Medicare ACO program improvements

(a)

In general

Section 1899 of the Social Security Act (42 U.S.C. 1395jjj) is amended by adding at the end the following new subsection:

(l)

Improving outcomes through greater beneficiary engagement

(1)

Use of beneficiary incentives

Subject to approval of the Secretary and in the case of an ACO that has elected a two-sided risk model (as provided for under regulations), the Secretary shall permit the ACO— (A)to reduce or eliminate cost-sharing otherwise applicable under part B for some or all primary care services (as identified by the ACO) furnished by health care professionals (including, as applicable, professionals furnishing services through a rural health clinic or Federally qualified health center) within the network of the ACO; and (B)to develop additional incentive programs to encourage patient engagement and participation in their own wellness.

The cost of the such incentives shall be borne by the ACO and shall not affect the payments under subsection (d).

(2)

Fostering stronger patient-provider ties

(A)

Providing prospective assignment of beneficiaries

(i)

In general

In carrying out subsection (c), the Secretary shall provide for a prospective assignment of Medicare fee-for-service beneficiaries before the beginning of a year to an ACO and primary care ACO professional in accordance with the practice under this section for Pioneer ACOs, subject to clause (ii). (ii)

Changing primary care ACO professionals

An ACO shall permit a beneficiary to select the primary care ACO professional within the ACO to which the beneficiary is assigned. (B)

Inclusion of ACO information in welcome to medicare visit and annual wellness visits

The Secretary shall require a primary care ACO professional to include, as part of the initial preventive physical examination under section 1861(ww)(1) or personalized prevention plan services under section 1861(hhh)(1) for a Medicare fee-for-service beneficiary assigned to that professional under this section, to provide the beneficiary with information concerning the ACO program under this section, including information on any cost-sharing reductions allowed under this section. (C)

Stakeholder advisory group

The Secretary shall form a stakeholder group, including representatives of ACOs, health care providers (including ACO professionals), Medicare beneficiaries, and ACO experts, to advise the Secretary with recommendations to improve the process of ACO-to-beneficiary communication. (3)

Moving from volume to value

(A)

Regulatory relief for moving to two-sided risk

In the case of an ACO that has elected a two-sided risk model (as described in paragraph (1)), in addition to the authority provided under paragraph (1), the Secretary shall provide the following regulatory relief: (i)

3-day prior hospitalization waiver for SNF services

Waiver of the 3-day prior hospitalization requirement for coverage of skilled nursing facility services. (ii)

Homebound requirement waiver for home health services

Waiver of the homebound requirement for coverage of home health services. (iii)

RAC hospital audit relief

Relief from reviews of scheduled admissions by recovery audit contractors for individuals attributed to an ACO when admitted on orders of a physician participating in the ACO. (B)

Improving care coordination through access to telehealth

(i)

Flexibility in furnishing telehealth services

In applying section 1834(m) in the case of an ACO that has elected a two-sided risk model (as described in paragraph (1)), the ACO may elect to have the limitations on originating site (under paragraph (4)(C) of such section) and on the use of store-and-forward technologies (under paragraph (1) of such section) not apply. The previous sentence shall not be construed as affecting the authority of the Secretary under subsection (f) to waive other provisions of such section. (ii)

Provision of remote monitoring in connection with home health services

Nothing in this section shall be construed as preventing an ACO from including payments for remote patient monitoring and home-based video conferencing services in connection with the provision of home health services (under conditions for which payment for such services would not be made under section 1895 for such services) in a manner that is financially equivalent to the furnishing of a home health visit. (4)

Establishing greater certainty for ACOs

(A)

Benchmarks and payments

The Secretary shall conduct a demonstration project to test the use of payment benchmarks that take into account geographic area differences, such as differences in spending trends within and across regions, and variations in delivery and utilization based on the socioeconomic status of beneficiaries served. (B)

Advance notification of ACOs of benchmarks and past performance

The Secretary shall inform ACOs, in advance of each performance period, of the quality benchmarks applicable to the ACO and period and of the past performance (if any) of the ACO under this section. (C)

Study and report on feasibility on providing electronic access to Medicare claims data

The Secretary shall conduct a study regarding the feasibility of establishing a system of electronic access of providers of services and suppliers to in-process and complete patient claims data. Such system may be a modification of an existing data base, such as the Virtual Research Data Center. The study shall take into account the measures needed to ensure the security and privacy of beneficiary and provider information. Not later than one year after the date of the enactment of this Act, the Secretary shall submit to Congress a report on such study. The Secretary shall include in such report such recommendations as the Secretary deems appropriate.

(b)

Requiring testing of global capitation payment model

Section 1899(i) of the Social Security Act (42 U.S.C. 1395jjj(i)) is amended— (1)in the heading, by striking

Option to use other payment models

and inserting

Alternative payment models

; (2)in paragraph (1), by inserting before the period at the end the following: except that the Secretary shall, beginning no later than January 1, 2016, establish one or more demonstration programs to test the payment model described in paragraph (3)(A); and (3)in paragraph (3)(A), by striking is any payment model and inserting the following:

(i)a global capitation model in which an ACO is at financial risk for all items and services covered under parts A and B; and(ii)any other payment model that the Secretary determines will improve the quality and efficiency of items and services furnished under this title.

(c)

Assignment taking into account services of non-Physician practitioners

Section 1899(c) of the Social Security Act (42 U.S.C. 1395jjj(c)) is amended by inserting (or, in the case of an ACO that is located in a rural or medically underserved area or that is affiliated with a Federally qualified health center or rural health clinic, an ACO professional described in subsection (h)(1)(B)) after subsection (h)(1)(A). (d)

Creating incentives for ACO development

The Secretary of Health and Human Services shall develop a mechanism to make permanent those ACO-related pilot programs, including the Advance Payment ACO Model, that have been successful. The Secretary shall submit to Congress a report on the study and shall include in the report such recommendations, including such changes in legislation, as the Secretary deems appropriate. (e)

Effective date

The amendments made by subsection (a) shall apply to plan years beginning on or after January 1, 2016.