd726d2e26a5b49d6bd86a3811f589436"><enum>(B)</enum><header>Continuity of care</header><text>To the extent possible to prevent disruption and promote continuity of care, a State AIM program shall seek to ensure that individuals described in subparagraph (A) are assigned to the AIMP-administering entity that offers the plan or program in which the individual is enrolled in prior to the individual's transfer to, and enrollment in, the State AIM program.</text></subparagraph><subparagraph id="id7a6abfbdc099415495de1f7a2656b272"><enum>(C)</enum><header>Conditional initial assignment for other AIMP-eligible individuals</header><text>In the case of an AIMP-eligible individual who, at the time of enrollment under a State AIM program is enrolled in a Medicare Advantage plan that is operating as an AIMP-administering entity other than a plan described in subparagraph (A), or is enrolled in a Medicaid managed care plan offered by the same entity that is operating as an AIMP-administering entity in the State AIM Program, the State AIM program may initially assign the individual to that AIMP-administering entity if— </text><clause id="id62b31df78e9b42d29d73c9452bf2676a"><enum>(i)</enum><text>the provider network of such entity under the State AIM program is substantially similar to the network used under the Medicare Advantage plan or Medicaid managed care plan offered by the entity that the individual is enrolled in prior to such assignment; and</text></clause><clause id="idb78afb66f0ab49818dffdbbdf70ca1fb"><enum>(ii)</enum><text>the individual is provided with—</text><subclause id="idd03b88f097c54e0ea36d067d99274063"><enum>(I)</enum><text>at least 1 written notice of such assignment at least 60 days in advance of the effective date of the assignment; and</text></subclause><subclause id="id2475b81c55044e0b80b1963cfc890a9d"><enum>(II)</enum><text>at least 1 phone call notifying the individual of the assignment in advance of the effective date of the assignment. </text></subclause></clause></subparagraph></paragraph><paragraph id="id338458a9eaad433f91cde642b8f56949"><enum>(3)</enum><header>Rule of construction</header><text>Nothing in this subsection shall be construed as—</text><subparagraph id="id602F88D62ED24FB7AABE02C0078074CC"><enum>(A)</enum><text>preventing an individual from choosing to be assigned to a different participating AIMP-administering entity;</text></subparagraph><subparagraph id="idA95B8B2BA77549BDB3EB0FDB9A5AA978"><enum>(B)</enum><text>preventing an individual from changing their assignment to an AIMP-administering entity or from opting-out of participating in the State AIM program; or</text></subparagraph><subparagraph id="id934A76D0980D49CAA7D073B665A335E5"><enum>(C)</enum><text>constraining or changing the authority of a State under the State plan under title XIX or under a waiver of such plan to require a Medicaid-eligible individual to enroll with a managed care entity if the individual chooses not to participate in the AIM Program.</text></subparagraph></paragraph><paragraph id="id2fcce73f0c244c53a40da72c3b45fa34"><enum>(4)</enum><header>Choice of enrollment from fee-for-service medicare</header><text>An AIMP-eligible individual who, as of the date on which a State first implements the State AIM program, is enrolled in the Medicare fee-for-service program under title XVIII, may elect to enroll in the State AIM Program through a special enrollment period established for such individuals, consistent with the requirements of section 423.38(c)(4) of title 42, Code of Federal Regulations (or a successor regulation).</text></paragraph></subsection><subsection id="id43a83d2137c440ebb432505f0442a6ed"><enum>(g)</enum><header>Effect of enrollment on medicare and medicaid payments to states</header><text>Except as provided in this title, in the case of an individual who is enrolled as an AIMP enrollee under a State AIM program under this title, during the period of such enrollment payment to the State under this title shall be instead of the payment amounts which would otherwise be payable under title XVIII or XIX for items and services furnished to the enrollee.</text></subsection><subsection id="id2D3FFEBEE8DC4DB4A053FF870CF90C8A"><enum>(h)</enum><header>Outreach and enrollment support</header><paragraph id="id33888A3B2CCF40D396EB64A57DE745CA"><enum>(1)</enum><header>Funding</header><text>For the purpose of providing funding assistance to AIMP-participating States for outreach to, and enrollment support of, AIMP-eligible individuals, there is appropriated, out of any money in the Treasury not otherwise appropriated, such sums as may be necessary for each fiscal year beginning with the first fiscal year that begins on or after the date of enactment of this title. </text></paragraph><paragraph id="idDBB6D0AF498640F5BCC7B5DAC733FF1C"><enum>(2)</enum><header>Use of funds</header><text>An AIMP-participating State shall use funds provided to the State under this subsection for outreach to, and enrollment support of, AIMP-eligible individuals, that includes the following:</text><subparagraph id="id0ab52b01d96d4b57b0e59ef0453c3420"><enum>(A)</enum><text>Distributing outreach and enrollment materials printed in accessible language formats (including primary languages, Braille, large print, and alternative texts).</text></subparagraph><subparagraph id="id61afb5c1b4a44e23b22a5c4afc0d2971"><enum>(B)</enum><text>Engaging community-based organizations to conduct outreach to, and provide enrollment assistance for, AIMP-eligible individuals.</text></subparagraph><subparagraph id="idc48e3bdd2fac4b57a5b2d621de163f04"><enum>(C)</enum><text>Referring AIMP-eligible individuals to the State long-term care ombudsman, the qualified nonprofit AIM Ombudsman selected for the AIM program under section 2205(c), and other beneficiary support entities for enrollment assistance and information. </text></subparagraph></paragraph></subsection></section><section id="idf437521c7fb1410eb762e55b910604f6"><enum>2204.</enum><header>Benefits</header><subsection id="id504865efef864e9fa4ad98c32a977270"><enum>(a)</enum><header>Covered benefits</header><paragraph id="id60952aeb75a64ade8f0edd1a52fb9301"><enum>(1)</enum><header>In general</header><text>A State AIM program shall provide a core package of covered benefits to address medical, behavioral, long-term care, and social needs of AIMP enrollees in accordance with an individual assessment and plan of care. Such core package of available benefits shall include the following:</text><subparagraph id="idaf6cf245a9034f489dd5c8b5d0469d12"><enum>(A)</enum><header>Medicare benefits</header><text>All benefits available under parts A, B, and D of title XVIII, including with respect to benefits available under such part D, coverage of the 6 protected classes and 2 drugs from each class. </text></subparagraph><subparagraph id="idaa7f61ca147349d28c0c69bdfd13567a"><enum>(B)</enum><header>Medicaid mandatory benefits</header><text>All benefits otherwise required to be provided to AIMP-eligible individuals under title XIX in the State if they were not AIMP enrollees.</text></subparagraph><subparagraph id="id5812b13bd77e4dcb8a734f1a69b03e01"><enum>(C)</enum><header>Historic benefits</header><text>All Medicaid services and benefits offered as of 1 year prior to the enactment of this title, as required by section 2204(d).</text></subparagraph><subparagraph id="id1EDA6211065C4549BD2DC290BE2A36F3"><enum>(D)</enum><header>Drugs</header><text>All prescription drugs and covered outpatient drugs available under the State Medicaid program, including any such drugs that are available under a prescription drug plan under part D of title XVIII.</text></subparagraph><subparagraph id="id7f6ae21cabbe4f6d86263ea5356afc3d"><enum>(E)</enum><header>Additional services</header><text>An AIMP-participating State may, with approval from the Federal Coordinated Health Care Office, make available under the State AIM program additional behavioral health, social, and supportive services that enable flexibility to achieve person-centered outcomes in the most cost-effective setting.</text></subparagraph></paragraph><paragraph id="id13ce48ea713e44e7bf09c2f6526124f3"><enum>(2)</enum><header>Limitation on benefit carve-outs</header><text>The Secretary may permit a State AIM program to exclude benefits for some services under paragraph (1)(C) if the Secretary determines that such an exclusion is essential for the State to implement the AIM program but such exclusion may not extend over a period of longer than 4 years.</text></paragraph></subsection><subsection id="id6b5a897b230c481bb0f39bc4fbec8b4e"><enum>(b)</enum><header>Benefit assessment process</header><paragraph id="id8d2c27cb21f143c89c8a2b090abf351d"><enum>(1)</enum><header>Assessment tool and plan of care</header><subparagraph id="id1215f5cbf7ff4fef8aecfc6bf25c2dde"><enum>(A)</enum><header>Development</header><text>Not later than 18 months after the date of the enactment of this title, the Secretary, in consultation with State agencies administering State plans or waivers under title XIX and with input from other stakeholders, shall develop and publish a robust, comprehensive standard assessment tool for use by all AIM programs in evaluating the condition and needs of AIMP enrollees for benefits under the program.</text></subparagraph><subparagraph id="id16d03495b86148bcac07ca6f097478ad"><enum>(B)</enum><header>Application to plan of care</header><text>Each AIM program shall provide for an assessment for each AIMP enrollee, using such standard assessment tool, to form a basis for the enrollee’s plan of care under the program. Such an assessment shall be conducted at least annually, and when a triggering event (as defined by the Secretary) affecting the enrollee’s need for care occurs.</text></subparagraph><subparagraph id="id91f8182cdf8b49e498617135991a6767"><enum>(C)</enum><header>Application of grievance and appeals procedures</header><text>Disagreements concerning the plan of care for an AIM enrollee shall be subject to grievance and appeal rights under section 2205(b).</text></subparagraph></paragraph><paragraph id="ida004fe978cfd4c6c85f7b4aea5422fb1"><enum>(2)</enum><header>Standard assessment tool</header><text>The standard assessment tool under paragraph (1) shall—</text><subparagraph id="id99B37194F2B64200B43C784A3A14C5BB"><enum>(A)</enum><text>contain a required set of core elements, to which States and AIMP-administering entities may add additional requirements so long as the requirements a State or AIMP administering entity uses contain at a minimum the core set of elements;</text></subparagraph><subparagraph id="ida1c7d9b0f25b443a99f5e9ca43af861c"><enum>(B)</enum><text>cover multiple domains, including medical, functional, behavioral, and social domains; and</text></subparagraph><subparagraph id="id729bb865613a4a6eae0ac91e92c706b4"><enum>(C)</enum><text>be applicable to the full range of AIMP enrollees, including individuals with serious mental illness and with needs for assistance with activities of daily living.</text></subparagraph></paragraph></subsection><subsection id="id4fa0e6e19c084aca93a26cc84ee737d5"><enum>(c)</enum><header>State provision of covered benefits</header><paragraph id="id7a0b2b41c6a44f0e84bde2cf29d4e45c"><enum>(1)</enum><header>Use of tiered-benefit model</header><text>An AIMP-participating State may establish a tiered-benefit design structure for benefits so that specialized benefits may be available to meet the needs of specific subpopulations of AIMP enrollees so long as such tiering—</text><subparagraph id="id2965b58afc7d4c80b4d26c610d5a0dae"><enum>(A)</enum><text>only applies to benefits described in subparagraph (E) of subsection (a)(1) and does not limit the coverage of core covered benefits described in subparagraphs (A) and (B) of such subsection; and</text></subparagraph><subparagraph id="id412ddf97ecec4b2eaefc168fb05a2252"><enum>(B)</enum><text>is no more restrictive than the benefit structure in place in the State under title XIX in the year before the date of the enactment of this title.</text></subparagraph></paragraph><paragraph id="idff813242fe4646229c3cb01315c6f2a1"><enum>(2)</enum><header>In-lieu-thereof alternative services permitted</header><text>An AIMP-participating State may permit AIMP-administering entities to cover benefits for cost-effective alternative services (known as <quote>in lieu of services</quote>) instead of benefits for services otherwise included under the AIM program but in no case shall an AIMP enrollee be required to use such alternative services.</text></paragraph><paragraph id="id47a41660fa8142109b7defb7c776c675"><enum>(3)</enum><header>Continuity of services</header><subparagraph id="id1f87b1a76f604ecfb52d98d323c47b42"><enum>(A)</enum><header>In general</header><text>Except as provided in subparagraph (B), during the first 6 months of an AIM enrollee’s enrollment in an AIM program (or for such longer period as the AIM program may provide) an AIMP-participating State shall continue to provide access to all medically necessary covered items and services and providers (for continuity of care) that were being provided at the time of enrollment.</text></subparagraph><subparagraph id="id6346bb067a34460fadc459953ca74bee"><enum>(B)</enum><header>Exception</header><text>Subparagraph (A) shall not apply in cases in which it is determined by the State, and agreed to by the Secretary, that the AIMP enrollee was not eligible for such services at the time of enrollment or was enrolled in the AIM program due to error or fraud.</text></subparagraph></paragraph></subsection><subsection id="ide8ec29d29ea249848ba1e756cfd1a827"><enum>(d)</enum><header>Maintenance of effort</header><text>As a condition for approval of an AIM program of a State, the State shall maintain levels of benefits for AIM enrollees under the program that are not less than the level of benefits under its State plan (including under a waiver) under title XIX for full-benefit dual eligible individuals as of fiscal year 2021, as of the fiscal year before the fiscal year in which this title is enacted, or as of the fiscal year before the 1st fiscal year in which the program is implemented in the State, whichever fiscal year has the highest level of benefits.</text></subsection><subsection id="id232c0cb5c996451281f5db55393a75dc"><enum>(e)</enum><header>Administration of benefits through AIM-Administering entities</header><text>AIMP-participating States shall provide for the coordination of, and the responsibility for the delivery of covered services through AIM-administering entities under an AIM contract under section 2207.</text></subsection></section><section id="idb3116bca3b0646d4b2e677f505308105"><enum>2205.</enum><header>Beneficiary protections</header><subsection commented="no" id="idD9E0BA28589C4A1CB61408C3FB0325AD"><enum>(a)</enum><header>In general</header><text display-inline="yes-display-inline">Except as otherwise provided, the beneficiary protections applicable to individuals enrolled under plans under parts C and D of title XVIII and under a State plan under title XIX shall apply in a manner specified by the Secretary to AIMP enrollees under an AIM program under this title and are in addition to beneficiary protections provided under this title. </text></subsection><subsection id="id32a28619db35478e805b36abdb9f23db"><enum>(b)</enum><header>Application of grievances and internal and external appeals under AIMP contracts</header><text>The rights of individuals with respect to internal and external complaints and appeals processes shall be specified in the contract between the AIMP-participating State and an AIMP-administering entity. Such processes shall, at a minimum, incorporate relevant rights and processes from the requirements for plans under parts C and D of title XVIII as well as requirements for Medicaid managed care organizations under title XIX.</text></subsection><subsection id="id1a9475481a26414e8737ed007bb47e9c"><enum>(c)</enum><header>Requirement for qualified AIM ombudsman program</header><paragraph id="id924842fa02c646b6926b9a9e3f2295db"><enum>(1)</enum><header>In general</header><text>As a condition for approval of an AIM program for a State under this title—</text><subparagraph id="id2d5a67401c914b27a3e3e0916cceef3f"><enum>(A)</enum><text>the State shall have established and have ready for implementation not later than 18 months prior to implementing the AIM program, a qualified nonprofit AIM Ombudsman program run by a community-based organization for such AIM program; and </text></subparagraph><subparagraph id="id67f13d2cc2de490f8c79faaa92c82091"><enum>(B)</enum><text>the State, before implementation of its AIM program, shall demonstrate to the satisfaction of the Secretary (through an application of certification process specified by the Secretary) that its AIM Ombudsman program has the capacity to carry out its functions in the State, including that the program has the independence, expertise, and adequate resources in place to serve AIMP-eligible individuals and AIMP enrollees under the State AIM program.</text></subparagraph></paragraph><paragraph id="id2c46ebb5a04a430486040516989749a5"><enum>(2)</enum><header>Qualifications for qualified aim ombudsman program</header><subparagraph id="id653f2df6049a487199dde9b0031a998e"><enum>(A)</enum><header>In general</header><text>In order to be a qualified AIM Ombudsman program, such program must meet the requirements of this subsection for such a program.</text></subparagraph><subparagraph id="ideae7d57eaa71405aad02cc270b2cd805"><enum>(B)</enum><header>Construction</header><text>Nothing in this subsection shall be construed as preventing a qualified AIM Ombudsman program from being structured as part of another protection service (including those specified in paragraph (3)), so long as such other protection service meets the requirements of this subsection for a qualified AIM Ombudsman program.</text></subparagraph></paragraph><paragraph id="id28c4fe896fc9449d91b189646b0bc7fe"><enum>(3)</enum><header>Coordination with other beneficiary protection services</header><text>A qualified AIM Ombudsman program shall coordinate with State and Federal beneficiary protection services, including the following:</text><subparagraph id="id4bd75e0afd214cb79fe871b4a3ab682a"><enum>(A)</enum><text>Demonstration Ombudsman Programs Serving Medicare-Medicaid Enrollees. </text></subparagraph><subparagraph id="id7695608b753d45ec882c562bfd596ad7"><enum>(B)</enum><text>Managed Care Beneficiary Support Systems.</text></subparagraph><subparagraph id="idaba1653c9a2d4776a5367c59bd280002"><enum>(C)</enum><text>Long-Term Care Ombudsman Programs.</text></subparagraph><subparagraph id="idb51a4789d9914425bbc349fdfc9b53a7"><enum>(D)</enum><text>Disability Protection and Advocacy Programs.</text></subparagraph></paragraph><paragraph id="id3432884268854ac289bcc04cbe671652"><enum>(4)</enum><header>Core services</header><text>A qualified AIM Ombudsman program for an AIMP-participating State shall have authority to provide the following core services with respect to the AIM program in the State:</text><subparagraph id="id449caf3cc86b407da7b6bcb2c5649c44"><enum>(A)</enum><text>Individual assistance (including consumer education and empowerment, assistance with and representation in beneficiary appeals, fair hearings, and grievances, guidance regarding plan and provider selection, and support during enrollment and disenrollment) for AIMP-eligible individuals considering enrollment in the State AIM program and for AIMP enrollees in such program. </text></subparagraph><subparagraph id="idd218e8c031d04a31bce4441449fe8325"><enum>(B)</enum><text>Systemic monitoring and reporting to the State regarding compliance with applicable requirements.</text></subparagraph></paragraph><paragraph id="id3bbd6bd012bd4e72a0e076f3a66bc2b9"><enum>(5)</enum><header>Providing reports to consumer advisory boards</header><text>A qualified AIM Ombudsman program for a State shall provide, on a timely basis, any reports it produces to the consumer advisory boards (established under subsection (e)) for the State and shall make them publicly available.</text></paragraph><paragraph id="id647f6e94162b4dd59412e7d4bd0be84e"><enum>(6)</enum><header>Funding and oversight</header><subparagraph id="id9734eba6e9524bfc98bc3238e4bbab51"><enum>(A)</enum><header>In general</header><text>The Secretary shall oversee and administer Federal funding directly to qualified AIM Ombudsman programs established by States.</text></subparagraph><subparagraph id="id19fdaeb2d07744ef88aa0de1ff66cd83"><enum>(B)</enum><header>Funding level</header><text>For the purpose of providing funding to qualified AIMP Ombudsman programs in each State over a period of 3 fiscal years, there is appropriated, out of any money in the Treasury not otherwise appropriated, not less than $1,000,000, and not more than $5,000,000. The Secretary shall determine the funding for each such program based on the estimated number of AIMP-eligible individuals in each State.</text></subparagraph><subparagraph id="idC8270B5882E740ED8E299AE5C7EA0A9E"><enum>(C)</enum><header>Supplemental funding</header><text>Nothing in this paragraph shall be construed as preventing an AIMP-participating State from providing supplemental funding for the qualified AIM Ombudsman program for the State. </text></subparagraph></paragraph></subsection><subsection id="id6e1b2798d66845a9a2cc121684f7c34c"><enum>(d)</enum><header>Beneficiary advisory council</header><text>Each AIMP-participating State shall have in operation a Beneficiary Advisory Council to advise the State regarding the treatment of AIMP-eligible individuals and AIMP enrollees under this title. The composition and specific functions and authority of such a Council shall be delineated in readiness review requirements specified by the Secretary in carrying out paragraphs (2) and (3) of section 2201(d).</text></subsection><subsection id="idfe4ac23d6d97485abc680355a3654750"><enum>(e)</enum><header>Consumer advisory boards</header><paragraph id="id9108df87b01c48e596f56faa3f20d2c0"><enum>(1)</enum><header>In general</header><text>Each AIMP-participating State and each AIMP-administering entity in each such State shall establish a consumer advisory board that will provide regular feedback to the State or governing board of the entity, respectively, on issues of care of AIMP enrollees under the AIM program in that State or through that entity, respectively.</text></paragraph><paragraph id="id4fef8f51e40346d0b4b5c437d84980e9"><enum>(2)</enum><header>Composition; functions</header><text>Each such consumer advisory board shall—</text><subparagraph id="id8216b20c82fc4799a174463395f751ff"><enum>(A)</enum><text>meet at least quarterly;</text></subparagraph><subparagraph id="idecb55c4e3ac544eaa4e8985ac5a9d044"><enum>(B)</enum><text>be comprised of members who—</text><clause id="id0E2BC43694954E31BCCC34E46CB51ACD"><enum>(i)</enum><text>may be subject to approval by the Secretary and the AIMP-participating State;</text></clause><clause id="id4118B296278A4052B75B60E18FBB457C"><enum>(ii)</enum><text>are AIMP enrollees; </text></clause><clause id="id4D935503BDAC4137861DD8948E5FE390"><enum>(iii)</enum><text>are family members and other caregivers for AIMP enrollees; and</text></clause><clause id="id7DA3A465E7794C58948181359695EDF8"><enum>(iv)</enum><text>are chosen in a manner that reflects the demographic diversity of the population of AIMP enrollees, including with respect to race, ethnicity, age, and urban and rural populations, and which includes individuals with disabilities;</text></clause></subparagraph><subparagraph id="idB972D748F7244A89A5BF470267CB46DF"><enum>(C)</enum><text>meet the requirements for member advisory committees under section 438.110 of title 42, Code of Federal Regulations; and </text></subparagraph><subparagraph id="id03322dea5f6741bebca28dfd26e0ca4c"><enum>(D)</enum><text>file and make publicly available an annual report that includes at least information on—</text><clause id="id16182f92616c44cf88e59f8c5de692bf"><enum>(i)</enum><text>the dates for its meetings held within the reporting year;</text></clause><clause id="idd33e78fc5763448d9a531da1058dfe7f"><enum>(ii)</enum><text>the names of board members invited and of those members in attendance at each such meeting; and</text></clause><clause id="idc6d9667d78104290a92ec2f493369025"><enum>(iii)</enum><text>the agenda and minutes for each such meeting.</text></clause></subparagraph></paragraph></subsection></section><section id="idaf043e6567814343b28b42a8d5f6f4e7"><enum>2206.</enum><header>Federal administration</header><subsection id="id0cd1f1f6d8ce4be080460495ca649a96"><enum>(a)</enum><header>Primary administration through the Federal Coordinated Health Care Office</header><paragraph id="id67061b64554649b389ed296438a8d832"><enum>(1)</enum><header>In general</header><text>The Secretary shall carry out this title through the Federal Coordinated Health Care Office, except that with respect to payments under section 2208, the Secretary may delegate such authority to the Administrator of the Centers for Medicare & Medicaid Services.</text></paragraph><paragraph id="id388b74cd905f4c809ee32d00508b31f1"><enum>(2)</enum><header>Appropriations</header><text>There are hereby appropriated to the Secretary to carry out this title, out of any funds in the Treasury not otherwise appropriated—</text><subparagraph id="idc6b7bb9666c2479f93e507524bc7fe69"><enum>(A)</enum><text>for each of fiscal years 2022, 2023, and 2024, $100,000,000; and</text></subparagraph><subparagraph id="id69e6632ea36d4581a126f1673454f4a0"><enum>(B)</enum><text>for each succeeding fiscal year, $30,000,000.</text></subparagraph></paragraph></subsection><subsection id="id882899b7af014b358d68e0f17fea8597"><enum>(b)</enum><header>Standards and process</header><paragraph id="id8cd06ac7cf654176b3a2e99eeab843d0"><enum>(1)</enum><header>Federal standards</header><text>In carrying out this title, the Secretary shall specify a minimum set of Federal standards, including standards relating to access to care, quality of care, beneficiary protections, marketing and enrollment, grievances and appeals, and procurement.</text></paragraph><paragraph id="id90490fb5f8c64a159c53489cb24652a9"><enum>(2)</enum><header>Transparency in rulemaking</header><text>In implementing the provisions of this title, to the extent practical, the Secretary shall utilize notice and comment rulemaking to ensure transparency for stakeholders.</text></paragraph><paragraph id="idcb8ea0487d414bc7a43135157cf6b2ac"><enum>(3)</enum><header>Application of knowledge gained from demonstration projects and contract management teams under the financial alignment initiative</header><text>The Secretary shall carry out this title taking into account the knowledge gained from the use of contract management teams in demonstration projects under the Financial Alignment Initiative for Medicare-Medicaid Enrollees administered by the Federal Coordinated Health Care Office.</text></paragraph></subsection><subsection id="idd59a1745b1af4cd399eb7cca8ec22965"><enum>(c)</enum><header>Direct-Hire authority</header><text>In carrying out this title, the Secretary (acting through the Federal Coordinated Health Care Office) shall have direct-hire authority to the extent required to implement and administer this title on a timely basis. </text></subsection></section><section id="id0d9de316bd9c43c697657f3724b78f60"><enum>2207.</enum><header>Selection and role of AIM-administering entities</header><subsection id="idb082cff8fa5e48cb942681e7f305a241"><enum>(a)</enum><header>Requirements for State selection of AIM-Administering entities</header><text>The Secretary, in consultation with States, shall develop (not later than 1 year after the date of the enactment of this title) a set of standardized requirements for the selection of qualified organizations to serve as AIMP-administering entities in the AIM programs in each AIMP-participating State.</text></subsection><subsection id="ida1791cd770e04a1f9f5bfe9353f475c9"><enum>(b)</enum><header>Application of criteria for the qualification and selection of AIMP-Administering entities</header><paragraph id="id745edc96bec94332a6ec932f8936b38c"><enum>(1)</enum><header>In general</header><text>Each AIM program in an AIMP-participating State shall be implemented through contracts entered into by the AIMP-participating State and organizations that qualify as AIMP-administering entities under this title. A contract with an AIMP-administrating entity shall require the entity to assume 2-sided financial risk in return for payment for the arrangement and delivery of covered benefits to AIMP enrollees assigned to the entity under the program.</text></paragraph><paragraph id="id80637707bcb34247a52c3ce5f06ac893"><enum>(2)</enum><header>Specification of criteria</header><text>The Secretary and AIMP-participating States shall establish basic national criteria for the qualification and selection of organizations to be AIMP-administering entities. Such criteria shall take into account the prior experience (including under both the Medicare program under title XVIII and Medicaid programs under title XIX) of such an organization in serving the population of AIMP-eligible individuals as well as other criteria, including the following:</text><subparagraph id="ide9fa4071e61443d2a5be1671ae7a575f"><enum>(A)</enum><text>The organization’s experience serving AIMP-eligible individuals in that State (or another State), including the organization’s experience in providing covered services described in section 2204(a)(1) (including long-term services and supports and behavioral health services) to such individuals, and in integrating all of those services and supports for such individuals in that State (or another State).</text></subparagraph><subparagraph id="idf078e22889634abea8f2bb5ca0223d8c"><enum>(B)</enum><text>The organization’s performance on key quality measures in providing such services, such as on measures of key health outcomes and enrollee satisfaction.</text></subparagraph><subparagraph id="id0d3fe5323f8e4c8da26a91020f049f9f"><enum>(C)</enum><text>The adequacy of the organization’s provider network in ensuring timely access to care. </text></subparagraph><subparagraph id="id0ff1c368d6894b119d1f3df275fea4e7"><enum>(D)</enum><text>The organization’s demonstrated experience in implementing models of care for the full range of such services, including with respect to non-medical services described in section 2204(a)(1).</text></subparagraph></paragraph><paragraph id="id29b835be8e884f5aab804ff160f85cf1"><enum>(3)</enum><header>Additional state-specific criteria</header><text>Nothing in this subsection shall be construed as preventing a State, with the approval of the Secretary, from applying additional criteria or requirements regarding health care quality, equity, or access on AIMP-administering entities specific to quality, equity, or access, so long as such requirements and criteria—</text><subparagraph id="idCEC100BCCAE4456CA6A9B5560EE05774"><enum>(A)</enum><text>can be applied consistently to all AIMP-administering entities; and</text></subparagraph><subparagraph id="id3DCDA1A9CF024FB1930FE14BC3E9BEA8"><enum>(B)</enum><text>are made available for public comment prior to being imposed.</text></subparagraph></paragraph><paragraph id="id6e4c942bbc1a42778e6c0256d5f75ae6"><enum>(4)</enum><header>Application of medical loss ratio requirements</header><subparagraph id="idE631E7FD0AFB44178F2D313261992545"><enum>(A)</enum><header>In general</header><text>Any AIMP contract between an AIMP-participating State and an AIMP-administering entity to administer benefits under an AIM program shall include a requirement that the medical loss ratio under the AIM program shall not be not less than a percentage (not less than 85 percent) specified by the State and that the entity shall return to the State payment amounts that result in the medical loss ratio being below such percentage.</text></subparagraph><subparagraph id="id1675B50DD4204D7C8A8E875349C206E2"><enum>(B)</enum><header>Special rules</header><text>If an administering entity who is contracting with a participating State to administer a program under this title is an entity bearing 2-sided risk, the State shall establish with the approval of the Secretary a mechanism comparable to a medical loss ratio target to ensure appropriate spending on services by the entity.</text></subparagraph></paragraph></subsection><subsection id="id57a83cc6cbe94572b27652e3fcd9e235"><enum>(c)</enum><header>State procurement process for AIMP-Administering entities</header><paragraph id="idd5a268db1a5f470bbe677dede8f57107"><enum>(1)</enum><header>In general</header><text>Each AIMP-participating State shall be responsible for establishing and implementing a process for the procurement and selection of AIMP-administering entities for the State AIM program, subject to the approval of the Secretary. The Secretary shall not approve such a process unless the State demonstrates to the Secretary’s satisfaction that the process results in the selection of AIMP-administering entities that meet the requirements of this title and are qualified to serve the needs of AIMP enrollees in the State under the State’s AIM program. An AIMP-participating State may add additional requirements specific to quality, equity, or access that further the State’s overall integrated care strategy and goals, so long as such requirements are posted for public comment and approved by the Federal Coordinated Health Care Office. </text></paragraph><paragraph id="id155d17021adc45edb64dd5cab7aefb36"><enum>(2)</enum><header>Separate procurement process required for initial procurement</header><text>For the initial procurement executed to establish an AIM program in an AIMP-participating State, the State shall not combine its AIM administering entity procurement process with a procurement process that is also used for procurement under the State plan or waiver under title XIX and shall select AIM administering entities through a standalone procurement process.</text></paragraph></subsection><subsection id="id2bb03b9de3684e5c8fa777a5698170c5"><enum>(d)</enum><header>Payments to AIM-Administering entities</header><text>Each AIMP-participating State shall make payments to AIM-administering entities under a risk-adjusted payment model that—</text><paragraph id="id3182258BF0344C30A9A03C567D254D59"><enum>(1)</enum><text>reflects the risk of the population of AIMP enrollees served by each entity;</text></paragraph><paragraph id="id5675668F3EA141B6B23AA15F821761E8"><enum>(2)</enum><text>ensures that there are appropriate resources to serve the AIMP enrollees in the State; and</text></paragraph><paragraph id="id9EF5764250A9418AA9CAF418BB50D5D9"><enum>(3)</enum><text>protects against any adverse selection of AIMP enrollees by entities. </text></paragraph></subsection></section><section id="id7898a4b446a7403d99eb7ba2abcc5dc9"><enum>2208.</enum><header>Program financing</header><subsection id="id9a33824d431449a6b745844f0f045a9b"><enum>(a)</enum><header>Payments to States with AIM programs</header><paragraph id="ida96ea206ea7f4a27997f82e35e7e3dbf"><enum>(1)</enum><header>For program benefits</header><subparagraph id="idf3a7a8c6a91844dc864ce552d8372be0"><enum>(A)</enum><header>In general</header><text>From the sums appropriated under paragraph (3), the Secretary shall pay to each AIMP-participating State for each quarter in a fiscal year (beginning with the first fiscal year that begins after the date of enactment of this title), an amount equal to the Federal AIMP matching percentage (as defined in subsection (b)(1)) of the total amount expended during the quarter as AIMP assistance (as defined in subparagraph (B).</text></subparagraph><subparagraph id="id9d058609fa5a4757b3795f660dac951e"><enum>(B)</enum><header>AIMP assistance defined</header><text>In this title, the term <term>AIMP assistance</term> has the meaning given the term <term>medical assistance</term> under section 1905(a), except that in applying such term under this subparagraph—</text><clause id="ida64dd9b15fbd4402a00fc04a475f5859"><enum>(i)</enum><text>the services described in section 2204(a)(1) shall be substituted for the services described in paragraph (1) and the subsequent paragraphs of such section 1905(a);</text></clause><clause id="id278ff248dc7c472f9233a41649cfb5e1"><enum>(ii)</enum><text>an AIMP enrollee shall be treated as an individual referred to in the matter in section 1905(a) before paragraph (1) of such section; and</text></clause><clause id="idab83e0cb0e8c4cec909797d51a2e2b23"><enum>(iii)</enum><text>the exclusion in the subdivision (B) following the last paragraph of the first sentence of section 1905(a) shall not apply.</text></clause></subparagraph></paragraph><paragraph id="idd4d7709a59674670b65110664f2dc73c"><enum>(2)</enum><header>For administrative expenses</header><text>In addition to the amount paid for each quarter in a fiscal year to an AIMP-participating State under paragraph (1), the Secretary shall pay to each such State for each quarter in a fiscal year (beginning with the first fiscal year that begins after the date of enactment of this title), from the sums appropriated under paragraph (3), not less than 50 percent of the total amount expended during such quarter as found necessary by the Secretary for the proper and efficient administration of the State AIM program under this title. </text></paragraph><paragraph id="id835984fdbefd451f920e8bcc50686057"><enum>(3)</enum><header>Appropriation</header><text>There is appropriated, out of any money in the Treasury not otherwise appropriated, such amounts as may be required to provide payments to States under this section, reduced by any amounts made available from the Medicare trust funds under paragraph (5). </text></paragraph><paragraph id="idf2e654cf9a764cf1b880e9f51d2ebb82"><enum>(4)</enum><header>Relation to other payments</header><text>Payment amounts provided under this subsection are in addition to payments provided under other provisions of this title.</text></paragraph><paragraph commented="no" id="idf18e1e52f84f4a9ebb2711074fab86b1"><enum>(5)</enum><header>Relation to medicare trust funds</header><text>There shall be made available for application under this title from the Federal Hospital Insurance Trust Fund (under section 1817) and from the Federal Supplementary Medical Insurance Trust Fund (under section 1841) (and from the Medicare Prescription Drug Account (under section 1860D–16) within such Trust Fund) such amounts as the Secretary determines appropriate, taking into account the reductions in payments from such Trust Funds and Account that are attributable to the coverage of AIMP enrollees under AIM programs under this title.</text></paragraph></subsection><subsection id="idBFE318483DFA4027BE6A4B0CA0A9500A"><enum>(b)</enum><header>Federal AIMP matching percentage</header><paragraph id="ide4ac89687cd845729b9619483806b4f2"><enum>(1)</enum><header>In general</header><text>In this section, the term <term>Federal AIMP matching percentage</term> means, for an AIMP-participating State for a fiscal year, 100 percent minus the State contribution percentage (as defined in paragraph (2)) for the State and fiscal year.</text></paragraph><paragraph id="ide5d3fc0253b44a1fbffea268940a3144"><enum>(2)</enum><header>State contribution percentage formula</header><subparagraph id="ide1b7fccbcd544f54bd78213f589fd451"><enum>(A)</enum><header>In general</header><text>In this section, the term <term>State contribution percentage</term> means, subject to adjustment under the subsequent provisions of this paragraph, with respect to an AIMP-participating State for—</text><clause id="idb7a43f3031204b288c091184501754dd"><enum>(i)</enum><text>the 1st fiscal year of the AIM program in the State, the base AIMP State percentage computed under subsection (c); or</text></clause><clause id="idd8a3791cecf849c9a31f8c7b3447f230"><enum>(ii)</enum><text>a subsequent fiscal year, the State contribution percentage under this paragraph for the previous fiscal year adjusted in accordance with subparagraph (B) or (C), as applicable.</text></clause></subparagraph><subparagraph id="id18faeb93ab0441669e1d73b63e8cf05e"><enum>(B)</enum><header>Annual adjustment based on changes in expenditures</header><text>For an AIMP-participating State for a fiscal year after such 1st fiscal year, if the expenditures for AIMP assistance for which payment is made under subsection (a)(1) under the State AIM program for the second previous fiscal year—</text><clause id="id561780d0f4fb4e0094d1d02b4c5c6c07"><enum>(i)</enum><text>are not greater than 110 percent, or less than 90 percent, of the AIMP assistance expenditures for the previous fiscal year, there shall be no adjustment for the fiscal year involved under this subparagraph;</text></clause><clause id="id8c7a60728ccc47a8b204c35b9550a38f"><enum>(ii)</enum><text>is greater than 110 percent of the AIMP assistance expenditures for the previous fiscal year, the adjustment under this subparagraph for the fiscal year involved shall be an increase in the State contribution percentage of 1 percentage point for each multiple of 10 percentage points by which such AIMP assistance expenditures exceed 110 percent; or </text></clause><clause id="id2f49187e2722481c847922815c857649"><enum>(iii)</enum><text>is less than 90 percent of the AIMP assistance expenditures for the previous fiscal year, the adjustment under this subparagraph for the fiscal year involved shall be a decrease in the State contribution percentage of 1 percentage point for each multiple of 10 percentage points by which such AIMP assistance expenditures is less than 90 percent. </text></clause></subparagraph><subparagraph id="id1460db4f668c4b159436029c29f626b2"><enum>(C)</enum><header>Additional adjustments for exceptions</header><text>The Secretary shall provide a process by which adjustments may be made to the State contribution percentage to take into account increases and decreases in AIMP expenditures described in clause (ii) or (iii) of subparagraph (B) in which the adjustments under such clauses would not apply, such as in cases of a significant increase or decrease in AIMP enrollees, a declaration of a national emergency that impacts on AIMP expenditures under this title, or a significant cost increase beyond the control of the State, as determined by the Secretary.</text></subparagraph></paragraph></subsection><subsection id="id482a10d0b8b74b3ab50b04b394632309"><enum>(c)</enum><header>Baseline expenditure and percentage computations</header><paragraph id="id1c40bbf26a224c678584533959fef9ce"><enum>(1)</enum><header>In general</header><text>Using the data reported under paragraph (2):</text><subparagraph id="id59224bed029e4f01a9672c4f9c63be93"><enum>(A)</enum><header>Computation of base aimp percentages</header><text>For the base Federal fiscal year (as defined in paragraph (3)), the Secretary shall compute and publish for each State—</text><clause id="id6DD9D29844E942539F5B4DC970D6BF69"><enum>(i)</enum><text>the base AIMP State percentage (as defined in subparagraph (B)) for the State and such fiscal year; and</text></clause><clause id="id3577a601069e46c68f6b184dd4c6ba80" commented="no"><enum>(ii)</enum><text>the Federal AIMP matching percentage for the State and such fiscal year. </text></clause></subparagraph><subparagraph id="idb385a0fea0804e7ca497613398655fcf"><enum>(B)</enum><header>Base AIMP state percentage defined</header><text>In this section, the <term>base AIMP State percentage</term> means the amount equal to the ratio (expressed as a percentage) of—</text><clause id="idca919276997e4e229068ec29ac58177a"><enum>(i)</enum><text>the sum of—</text><subclause id="id9c06d60957c44f1c9f7a9395a6f8eca4"><enum>(I)</enum><text>the amount of the State share of expenditures under title XIX for medical assistance during the base Federal fiscal year attributable to full-benefit dual eligible individuals; and</text></subclause><subclause id="idc36d0309f972412286e877c91de3325c"><enum>(II)</enum><text>the amount of the payment made to the Federal Government during the base Federal fiscal year under section 1935(c) (commonly referred to as the <quote>part D clawback</quote>) attributable to such individuals; to</text></subclause></clause><clause id="id946de230442144fe98483db99739620a"><enum>(ii)</enum><text>the sum of—</text><subclause id="id17e55ff974b340f4aad36258c10ed192"><enum>(I)</enum><text>the total expenses paid under title XVIII that are attributable to full-benefit dual eligible individuals for services (or periods of coverage) occurring the base Federal fiscal year (as estimated by the Secretary); and</text></subclause><subclause id="idde22ec5774994b81b3e6fdbd8a0119c7"><enum>(II)</enum><text>the total amount expended on items and services described in section 2204(a)(1) paid under title XIX (including any waivers under title XI) for full-benefit dual eligible individuals in the base Federal fiscal year.</text></subclause></clause></subparagraph><subparagraph id="iddf278333fced4c3181ef219e2faeec94"><enum>(C)</enum><header>Adjustments to base AIMP percentages</header><text>With respect to the base AIMP State percentages and the Federal AIMP matching percentages otherwise computed under this paragraph for the base Federal fiscal year, the Secretary shall adjust such percentages to take into account material changes in the programs under titles XVIII and XIX between the base Federal fiscal year and the first fiscal year for which AIM programs may be implemented under this title insofar as such material changes have a direct material impact on AIMP expenditures relating to AIMP-eligible individuals.</text></subparagraph></paragraph><paragraph id="ided9c2f3da3fa4f768bc85be18075a1dd"><enum>(2)</enum><header>Data reporting for baseline computations</header><text>Each State, in its application for approval of its AIM program, shall provide the Secretary (in such form and manner as the Secretary may require) such financial data (including detailed and aggregate, historical and projected expenditures data) on its expenditures under title XIX as the Secretary may require to carry out the computations required under this section. The Secretary shall share with the State, in a process defined by the Secretary, Medicare expenditure data (including detailed and aggregate historical and projected expenditures data) for services and benefits for full-benefit dual eligible individuals in such State. </text></paragraph><paragraph id="id34d2c599e4224ecd9468c2449a04e76e"><enum>(3)</enum><header>Base federal fiscal year defined</header><text>In this section, the term <term>base Federal fiscal year</term> means the Federal fiscal year that is the second preceding fiscal year to the 1st fiscal year for which AIM programs may be implemented under this title.</text></paragraph></subsection><subsection id="id9cd00d53af4f45e1a473ee8f9303a935" commented="no"><enum>(d)</enum><header>Reinvestment of shared savings</header><paragraph id="ida1e4df76e1e74631979ad3aedc37da78" commented="no"><enum>(1)</enum><header>In general</header><subparagraph id="id2af7bd854b6d4e1eae2d3f6ba5795f1f" commented="no"><enum>(A)</enum><header>In general</header><text>If, with respect to a fiscal year, an AIMP-participating State has expenditures under this title for AIMP assistance that for the preceding fiscal year, are less than 85 percent of the expenditures for such assistance under the State AIM program for the second preceding fiscal year, the Secretary shall ensure that for each quarter in the following fiscal year, the State spends at least the shared savings amount determined for the State for the fiscal year on 1 or more of the core applications described in paragraph (3). Amounts expended by a State to meet the requirement of the preceding sentence shall not be subject to any Federal matching payments under this title. </text></subparagraph><subparagraph id="idbec6304a06bf4a13b998212658f9ffb4" commented="no"><enum>(B)</enum><header>Shared savings amount defined</header><text>In this subsection, the term <term>shared savings amount</term> means, with respect to an AIMP-participating State for a fiscal year, the amount by which the AIMP assistance expenditures for the fiscal year is less than 85 percent of the expenditures for such assistance under the State AIM program for the second preceding fiscal year.</text></subparagraph></paragraph><paragraph id="idb6f12b7beb2a41f3bc8cf6b80462f4eb" commented="no"><enum>(2)</enum><header>Application of shared savings</header><text>The Secretary shall issue guidance outlining allowable use of the shared savings payments under paragraph (1). Under such guidance, the Secretary shall outline the types of services and benefits for which a State has the authority to apply the payments for the benefit of consumers who are AIMP-eligible individuals. Such guidance shall permit the use of such payments consistent with the core applications described in paragraph (3) and with paragraph (4), and may be used for existing State-funded health programs or new health-related initiatives that serve full-benefit dual eligible individuals under this title.</text></paragraph><paragraph id="id876f6e32b669436eb3009b1b1c7873ae" commented="no"><enum>(3)</enum><header>Core applications</header><text>The core applications described in this paragraph for such consumers are as follows:</text><subparagraph id="id84c932f6573b4b1a823fb12705ec4882" commented="no"><enum>(A)</enum><header>Consumer power and choice</header><text>To provide such consumers more information and control over their health care and community support options.</text></subparagraph><subparagraph id="id3a68ae3bb5374d2e9448054b345fc07e" commented="no"><enum>(B)</enum><header>Equity and access to care</header><text>To improve access to, and quality of, care across populations, advance health equity for consumers, and reduce health disparities and eliminate barriers to care. </text></subparagraph><subparagraph id="id494b2cc8512040d08a83a877ea497917" commented="no"><enum>(C)</enum><header>Prevention and wellness</header><text>To strive to better enable such consumers to receive individualized health care that is outcomes-oriented and focused on prevention, wellness, recovery and maintaining independence.</text></subparagraph><subparagraph id="idc9290d820e1b44d49f5c0a89a997226e" commented="no"><enum>(D)</enum><header>Pay for performance</header><text>To employ purchasing and payment methods that encourage and reward service quality and cost-effectiveness by linking reimbursements for services to such consumers to common, evidence-based quality performance measures, including patient satisfaction.</text></subparagraph><subparagraph id="id3dd0937bfc7e4c11a9f04c5560e9fb29" commented="no"><enum>(E)</enum><header>Innovative advancement</header><text>To implement innovative and technological advancements that facilitate such consumers remaining in the community.</text></subparagraph><subparagraph id="id48de184b947c41ef8a2eb039765e6503" commented="no"><enum>(F)</enum><header>Service integration</header><text>To increase integration of services with social needs to improve health outcomes for such consumers.</text></subparagraph><subparagraph id="idbad043542d8543de954377eb0fb78e22" commented="no"><enum>(G)</enum><header>State personnel</header><text>To hire additional State personnel to carry out this title.</text></subparagraph><subparagraph id="idb2bed59d2cb04bb383e7d384aa53e107" commented="no"><enum>(H)</enum><header>Capacity building</header><text>To expand capacity in providing services to such consumers, such as in—</text><clause id="id5d647073f89d48e1b6c9f9fa0e4c5ecb" commented="no"><enum>(i)</enum><text>community-based care; and</text></clause><clause id="id225ca789b588403897c907bb3e23d8ae" commented="no"><enum>(ii)</enum><text>caregiver assistance.</text></clause></subparagraph><subparagraph commented="no" id="id530EEA6157194861AEF0E44ABB0684DE"><enum>(I)</enum><header>Improve enrollment policies and process</header><text>To improve the ability to enroll in the State AIMP program through streamlining enrollment policies and processes.</text></subparagraph><subparagraph commented="no" id="id6E9599B8D1F44893848A1C2B495884DB"><enum>(J)</enum><header>Increase education for providers and beneficiaries</header><text>To ensure providers and beneficiaries understand the State AIMP program and the choices available under such program.</text></subparagraph><subparagraph commented="no" id="id140765F9C7C14FE09E6FE31D50E6FA9B"><enum>(K)</enum><header>Improve data collection regarding racial disparities and health inequities</header><text>To ensure appropriate data is collected and used to determine program inequities.</text></subparagraph><subparagraph commented="no" id="idF6022424152043CFB6887B45766DE54E"><enum>(L)</enum><header>Other services and initiatives</header><text>Other services and initiatives approved by the Secretary that serve full-benefit dual eligible individuals under this title. </text></subparagraph></paragraph><paragraph id="id6bb74555b6a44286903f37246dabf9e2" commented="no"><enum>(4)</enum><header>Limitation on payment to AIMP-administering entities</header><text>An AIMP-participating State may use payments under this subsection for an AIMP-administering entity only if the State demonstrates, to the satisfaction of the Secretary, that the State’s AIM program provides appropriate maintenance of access to and quality of care based on the requirements imposed by the State on the applicable AIMP-administering entities.</text></paragraph></subsection><subsection id="id601bd95594b94944a5636f739900a739"><enum>(e)</enum><header>Application of medicaid payment methodologies financing limitations for the non-Federal share of expenditures</header><paragraph id="id7eee5cb51600401eaec29d187b0bd0d3"><enum>(1)</enum><header>In general</header><text>Except as the Secretary may otherwise provide through notice and comment regulation, the following provisions of title XIX (and related regulations) shall apply to AIMP-participating States’ expenditures in the AIM program in a manner similar to the manner in which such provisions apply under title XIX:</text><subparagraph id="id18A97D04F70D4519832097E1F655208E"><enum>(A)</enum><text>Section 1903(d) (relating to estimated payments, recovery of overpayments, disallowance of provisions).</text></subparagraph><subparagraph id="id955697DD355A4764B8321893BA7B63B3"><enum>(B)</enum><text>Section 1903(w) (relating to provider-related donations, health care related taxes, and broad-based health care related taxes).</text></subparagraph><subparagraph id="idCFB6B5EB11844F01B1AFA34D082FEDC8"><enum>(C)</enum><text>Section 1903(w)(6) (relating to certified public expenditures and intergovernmental transfers).</text></subparagraph><subparagraph id="id21C5555B0E9049F8978A2785475172DD"><enum>(D)</enum><text>Other provisions relating to deferral of payments, preventing fraud and abuse, and ensuring program integrity.</text></subparagraph></paragraph><paragraph id="id74662ce790ad4e38ace97be13879927c"><enum>(2)</enum><header>Processes and forms</header><subparagraph id="idc1fd1cdc40b347669fa2717fcd72a8b2"><enum>(A)</enum><header>In general</header><text>The Secretary shall establish appropriate forms and processes (including expenditure reconciliation processes) for submission of information on State expenditures under this title in a manner similar to the processes used for purposes of payments to States under title XIX, but through the use of such alternative forms as may be appropriate in implementing this title.</text></subparagraph><subparagraph id="id0129f716cc8b478dbd77b1f37208b35c"><enum>(B)</enum><header>Reporting of estimated expenditures by quarter</header><text>An AIMP-participating State shall estimate matchable expenditures (including both total expenditures as well as the estimated Federal share of those expenditures) and separately report these expenditures by quarter for each fiscal year for its AIM program. The Secretary shall make Federal funds available based upon the State's estimate, as approved by the Secretary.</text></subparagraph><subparagraph id="id3364d76f60a8428ea1d4c569296a3620"><enum>(C)</enum><header>Reporting and reconciliation of actual expenditures on a quarterly basis</header><text>Not later than 30 days after the end of each quarter, each AIMP-participating State shall submit to the Secretary (on an appropriate form) a quarterly expenditure report, showing expenditures made in the quarter just ended under its AIM program. The Secretary shall reconcile expenditures so reported with Federal funding previously made available to the State under this section and include the reconciling adjustment in the finalization of the grant award to the State.</text></subparagraph></paragraph><paragraph id="id3E91BB29313E4223B2E01E7DFAD56363"><enum>(3)</enum><header>Rule of construction</header><text>Nothing in this title shall be construed as constraining or limiting the authority of the Secretary, the Administrator of the Centers for Medicare & Medicaid Services, the Inspector General of the Department of Health and Human Services, or the Comptroller General of the United States, to conduct routine and targeted program and financial management audits and other oversight activities of funds expended under this title, including oversight activities relating to the allowable use of funds.</text></paragraph></subsection><subsection id="idB3D8464A610D403FA45842E78606814B"><enum>(f)</enum><header>Option for multi-Year investment initiative</header><text>The Secretary may specify a process by which an AIM-participating State may elect to participate in a multi-year investment initiative during the first 3-year period in which the State participates in the AIM program. Under such option, an AIM-participating State shall be eligible for additional Federal financial participation (as determined by the Secretary) for expenditures under this title that do not exceed an annual budget target established for the State, based on the expenditures of the State used to determined the base AIMP State percentage under subsection (c)(1)(B), and increased for the 2d and 3rd years of such period, by 9.99 percent over the budget target established for the preceding year. </text></subsection></section><section id="ida282204990584efe832959212764e22d"><enum>2209.</enum><header>Accountability and oversight</header><subsection id="id6a74fa81e68140f5965de1e6ccda9207"><enum>(a)</enum><header>Quality assessment</header><text>To ensure that full-benefit dual eligible individuals receive high quality care and to encourage quality improvement under AIM programs, each AIM-participating State shall establish a quality incentive program that uses financial rewards, penalties, or both that are meaningful enough to influence the administering entity’s behavior and is approved by the Federal Coordinated Health Care Office. Each AIM program will be expected to tie financial incentives to performance either in the form of quality withholds or incentives, such as making additional quality payments to an AIMP-administering entity that achieves quality or equity goals or the withholding of a portion of a capitation payment to an entity that fails to achieve such goals. Each AIM-participating State shall publicly post and seek comment on its proposed quality incentive program prior to submitting to the Federal Coordinated Health Care Office for approval.</text></subsection><subsection id="iddccee9edaea842fe8a93287f81af0a74"><enum>(b)</enum><header>Monitoring and program evaluation</header><paragraph id="id4607067dc24144ea9d8d3303ba3d5fef"><enum>(1)</enum><header>Consolidated reporting requirements for aim-administering entities</header><text>The Secretary and each AIMP-participating State shall define and specify in the contract for each AIMP-administering entity under this title a consolidated reporting process that ensures the provision of the necessary data on diagnosis, HEDIS measures, encounter reports, enrollee satisfaction, and evidence-based measures and other information as may be useful in order to monitor each AIMP-administering entity’s performance under the AIMP contract.</text></paragraph><paragraph id="idaff576f2083d4524a167bb16f77fa9e2"><enum>(2)</enum><header>Evaluation</header><text>The Secretary and each AIMP-participating State shall develop processes and protocols for collecting (or ensuring that AIMP-administering entities collect) and reporting to the Secretary and the State the data needed for an evaluation by the Secretary to measure the impact of AIMP-administering entities, the effectiveness of the process in enrolling AIMP-eligible individuals under the AIM program, and the effectiveness of the AIM program in reducing disparities, improving quality of care, and advancing health equity. </text></paragraph><paragraph id="idfe8617e57bd3415fa40d432ef5ccd864"><enum>(3)</enum><header>Collaborative evaluation</header><text>The Secretary and AIMP-participating States shall collaborate on and coordinate during any evaluation activity conducted under this subsection.</text></paragraph></subsection><subsection id="id25fe6a8a1a9b4881ac54389ad7d8b094"><enum>(c)</enum><header>Administrative oversight responsibilities</header><paragraph id="id0e6a3b4572f14e558aaf30cf76be2c14"><enum>(1)</enum><header>State role</header><text>Each AIMP-participating State shall be responsible for day-to-day oversight of the AIMP-administering entities providing services with respect to AIMP enrollees under the AIMP contract with the State under its AIM program. Such oversight shall include the following activities:</text><subparagraph id="id39d4939ac4fe4a94b778d2f121ecddea"><enum>(A)</enum><text>Conducting a comprehensive readiness review of each entity (as required under section 2201(d)).</text></subparagraph><subparagraph id="idcdf59c43573b4ebca3e72ea2b09c1be9"><enum>(B)</enum><text>Monitoring compliance of the entity with the terms of its AIMP contract under the AIM program, including—</text><clause id="id95b1d73a614c4afc92f61fce83e74157"><enum>(i)</enum><text>ensuring adherence to and protection of enrollee rights as provided under this title;</text></clause><clause id="id6449d7fcd4be48a8baf75ca627821884"><enum>(ii)</enum><text>monitoring the entity to ensure it authorizes, arranges, coordinates, and provides all covered and medically necessary services (as required under this title) to AIMP enrollees receiving benefits administered by the entity, in accordance with the requirements of the AIMP contract; and </text></clause><clause id="idf6e9f524cf214b169d22222d3a8b2a51"><enum>(iii)</enum><text>ensuring compliance with applicable reporting requirements under this title.</text></clause></subparagraph><subparagraph id="id8de6783c43c34d7f9dd6a0aa06e5817e"><enum>(C)</enum><text>Reviewing, approving, and monitoring—</text><clause id="ide45c113e16de422386dcba8f58ced8af"><enum>(i)</enum><text>the entity’s network adequacy;</text></clause><clause id="idaa013e03a4774901845b23dc7732a69b"><enum>(ii)</enum><text>the outreach and orientation materials and procedures of the entity;</text></clause><clause id="id2c9d4b4f725449b7a2ae505d9e9e621f"><enum>(iii)</enum><text>the complaint and appeals procedures carried out by the entity;</text></clause><clause id="id1cc76a7742d24140b1ea04df9034fe88"><enum>(iv)</enum><text>the utilization management functions of the entity;</text></clause><clause id="id7c2d588198aa4b0aabb7a17ca0e6862d"><enum>(v)</enum><text>the entity’s adherence to required continuity of care provisions under section 2204(c)(3);</text></clause><clause id="id1e9ab723b4834aa682cdc09d72d6075a"><enum>(vi)</enum><text>the entity’s use of required standard assessment tool under section 2204(b);</text></clause><clause id="id64c5aa9335584d5fb604821db2b7c5e1"><enum>(vii)</enum><text>the entity’s informational materials, particularly for those individuals who will be assigned to the entity under section 2203(f); and</text></clause><clause id="idb60809f0e90f435084a1b43b90622167"><enum>(viii)</enum><text>the entity's use of streamlined eligibility processes under this title. </text></clause></subparagraph><subparagraph id="idb9473f7c3a234c629406773703caff22"><enum>(D)</enum><text>Conducting monthly (or more frequent) performance review meetings with the entity.</text></subparagraph><subparagraph id="id9e8ead83d04f4f4a8b39e529b8bb5c0f"><enum>(E)</enum><text>Conducting periodic audits of the entity, including at least an annual independent external review and an annual site visit.</text></subparagraph><subparagraph id="idf3eea93e7d214757833ca93215c29450"><enum>(F)</enum><text>Receiving and responding to complaints about the entity.</text></subparagraph><subparagraph id="idff525291486948de8e4f391fadf0968f"><enum>(G)</enum><text>Conducting annual surveys of AIMP enrollees and providing the entity with written results of such surveys.</text></subparagraph><subparagraph id="id9fce9d097fe24bb287dccc56a77a3d01"><enum>(H)</enum><text>Applying 1 or more sanctions (such as those provided under title XIX), which may include termination of the contract, if the State or the Secretary determines that the entity is in material violation of any of the terms of the AIMP contract.</text></subparagraph></paragraph><paragraph id="id1c18e936813a441ba353d3fbbf5398c2" commented="no"><enum>(2)</enum><header>Federal oversight role</header><subparagraph id="idB7AB89DCCD754FEDAA74377C8ACD2EF6" commented="no"><enum>(A)</enum><header>In general</header><text>The Secretary shall be responsible for the oversight of AIMP-participating States. Such oversight shall include activities developed through engagement with stakeholders, including consumer advocates, and shall include at the least the following activities: </text><clause id="id26c392f9e92d45f2afc1d365808ab6d9" commented="no"><enum>(i)</enum><text>Monitoring the process to select organizations to serve as AIMP-administering entities under the AIM program.</text></clause><clause id="id42ef45521bbb42c1a272b70a43e28e56" commented="no"><enum>(ii)</enum><text>Conducting a thorough readiness review of the State (before readiness reviews for such organizations) under section 2201(d)(2).</text></clause><clause id="id8e590fda6ac34617a9f1e623c735863b" commented="no"><enum>(iii)</enum><text>Ensuring, including through complaint tracking and secret shopping, the State creates and maintains a highly functional, dedicated AIMP Ombudsman program under section 2205(c). </text></clause><clause id="id5b784a0a37ef43a88f739c51e747480b" commented="no"><enum>(iv)</enum><text>Ensuring, through direct monitoring, State oversight of compliance of AIMP-administering entities with the terms of their AIMP contracts under the AIM program. </text></clause><clause id="id5acb8e6239ed4ca3b7190f2fc943eed7" commented="no"><enum>(v)</enum><text>Reviewing eligibility and enrollment processes and procedures.</text></clause><clause id="id06a26f11f7064bb7bf6602ad14f89fa2" commented="no"><enum>(vi)</enum><text>Monitoring State data systems to ensure they are sufficient for providing timely data on program performance.</text></clause><clause commented="no" id="idAE44C66F41A64CF18FA6114FAEE87161"><enum>(vii)</enum><text>Ensuring payment rates to AIMP-administering entities under the AIMP contract are actuarially sound, including by establishing a rate setting process established through rulemaking whereby, at a minimum—</text><subclause commented="no" id="id22DC432D7E0E41189CF658A8044CC585"><enum>(I)</enum><text>States and the Secretary provide AIMP-administering entities with comprehensive and timely data as part of the rate setting process and procurement, including historical Medicaid and Medicare cost and utilization data for full-benefit dual eligible individuals by region and including detailed categories of service;</text></subclause><subclause commented="no" id="idA5CC43A1DDF843278C887810EF37F8B5"><enum>(II)</enum><text>States may elect to share the final rate certification package provided to the Secretary with AIMP-administering entities; and</text></subclause><subclause commented="no" id="id4909BEDDC02648E5A8D7E4A17A45E044"><enum>(III)</enum><text>an opportunity for public input is established for annual rate setting or when rates are significantly modified whereby stakeholders, including patient advocacy groups, health care providers, and AIMP-administering entities, can provide feedback to the Secretary prior to rate approval. </text></subclause></clause><clause id="ide841aeb0b7ac49eab4ffb99ec3bb286f" commented="no"><enum>(viii)</enum><text>Coordinating periodic audits of the State with respect o its AIM program.</text></clause><clause id="idf20b157ab03c4caaa0ee0c611f2a4862" commented="no"><enum>(ix)</enum><text>Conducting regular meetings with the State.</text></clause><clause id="id46a6526b4d434927be458f53674d3179" commented="no"><enum>(x)</enum><text>Applying discretionary action, if warranted.</text></clause><clause id="id2b0201a351ed48389432a252c4b21a01" commented="no"><enum>(xi)</enum><text>Ensuring regular engagement with dually eligible individuals and their caregivers. </text></clause></subparagraph><subparagraph id="id4f6cb066b8be4f0bbdf92613e32685fa" commented="no"><enum>(B)</enum><header>Compliance authority</header><text>If the Secretary finds with respect to a State AIM program that the State failed to achieve the appropriate performance levels or compliance with the activities required under subparagraph (A), the Secretary shall take such action as is necessary to address and correct the State failures, which may include, to the extent the Secretary determines appropriate, 1 or more of the following:</text><clause id="id5FA80FC1B7404601ACB95A9D547AB48E" commented="no"><enum>(i)</enum><text>Developing in consultation with the State, a corrective compliance plan for achieving appropriate performance levels or compliance.</text></clause><clause id="idA1D3FF797018496AB891B966CA8CCA6E" commented="no"><enum>(ii)</enum><text>Remedial education and supervised training.</text></clause><clause id="id725CEA04F4B14BDCB310BA8D063FDD96" commented="no"><enum>(iii)</enum><text>Imposition of penalties or sanctions.</text></clause><clause id="id09457BFE11F04262BDDF72452033B1B7" commented="no"><enum>(iv)</enum><text>Removal of the State from the AIM program. </text></clause></subparagraph></paragraph><paragraph id="id9256d49a4ef041a49ebe06f4201f22fe"><enum>(3)</enum><header>State-federal partnership role through joint contract management teams (cmt)</header><subparagraph id="id4881553689fe4a1d8c215534f1f443b4"><enum>(A)</enum><header>Establishment</header><text>The Secretary shall, jointly with each AIMP-participating State, establish a Joint Contract Management Team (in this paragraph referred to as a <quote>CMT</quote>) following the model used in the demonstration projects conducted under the Financial Alignment Initiative for Medicare-Medicaid Enrollees administered by the Federal Coordinated Health Care Office.</text></subparagraph><subparagraph id="idec2220274c1d453ab6f25f638f9a1ea6"><enum>(B)</enum><header>Composition and structure</header><clause id="id8fa36000086f4bf9b88c3b95bb18b68a"><enum>(i)</enum><header>In general</header><text>Each CMT shall include at least 1 contract officer from the Centers for Medicare & Medicaid Services and at least 1 contract officer from the AIMP-participating State, each of whom is authorized and empowered to represent the Secretary and the State, respectively, about all aspects of the AIMP contract with an AIMP-administering entity under the AIM program of the State.</text></clause><clause id="idcde9b278fe544f1fba1ddbf6df7a5617"><enum>(ii)</enum><header>Lead</header><text>The representation from the Federal Government shall be led by the individual from the Federal Coordinated Health Care Office who is assigned to work with the State, who will bring in additional individuals, as appropriate.</text></clause><clause id="idee21c9a5c5f84ad3b54ed60691cc0d98"><enum>(iii)</enum><header>State lead</header><text>The representation from the AIMP-participating State shall be led by the Director of the State Medicaid program under title XIX (or such Director’s designee) who will bring in additional individual to represent the State, as appropriate.</text></clause></subparagraph><subparagraph id="id77ecf8fc7ff343fb9ab2573a73809644"><enum>(C)</enum><header>Responsibilities of cmt</header><text>Each CMT for a State shall act as a liaison among the AIMP-administering entity, the Secretary, and the State for the duration of the AIMP contract with such entity and shall serve to facilitate communications and operations among the 3 parties. Each CMT shall, among other functions—</text><clause id="id0313e50adf8643ed90254cc3267a839e"><enum>(i)</enum><text>receive and respond to complaints;</text></clause><clause id="id4a48684ebf3b49ceb5078cbb1945db1f"><enum>(ii)</enum><text>conduct quarterly meetings among the parties;</text></clause><clause id="ida301342d1ddd4d12b9d54b587bb9502e"><enum>(iii)</enum><text>establish a mechanism for ongoing consumer engagement;</text></clause><clause id="id08965321b512486883808aab9a2d9597"><enum>(iv)</enum><text>coordinate requests for assistance from the entity and assign Federal and State staff with appropriate expertise to provide technical assistance to the entity;</text></clause><clause id="id1c5c040606974ce389c8a6457b710cec"><enum>(v)</enum><text>make best efforts to resolve any issues applicable to the parties; and</text></clause><clause id="id72ca34e45fbb48aa8f06c8bfaf46460e"><enum>(vi)</enum><text>monitor any discretionary action by the State or the Secretary under the provisions of the AIMP contract.</text></clause></subparagraph></paragraph></subsection></section><section id="id8c3b1538456043f6a83773ee68eed003"><enum>2210.</enum><header>Definitions; miscellaneous provisions</header><subsection id="id50fccd37d1b74395abc9533d3026f4cf"><enum>(a)</enum><header>Definitions</header><text>In this title:</text><paragraph id="idca8656dd4f64402b948142c15ad281ad"><enum>(1)</enum><header>Terms relating to AIMP</header><subparagraph id="id159e996e0d834ffc8729e65c92814477"><enum>(A)</enum><header>AIMP-administering entity</header><text>The term <term>AIMP-administering entity</term> means an organization that has been determined to meet the requirements for such an entity under this title and has an AIMP contract with an AIMP-participating State under this title.</text></subparagraph><subparagraph id="id09d40c2867ab4b96b36c76b82494cdab"><enum>(B)</enum><header>AIMP assistance</header><text>The term <term>AIMP assistance</term> has the meaning given such term in section 2208(a)(1)(B).</text></subparagraph><subparagraph id="id7a603bc0073a4c6597949bcc4ec867c2"><enum>(C)</enum><header>AIMP contract</header><text>The term <term>AIMP contract</term> is a contract described in section 2207(b)(1).</text></subparagraph><subparagraph id="idbfe5068dea944e3aaf9fb7e4ae00a11b"><enum>(D)</enum><header>AIMP-eligible individual</header><text>The term <term>AIMP-eligible individual</term> has the meaning given such term in section 2202(a).</text></subparagraph><subparagraph id="idd6d6e4fd06c84a09b6bef5f970c423d7"><enum>(E)</enum><header>AIMP enrollee</header><text>The term <term>AIMP enrollee</term> means an individual who is enrolled in an AIM program under this title.</text></subparagraph><subparagraph id="id9d8c750b8c3343ca912b28dbffa771ac"><enum>(F)</enum><header>AIMP-participating State</header><text>The term <term>AIMP-participating State</term> means a State administering an AIM program under this title.</text></subparagraph><subparagraph id="id5bd4ec97bcde4b3a93c44bc21b8251f7"><enum>(G)</enum><header>AIM program; AIMP</header><text>The terms <term>AIM program</term> and <term>AIMP</term> mean, with respect to a State, the program established by the State under this title.</text></subparagraph></paragraph><paragraph id="id55c4c8490867444cb6a762934879958e"><enum>(2)</enum><header>Other definitions</header><subparagraph id="id205a75244dad42e2bc80dbdf6f27bc13"><enum>(A)</enum><header>Full-benefit dual eligible individual</header><text>The term <term>full-benefit dual eligible individual</term> has the meaning given such term in section 1935(c)(6) but without the application of subparagraph (A)(i) of such section.</text></subparagraph><subparagraph id="id98a7f4a38add46cc94a9a77be24f9a9f"><enum>(B)</enum><header>Federal Coordinated Health Care Office</header><text>The term <term>Federal Coordinated Health Care Office</term> means the office established under section 2602 of the Patient Protection and Affordable Care Act. </text></subparagraph><subparagraph id="idB1EA0745D5554AD38C9CD4C80C25B19D"><enum>(C)</enum><header>Medicaid managed care organization</header><text>The term <term>medicaid managed care organization</term> has the meaning given that term in section 1903(m)(1)(A) and includes a prepaid inpatient health plan, as defined in section 438.2 of title 42, Code of Federal Regulations (or any successor regulation) and a prepaid ambulatory health plan, as defined in such section (or any successor regulation).</text></subparagraph></paragraph></subsection><subsection id="id013bd4cd2f7e45129b863a1dcc63e7fb"><enum>(b)</enum><header>Miscellaneous provisions</header><paragraph id="idf1278b4f8bbb4ad492767c231b82be77"><enum>(1)</enum><header>Relation to other requirements</header><text>Except as otherwise provided under this title or by regulation, the requirements of title XIX shall apply under an AIM program in relation to AIMP-eligible individuals, AIMP enrollees, and the provision of benefits under an AIM program, in the same manner as such requirements apply with respect to individuals eligible for medical assistance who are enrolled in under a medicaid managed care organization.</text></paragraph><paragraph id="id9f732c39b82546c59cd284aa29c65b06"><enum>(2)</enum><header>Limitation on waiver authority</header><text>Except as provided in this title, the Secretary is not authorized (under section 1115, 1115A, or otherwise) to waive the requirements specified in this title.</text></paragraph></subsection></section>.(b)Conforming amendments to medicare(1)Section 1851(a) of the Social Security Act (42 U.S.C. 1395w–21(a)) is amended by adding at the end the following new paragraph:(4)Additional enrollment option for certain full-benefit dual eligible individualsFull-benefit dual eligible individuals may also be eligible to enroll under a State AIM program under title XXII..(2)During the period in which an AIM program is fully implemented in an AIMP-participating State under title XXII, AIMP-eligible individuals in the State may not enroll in a managed Medicare and other integrated duals product (other than a PACE program).(c)Conforming amendments to medicaid(1)Preventing duplicate paymentsSection 1903(i) of the Social Security Act (42 U.S.C. 1396(i)) is amended—(A)by striking or
at the end of paragraph (26);(B)by striking the period at the end of paragraph (27) and inserting ; or
; and(C)by inserting after paragraph (27) the following new paragraph:(28)with respect to any amount expended for medical assistance for an individual who is an AIMP enrollee under a State AIM program under title XXII, except specifically permitted under such title..(2)Note: Additional conforming amendments to be provided.(d)Section 2602(d) of the Patient Protection and Affordable Care Act (42 U.S.C. 1315b(d)) is amended by adding at the end the following:(9)To be primarily responsible for the Federal administration of title XXII of the Social Security Act..(e)Other conforming amendmentsSection 1101(a)(1) of the Social Security Act (42 U.S.C. 1301(a)(1)) is amended—(1)by striking XIX, and XXI
and inserting XIX, XXI, and XXII
; and(2)by striking XIX and XXI
and inserting XIX, XXI, and XXII
.3.(a)The Medicare Payment Advisory Commission shall conduct a study for purposes of making recommendations regarding how to improve health care and other support needs of individuals who are eligible for and are receiving medical assistance for the payment of medicare cost-sharing under a State Medicaid program pursuant to clause (i), (iii), or (iv) of section 1902(a)(10)(E) of the Social Security Act (42 U.S.C. 1396a(a)(10)(E)).(b)Not later than 18 months after the date of enactment of this Act, the Medicare Payment Advisory Commission shall submit to Congress a report on the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Commission determines to be appropriate.