HR 2758 IHCommentsClose CommentsPermalink

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

June 8, 2009CommentsClose CommentsPermalink

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

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

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

(a) Short Title- This Act may be cited as the ‘Medicare Specialty Care Improvement and Protection Act of 2009’.CommentsClose CommentsPermalink





(b) Table of Contents- The table of contents of this Act is as follows:CommentsClose CommentsPermalink





Sec. 1. Short title; table of contents.CommentsClose CommentsPermalink





Sec. 2. Extension of SNP authority through December 31, 2013.CommentsClose CommentsPermalink





Sec. 3. Improve risk adjustment for high-risk, high-cost beneficiaries.CommentsClose CommentsPermalink





Sec. 4. Additional enhancements to ensure payment equity for specialized MA plans.CommentsClose CommentsPermalink





Sec. 5. Advance alignment of Medicare and Medicaid for dual eligibles.CommentsClose CommentsPermalink





Sec. 6. Continuous eligibility for Medicaid for certain individuals.CommentsClose CommentsPermalink





Sec. 7. Definitions.CommentsClose CommentsPermalink

SEC. 2. EXTENSION OF SNP AUTHORITY THROUGH DECEMBER 31, 2013.

Section 1859(f) of the Social Security Act (42 U.S.C. 1395w-28(f)), as amended by section 164(a) of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275), is amended by striking ‘2011’ and inserting ‘2014 (or before January 1, 2016, in the case of a Fully Integrated Dual Eligible Special Needs Plan designated under section 5(a)(1)(A) of the Medicare Specialty Care Improvement and Protection Act of 2009)’.CommentsClose CommentsPermalink

SEC. 3. IMPROVE RISK ADJUSTMENT FOR HIGH-RISK, HIGH-COST BENEFICIARIES.

(a) Evaluation-CommentsClose CommentsPermalink





(1) IN GENERAL- The Secretary shall evaluate the Medicare Advantage risk adjustment payment mechanism under section 1853(a)(1)(C) of the Social Security Act (42 U.S.C. 1395w-23(a)(1)(C)) and the risk adjustment payment mechanism under section 1860D-15(c)(1)(A) of such Act (42 U.S.C. 1395w-115(c)(1)(A)) in order to resolve plan payment inequities relative to Medicare fee-for-service payments for beneficiaries identified under paragraph (2).CommentsClose CommentsPermalink





(2) REQUIREMENTS- The evaluation conducted under paragraph (1) shall address the need for improving the adequacy of the existing hierarchical condition categories and pharmacy risk adjustment methods for Medicare Advantage plans that exclusively or disproportionately serve high-risk beneficiaries as it relates to--CommentsClose CommentsPermalink





(A) accurately predicting costs relative to Medicare fee-for-service for beneficiaries with--CommentsClose CommentsPermalink





(i) sustained high-risk scores over multiple contract periods;CommentsClose CommentsPermalink





(ii) sustained high costs over multiple contract periods;CommentsClose CommentsPermalink





(iii) co-morbid chronic conditions;CommentsClose CommentsPermalink





(iv) diagnoses not included in the risk-adjustment methodology, including dementia and other cognitive impairments;CommentsClose CommentsPermalink





(v) physical disabilities, developmental disabilities, or both; andCommentsClose CommentsPermalink





(vi) frailty;CommentsClose CommentsPermalink





(B) accurately predicting costs relative to Medicare fee-for-service for beneficiaries near the end of life;CommentsClose CommentsPermalink





(C) accurately predicting costs relative to Medicare fee-for-service for other conditions for which the current risk adjustment methodology underpays in relation to Medicare fee-for-service, as determined by the Secretary;CommentsClose CommentsPermalink





(D) further gradations of diseases and conditions to better reflect stage of condition, condition severity, and costs related to burden of illness;CommentsClose CommentsPermalink





(E) accounting for costs of pre-existing conditions at the time of initial enrollment for new entrants into Medicare; andCommentsClose CommentsPermalink





(F) enhancing coding persistency by calculating risk scores using data covering at least 2 years.CommentsClose CommentsPermalink





(b) Use of the Results of the Study for Refinements-CommentsClose CommentsPermalink





(1) REFINEMENTS-CommentsClose CommentsPermalink





(A) IN GENERAL- Beginning with plan year 2011, the Secretary, using the results of the evaluation conducted under subsection (a)(1), shall refine the risk adjustment payment mechanisms referred to in subsection (a)(1) for beneficiaries identified under subsection (a)(2). The Secretary shall make additional refinements, as appropriate, for subsequent plan years.CommentsClose CommentsPermalink





(B) PROTECTION- To the extent that the Secretary determines that the risk adjustment payment mechanisms referred to in subsection (a)(1) do not accurately pay for Medicare beneficiaries identified under subsection (a)(2), the Secretary shall ensure that no Medicare Advantage plan that exclusively or disproportionately serves high-risk beneficiaries is paid less, in the aggregate, than 100 percent of Medicare fee-for-service payment rates (as determined under section 1853(c)(1)(D)(i)).CommentsClose CommentsPermalink





(C) RECALIBRATION- Beginning with plan year 2011, the Secretary shall recalibrate the risk adjustment payment mechanisms referred to in subsection (a)(1) so that the overall predicted costs for all Medicare beneficiaries are identical to what they would have been in the absence of the new risk adjustment payment mechanism.CommentsClose CommentsPermalink





(2) BUDGET NEUTRAL ADJUSTMENTS- If the Secretary determines that the application of paragraph (1) results in expenditures under title XVIII of the Social Security Act that exceed the expenditures under such title that would have been made without such application, the Secretary shall provide for an appropriate adjustment to payment rates under part C of such title for beneficiaries for whom the risk adjustment payment mechanism overpays in relation to Medicare fee-for-service in order to eliminate such excess.CommentsClose CommentsPermalink

SEC. 4. ADDITIONAL ENHANCEMENTS TO ENSURE PAYMENT EQUITY FOR SPECIALIZED MA PLANS.

(a) Accounting for Added Regulatory Costs- For plan year 2011 and subsequent plan years, the Secretary shall provide bonus payments to account for added SNP costs associated with additional benefit, care management, reporting, and other requirements established by Congress and the Secretary in excess of other Medicare Advantage plans.CommentsClose CommentsPermalink





(b) Ensuring Fair Bidding Practices- For plan year 2011 and subsequent plan years, the Secretary shall take into account the following factors with respect to the bid structure for SNPs:CommentsClose CommentsPermalink





(1) Dual eligibility.CommentsClose CommentsPermalink





(2) Geographic cost differences.CommentsClose CommentsPermalink





(3) Population characteristics.CommentsClose CommentsPermalink





(4) The differences in plan requirements, including differences in additional benefits, care management, and reporting requirements.CommentsClose CommentsPermalink





(5) The differences between community-based and regional or nationally based plans.CommentsClose CommentsPermalink





(c) Authority To Apply PACE Rules- For plan year 2011 and subsequent plan years, the Secretary may apply the payment rules under section 1894(d) of the Social Security Act (42 U.S.C. 1395eee(d)) to Fully Integrated Dual Eligible Special Needs Plans rather than the payment rules that would otherwise apply to such plans under part C.CommentsClose CommentsPermalink





(d) Budget Neutral Adjustments- If the Secretary determines that the application of subsections (a), (b), and (c) result in expenditures under title XVIII of the Social Security Act that exceed the expenditures under such title that would have been made without such application, the Secretary shall provide for an appropriate adjustment to payment rates under part C of such title for beneficiaries for whom the risk adjustment payment mechanism overpays in relation to Medicare fee-for-service in order to eliminate such excess.CommentsClose CommentsPermalink

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

(a) Medicare and Medicaid Integration Programs-CommentsClose CommentsPermalink





(1) DESIGNATION-CommentsClose CommentsPermalink





(A) IN GENERAL- For plan year 2011 and subsequent plan years, the Secretary shall have in place a process under which the Secretary designates dual eligible SNPs as Fully Integrated Dual Eligible Special Needs Plans for the purpose of advancing fully integrated Medicare and Medicaid benefits and services for dual beneficiaries, including State designated Dual subsets.CommentsClose CommentsPermalink





(B) CRITERIA FOR DESIGNATION- In order to be designated as a Fully Integrated Dual Eligible Special Needs Plan, the dual eligible SNP shall meet the following requirements:CommentsClose CommentsPermalink





(i) The dual eligible SNP provides dual eligibles with access to Medicare and Medicaid benefits specified by the State for Medicaid beneficiaries enrolled in integrated programs under a single managed care organization (MCO).CommentsClose CommentsPermalink





(ii) The dual eligible SNP has a contract in place with a State Medicaid agency that includes coverage of specified primary, acute, and long-term care benefits and services, consistent with State policy, under risk-based financing.CommentsClose CommentsPermalink





(iii) The dual eligible SNP coordinates the delivery of covered Medicare and Medicaid health and long-term care services, consistent with State policy, using aligned care management and specialty care network methods for high-risk beneficiaries.CommentsClose CommentsPermalink





(iv) The dual eligible SNP employs policies and procedures approved by the Secretary and the State to coordinate or integrate enrollment, member materials, communications, grievance and appeals, and quality assurance.CommentsClose CommentsPermalink





(v) The dual eligible SNP provides advanced person-centered, integrated care for the full array of primary, acute, and residential and home and community-based long-term care services, using a robust advanced medical home model that--CommentsClose CommentsPermalink





(I) empowers dual eligibles with serious chronic conditions and their family caregivers to optimize their health and well-being;CommentsClose CommentsPermalink





(II) provides a comprehensive array of patient-centered benefits and services designed to meet the unique needs of dual eligibles;CommentsClose CommentsPermalink





(III) helps dual eligibles and their family caregivers to access the right care, at the right time, in the right place, given the nature of their condition;CommentsClose CommentsPermalink





(IV) aligns the incentives of related care providers to improve transitions and care continuity; andCommentsClose CommentsPermalink





(V) optimizes total quality and cost performance across time, place, and profession.CommentsClose CommentsPermalink





(2) INTEGRATION AUTHORITY- In order to increase simplicity for dual eligibles in accessing and coordinating Medicare and Medicaid benefits, the Secretary, working in conjunction with States, on a State by State basis, consistent with existing statutory authority, is encouraged to establish a single administrative structure and process under titles XVIII and XIX for Fully Integrated Dual Eligible Special Needs Plans, under a three-way contract or Memorandum of Understanding, among CMS, the State, and related plans, for--CommentsClose CommentsPermalink





(A) the enrollment of dual eligibles;CommentsClose CommentsPermalink





(B) member materials and related communications;CommentsClose CommentsPermalink





(C) care management and model of care requirements;CommentsClose CommentsPermalink





(D) reporting, auditing, and performance evaluation;CommentsClose CommentsPermalink





(E) grievance and appeals procedures; andCommentsClose CommentsPermalink





(F) payment methods.CommentsClose CommentsPermalink





(3) ALIGNMENT OF MEDICARE AND MEDICAID POLICIES AND PROCEDURES FOR SNPS SERVING DUAL ELIGIBLES- In order to increase simplicity for dual eligibles in accessing and coordinating Medicare and Medicaid benefits by enhancing coordination between CMS and State Medicaid agencies in the oversight of SNPs insofar as they serve dual eligibles, the Secretary, working in collaboration with State Medicaid Agencies, may modify rules, policies, and procedures under titles XVIII and XIX of such Act in order to provide for the alignment of Medicare and Medicaid requirements, including marketing, enrollment, care coordination, auditing, reporting, quality assurance, and other relevant oversight functions.CommentsClose CommentsPermalink





(4) REPORTS TO CONGRESS-CommentsClose CommentsPermalink





(A) INTERIM REPORT- Not later than December 31, 2013, the Secretary shall submit to Congress an interim report on the impact of integrating Medicare and Medicaid benefits and services on total quality and cost performance in serving dual eligibles.CommentsClose CommentsPermalink





(B) FINAL REPORT- Not later than December 31, 2015, the Secretary shall submit to Congress a final report on the impact of integrating Medicare and Medicaid benefits and services on total quality and cost performance in serving dual eligibles.CommentsClose CommentsPermalink





(C) REQUIREMENT- A report under subparagraph (A) and (B) shall include recommendations for such legislative and administrative actions as the Secretary determines appropriate to further advance Medicare and Medicaid integration, including options for integrating Medicare and Medicaid funding, to facilitate ongoing improvements in total quality and cost performance in care of dual eligibles.CommentsClose CommentsPermalink





(D) QUALITY AND COST PERFORMANCE- Not later than 6 months after the date of the enactment of this Act, the Secretary, working in consultation with consumers, plans, and States, shall identify the measures and benchmarks to be used for evaluating cost and quality performance for purposes of subparagraph (C).CommentsClose CommentsPermalink





(b) Office of Medicare/Medicaid Integration-CommentsClose CommentsPermalink





(1) ESTABLISHMENT- The Secretary shall establish or designate an Office on Medicare/Medicaid Integration (in this subsection referred to as the ‘Office’) for the purpose of aligning Medicare and Medicaid policies and procedures and developing tools to support State integration efforts in order to--CommentsClose CommentsPermalink





(A) simplify dual eligible access to Medicare and Medicaid benefits and services;CommentsClose CommentsPermalink





(B) improve care continuity and ensure safe and effective care transitions;CommentsClose CommentsPermalink





(C) eliminate cost shifting between Medicare and Medicaid and among related care providers;CommentsClose CommentsPermalink





(D) eliminate regulatory conflicts between Medicare and Medicaid rules; andCommentsClose CommentsPermalink





(E) improve total cost and quality performance.CommentsClose CommentsPermalink





(2) RESPONSIBILITIES- The responsibilities of the Office are to develop policies and procedures to--CommentsClose CommentsPermalink





(A) oversee the designation, implementation, and oversight of Fully Integrated Dual Eligible Special Needs Plans under subsection (a)(1) in collaboration with the States, with authority to effectively align Medicare and Medicaid policy for dual eligibles;CommentsClose CommentsPermalink





(B) provide State Medicaid agencies with training, materials, technical assistance, and other resources in support of advancing Medicare and Medicaid integration in States where Fully Integrated Dual Eligible Special Needs Plans have been designated and other integration initiatives are being advanced to coordinate and align primary, acute, and long-term care benefits for dual eligibles through a State plan option or other means;CommentsClose CommentsPermalink





(C) identify incentives for States to advance the integration of Medicare and Medicaid to improve total cost and quality performance, including shared cost savings among consumers, plans, and Federal and State governments with respect to State initiatives for advancing Medicare and Medicaid integration;CommentsClose CommentsPermalink





(D) support State efforts to coordinate and align acute and long-term care benefits for dual eligibles through a State plan option or other means;CommentsClose CommentsPermalink





(E) provide support for coordination of State and Federal contracting and oversight for dual integration programs supportive of the goals described in paragraph (1);CommentsClose CommentsPermalink





(F) align Federal rules for Medicaid managed care and Medicare Advantage Plans to include methods for integrating marketing, enrollment, grievances and appeals, auditing, reporting, quality assurance, and other relevant oversight functions;CommentsClose CommentsPermalink





(G) serve as a liaison between CMS central and regional offices to ensure consistent application of CMS rules, policies, and auditing practices as such rules, policies, and auditing practices pertain to dual eligibles;CommentsClose CommentsPermalink





(H) monitor total combined Medicare and Medicaid costs in serving dual eligibles and make recommendations for optimizing total quality and cost performance across both programs; andCommentsClose CommentsPermalink





(I) work with the Congressional Budget Office and the Office of Management and Budget to establish a process for evaluating total Medicare and Medicaid spending for dual eligibles who are enrolled in Fully Integrated Dual Eligible Special Needs Plans such that the enrollment of such dual eligibles in such plans is treated as ‘budget neutral’ if the combined Medicare and Medicaid costs under such plans do not exceed the combined costs of providing Medicare and Medicaid services on a fee-for-service basis for a comparable risk group.CommentsClose CommentsPermalink





(3) FUNDING- For each of fiscal years 2010 through 2014, of the amount of the reductions in payments attributable to average per capita monthly savings described in paragraph (3)(C) or (4)(C) of section 1854(b) of the Social Security Act that are not provided as a monthly rebate under paragraph (1)(C) of such section, $2,000,000 shall be available for purposes of funding the Office.CommentsClose CommentsPermalink

SEC. 6. CONTINUOUS ELIGIBILITY FOR MEDICAID FOR CERTAIN INDIVIDUALS.

(a) In General- Section 1902(e) of the Social Security Act (42 U.S.C. 1396a(e)) is amended by adding at the end the following:CommentsClose CommentsPermalink





‘(14) The plan shall provide that an individual who has attained age 65 and has been determined for a period of 12 consecutive months to be a full-benefit dual eligible individual (as defined in section 1935(c)(6)) shall be presumed to remain eligible for benefits under the plan without any need for further redetermination or recertification.’.CommentsClose CommentsPermalink





(b) Effective Date- The amendment made by subsection (a) takes effect on January 1, 2010.CommentsClose CommentsPermalink

SEC. 7. DEFINITIONS.

In this Act:CommentsClose CommentsPermalink





(1) CMS- The term ‘CMS’ means the Centers for Medicare & Medicaid Services.CommentsClose CommentsPermalink





(2) DUAL ELIGIBLE- The term ‘dual eligible’ means an MA eligible individual (as defined in section 1851(a)(3) of the Social Security Act, 42 U.S.C. 13195w-21(a)(3)) who is also entitled to medical assistance under a State plan under title XIX of the Social Security Act.CommentsClose CommentsPermalink





(3) DUAL ELIGIBLE SNP- The term ‘dual eligible SNP’ means a SNP described in section 1859(b)(6)(A)(ii) of the Social Security Act.CommentsClose CommentsPermalink





(4) MEDICAID- The term ‘Medicaid’ means the program under title XIX of the Social Security Act.CommentsClose CommentsPermalink





(5) MEDICARE- The term ‘Medicare’ means the program under title XVIII of the Social Security Act.CommentsClose CommentsPermalink





(6) MEDICARE FEE-FOR-SERVICE- The term ‘Medicare fee-for-service’ means the original Medicare fee-for-service program under parts A and B of title XVIII of the Social Security Act.CommentsClose CommentsPermalink





(7) SECRETARY- The term ‘Secretary’ means the Secretary of Health and Human Services.CommentsClose CommentsPermalink





(8) SNP- The term ‘SNP’ means a specialized MA plan for special needs individuals, as defined in section 1859(b)(6)(A) of the Social Security Act (42 U.S.C. 1395w-28(b)(6)(A)).CommentsClose CommentsPermalink





(9) STATE- The term ‘State’ has the meaning given such term for purposes of title XIX of the Social Security Act.CommentsClose CommentsPermalink