To amend title XIX of the Social Security Act to require States to take into account performance when assigning individuals to managed care entities under the Medicaid program.

To amend title XIX of the Social Security Act to require States to take into account performance when assigning individuals to managed care entities under the Medicaid program.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. Short title.

SEC. 2. Requiring States to take into account performance when assigning individuals to managed care entities under the Medicaid program.

(a) In general.—Section 1932(a)(4) of the Social Security Act (42 U.S.C. 1396u–2(a)(4)) is amended-—

(1) in subparagraph (D)(ii)(II), by striking “the equitable” and all that follows through the period and inserting “the performance score of such entities, as determined under the system established by the State under subparagraph (E).”; and

(2) by adding at the end the following new subparagraph:

“(E) PERFORMANCE.—

“(i) IN GENERAL.—A State shall—

“(I) establish a system to evaluate the performance of managed care entities participating under the State plan (or wavier of such plan) of such State; and

“(II) on an annual basis, publish a report—

“(aa) evaluating the differences in default enrollments made taking into account the performance scores of managed care entities under this subparagraph compared to such enrollments that would have been made had such scores not been taken into account; and

“(bb) quantifying any estimated reduction in expenditures under such plan (or waiver) attributable to taking into account such scores in default enrollments.

“(ii) SCORE.—Under the system established by a State under clause (i), the State shall assign a performance score for each managed care entity described in such clause based on such cost and outcome measures and such individual satisfaction measures as determined appropriate by the State. Measures used under such system may include, with respect to individuals enrolled under such entity, measures of the performance of such entity (compared to the risk-adjusted expected performance of such entity) with respect to the following:

“(I) Expenditures for medical assistance.

“(II) Potentially avoidable hospital readmissions.

“(III) Potentially avoidable emergency department visits.

“(IV) Potentially avoidable hospital admissions.

“(V) Satisfaction scores from such individuals and the rate at which such individuals elect to terminate enrollment with such entity.”.

(b) Effective date.—The amendments made by this section shall apply with respect to the enrollment of individuals in managed care entities under a State plan under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), or under a waiver of such plan, on or after January 1, 2028.