[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 8503 Introduced in House (IH)]
<DOC>
118th CONGRESS
2d Session
H. R. 8503
To provide States with support to establish integrated care programs
for individuals who are dually eligible for Medicare and Medicaid, and
for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
May 22, 2024
Mr. Kelly of Pennsylvania (for himself and Mr. Bera) 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 concerned
_______________________________________________________________________
A BILL
To provide States with support to establish integrated care programs
for individuals who are dually eligible for Medicare and Medicaid, 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 ``Delivering Unified
Access to Lifesaving Services Act of 2024'' or the ``DUALS Act of
2024''.
(b) Table of Contents.--The table of contents for this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--STATE INTEGRATED CARE PROGRAMS FOR DUAL ELIGIBLE INDIVIDUALS
Sec. 101. State implementation.
``TITLE XXII--STATE INTEGRATED CARE PROGRAMS FOR DUAL ELIGIBLE
INDIVIDUALS
``Sec. 2201. Definitions.
``Sec. 2202. State selection of program models, development,
and implementation.
``Sec. 2203. Enrollment in integrated care plans.
``Sec. 2204. Plan requirements and payments.
``Sec. 2205. Data collection and reporting.
``Sec. 2206. State ombudsman.
``Sec. 2207. Funding.
``Sec. 2208. Federal administration through the Federal
Coordinated Health Care Office.
Sec. 102. Providing Federal Coordinated Health Care Office authority
over dual snps.
Sec. 103. Additional conforming amendments.
TITLE II--IMPROVING ELIGIBILITY DETERMINATIONS, ENROLLMENT PROCESSES,
AND QUALITY OF CARE FOR DUAL ELIGIBLE INDIVIDUALS
Sec. 201. Identifying opportunities for State coordination with respect
to eligibility determinations.
Sec. 202. Alignment of bidding, reporting, and other dates and
deadlines for integrated care plans.
Sec. 203. Grants to State and local community organizations for
outreach and enrollment.
Sec. 204. Application of model standards to information requirements
for integrated care plans.
Sec. 205. Enrollment through independent brokers.
Sec. 206. Reducing threshold for look-alike D-SNP plans under Medicare
Advantage.
Sec. 207. Requiring regular update of provider directories.
Sec. 208. Review of hospital quality star rating system.
Sec. 209. Requirement for FCHCO and State Medicaid agencies to develop
maximum staffing ratios for care
coordinators.
Sec. 210. CMMI testing of coverage of partial benefit dual eligible
individuals through State Integrated Care
Programs.
TITLE III--ADMINISTRATION
Sec. 301. Alignment of billing codes under titles XVIII, XIX, and XXII.
TITLE IV--PACE
Sec. 401. Requiring States to offer PACE program services to eligible
individuals.
Sec. 402. Enrollment of PACE beneficiaries at any time.
Sec. 403. Extending eligibility for PACE to medicare-eligible
individuals under the age of 55.
Sec. 404. Removal of quarterly restrictions for submission of a new
PACE organization application, and removal
of quarterly restrictions for applications
in a new service area.
Sec. 405. Ensuring Medicare-only PACE program enrollees have a choice
of prescription drug plans under Medicare
part D.
TITLE I--STATE INTEGRATED CARE PROGRAMS FOR DUAL ELIGIBLE INDIVIDUALS
SEC. 101. STATE IMPLEMENTATION.
The Social Security Act is amended by adding at the end the
following new title:
``TITLE XXII--STATE INTEGRATED CARE PROGRAMS FOR DUAL ELIGIBLE
INDIVIDUALS
``SEC. 2201. DEFINITIONS.
``In this title:
``(1) Director.--The term `Director' means the Director of
the Federal Coordinated Health Care Office of the Centers for
Medicare & Medicaid Services.
``(2) Dual eligible individual.--The term `dual eligible
individual' means an individual who is entitled to, or enrolled
for, benefits under part A of title XVIII, or enrolled for
benefits under part B of title XVIII, and is eligible for
medical assistance for full benefits under title XIX under
section 1902(a)(10)(A) or 1902(a)(10)(C), by reason of section
1902(f), or under any other category of eligibility for medical
assistance for full benefits under such title, as determined by
the Secretary.
``(3) Integrated care plan.--The term `integrated care
plan' means an entity or organization that is selected by a
State under section 2202(a) to provide fully integrated care
for a dual eligible individual in accordance with the
requirements of this title and related Federal and State
regulations. Such term shall not include a PACE program (as
defined in sections 1894(a)(2) and 1934(a)(2)).
``SEC. 2202. STATE SELECTION OF PROGRAM MODELS, DEVELOPMENT, AND
IMPLEMENTATION.
``(a) State Selection of Program Models.--Not later than 1 year
after the date on which the Director first publishes the range of
program models for providing integrated care for dual eligible
individuals required by section 2208(b)(1), each State shall select
from such published models, and shall work with the Director to
implement such models in the State in accordance with the requirements
of this title a program model to provide comprehensive, fully
integrated care for dual eligible individuals.
``(b) Timing.--Each State shall work with the Director to implement
the models selected by the State under subsection (a) so that, to the
extent practicable, the State may begin to enroll dual eligible
individuals in the program models selected during the fourth year that
occurs after the year in which the State makes such selection and, by
the end of such fourth year, the models are fully implemented and
operated in accordance with the requirements of this title and related
Federal and State regulations. Nothing in this subsection shall
prohibit a State from enrolling dual eligible individuals in such
program models earlier than the end of such fourth year if the models
are fully implemented and operated in accordance with the requirements
of this title and related Federal and State regulations.
``(c) Adjustment Authority.--The Director may modify the timing
required by subsections (a) and (b) as appropriate to account for the
particular needs or circumstances of a State.
``(d) Implementation Council.--
``(1) In general.--A State shall establish an
implementation council in accordance with such requirements as
the Secretary shall establish. The members of the council shall
include representatives of a wide range of stakeholders
relevant to the provision of integrated care for dual eligible
individuals.
``(2) Duties.--The implementation council shall provide
advice and counsel to the State with respect to the
implementation of the models selected by the State under
subsection (a).
``SEC. 2203. ENROLLMENT IN INTEGRATED CARE PLANS.
``(a) Passive Enrollment; Opt-Out Permitted.--
``(1) Passive enrollment and notice requirements.--A State
shall automatically enroll a dual eligible individual with an
integrated care plan under a contract with the State provided
that the State notifies the individual that the individual will
be enrolled with such plan at least 60 days (90 days, in the
case of the first time the individual is provided such notice)
prior to the effective date of such enrollment. Notice provided
to a dual eligible individual under this paragraph shall
include the following:
``(A) The name and contact information for the
integrated care plan.
``(B) The date on which the enrollment takes effect
and, if applicable, whether the State has elected the
option for a 12-month continuous eligibility period
under paragraph (4).
``(C) A summary of the benefits to be provided by
the plan.
``(D) Information regarding the provider network of
the plan.
``(E) Information regarding how the dual eligible
individual may elect to opt-out of enrollment with the
plan within 60 days (90 days, in the case of the first
time the individual is provided such notice).
``(2) Enrollment in plan with in-network, participating
primary care provider required.--A State shall not passively
enroll a dual eligible individual in an integrated care plan
unless the individual's primary care physician is an in-
network, participating provider for the plan.
``(3) Voluntary enrollment.--A State shall offer a dual
eligible individual the option to enroll in an integrated care
plan without regard to meeting the requirement of paragraph
(2).
``(4) State option for continuous eligibility and
enrollment.--A State may elect for a dual eligible individual
who is determined to be eligible for medical assistance under
the State plan under title XIX or under a waiver of such plan
and who is enrolled with an integrated care plan under a
contract with the State to remain eligible for medical
assistance and enrolled with such plan until the earlier of--
``(A) the end of the 12-month period beginning on
the date of such determination; or
``(B) the date that such individual ceases to be a
resident of such State.
``(b) Change of Enrollment.--A State shall permit a dual eligible
individual to change enrollment in an integrated care plan--
``(1) on a monthly basis if the individual is electing to
enroll in another integrated care plan;
``(2) during the general enrollment period applicable under
section 1837, if the individual is electing to disenroll from
an integrated care plan and not enroll in another integrated
care plan; and
``(3) during the 60-day period beginning on the date the
individual receives notice from the State that the individual
has been determined to no longer be eligible for treatment as a
dual eligible individual, if the individual is no longer
eligible to enroll in an integrated care plan.
``(c) Contact by Plan Care Coordinator Permitted Prior to Effective
Date of Enrollment.--A care coordinator for an integrated care plan may
contact a dual eligible individual who has been passively enrolled in
the plan prior to the effective date of the enrollment.
``SEC. 2204. PLAN REQUIREMENTS AND PAYMENTS.
``(a) In General.--A contract between a State, an offeror of an
integrated care plan, and the Director shall not be considered to meet
the requirements of this title unless--
``(1) in the case of a dual eligible individual enrolled
with the plan who changes enrollment to another integrated care
plan for which the individual's primary care provider is not a
participating, in-network provider, or who disenrolls from the
plan and does not enroll in another integrated care plan, the
offeror of the plan will, during the 30-day period that begins
on the date on which the individual's disenrollment from the
plan takes effect--
``(A) allow the individual to continue to be
treated by the individual's primary care provider; and
``(B) cover any treatment provided to the
individual by such provider as if the individual were
still enrolled with the plan;
``(2) the offeror of the plan administers a health risk
assessment to each dual eligible individual enrolled with the
plan within 90 days of the effective date of the individual's
enrollment in accordance with the requirements of subsection
(c) and shall affirm that there are no changes in the
information provided at least every 12 months thereafter;
``(3) the offeror of the plan provides benefits for a dual
eligible individual under a comprehensive care plan in
accordance with the requirements of subsections (d) and (f);
``(4) the offeror of the plan assigns a care coordinator to
each dual eligible individual enrolled with the plan in
accordance with the requirements of subsection (e) and notifies
such individual in a timely and accessible manner when a new
care coordinator is assigned; and
``(5) the contract provides for payment to the offeror for
benefits provided to dual eligible individuals enrolled with
the plan using a financing structure that satisfies the
requirements of section 2208(c).
``(b) Disregard of Certain Disenrollment Data for Ratings
Purposes.--The disenrollment of a dual eligible individual from an
integrated care plan who was passively enrolled in the plan under
section 2203 shall be disregarded for purposes of any data used for
rating of the plan for such plan year.
``(c) Health Risk Assessment.--An offeror of an integrated care
plan shall administer a health risk assessment to each dual eligible
individual enrolled with the plan using the standardized health risk
assessment questionnaire developed by the Director under section
2208(b)(3) and in accordance with such additional requirements as the
State may establish. An integrated care plan may rely on the results of
a previously administered health risk assessment of a dual eligible
individual if such results are accessible to the plan and the dual
eligible individual affirms that there are no changes in the
information previously provided.
``(d) Benefits.--
``(1) In general.--An integrated care plan shall provide
benefits under the plan in accordance with requirements
established by the Director and the State, and which shall
include the following:
``(A) Clinical health services.
``(B) Behavioral health services.
``(C) Long-term services and supports.
``(2) Carve-out exceptions.--The Director may permit a
State and integrated care plan to separately contract for the
provision of services or supports required under paragraph (1)
but only if the State demonstrates to the Director that--
``(A) the level of care provided for a dual
eligible individual under the separate contract with
respect to such services or supports is not less than
the level of care that would be provided without the
exception; and
``(B) the dual eligible individual will not be
subject to any unreasonable administrative requirements
to access the services or supports, as determined by
the Secretary.
``(3) Supplemental benefits.--An integrated care plan may
provide customized, supplemental benefits to a dual eligible
individual enrolled with the plan, including supplemental
health care benefits described in section 1852(a)(3), other
primarily health-related benefits offered by Medicare Advantage
plans and benefits permitted by the Secretary to be offered as
Special Supplemental Benefits for the Chronically Ill (SSBCI),
without regard to whether the dual eligible individual has a
requisite condition or diagnosis, so long as the plan
demonstrates to the Director and the State that the offering of
such benefits has a positive impact on patient health.
``(e) Care Coordinator Requirements.--A care coordinator assigned
to a dual eligible individual enrolled in an integrated care plan
shall--
``(1) serve as the single point of contact between the
individual and the plan;
``(2) be responsible for helping the individual and the
individual's caregivers and family make benefit and service
decisions;
``(3) design a beneficiary-focused comprehensive care plan
for the individual that meets the requirements of subsection
(f); and
``(4) connect and coordinate acute, subacute, social,
primary, and specialty care for the individual and the
provision of long-term services and supports for the
individual.
``(f) Comprehensive Care Plan Requirements.--The comprehensive care
plan for a dual eligible individual enrolled in an integrated care plan
shall be--
``(1) designed to address the totality of the individual's
medical, functional, behavioral, social, and caregiving needs
and goals, and to the extent practicable, to apply to multiple
years;
``(2) be based on the health risk assessment of the
individual required by subsection (c);
``(3) be implemented by an interdisciplinary care team that
includes relevant specialists to ensure access to all aspects
of care that are required for the individual;
``(4) be approved by the individual (or by an authorized
caregiver or guardian) prior to implementation; and
``(5) be reviewed at least annually and within 30 days of a
major health event, such as hospitalization or an emergency
room visit.
``(g) Continuity of Care Requirement.--An integrated care plan
shall provide a dual eligible individual enrolled in the plan with a
minimum 90-day transition period for any active course of treatment
when the individual has enrolled in an integrated care plan after
starting a course of treatment, even if the service is furnished by an
out-of-network provider. This includes enrollees new to a plan and
enrollees new to Medicare. The integrated care plan must not disrupt or
require reauthorization fo