The DUALS Act of 2024 aims to improve care for individuals eligible for both Medicare and Medicaid by establishing state-integrated care programs. It outlines the responsibilities related to state implementation, program development, enrollment, plan requirements, and coordination among federal and state agencies. The Act also addresses improvements in eligibility determination, enrollment processes, care quality, and requires states to offer specific services like PACE to eligible individuals, including those under 55.

The provisions describe a new federal initiative, "State Integrated Care Programs for Dual Eligible Individuals," which aims to establish integrated care plans for individuals who qualify for both Medicare and Medicaid benefits. The program outlines procedures for automatic and voluntary enrollment, plan requirements, state responsibilities, funding mechanisms, and data reporting standards, ensuring coordinated healthcare services to improve patient outcomes and streamline administrative processes.

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.

Each state needs to choose a program model to provide fully integrated care for individuals who are eligible for both Medicare and Medicaid within a year of the program models being published. The state should work with the Director to implement the model, aiming to enroll people by the fourth year after selection, but may start earlier if ready. A council made up of various stakeholders will be established to assist in the implementation process.

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.

A state contract with an integrated care plan must meet specific criteria to be valid, such as allowing a 30-day period for continuity of care if a dual eligible individual changes plans, performing a health risk assessment, providing comprehensive benefits, and assigning a care coordinator. It also sets guidelines for care plan creation, transition periods for ongoing treatments, and allows for a frailty adjustment factor in payments.

Each state and integrated care plan must collect and report specific data annually to the Director, including details about age, gender, disability, and other demographics of individuals enrolled in the plan. States may also require integrated care plans to gather additional information.

Each state must create an Office of the Ombudsman to help people who qualify for both Medicare and Medicaid. This office will support those in special care programs, have enough staff, and receive funding to cover its operation costs, especially in the first two years.

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 section outlines the responsibilities of the Federal Coordinated Health Care Office (FCHCO) Director, including the development of integrated care programs, unified appeals processes, and quality measures for dual eligible individuals who qualify for both Medicare and Medicaid. It also discusses funding, hiring authority, and requires States to collect and report specific health-related data, with a focus on cooperation between federal and state agencies to improve care and efficiency for these individuals.

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 section requires the Secretary of Health and Human Services to work with states to review and improve how they determine if someone qualifies for certain healthcare benefits, such as those for low-income individuals and Medicare assistance, and to provide guidance to help state and federal systems work better together.

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 review billing codes and ensure they are aligned across Medicare, Medicaid, and State Integrated Care Programs for Dual Eligible Individuals. They must also hold a public listening session and recommend any administrative or legislative changes needed for consistency.

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 bill removes restrictions that previously limited how often and where an entity could apply to operate a PACE program, allowing them to submit multiple applications in the same quarter or service area. These changes will be effective 180 days after the bill becomes law.

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.