The act is officially named the "Delivering Unified Access to Lifesaving Services Act of 2024," also called the "DUALS Act of 2024." It outlines various programs and requirements to improve care coordination, eligibility, and enrollment processes for individuals eligible for both Medicare and Medicaid, along with guidelines for state integrated care programs and the PACE program, which offers healthcare services to older adults.

The bill introduces State Integrated Care Programs aimed at providing comprehensive health care for individuals eligible for both Medicare and Medicaid, known as dual eligible individuals. It defines key terms, outlines state responsibilities for implementing care models, and details requirements for integrated care plans, including enrollment, care coordination, continuity of care, and data reporting, while establishing funding mechanisms and appointing a state ombudsman for oversight.

In this section, the term "Director" refers to the head of a specific health care office in the Centers for Medicare & Medicaid Services. "Dual eligible individual" identifies a person who qualifies for both Medicare and Medicaid benefits. "Integrated care plan" describes a program chosen by a state to provide comprehensive care to dual eligible individuals, but it doesn't include a PACE program.

In this section, each state must choose and implement a program to provide integrated care for individuals eligible for both Medicare and Medicaid within one year of the Director's model announcement. The implementation should start enrolling people by the fourth year, but could begin earlier if ready. States must also form an implementation council with a variety of stakeholders to guide this process, while the Director can adjust timelines based on state needs.

The section outlines how states can automatically enroll dual eligible individuals in integrated care plans while allowing them to opt out, requiring that they are informed at least 60 days before enrollment. It also covers enrollment conditions, such as needing an in-network primary care provider, and permits enrollment changes monthly or during specified periods, while allowing care coordinators to contact individuals before enrollment becomes effective.

The section outlines requirements for contracts between states, integrated care plan providers, and the Director regarding dual eligible individuals. It includes provisions for maintaining continuity of care, conducting health risk assessments, offering comprehensive care plans and benefits, and appointing care coordinators, along with payment structures and potential adjustments for frail individuals.

Under Section 2205, each state and integrated care plan must annually gather and report data about dual eligible individuals to the Director. This information includes personal details such as age, gender, disability, and other demographics. States can also require these plans to collect additional data.

Each state is required to set up an Office of the Ombudsman to assist people who qualify for both Medicare and Medicaid with their healthcare plans. The Office will be managed by someone experienced in these programs and will offer support to the individuals and their families, with specific funding and staffing requirements.

The section explains how states will receive funding when they make payments to integrated care plans for Medicaid services. It states that the funding will come from federal sources, including Medicare trust funds, and outlines how this money will be allocated for shared savings, administrative expenses, and data collection related to dual eligible individuals, starting from the first full calendar year the law is enacted in a state.

The Federal Coordinated Health Care Office (FCHCO) is responsible for creating and managing programs to improve healthcare for people eligible for both Medicare and Medicaid. The Director must develop care models, appeals processes, and quality measures, while also ensuring states report on benefits and maintaining oversight of integrated care plans. This includes creating payment structures, training programs, and data collection to enhance care coordination and patient satisfaction.

For plan years starting on or after January 1, 2025, the Federal Coordinated Health Care Office will take charge of managing the integration of special Medicare Advantage plans designed for individuals with special needs. Additionally, an amendment to the Patient Protection and Affordable Care Act ensures they have the authority to carry out this responsibility.

The section makes updates to the Social Security Act by expanding certain definitions and amending rules related to Medicare and Medicaid enrollment. It allows dual eligible individuals to enroll in new care plans and aims to prevent Medicaid from making duplicate payments for these individuals.

The Secretary of Health and Human Services, in consultation with States, is required to review State processes for determining eligibility for certain healthcare programs within one year of the Act's enactment. Additionally, the Secretary must issue guidance to improve coordination between States and the Federal government for these eligibility determinations.

The section requires the Director of the Federal Coordinated Health Care Office and the Administrator of the Centers for Medicare & Medicaid Services to review and identify necessary changes to align the important dates and deadlines for integrated care plans under Medicare, Medicaid, and State Integrated Care Programs for Dual Eligible Individuals, ensuring consistency within 180 days after the Act's passage.

The Secretary of Health and Human Services will give grants to state and local community organizations to help dual eligible individuals enroll in health plans that provide integrated care. These organizations must follow certain standards to ensure information is accessible and understandable, including being available in multiple languages and accessible formats for people with disabilities. An annual budget of $50 million is allocated for this initiative.

The section requires that within one year of the law being passed, the directors responsible for Medicare and Medicaid must publish guidance or rules. These rules will ensure that any information given to people who qualify for both Medicare and Medicaid meets specific standards.

The section requires that, within a year, guidance or regulations be established to ensure that dual eligible individuals can only be enrolled in certain health plans by independent brokers, with brokers receiving commissions only on initial enrollments. If a broker switches an individual to a plan with less integrated care, they must inform the individual about the change and its potential effects on their healthcare.

In this section, the Secretary of Health and Human Services is instructed to change a regulation concerning Medicare Advantage plans for look-alike D–SNPs by lowering a percentage threshold from 80% to 50%. Additionally, only full-benefit dual eligible individuals will be counted when applying this threshold.

The section requires the Centers for Medicare & Medicaid Services to create rules within a year that ensure Medicare Advantage and integrated care plans regularly update their provider directories. It also mandates including a rating for how current these directories are in the star rating systems for such health plans.

The section requires the Administrator of the Centers for Medicare & Medicaid Services to review the hospital quality star rating system within 180 days of the new law's enactment. They must identify any changes needed to ensure the system collects enough information to accurately measure the quality of hospitals.

The section requires the director of the Federal Coordinated Health Care Office to work with State Medicaid agencies to create a plan for a maximum number of patients each care coordinator should handle in integrated care programs for people eligible for both Medicare and Medicaid. This plan must be submitted within 180 days to various government officials and committees.

The bill proposes changes to the Social Security Act to test a model that allows states to provide healthcare coverage to individuals who are partially eligible for both Medicare and Medicaid but do not receive full benefits, through partly integrated care programs. This model aims to help low-income individuals who qualify for certain subsidies but not full dual eligibility benefits.

The section requires the Director of the Federal Coordinated Health Care Office and the Administrator of the Centers for Medicare & Medicaid Services to align billing codes for Medicare, Medicaid, and State Integrated Care Programs for Dual Eligible Individuals. They must review existing codes, hold a public listening session, and propose necessary changes within 180 days to ensure consistency across these programs.

The bill changes the Social Security Act to require states to offer PACE program services to eligible individuals, removing previous state options to limit enrollment numbers. It also mandates that state plans provide medical assistance for PACE services to those enrolled in a PACE program, with these changes taking effect 180 days after the bill is enacted.

The section allows individuals eligible for the PACE program to enroll at any time, and it provides for adjustments in payment to PACE providers based on when during the month a person enrolls. These changes will take effect 180 days after the law is enacted.

The bill section extends eligibility for the PACE program, which helps people with healthcare and support services, to Medicare-eligible individuals who are younger than 55, as long as they qualify for Medicare Part A or Part B. This change takes effect 180 days after the bill is enacted.

The section removes limitations that previously restricted how often and where organizations can apply to start PACE programs, allowing them to submit applications multiple times in the same quarter and in the same service area. This change will become effective 180 days after the law is enacted.

Medicare enrollees in PACE programs will have the option to choose a standalone prescription drug plan starting in 2024. These plans must offer equal or lower out-of-pocket costs than the current PACE plan, and PACE programs are required to educate and assist enrollees in making their choices.