PRIA, Government Policy, Made Personal

Summary

Create a Federal Coordinated Health Care Office inside the Centers for Medicare & Medicaid Services by March 1, 2010. The office must have a Director who reports to the CMS Administrator. Its job is to get Medicare and Medicaid staff working together so people who have both programs get the benefits they should and the Federal and State governments coordinate better. The office must help states, special Medicare plans, doctors, and others align Medicare and Medicaid benefits. It must support coordination of short-term and long-term care, help with contracting and oversight, work with advisory commissions, study drug coverage for new full-benefit enrollees, and track yearly spending, health results, and access for people in both programs. The office is the contact point for certain special Medicare plans and must develop rules and guidance for unified appeals and aligned oversight, subject to the Secretary’s final approval. Each year the Secretary must include a report and suggested laws in the budget sent to Congress to improve coordination and benefits. Defined term: dual eligible individual — a person who has Medicare Part A or B and is eligible for Medicaid under a State plan or waiver.

Title 42, §1315b

The Public Health and Welfare, Source: USLM XML via OLRC

(a)Establishment of Federal Coordinated Health Care Office

(1)In general

Not later than March 1, 2010, the Secretary of Health and Human Services (in this section referred to as the “Secretary”) shall establish a Federal Coordinated Health Care Office.

(2)Establishment and reporting to CMS administrator

The Federal Coordinated Health Care Office—

(A)shall be established within the Centers for Medicare & Medicaid Services; and

(B)have as the Office a Director who shall be appointed by, and be in direct line of authority to, the Administrator of the Centers for Medicare & Medicaid Services.

(b)Purpose

The purpose of the Federal Coordinated Health Care Office is to bring together officers and employees of the Medicare and Medicaid programs at the Centers for Medicare & Medicaid Services in order to—

(1)more effectively integrate benefits under the Medicare program under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] and the Medicaid program under title XIX of such Act [42 U.S.C. 1396 et seq.]; and

(2)improve the coordination between the Federal Government and States for individuals eligible for benefits under both such programs in order to ensure that such individuals get full access to the items and services to which they are entitled under titles XVIII and XIX of the Social Security Act.

(c)Goals

The goals of the Federal Coordinated Health Care Office are as follows:

(1)Providing dual eligible individuals full access to the benefits to which such individuals are entitled under the Medicare and Medicaid programs.

(2)Simplifying the processes for dual eligible individuals to access the items and services they are entitled to under the Medicare and Medicaid programs.

(3)Improving the quality of health care and long-term services for dual eligible individuals.

(4)Increasing dual eligible individuals’ understanding of and satisfaction with coverage under the Medicare and Medicaid programs.

(5)Eliminating regulatory conflicts between rules under the Medicare and Medicaid programs.

(6)Improving care continuity and ensuring safe and effective care transitions for dual eligible individuals.

(7)Eliminating cost-shifting between the Medicare and Medicaid program and among related health care providers.

(8)Improving the quality of performance of providers of services and suppliers under the Medicare and Medicaid programs.

(d)Specific responsibilities

The specific responsibilities of the Federal Coordinated Health Care Office are as follows:

(1)Providing States, specialized MA plans for special needs individuals (as defined in section 1859(b)(6) of the Social Security Act (42 U.S.C. 1395w–28(b)(6))), physicians and other relevant entities or individuals with the education and tools necessary for developing programs that align benefits under the Medicare and Medicaid programs for dual eligible individuals.

(2)Supporting State efforts to coordinate and align acute care and long-term care services for dual eligible individuals with other items and services furnished under the Medicare program.

(3)Providing support for coordination of contracting and oversight by States and the Centers for Medicare & Medicaid Services with respect to the integration of the Medicare and Medicaid programs in a manner that is supportive of the goals described in paragraph (3).

(4)To consult and coordinate with the Medicare Payment Advisory Commission established under section 1805 of the Social Security Act (42 U.S.C. 1395b–6) and the Medicaid and CHIP Payment and Access Commission established under section 1900 of such Act (42 U.S.C. 1396) with respect to policies relating to the enrollment in, and provision of, benefits to dual eligible individuals under the Medicare program under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] and the Medicaid program under title XIX of such Act [42 U.S.C. 1396 et seq.].

(5)To study the provision of drug coverage for new full-benefit dual eligible individuals (as defined in section 1935(c)(6) of the Social Security Act (42 U.S.C. 1396u–5(c)(6)), as well as to monitor and report annual total expenditures, health outcomes, and access to benefits for all dual eligible individuals.

(6)To act as a designated contact for States under subsection (f)(8)(A) of section 1859 of the Social Security Act (42 U.S.C. 1395w–28) with respect to the integration of specialized MA plans for special needs individuals described in subsection (b)(6)(B)(ii) of such section.

(7)To be responsible, subject to the final approval of the Secretary, for developing regulations and guidance related to the implementation of a unified grievance and appeals process as described in subparagraphs (B) and (C) of section 1859(f)(8) of the Social Security Act (42 U.S.C. 1395w–28(f)(8)).

(8)To be responsible, subject to the final approval of the Secretary, for developing regulations and guidance related to the integration or alignment of policy and oversight under the Medicare program under title XVIII of such Act [42 U.S.C. 1395 et seq.] and the Medicaid program under title XIX of such Act [42 U.S.C. 1396 et seq.] regarding specialized MA plans for special needs individuals described in subsection (b)(6)(B)(ii) of such section 1859.

(e)Report

The Secretary shall, as part of the budget transmitted under section 1105(a) of title 31, submit to Congress an annual report containing recommendations for legislation that would improve care coordination and benefits for dual eligible individuals.

(f)Dual eligible individual defined

In this section, the term “dual eligible individual” means an individual who is entitled to, or enrolled for, benefits under part A of title XVIII of the Social Security Act [42 U.S.C. 1395c et seq.], or enrolled for benefits under part B of title XVIII of such Act [42 U.S.C. 1395j et seq.], and is eligible for medical assistance under a State plan under title XIX of such Act or under a waiver of such plan.

Notes & Related Subsidiaries

Editorial Notes

References in Text

The Social Security Act, referred to in subsecs. (b), (d)(4), (8), and (f), is act Aug. 14, 1935, ch. 531, 49 Stat. 620. Titles XVIII and XIX of the Act are classified generally to subchapters XVIII (§ 1395 et seq.) and XIX (§ 1396 et seq.), respectively, of this chapter. Parts A and B of title XVIII of the Act are classified generally to parts A (§ 1395c et seq.) and B (§ 1395j et seq.), respectively, of subchapter XVIII of this chapter. For complete classification of this Act to the Code, see section 1305 of this title and Tables. Codification Section was enacted as part of the Patient Protection and Affordable Care Act, and not as part of the Social Security Act which comprises this chapter.

Amendments

2018—Subsec. (d)(6) to (8). Pub. L. 115–123 added pars. (6) to (8).

§1315b Providing Federal Coverage and Payment Coordination for Dual Eligible Beneficiaries