42 U.S.C. § 1315b — Providing Federal coverage and pay-

Page 2593 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1315b 1 So in original. Statutory Notes and Related Subsidiaries CONSTRUCTION REGARDING TELEHEALTH SERVICES Pub. L. 114–10, title I, § 101(e)(5), Apr. 16, 2015, 129 Stat. 122, provided that: ‘‘Nothing in the provisions of, or amendments made by, this title [see Tables for classi- fication] shall be construed as precluding an alter- native payment model or a qualifying APM participant (as those terms are defined in section 1833(z) of the So- cial Security Act [42 U.S.C. 1395l(z)], as added by para- graph (1)) from furnishing a telehealth service for which payment is not made under section 1834(m) of the Social Security Act (42 U.S.C. 1395m(m)).’’ MEDICAID GLOBAL PAYMENT SYSTEM DEMONSTRATION PROJECT Pub. L. 111–148, title II, § 2705, Mar. 23, 2010, 124 Stat. 324, provided that: ‘‘(a) IN GENERAL.—The Secretary of Health and Human Services (referred to in this section as the ‘Sec- retary’) shall, in coordination with the Center for Medi- care and Medicaid Innovation (as established under sec- tion 1115A of the Social Security Act [42 U.S.C. 1315a], as added by section 3021 of this Act), establish the Med- icaid Global Payment System Demonstration Project under which a participating State shall adjust the pay- ments made to an eligible safety net hospital system or network from a fee-for-service payment structure to a global capitated payment model. ‘‘(b) DURATION AND SCOPE.—The demonstration project conducted under this section shall operate dur- ing a period of fiscal years 2010 through 2012. The Sec- retary shall select not more than 5 States to partici- pate in the demonstration project. ‘‘(c) ELIGIBLE SAFETY NET HOSPITAL SYSTEM OR NET- WORK.—For purposes of this section, the term ‘eligible safety net hospital system or network’ means a large, safety net hospital system or network (as defined by the Secretary) that operates within a State selected by the Secretary under subsection (b). ‘‘(d) EVALUATION.— ‘‘(1) TESTING.—The Innovation Center shall test and evaluate the demonstration project conducted under this section to examine any changes in health care quality outcomes and spending by the eligible safety net hospital systems or networks. ‘‘(2) BUDGET NEUTRALITY.—During the testing pe- riod under paragraph (1), any budget neutrality re- quirements under section 1115A(b)(3) of the Social Se- curity Act [42 U.S.C. 1315a(b)(3)] (as so added) shall not be applicable. ‘‘(3) MODIFICATION.—During the testing period under paragraph (1), the Secretary may, in the Secretary’s discretion, modify or terminate the demonstration project conducted under this section. ‘‘(e) REPORT.—Not later than 12 months after the date of completion of the demonstration project under this section, the Secretary shall submit to Congress a re- port containing the results of the evaluation and test- ing conducted under subsection (d), together with rec- ommendations for such legislation and administrative action as the Secretary determines appropriate. ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated such sums as are nec- essary to carry out this section.’’ § 1315b. Providing Federal coverage and pay- ment coordination for dual eligible bene- ficiaries (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 admin- istrator The Federal Coordinated Health Care Of- fice— (A) shall be established within the Centers for Medicare & Medicaid Services; and (B) have as the Office 1 a Director who shall be appointed by, and be in direct line of authority to, the Administrator of the Cen- ters for Medicare & Medicaid Services. (b) Purpose The purpose of the Federal Coordinated Health Care Office is to bring together officers and em- ployees 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 individ- uals eligible for benefits under both such pro- grams 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 individ- uals are entitled under the Medicare and Med- icaid programs. (2) Simplifying the processes for dual eligi- ble individuals to access the items and serv- ices they are entitled to under the Medicare and Medicaid programs. (3) Improving the quality of health care and long-term services for dual eligible individ- uals. (4) Increasing dual eligible individuals’ un- derstanding of and satisfaction with coverage under the Medicare and Medicaid programs. (5) Eliminating regulatory conflicts between rules under the Medicare and Medicaid pro- grams. (6) Improving care continuity and ensuring safe and effective care transitions for dual eli- gible individuals. (7) Eliminating cost-shifting between the Medicare and Medicaid program and among re- lated 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 Co- ordinated Health Care Office are as follows: (1) Providing States, specialized MA plans for special needs individuals (as defined in sec- tion 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 edu- cation and tools necessary for developing pro- grams that align benefits under the Medicare Page 2594 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1316 2 So in original. Probably should be ‘‘subsection (c).’’ 3 So in original. Another closing parenthesis probably should precede the comma. and Medicaid programs for dual eligible indi- viduals. (2) Supporting State efforts to coordinate and align acute care and long-term care serv- ices for dual eligible individuals with other items and services furnished under the Medi- care 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 sup- portive of the goals described in paragraph (3).2 (4) To consult and coordinate with the Medi- care Payment Advisory Commission estab- lished under section 1805 of the Social Secu- rity Act (42 U.S.C. 1395b–6) and the Medicaid and CHIP Payment and Access Commission es- tablished 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 Secu- rity Act [42 U.S.C. 1395 et seq.] and the Med- icaid 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)),3 as well as to monitor and report annual total expendi- tures, 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 ap- proval of the Secretary, for developing regula- tions and guidance related to the implementa- tion 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 ap- proval of the Secretary, for developing regula- tions 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 sub- section (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, sub- mit to Congress an annual report containing recommendations for legislation that would im- prove care coordination and benefits for dual eli- gible individuals. (f) Dual eligible individual defined In this section, the term ‘‘dual eligible indi- vidual’’ 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. (Pub. L. 111–148, title II, § 2602, Mar. 23, 2010, 124 Stat. 315; Pub. L. 115–123, div. E, title III, § 50311(b)(2), Feb. 9, 2018, 132 Stat. 196.) 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 gen- erally 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.), respec- tively, of subchapter XVIII of this chapter. For com- plete 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). § 1316. Administrative and judicial review of pub- lic assistance determinations (a) Determination of conformity with require- ments for approval; petition for reconsider- ation; hearing; time limitations; review by court of appeals (1) Whenever a State plan is submitted to the Secretary by a State for approval under sub- chapter I, X, XIV, XVI, or XIX, he shall, not later than 90 days after the date the plan is sub- mitted to him, make a determination as to whether it conforms to the requirements for ap- proval under such subchapter. The 90-day period provided herein may be extended by written agreement of the Secretary and the affected State. (2) Any State dissatisfied with a determina- tion of the Secretary under paragraph (1) of this subsection with respect to any plan may, within 60 days after it has been notified of such deter- mination, file a petition with the Secretary for reconsideration of the issue of whether such plan conforms to the requirements for approval under such subchapter. Within 30 days after re- ceipt of such a petition, the Secretary shall no- tify the State of the time and place at which a hearing will be held for the purpose of reconsid- ering such issue. Such hearing shall be held not less than 20 days nor more than 60 days after the date notice of such hearing is furnished to such State, unless the Secretary and such State agree in writing to holding the hearing at another time. The Secretary shall affirm, modify, or re- verse his original determination within 60 days of the conclusion of the hearing. (3) Any State which is dissatisfied with a final determination made by the Secretary on such a reconsideration or a final determination of the