To provide States with support to establish integrated care programs for individuals who are dually eligible for Medicare and Medicaid, and for other purposes.
Analysis under review: This bill has generated analysis that may be too generic or incomplete. Clause-level evidence remains available below.
Summary
What This Bill Does
The DUALS Act creates a new national program requiring all states to establish integrated care plans that combine Medicare and Medicaid benefits for people who qualify for both programs (called dual eligible individuals). The bill mandates that states select from federally-approved care models and automatically enroll eligible individuals into these plans, though individuals may opt out.
Who Benefits and How
Dual eligible individuals (approximately 12 million Americans) benefit from simplified, coordinated healthcare with a single care coordinator, comprehensive care plans, and 90-day continuity of treatment when switching plans. Managed care organizations and health insurers gain access to a new integrated care market with capitated payments from both Medicare and Medicaid. States receive shared savings payments and administrative funding from the federal government for implementing these programs.
Who Bears the Burden and How
State Medicaid agencies face significant new administrative requirements including mandatory program implementation within 4 years, establishing implementation councils, creating ombudsman offices with minimum staffing ratios, and extensive data collection and reporting. Healthcare providers must comply with new network adequacy standards, quality measures, and model-of-care requirements. The federal government bears substantial funding obligations through appropriations and Medicare trust fund transfers.
Key Provisions
- States must select and implement integrated care models within 4 years of federal model publication
- Passive enrollment with 60-90 day opt-out period; enrollment requires in-network primary care physician
- Mandatory care coordinators, health risk assessments, and comprehensive care plans for all enrollees
- 90-day continuity of care protection for active treatments when changing plans
- New star rating system and quality measures specific to dual eligible populations
Evidence Chain:
This summary is generated from the full bill text using AI analysis. Expand "Detailed Analysis" below for identified beneficiaries/burden bearers.
At a Glance
What This Bill Does
Establishes a mandatory national program for providing fully integrated Medicare-Medicaid care to dual eligible individuals through state-administered integrated care plans.
Key Policy Areas
Healthcare, Medicare, Medicaid, Social Security
Primary Purpose
Establishes a mandatory national program for providing fully integrated Medicare-Medicaid care to dual eligible individuals through state-administered integrated care plans.
Policy Domains
Title XXII - State Integrated Care Programs for Dual Eligible Individuals
Identified Gains
Contextual inference, no direct clause citation- Dual eligible individuals
- Managed care organizations
- States
- Care coordinators
Contextual inference, no direct clause citation
Identified Costs
Contextual inference, no direct clause citation- State Medicaid agencies
- Federal government
- Healthcare providers
Contextual inference, no direct clause citation
Sponsors
Legislative Progress
IntroducedMr. Cassidy (for himself, Mr. Carper, Mr. Cornyn, Mr. Warner, …
Stakeholder Effects
cui bono?How this legislation distributes effects. Mention counts reflect frequency, not effect magnitude.
CMS (Secretary), CMS and FCHCO, Center for Medicare and Medicaid Innovation
State Medicaid agencies, State governments face effects in multiple directions
Dual Eligible Special Needs Plan (D-SNP) providers, Health insurance brokers, Healthcare managed care organizations
Integrated care plan providers faces effects in multiple directions
Positive-direction: Healthcare managed care organizations, Independent health insurance brokers, Managed care organizations, Managed care organizations offering integrated care plans, Standalone prescription drug plan providers
Negative-direction: Health insurance brokers, Medicare Advantage plans, Medicare Advantage plans operating look-alike D-SNPs
Dual eligible individuals, Elderly and disabled individuals eligible for PACE, Healthcare consumers
Care coordinators, Healthcare ombudsman professionals, Healthcare providers
PACE program providers faces effects in multiple directions
Bill Structure & Actor Mappings
Who is "The Secretary" in each section?
- "the_director"
- → Director of the Federal Coordinated Health Care Office of CMS
- "the_secretary"
- → Secretary of Health and Human Services
Key Definitions
Terms defined in this bill
The Director of the Federal Coordinated Health Care Office of the Centers for Medicare & Medicaid Services
An individual entitled to or enrolled in Medicare Part A or B and eligible for full Medicaid benefits under specified sections
An entity or organization selected by a State to provide fully integrated care for dual eligible individuals, excluding PACE programs
A prescribed order or ordered course of treatment for a specific individual with a specific condition outlined ahead of time with patient and provider
A course of treatment in which a patient is actively seeing the provider and following the course of treatment
We use a combination of our own taxonomy and classification in addition to large language models to assess meaning and potential beneficiaries. High confidence means strong textual evidence. Always verify with the original bill text.
Learn more about our methodology