j!CC'2Ar-OS0O7LS-i'1b:r3caur-y!tyBlvd. _^ tUntcr2, Maryfepci 21n244 , 110thCONGRESS TT £^0£^fif 2DSession OtjOD To amend part C oftitle XVUI ofthe Social SecurityActwith respect to Medicare special needs plans and the alignment of Medicare and Medicaidforduallyeligibleindividuals. IN THE HOUSE OF REPRESENTATIVES June25,2008 Mr.Kdto(forhimselfandMr.Ramstad)introducedthefollowingbiU;which wasreferredtotheCommitteeonWaysandMeans,andinadditionto theCommitteeonEnergyandCommerce,foraperiodtobesubsequently determinedbytheSpeaker,ineachcaseforconsiderationofsuchprovi- sionsasfallwithinthejurisdictionofthecommitteeconcerned A BILL To amend part C oftitle XVIH ofthe Social SecurityAct with respect to Medicare special needs plans and the alignment of Medicare and Medicaid for dually ehgible individuals. 1 BeitenactedhytheSenateandHouseofRepresenta- 2 tivesoftheUnitedStatesofAmericainCongressassembled, 3 SECTION1.SHORTTITLE;TABLEOFCONTENTS. — 4 (a) Short Title. This Act may be cited as the 5 ''Medicare Special Needs Plans Extension and Amend- 6 mentsActof2008". — — 2 — 1 (b) Table ofContents. Thetableofcontentsof 2 thisActisasfollows: See. 1. Shorttitle;tableofcontents. Sec. 2.ExtendSNPauthoritythroughDecember31,2012. Sec. 3.Requiretargetingofhigh-riskgroups;advancespecialtycarecapabih- ties. Sec. 4. Study on improving risk adjustment for high-risk, high-cost bene- ficiaries. Sec. 5.AdvancealignmentofMedicareandMedicaidfordualehgibles. 3 SEC.2.EXTENDSNPAUTHORITYTHROUGHDECEMBER31, 4 2012. 5 Section1859(f)oftheSocialSecurityAct(42U.S.C. 6 1395w-28(f)),asamendedbysection108oftheMedicare, 7 Medicaid,andSCHIPExtensionActof2007(PubhcLaw 8 110-173), is amendedbystriking "2010" and insertmg 9 ''2013". 10 SEC.3.REQUmETARGETINGOFHIGH-RISKGROUPS;AD- 11 VANCESPECIALTYCARECAPABILITIES. 12 (a) Requiring Targeting of High-Risk — 13 Groups. 14 (1) In general.—Section 1859(b)(6) of the 15 Social SecurityAct (42 U.S.C. 1395w-28(b)(6)) is 16 amended 17 (A) in subparagraph (A), by striking aU 18 that follows "means" and inserting the fol- 19 loAving: "anMAplan 20 "(i) that serves special needs individ- 21 uals (asdefinedinsubparagraph (B)); and 22 "(ii)forwhich— •HR6365ffl 3 1 ''(I) atleast90percentofthein- 2 dividuals enrolled after December 31, 3 2008, are described in subparagraph 4 (B)(i); 5 "(n) at least 90 percent of the 6 individuals enrolled after December 7 31, 2008, are described in subpara- 8 graph(B)(ii);or 9 '^lU) at least 90 percent ofthe 10 indi\dduals enrolled after December 11 31, 2008, are described in subpara- 12 graph (B)(iii) and have a severe or 13 disabhngchronicconditionofthetype 14 thattheplaniscommittedto serve."; 15 (B) byaddingatthe endofsubparagraph 16 (A) the following: "For purposes of applying 17 clause (ii), an individual who is described in 18 subparagraph (B)(i) or (B)(ii) and who is en- 19 roUedinaspecializedMAplanforspecialneeds 20 individuals shall thereafter be treated as con- 21 tinningto be described in such respective sub- 22 paragraph regardless ofchanges inthe individ- 23 ual's circumstances so long as the individual 24 maintains continuous enrollment in such plan. 25 Clause (ii) shall not apply to a plan described m >HR6365 — 4 1 in section 231(d) ofthe Medicare Prescription 2 Drug, Improvement, and ModernizationAct of 3 2003 (Public Law 108-173) which was pre- 4 viouslyoperatedundersection2355oftheDef- 5 ieit Reduction Act of 1984 (Public Law 98- 6 369) and which is operating as a specialized 7 MAplanforspecialneedsindividuals as ofthe 8 dateoftheenactmentofthissentence.";and 9 (C)insubparagraph(B) 10 (i) in clause (i), by inserting ''under 11 regulations in effect as of July 1, 2007" 12 after''asdefinedbytheSecretary";and 13 (ii)byamendingclause(iii)toreadas 14 follows: 15 "(iii)hasasevereordisabhngchronic 16 condition that requires complexcare man- 17 agement capabUities, ofthetype described 18 in subsection (f)(4), and speciahzed dehv- 19 ery systems to reduce medical compUca- 20 tionsandadversehealthoutcomes.". 21 (2) Coordinatedfinancingfordual-eligi- — 22 BLE SNPS. The Secretary of Health and Human 23 Services shall enterinto agreementswith States (as 24 definedforpurposesoftitleXIXofthe SocialSecu- 25 rity Act) for coordinatiug the financing of special- m •HR6365 — — 5 1 izedMAplansforspecialneedsindividualsdescribed 2 in section 1859(b)(6)(A)(ii)(n) of such Act for en- 3 roUeeswho are entitled to medical assistance under 4 Stateplansundersuchtitle. — 5 (b)AdvanceSpecialtyCareCapabilities. — 6 (1) In general. Section 1859 of such Act 7 (42U.S.C. 1395W-28)isfartheramended— 8 (A) insubsection(b)(6)(A), asamendedby 9 subsection(a)(1) 10 (i) by striking "and" at the end of 11 clause(i); 12 (ii) by striking the period at the end 13 ofclause (ii) and inserting and" ; and 14 (iii) by adding at the end the fol- 15 lowingnewclause: 16 "(iii) meets the apphcable require- 17 ments specified in subsection (f) for the 18 plan.";and 19 (B)insubsection(f) 20 (i) by amending the heading to read 21 asfoUows: "RequirementsforEnroll- 22 ment in Specialized MA Plans for 23 SpecialNeedsBeneficiaries"; 24 (ii)bydesignatingthesentencebegin- 25 ning "In the case of as paragraph (1) •HR6365IH 6 1 with the heading "Requirements for — 2 ENROLLMENT. " andwithappropriatein- 3 dentation;and 4 (iii) by adding at the end the fol- 5 lowingnewparagraphs: 6 "(2) Additional requirements for dual 7 SNPS.—^InthecaseofaspeciahzedMAplanforspe- 8 cial needs individuals described in subsection 9 (b)(6)(A)(ii)(II), the appMcable requirements ofthis 10 subsectionincludethefollowing: 11 "(A)(i) Subjectto clause (ii), theplanhas 12 an agreement with the State Medicaid agency 13 that— 14 "(I) includes provisions regarding co- 15 operation on the coordination ofcare and 16 the coordination of the financing of care 17 forsuchindividuals; 18 "(II) includes a description of any 19 Medicaidservicestobecoveredbytheplan 20 forindividuals enrolledintheplan ehgible 21 undersuchtitleformedicalassistance; 22 "(in) includes a description of the 23 manner that the State Medicaid program 24 under title XTXwill fulfill its responsibil- 25 ities under such title (including section >HR6365IH 7 1 1902) with respect to payment for Medi- 2 care cost-sharingandwith respect to pay- 3 mentforanyMedicaidservicesnotcovered 4 byMedicare forindividuals enrolledinthe 5 plan ehg^ble under such title for medical 6 assistance;and 7 "(IV)requiresthedisclosuretoenroU- 8 ees, including in the marketing materials 9 of such plan, ofMedicaid benefits and of 10 thoseprovidernetworksthatcontractwith 11 theStateundertheMedicaidprogram. 12 "(ii) The agreement requirement ofclause 13 (i)betweenaplanandaStateMedicaidagency 14 shallnotapplyifthe Secretarydeterminesthat 15 theState— 16 "(I) does not have the administrative 17 infrastructure to enter into such agree- 18 mentswith suchplan ortoprovideforco- 19 ordination of benefits or payments with 20 suchplans; 21 "(n) is unable to enter into such an 22 agreementbecauseofaStatehmitationon 23 thenumberofMedicaidmanagedcarecon- 24 tractsissued;or >HR6365IH 8 1 ''(HI)isotherwiseunwillingorunable 2 toenterintosuchanagreement. 3 "(B) The out-of-pocket costs for services 4 underpartsAandBthatarechargedtoenroll- 5 ees may not exceed the out-of-pocket costs for 6 same services permitted for such individuals 7 undertitleXIX. 8 "(3) Additional requirements for severe — 9 OR DISABLING CHRONIC CONDITION SNPS. In the 10 caseofaspecializedMAplanforspecialneedsindi- 11 vidualsdescribedinsubsection (b)(6)(A)(ii)(III),the 12 apphcable requirements of this subsection include 13 thefollowing: 14 "(A) Theplan is designated to serve, and 15 serves, individuals described in subsection 16 (b)(6)(l)(B)(iii). 17 "(B)Theplanmeetsanyofthe3following 18 criteria: 19 "(i) Theplanspeciahzesincareofin- 20 dividuals who are disabled or have end- 21 stage renal disease, including individuals 22 who are ehgible forbenefits under partA 23 through the apphcation of section 226(b) 24 orsection226A. •HR6365IH 9 1 "(ii) The plan specializes in care for 2 persons who have eo-morbid or complex 3 chronic conditions that influence other as- 4 pectsofhealthandhaveahighriskofhos- 5 pitahzation or other significant adverse 6 healthoutcomes. 7 "(iii) The plan has an average risk 8 score under section 1853(a)(1)(C) of 1.35 9 orgreater. 10 "(4) Complex care management capabili- — 11 TIBS FOR ALL SNPS. The complex care manage- 12 mentcapabiUtiesforaspecializedneedplanshallin- 13 elude with respect to a special needs individual en- 14 rolledundertheplanthefollowing: 15 "(A) Conductinganinitialassessment,and 16 annual reassessment, of the individual's phys- 17 ical, social, medical, and functional needs for 18 eachindividualenrolledintheplan. 19 "(B) Developing, for each such individual 20 andwith inputofthe individual, an individual- 21 izedplanofcarethatidentifiesgoalsandobjec- 22 tives,includingmeasurableoutcomes. 23 ''(C) Using an interdisciphnary team in 24 management of care and assuring appropriate 25 accesstospecialtycarenetworks. m •HR6365 — 10 1 "(D) Developing interventions based on 2 population-basedprotocolsandbestpracticesto 3 theextentavailable. 4 ''(E) Assigning appropriate clinicians to 5 meet the unique needs ofthe population being 6 served. 7 "(F) Assuring coordination among clini- 8 ciansandotherserviceprovidersinvolved. 9 "(G) Assisting individuals enrolled in the 10 plan who are entitled to medical assistance 11 under title XIX in accessing and coordinating 12 benefits andservicesunderthistitleandunder 13 suchtitle. — 14 "(5) Specialtycare networkdefined. ^In 15 this subsection, the term 'specialty care network' 16 means, with respect to a specialized need plan, a 17 group ofhealth care providers under contract with 18 theplanthat 19 "(A)includesphysicians,hospitals,nursing 20 facUities, and aUied health and social service 21 providers with special expertise relevant to the 22 specialneedspopulationbeingserved; 23 "(B) servesacommonchronicallyillorim- 24 pairedpopulation,eitheratthesametimeorin 25 sequencetooneanother;and •HR6365IH