[Congressional Bills 117th Congress]
[From the U.S. Government Publishing Office]
[S. 4635 Introduced in Senate (IS)]
<DOC>
117th CONGRESS
2d Session
S. 4635
To amend the Social Security Act to establish an optional State-
administered program to provide fully integrated, comprehensive,
coordinated care for full-benefit dual eligible individuals under the
Medicare and Medicaid programs, and for other purposes.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
July 27, 2022
Mr. Brown (for himself and Mr. Portman) introduced the following bill;
which was read twice and referred to the Committee on Finance
_______________________________________________________________________
A BILL
To amend the Social Security Act to establish an optional State-
administered program to provide fully integrated, comprehensive,
coordinated care for full-benefit dual eligible individuals under the
Medicare and Medicaid programs, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Comprehensive Care
for Dual Eligible Individuals Act''.
(b) Table of Contents.--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 INDIVIDUALS
``Sec. 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.
SEC. 2. ESTABLISHMENT OF ALL INCLUSIVE MEDICARE-MEDICAID PROGRAM FOR
FULL-BENEFIT DUAL ELIGIBLE INDIVIDUALS.
(a) In General.--The Social Security Act is amended by adding at
the end the following new title:
``TITLE XXII--ALL INCLUSIVE MEDICARE-MEDICAID (AIM) PROGRAM FOR FULL-
BENEFIT DUAL ELIGIBLE INDIVIDUALS
``SEC. 2201. PURPOSE; GENERAL REQUIREMENTS.
``(a) Purpose.--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.
``(b) Requirement for Approved AIM Program Application.--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)--
``(1) 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
``(2) 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).
``(c) General Requirements.--The requirements specified in this
subsection for an AIM program of a State are as follows:
``(1) Eligibility and enrollment.--The program provides for
eligibility and enrollment of AIMP-eligible individuals under
the program in accordance with sections 2202 and 2203.
``(2) Benefits.--The program provides for benefits for AIMP
enrollees under the program in accordance with section 2204.
``(3) Beneficiary protections.--The program provides for
beneficiary protections for AIMP enrollees under the program
that are not less than those required under section 2205.
``(4) Coordinating and integration of benefits.--The
program provides for the coordination and integration of
benefits by AIM-administering entities in accordance with
section 2205.
``(5) Program accountability.--The program provides for
accountability in administration and financing in accordance
with section 2208.
``(6) Other requirements.--The program meets such other
requirements as the Secretary may establish to carry out this
title.
``(d) Program Approval Process.--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:
``(1) Notice of intent.--
``(A) In general.--Subject to subparagraph (B), the
State submits to the Secretary a notice of intent to
establish the AIMP.
``(B) Conditions for transparent process.--The
Secretary shall not accept a notice of intent submitted
under subparagraph (A) unless, before the date of such
submission, the State--
``(i) 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;
``(ii) has held at least 2 public meetings
regarding the establishment of the program; and
``(iii) has conducted relevant consultation
with any relevant tribal authorities of
Federally recognized Indian tribes located in
the State.
``(2) Federal readiness review completed.--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.
``(3) State readiness review of aim-administering
entities.--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--
``(A) shall include elements specified by the
Secretary, including a network adequacy review;
``(B) may include activities such as a desk review,
separate network validation review, and site visit; and
``(C) 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.
``(e) Technical Assistance Planning Grants.--
``(1) Eligibility.--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.
``(2) Use of funds.--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).
``(3) Funding.--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.
``SEC. 2202. ELIGIBILITY.
``(a) In General.--In this title, the term `AIMP-eligible
individual' means, with respect to an AIMP-participating State, an
individual who--
``(1) is 21 years of age or older;
``(2) is entitled (or eligible to be enrolled) under part A
or part B, or both, of title XVIII;
``(3) 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
``(4) 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).
``(b) Process for Determination of Eligibility.--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.
``(c) Flexibility Permitted.--
``(1) Geographic scope.--
``(A) Statewide.--Except as provided in
subparagraph (B), an AIMP-participating State shall
provide for the implementation of its AIM program on a
statewide basis.
``(B) Phase-in permitted on a time-limited basis.--
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.
``(2) New population phase-in permitted.--
``(A) Carve-outs not permitted.--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.
``(B) Time-limited exception permitted.--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.
``(3) Pace continuation permitted.--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.
``(d) Income and Asset Standards.--
``(1) Income eligibility floor.--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.
``(2) Asset threshold floor.--In no case shall an AIMP-
participating State apply an asset threshold for eligibility
for a fiscal year that is less than the following:
``(A) For first fiscal year.--For the 1st fiscal
year (or portion of a fiscal year) in which the AIM
program is implemented in the State, the greater of--
``(i) $2,000; and
``(ii) 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.
``(B) For subsequent fiscal year.--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).
``(3) Flexibility.--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.
``(4) Eligibility threshold.--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.
``(e) Use of Streamlined Eligibility Determination and Enrollment
Processes.--
``(1) In general.--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.
``(2) Specific streamlined eligibility required.--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:
``(A) 12-month continuous eligibility.
``(B) 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.
``(C) Streamlined eligibility recertification every
12 months, including--
``(i) 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);
``(ii) with respect to verification of
eligibility, initially using of available
information to auto-verify eligibility;
``(iii) 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
``(iv) using a standard reconsideration
period of 90 days from the time of termination
of coverage.
``(3) Use of deeming.--Each AIMP-participating State shall
use deemed eligibility for a period of not less than 6 months.
``(4) Data sharing on enrollment.--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.
``(f) Rule of Construction of Continuation as a Medicare and
Medicaid Beneficiary for Purposes Other Than Benefits.--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.
``SEC. 2203. ENROLLMENT.
``(a) Beneficiary Choice.--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:
``(1) The State AIM program.
``(2) A PACE program (if available to the individual in the
State).
``(3) 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).
``(b) Initial Assignment at Time of Program Implementation or
Initial Enrollment.--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.
``(c) Coordination of Selection and Enrollment With Medicare
Enrollment Processes.--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--
``(1) a special enrollment period for individuals who--
``(A) 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
``(B) become AIMP-eligible individuals; and
``(2) 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).
``(d) Assistance in Enrollment Choice.--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).
``(e) Construction Regarding Continued Medicaid Use of Managed
Care.--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.
``(f) Assignment of Enrollees to AIMP-Administering Entities.--
``(1) In general.--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.
``(2) Initial assignment at time of program implementation
or initial enrollment.--
``(A) In general.--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--
``(i) 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
``(ii) the individual is provided with--
``(I) at least 1 written notice of
such assignment at least 60 days in
advance of the effective date of the
assignment; and
``(II) at least 1 phone call
notifying the individual of the
assignment in advance of the effective
date of the assignment.
``(B) Continuity of care.--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.
``(C) Conditional initial assignment for other
aimp-eligible individuals.--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--
``(i) 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
``(ii) the individual is provided with--
``(I) at least 1 written notice of
such assignment at least 60 days in
advance of the effective date of the
assignment; and
``(II) at least 1 phone call
notifying the individual of the
assignment in advance of the effective
date of the assignment.
``(3) Rule of construction.--Nothing in this subsection
shall be construed as--
``(A) preventing an individual from choosing to be
assigned to a different participating AIMP-
administering entity;
``(B) preventing an individual from changing their
assignment to an AIMP-administering entity or from
opting-out of participating in the State AIM program;
or
``(C) 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.
``(4) Choice of enrollment from fee-for-service medicare.--
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).
``(g) Effect of Enrollment on Medicare and Medicaid Payments to
States.--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.
``(h) Outreach and Enrollment Support.--
``(1) Funding.--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.
``(2) Use of funds.--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:
``(A) Distributing outreach and enrollment
materials printed in accessible language formats
(including primary languages, Braille, large print, and
alternative texts).
``(B) Engaging community-based organizations to
conduct outreach to, and provide enrollment assistance
for, AIMP-eligible individuals.
``(C) 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.
``SEC. 2204. BENEFITS.
``(a) Covered Benefits.--
``(1) In general.--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:
``(A) Medicare benefits.--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.
``(B) Medicaid mandatory benefits.--All benefits
otherwise required to be provided to AIMP-eligible
individuals under title XIX in the State if they were
not AIMP enrollees.
``(C) Historic benefits.--All Medicaid services and
benefits offered as of 1 year prior to the enactment of
this title, as required by section 2204(d).
``(D) Drugs.--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.
``(E) Additional services.--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.
``(2) Limitation on benefit carve-outs.--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.
``(b) Benefit Assessment Process.--
``(1) Assessment tool and plan of care.--
``(A) Development.--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.
``(B) Application to plan of care.--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.
``(C) Application of grievance and appeals
procedures.--Disagreements concerning the plan of care
for an AIM enrollee shall be subject to grievance and
appeal rights under section 2205(b).
``(2) Standard assessment tool.--The standard assessment
tool under paragraph (1) shall--
``(A) 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;
``(B) cover multiple domains, including medical,
functional, behavioral, and social domains; and
``(C) 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.
``(c) State Provision of Covered Benefits.--
``(1) Use of tiered-benefit model.--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--
``(A) 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
``(B) 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.
``(2) In-lieu-thereof alternative services permitted.--An
AIMP-participating State may permit AIMP-administering entities
to cover benefits for cost-effective alternative services
(known as `in lieu of services') 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.
``(3) Continuity of services.--
``(A) In general.--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.
``(B) Exception.--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.
``(d) Maintenance of Effort.--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.
``(e) Administration of Benefits Through AIM-Administering
Entities.--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.
``SEC. 2205. BENEFICIARY PROTECTIONS.
``(a) In General.--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.
``(b) Application of Grievances and Internal and External Appeals
Under AIMP Contracts.--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.
``(c) Requirement for Qualified AIM Ombudsman Program.--
``(1) In general.--As a condition for approval of an AIM
program for a State under this title--
``(A) 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
``(B) 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.
``(2) Qualifications for qualified aim ombudsman program.--
``(A) In general.--In order to be a qualified AIM
Ombudsman program, such program must meet the
requirements of this subsection for such a program.
``(B) Construction.--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.
``(3) Coordination with other beneficiary protection
services.--A qualified AIM Ombudsman program shall coordinate
with State and Federal beneficiary protection services,
including the following:
``(A) Demonstration Ombudsman Programs Serving
Medicare-Medicaid Enrollees.
``(B) Managed Care Beneficiary Support Systems.
``(C) Long-Term Care Ombudsman Programs.
``(D) Disability Protection and Advocacy Programs.
``(4) Core services.--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:
``(A) 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.
``(B) Systemic monitoring and reporting to the
State regarding compliance with applicable
requirements.
``(5) Providing reports to consumer advisory boards.--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.
``(6) Funding and oversight.--
``(A) In general.--The Secretary shall oversee and
administer Federal funding directly to qualified AIM
Ombudsman programs established by States.
``(B) Funding level.--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.
``(C) Supplemental funding.--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.
``(d) Beneficiary Advisory Council.--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).
``(e) Consumer Advisory Boards.--
``(1) In general.--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.
``(2) Composition; functions.--Each such consumer advisory
board shall--
``(A) meet at least quarterly;
``(B) be comprised of members who--
``(i) may be subject to approval by the
Secretary and the AIMP-participating State;
``(ii) are AIMP enrollees;
``(iii) are family members and other
caregivers for AIMP enrollees; and
``(iv) 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;
``(C) meet the requirements for member advisory
committees under section 438.110 of title 42, Code of
Federal Regulations; and
``(D) file and make publicly available an annual
report that includes at least information on--
``(i) the dates for its meetings held
within the reporting year;
``(ii) the names of board members invited
and of those members in attendance at each such
meeting; and
``(iii) the agenda and minutes for each
such meeting.
``SEC. 2206. FEDERAL ADMINISTRATION.
``(a) Primary Administration Through the Federal Coordinated Health
Care Office.--
``(1) In general.--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.
``(2) Appropriations.--There are hereby appropriated to the
Secretary to carry out this title, out of any funds in the
Treasury not otherwise appropriated--
``(A) for each of fiscal years 2022, 2023, and
2024, $100,000,000; and
``(B) for each succeeding fiscal year, $30,000,000.
``(b) Standards and Process.--
``(1) Federal standards.--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.
``(2) Transparency in rulemaking.--In implementing the
provisions of this title, to the extent practical, the
Secretary shall utilize notice and comment rulemaking to ensure
transparency for stakeholders.
``(3) Application of knowledge gained from demonstration
projects and contract management teams under the financial
alignment initiative.--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.
``(c) Direct-Hire Authority.--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.
``SEC. 2207. SELECTION AND ROLE OF AIM-ADMINISTERING ENTITIES.
``(a) Requirements for State Selection of AIM-Administering
Entities.--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.
``(b) Application of Criteria for the Qualification and Selection
of AIMP-Administering Entities.--
``(1) In general.--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.
``(2) Specification of criteria.--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:
``(A) 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).
``(B) The organization's performance on key quality
measures in providing such services, such as on
measures of key health outcomes and enrollee
satisfaction.
``(C) The adequacy of the organization's provider
network in ensuring timely access to care.
``(D) 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).
``(3) Additional state-specific criteria.--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--
``(A) can be applied consistently to all AIMP-
administering entities; and
``(B) are made available for public comment prior
to being imposed.
``(4) Application of medical loss ratio requirements.--
``(A) In general.--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.
``(B) Special rules.--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.
``(c) State Procurement Process for AIMP-Administering Entities.--
``(1) In general.--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.
``(2) Separate procurement process required for initial
procurement.--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.
``(d) Payments to AIM-Administering Entities.--Each AIMP-
participating State shall make payments to AIM-administering entities
under a risk-adjusted payment model that--
``(1) reflects the risk of the population of AIMP enrollees
served by each entity;
``(2) ensures that there are appropriate resources to serve
the AIMP enrollees in the State; and
``(3) protects against any adverse selection of AIMP
enrollees by entities.
``SEC. 2208. PROGRAM FINANCING.
``(a) Payments to States With AIM Programs.--
``(1) For program benefits.--
``(A) In general.--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).
``(B) AIMP assistance defined.--In this title, the
term `AIMP assistance' has the meaning given the term
`medical assistance' under section 1905(a), except that
in applying such term under this subparagraph--
``(i) 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);
``(ii) 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
``(iii) the exclusion in the subdivision
(B) following the last paragraph of the first
sentence of section 1905(a) shall not apply.
``(2) For administrative expenses.--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.
``(3) Appropriation.--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).
``(4) Relation to other payments.--Payment amounts provided
under this subsection are in addition to payments provided
under other provisions of this title.
``(5) Relation to medicare trust funds.--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.
``(b) Federal AIMP Matching Percentage.--
``(1) In general.--In this section, the term `Federal AIMP
matching percentage' 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.
``(2) State contribution percentage formula.--
``(A) In general.--In this section, the term `State
contribution percentage' means, subject to adjustment
under the subsequent provisions of this paragraph, with
respect to an AIMP-participating State for--
``(i) the 1st fiscal year of the AIM
program in the State, the base AIMP State
percentage computed under subsection (c); or
``(ii) 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.
``(B) Annual adjustment based on changes in
expenditures.--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--
``(i) 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;
``(ii) 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
``(iii) 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.
``(C) Additional adjustments for exceptions.--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.
``(c) Baseline Expenditure and Percentage Computations.--
``(1) In general.--Using the data reported under paragraph
(2):
``(A) Computation of base aimp percentages.--For
the base Federal fiscal year (as defined in paragraph
(3)), the Secretary shall compute and publish for each
State--
``(i) the base AIMP State percentage (as
defined in subparagraph (B)) for the State and
such fiscal year; and
``(ii) the Federal AIMP matching percentage
for the State and such fiscal year.
``(B) Base aimp state percentage defined.--In this
section, the `base AIMP State percentage' means the
amount equal to the ratio (expressed as a percentage)
of--
``(i) the sum of--
``(I) 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
``(II) 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 `part D clawback') attributable
to such individuals; to
``(ii) the sum of--
``(I) 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
``(II) 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.
``(C) Adjustments to base aimp percentages.--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.
``(2) Data reporting for baseline computations.--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.
``(3) Base federal fiscal year defined.--In this section,
the term `base Federal fiscal year' 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.
``(d) Reinvestment of Shared Savings.--
``(1) In general.--
``(A) In general.--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.
``(B) Shared savings amount defined.--In this
subsection, the term `shared savings amount' 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.
``(2) Application of shared savings.--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.
``(3) Core applications.--The core applications described
in this paragraph for such consumers are as follows:
``(A) Consumer power and choice.--To provide such
consumers more information and control over their
health care and community support options.
``(B) Equity and access to care.--To improve access
to, and quality of, care across populations, advance
health equity for consumers, and reduce health
disparities and eliminate barriers to care.
``(C) Prevention and wellness.--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.
``(D) Pay for performance.--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.
``(E) Innovative advancement.--To implement
innovative and technological advancements that
facilitate such consumers remaining in the community.
``(F) Service integration.--To increase integration
of services with social needs to improve health
outcomes for such consumers.
``(G) State personnel.--To hire additional State
personnel to carry out this title.
``(H) Capacity building.--To expand capacity in
providing services to such consumers, such as in--
``(i) community-based care; and
``(ii) caregiver assistance.
``(I) Improve enrollment policies and process.--To
improve the ability to enroll in the State AIMP program
through streamlining enrollment policies and processes.
``(J) Increase education for providers and
beneficiaries.--To ensure providers and beneficiaries
understand the State AIMP program and the choices
available under such program.
``(K) Improve data collection regarding racial
disparities and health inequities.--To ensure
appropriate data is collected and used to determine
program inequities.
``(L) Other services and initiatives.--Other
services and initiatives approved by the Secretary that
serve full-benefit dual eligible individuals under this
title.
``(4) Limitation on payment to aimp-administering
entities.--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.
``(e) Application of Medicaid Payment Methodologies Financing
Limitations for the Non-Federal Share of Expenditures.--
``(1) In general.--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:
``(A) Section 1903(d) (relating to estimated
payments, recovery of overpayments, disallowance of
provisions).
``(B) Section 1903(w) (relating to provider-related
donations, health care related taxes, and broad-based
health care related taxes).
``(C) Section 1903(w)(6) (relating to certified
public expenditures and intergovernmental transfers).
``(D) Other provisions relating to deferral of
payments, preventing fraud and abuse, and ensuring
program integrity.
``(2) Processes and forms.--
``(A) In general.--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.
``(B) Reporting of estimated expenditures by
quarter.--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.
``(C) Reporting and reconciliation of actual
expenditures on a quarterly basis.--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.
``(3) Rule of construction.--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.
``(f) Option for Multi-Year Investment Initiative.--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.
``SEC. 2209. ACCOUNTABILITY AND OVERSIGHT.
``(a) Quality Assessment.--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.
``(b) Monitoring and Program Evaluation.--
``(1) Consolidated reporting requirements for aim-
administering entities.--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.
``(2) Evaluation.--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.
``(3) Collaborative evaluation.--The Secretary and AIMP-
participating States shall collaborate on and coordinate during
any evaluation activity conducted under this subsection.
``(c) Administrative Oversight Responsibilities.--
``(1) State role.--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:
``(A) Conducting a comprehensive readiness review
of each entity (as required under section 2201(d)).
``(B) Monitoring compliance of the entity with the
terms of its AIMP contract under the AIM program,
including--
``(i) ensuring adherence to and protection
of enrollee rights as provided under this
title;
``(ii) 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
``(iii) ensuring compliance with applicable
reporting requirements under this title.
``(C) Reviewing, approving, and monitoring--
``(i) the entity's network adequacy;
``(ii) the outreach and orientation
materials and procedures of the entity;
``(iii) the complaint and appeals
procedures carried out by the entity;
``(iv) the utilization management functions
of the entity;
``(v) the entity's adherence to required
continuity of care provisions under section
2204(c)(3);
``(vi) the entity's use of required
standard assessment tool under section 2204(b);
``(vii) the entity's informational
materials, particularly for those individuals
who will be assigned to the entity under
section 2203(f); and
``(viii) the entity's use of streamlined
eligibility processes under this title.
``(D) Conducting monthly (or more frequent)
performance review meetings with the entity.
``(E) Conducting periodic audits of the entity,
including at least an annual independent external
review and an annual site visit.
``(F) Receiving and responding to complaints about
the entity.
``(G) Conducting annual surveys of AIMP enrollees
and providing the entity with written results of such
surveys.
``(H) 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.
``(2) Federal oversight role.--
``(A) In general.--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:
``(i) Monitoring the process to select
organizations to serve as AIMP-administering
entities under the AIM program.
``(ii) Conducting a thorough readiness
review of the State (before readiness reviews
for such organizations) under section
2201(d)(2).
``(iii) Ensuring, including through
complaint tracking and secret shopping, the
State creates and maintains a highly
functional, dedicated AIMP Ombudsman program
under section 2205(c).
``(iv) Ensuring, through direct monitoring,
State oversight of compliance of AIMP-
administering entities with the terms of their
AIMP contracts under the AIM program.
``(v) Reviewing eligibility and enrollment
processes and procedures.
``(vi) Monitoring State data systems to
ensure they are sufficient for providing timely
data on program performance.
``(vii) 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--
``(I) 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;
``(II) States may elect to share
the final rate certification package
provided to the Secretary with AIMP-
administering entities; and
``(III) 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.
``(viii) Coordinating periodic audits of
the State with respect o its AIM program.
``(ix) Conducting regular meetings with the
State.
``(x) Applying discretionary action, if
warranted.
``(xi) Ensuring regular engagement with
dually eligible individuals and their
caregivers.
``(B) Compliance authority.--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:
``(i) Developing in consultation with the
State, a corrective compliance plan for
achieving appropriate performance levels or
compliance.
``(ii) Remedial education and supervised
training.
``(iii) Imposition of penalties or
sanctions.
``(iv) Removal of the State from the AIM
program.
``(3) State-federal partnership role through joint contract
management teams (cmt).--
``(A) Establishment.--The Secretary shall, jointly
with each AIMP-participating State, establish a Joint
Contract Management Team (in this paragraph referred to
as a `CMT') 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.
``(B) Composition and structure.--
``(i) In general.--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.
``(ii) Lead.--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.
``(iii) State lead.--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.
``(C) Responsibilities of cmt.--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--
``(i) receive and respond to complaints;
``(ii) conduct quarterly meetings among the
parties;
``(iii) establish a mechanism for ongoing
consumer engagement;
``(iv) coordinate requests for assistance
from the entity and assign Federal and State
staff with appropriate expertise to provide
technical assistance to the entity;
``(v) make best efforts to resolve any
issues applicable to the parties; and
``(vi) monitor any discretionary action by
the State or the Secretary under the provisions
of the AIMP contract.
``SEC. 2210. DEFINITIONS; MISCELLANEOUS PROVISIONS.
``(a) Definitions.--In this title:
``(1) Terms relating to aimp.--
``(A) AIMP-administering entity.--The term `AIMP-
administering entity' 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.
``(B) AIMP assistance.--The term `AIMP assistance'
has the meaning given such term in section
2208(a)(1)(B).
``(C) AIMP contract.--The term `AIMP contract' is a
contract described in section 2207(b)(1).
``(D) AIMP-eligible individual.--The term `AIMP-
eligible individual' has the meaning given such term in
section 2202(a).
``(E) AIMP enrollee.--The term `AIMP enrollee'
means an individual who is enrolled in an AIM program
under this title.
``(F) AIMP-participating state.--The term `AIMP-
participating State' means a State administering an AIM
program under this title.
``(G) AIM program; aimp.--The terms `AIM program'
and `AIMP' mean, with respect to a State, the program
established by the State under this title.
``(2) Other definitions.--
``(A) Full-benefit dual eligible individual.--The
term `full-benefit dual eligible individual' has the
meaning given such term in section 1935(c)(6) but
without the application of subparagraph (A)(i) of such
section.
``(B) Federal coordinated health care office.--The
term `Federal Coordinated Health Care Office' means the
office established under section 2602 of the Patient
Protection and Affordable Care Act.
``(C) Medicaid managed care organization.--The term
`medicaid managed care organization' 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).
``(b) Miscellaneous Provisions.--
``(1) Relation to other requirements.--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.
``(2) Limitation on waiver authority.--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.''.
(b) Conforming Amendments to Medicare.--
(1) Enrollment.--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 individuals.--Full-benefit dual eligible
individuals may also be eligible to enroll under a State AIM
program under title XXII.''.
(2) Prohibition.--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 payments.--Section 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) Conforming Amendment.--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 Amendments.--Section 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''.
SEC. 3. MEDPAC STUDY AND REPORT.
(a) Study.--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) Report.--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.
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