Medicare and Medicaid residential care coordination demonstration project

(a)

Establishment and implementation

(1)

In general

The Secretary of Health and Human Services (in this section referred to as the Secretary) shall establish and implement a demonstration project (in this section referred to as the demonstration project) under titles XVIII and XIX of the Social Security Act to evaluate the use of capitated payments made to eligible continuing care retirement communities for residential care coordination programs.(2)

Timetable for implementation

In carrying out this section—(A)not later than 1 year after the date of the enactment of this Act the Secretary shall complete the design for the demonstration project and enter into one or more agreements with eligible CCRCs for the implementation of the project with respect to such CCRCs; and(B)not later than 4 years after the date of entering into such agreements, first provide for implementation of the project through such CCRCs.(b)

Budget neutrality

With respect to the period of the demonstration project under this section, the aggregate expenditures under titles XVIII and XIX of the Social Security Act for such period shall not exceed the aggregate expenditures that would have been expended under such titles if the demonstration project had not been implemented.(c)

State election required

(1)

In general

The Secretary may only implement the demonstration project in a State that elects to participate in the demonstration project.(2)

Benefits and payments

A State that elects to participate in the demonstration project shall provide medical assistance through title XIX of the Social Security Act for each eligible CCRC resident who is eligible for medical assistance under the State plan under such title (including such residents who are made eligible under subsection (d)(3)(B)(iii)) and who is enrolled in a residential care coordination program in a manner that is consistent with the requirements of this section, including making the payments under subsection (e).(3)

Limitation

A State may establish a numerical limit on—(A)the number of eligible CCRC residents who may be enrolled in residential care coordination programs in the State; and(B)the number of eligible CCRCs that may operate residential care coordination programs in the State.(d)

Residential care coordination program (RCCP); eligible continue care retirement community (CCRC); eligible CCRC residents; comprehensive coordinated health care services defined

(1)

Residential care coordination program; RCCP

For purposes of this section, the terms residential care coordination program and RCCP mean a program that—(A)is operated within one or more eligible continuing care retirement communities (as defined in paragraph (2));(B)is designed with a capacity of serving at least 1,000, but not more than 1,500, eligible CCRC residents (as defined in paragraph (3)) at any one time; and(C)provides comprehensive coordinated health care services (as defined in paragraph (4)) to participating CCRC residents enrolled in the program in accordance with the program agreement under subsection (f) and the requirements of this section.(2)

Eligible continuing care retirement community; eligible CCRC

In this section, the terms eligible continuing care retirement community and eligible CCRC mean an entity that is a continuing care retirement community (as defined in section 1852(l)(4)(B) of the Social Security Act (42 U.S.C. 1395w–22(l)(4)(B))) that—(A)is built for the purposes of participating in the demonstration project;(B)provides onsite—(i)housing accommodations for eligible CCRC residents, including apartments for independent living; and(ii)additional services to facilitate aging in place for such residents, including assisted living and skilled nursing facilities or alternatives; and(C)has entered into a program agreement with the Secretary and the State with respect to its operation of the residential care coordination program and such agreement is consistent with the requirements of this section.(3)

Eligible CCRC resident; participating CCRC resident

(A)

In general

For purposes of this section:(i)

Eligible CCRC resident

The term eligible CCRC resident means an individual who—(I)is entitled to, or enrolled for, benefits under part A of title XVIII of the Social Security Act, and enrolled for benefits under part B of such title; and(II)resides in an eligible CCRC.(ii)

Participating CCRC resident

The term participating CCRC resident means, with respect to a resident care coordination program, an eligible CCRC resident who is enrolled in that program.(B)

Participation by dual-eligible individuals; expanded eligibility

(i)

In general

An eligible CCRC resident may be, but is not required to be, a dual-eligible individual.(ii)

Dual-eligible individual defined

In this section, the term dual-eligible individual means any individual who is—(I)a full-benefit dual eligible individual (as defined in section 1935(c)(6) of the Social Security Act); or(II)is described in clause (iii).(iii)

Qualification of participating CCRC residents for Medicaid benefits

An individual who is a participating CCRC resident, regardless of the level of care, who meets income and resource eligibility criteria established under the State Medicaid plan for an individual to obtain coverage for nursing facility services on the basis of the individual’s requirement for the level of care for such services, shall be treated as a dual-eligible individual under this section and under title XIX of the Social Security Act so long as the individual remains a participating CCRC resident.(C)

Enrollment and disenrollment rules

(i)

Deemed enrollment at time of initial residency

An individual who is described in subclause (I) of subparagraph (A)(i) is deemed, at the time of becoming a resident in an eligible CCRC, to have voluntarily consented to enroll in the RCCP operated by that CCRC for purposes of subparagraph (A)(ii).(ii)

Disenrollment process

The demonstration project shall provide a method for the disenrollment from the project of participating CCRC residents, which method shall take into account the unique circumstances of residents who are required to leave the CCRC and shall permit disenrollment at least in the same circumstances as would permit an individual to disenroll from a Medicare Advantage plan under part C of title XVIII of the Social Security Act for cause.(D)

Relation to Medicare Advantage and prescription drug program

(i)

Supercedes enrollment

A participating CCRC resident is not eligible to enroll in an MA plan under part C of title XVIII of the Social Security Act or under a prescription drug plan under part D of such title.(ii)

Coordination in case of disenrollment

In the case of a participating CCRC resident who disenrolls from the demonstration project, the disenrollment shall be treated, for purposes of parts C and D of such title, as if the individual had been previously enrolled in, and disenrolled from, an MA–PD plan under part C of such title.(E)

Premium payments

During the period in which an individual is a participating CCRC resident—(i)for purposes of payment of premiums under parts B, C, and D of title XVIII of the Social Security Act, the individual shall be treated as if the individual were enrolled under an MA–PD plan with a premium equal to an amount specified in the program agreement; and(ii)the individual shall be eligible for assistance with respect to such premiums under part D and Medicare cost-sharing in the same manner and in the equivalent amounts as if the individual had not been enrolled as a participating CCRC resident.(4)

Comprehensive coordinated health care services defined

For purposes of this section, the term comprehensive coordinated health care services, with respect to an eligible CCRC resident—(A)means all items and services that are otherwise payable under title XVIII of the Social Security Act, including the minimum prescription drug coverage required under a prescription drug plan under part D of such title;(B)includes in the case of a dual eligible individual all items and services that are otherwise payable under the State plan under title XIX of such Act of the State in which the resident resides; and(C)also includes—(i)care management services that coordinate acute and specialty services (including inpatient hospital services, services provided by specialty physicians, and other necessary services) provided to eligible CCRC residents;(ii)wellness services, including assistance and instruction in healthy living (including diet and exercise); and(iii)other health care items and services to manage chronic conditions, treat subacute conditions, and provide preventive care.(e)

Payment under Medicare and Medicaid

(1)

In general

In the case of an individual who is a participating CCRC resident who is enrolled in a residential care coordination program operated by an eligible CCRC—(A)the individual shall receive benefits under title XVIII of the Social Security Act, and, if such individual is a dual-eligible individual (as defined in subsection (d)(3)(B)(ii)), under the State Medicaid plan or waiver under title XIX of such Act, solely through the residential care coordination program, which shall provide such individual with comprehensive coordinated health care services; and(B)the eligible CCRC shall receive capitated payments for the provision of such services (from the Secretary for benefits under title XVIII and from the State for benefits under such State plan or waiver), in accordance with this section.(2)

Payment methodology

(A)

Payment under Medicare

(i)

Payment on monthly basis

With respect to each eligible CCRC, the Secretary shall make prospective monthly payments of a capitated amount, based on the rate established under clause (ii), for each participating CCRC resident enrolled in the residential care coordination program operated by such CCRC in the same manner and from the same sources as payments are made to a Medicare Advantage organization under section 1853 of the Social Security Act. Such payments shall be subject to adjustment in the manner described in paragraphs (2) and (3) of section 1853(a).(ii)

Establishment of payment rate

(I)

In general

The Secretary shall establish a risk-adjusted capitated payment rate under title XVIII of the Social Security Act for comprehensive coordinated health care services provided to eligible CCRC residents through a residential care coordination program operated by an eligible CCRC. The payment rate shall be 90 percent of the adjusted average per capita cost described in section 1853(c)(1)(D)(i) of such Act (42 U.S.C. 1395w–23(c)(1)(D)(i)), plus an amount equivalent to 90 percent of the amount that would have been paid to a prescription drug plan the standardized bid amount of which (as defined in 1860D–13(a)(5) of such Act) was equal to the adjusted national average monthly bid amount (as defined in section 1860D–13(a)(1)(B)(iii) of such Act) and taking into account low-income subsidies paid under section 1860D–14.(II)

Program agreement

The mechanism for establishing the capitated amount under this subparagraph for a specific eligible CCRC shall be specified in the program agreement.(B)

Payment under Medicaid

(i)

Payment on a monthly basis

With respect to an eligible CCRC operating an RCCP, the State shall make prospective monthly payments of the capitated amount determined under and specified in the program agreement for each eligible CCRC resident of such community who is a dual-eligible individual.(ii)

Relationship to Medicare payments

The payment made under this subparagraph shall be in addition to any payment made under subparagraph (A) to an eligible CCRC for eligible CCRC residents who are dual-eligible individuals.(iii)

Program agreement

The capitated amount under this subparagraph for a specific eligible CCRC shall be specified in the program agreement.(iv)

Payments to the State

The Secretary shall treat the payments made under clause (i) as medical assistance under title XIX of the Social Security Act for purposes of making payments to the State under section 1903 of such Act (42 U.S.C. 1396b).(v)

Payments to reflect spend down amounts and personal needs allowances

The payments under this subparagraph shall be made in a manner that takes into account the financial contributions required of dual-eligible individuals and the personal needs allowance established under the State plan. Such personal needs allowances may vary depending upon the level of care required by such an individual.(3)

Treatment of services furnished by noncontract physicians and other entities

(A)

Application of Medicare Advantage requirements

Section 1852(k)(1) of the Social Security Act (42 U.S.C. 1395w–22(k)(1)) (relating to limitations on balance billing against Medicare Advantage organizations for noncontract physicians and other entities with respect to services covered under title XVIII of such Act) shall apply to eligible CCRCs, eligible CCRC residents enrolled in a residential care coordination program, and physicians and other entities that do not have a contract or other agreement establishing payment amounts for services furnished to such a resident in the same manner as such section applies to Medicare Advantage organizations, individuals enrolled with such organizations, and physicians and other entities referred to in such section.(B)

Application of balanced billing limitations

Section 1866(a)(1)(O) shall apply to services that are covered under title XVIII of the Social Security Act and are furnished to any eligible CCRC residents enrolled in a residential care coordination program in the same manner that such section applies to services furnished to an individual enrolled with a PACE provider under section 1894 or 1934 of such Act.(f)

Program agreement

(1)

Requirement

The Secretary, in close cooperation with the single State agency that administers or supervises the administration of the State plan under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) (in this section referred to as the State Medicaid agency), shall establish procedures for entering into, extending, and terminating program agreements (each in this section referred to as a program agreement) for the operation of residential care coordination programs by eligible CCRCs.(2)

Agreement required for payment

In order to receive payment under subsection (e), each eligible CCRC operating a residential care coordination program shall enter into a program agreement with the Secretary and the State, which shall contain such terms and conditions as the parties may agree to, so long as such terms and conditions are consistent with this section.(3)

Duration

(A)

In general

A program agreement under this section shall be effective for a contract year, beginning consistent with subsection (a)(2)(B) not later than the fourth calendar year to begin after the establishment of the demonstration project, and shall be extended for additional contract years in the absence of notice by a party to terminate.(B)

Termination

(i)

End of demonstration project

The Secretary and the State Medicaid agency shall terminate the program agreement at the termination of the demonstration project under subsection (i).(ii)

Notice of provider termination

The eligible CCRC may terminate the agreement after appropriate notice to the Secretary, the State Medicaid agency, and eligible CCRC residents.(iii)

Termination for cause

The Secretary and the State Medicaid agency may terminate the program agreement at any time for cause (as provided under the agreement). Reasons for terminating an agreement under this clause include that the Secretary or State administering agency determines that—(I)there are significant deficiencies in the quality of care provided to eligible CCRC residents enrolled in the program or the eligible CCRC has failed to comply substantially with the requirements of this section; and(II)the entity has failed to develop and successfully initiate, within 30 days of the date of the receipt of written notice of such a determination, a plan to correct the deficiencies, or has failed to continue implementation of such a plan.(iv)

Right to remain

Nothing in this paragraph shall be construed, in the case that a program agreement is terminated—(I)for a previously participating CCRC resident continuing, as affecting the individual’s right to continue to reside in the CCRC and to receive traditional CCRC care and services in accordance with the contract between the CCRC resident and the CCRC; and(II)as relieving the State from continuing to provide medical assistance with respect to such services for individuals who would qualify as dual-eligible individuals if the agreement had not been terminated.(4)

Scope of benefits

(A)

In general

Under the agreement under paragraph (2), the eligible CCRC shall—(i)provide to participating CCRC residents of such community, regardless of source of payment, directly or under contracts with other entities, at a minimum, all comprehensive coordinated health care services, without regard to any limitation or condition as to amount, duration, or scope under title XVIII or title XIX of the Social Security Act;(ii)provide such residents with access to necessary covered items and services 24 hours a day, every day of the year;(iii)provide services to such residents onsite at the eligible CCRC through a multidisciplinary team that is led by a primary care physician and includes care coordinators, case managers, and nurses;(iv)has a ratio of accessible physicians to eligible CCRC residents that the Secretary determines is adequate; and(v)specify the covered items and services that will not be provided directly by the eligible CCRC and—(I)provide for delivery of those items and services through contracts to ensure compliance with the requirements of this section; and(II)provides, on an as needed basis for those residents who cannot transport themselves, for necessary transportation services to the providers of such items and services, if such items and services are provided outside of the eligible CCRC.(B)

Application of regular cost-sharing rules

Under such agreement the eligible CCRC may apply deductibles, copayments, coinsurance, or other cost sharing that would otherwise apply under titles XVIII and XIX of the Social Security Act in the case of a MA–PD plan under part C of title XVIII of such Act.(5)

Quality control

(A)

In general

Under the program agreement, the eligible CCRC shall—(i)collect data;(ii)maintain, and afford the Secretary and the State Medicaid agency access to, the records relating to the program, including pertinent financial, medical, and personnel records; and(iii)submit to the Secretary and the State Medicaid agency such reports as the Secretary finds (in consultation with State Medicaid agencies) necessary to monitor the operation, cost, and effectiveness of the demonstration project, including data relevant to the measurements established by the Secretary under subparagraph (B), to permit the Secretary and the State to evaluate such demonstration project.(B)

Quality and outcome measures

The Secretary shall establish clinical and other outcome measurements to assess the efficacy of the demonstration project in—(i)improving—(I)the health status and outcomes of participating CCRC residents enrolled in residential care coordination programs under this demonstration project, compared to Medicare beneficiaries (including traditional dual-eligible individuals described in subsection (d)(3)(B)(ii)(I)) who are not enrolled in such programs; and(II)the quality of health care provided to such participating CCRC residents; and(ii)controlling the overall cost of providing health care items and services to such participating CCRC residents, compared to the cost of providing such items and services to other Medicare beneficiaries.(6)

Patient safeguards

The agreement under paragraph (2) shall provide for written safeguards of the rights of participating CCRC residents enrolled in a residential care coordination program (including a patient bill of rights and procedures for grievances and appeals). Such safeguards shall be similar to the safeguards required under the section 1894(b)(2)(B) of the Social Security Act (42 U.S.C. 1395eee(b)(2)(B)) with respect to the PACE program.(7)

Transition

If a participating CCRC resident who is enrolled in a residential care coordination program is disenrolled from such program, the eligible CCRC shall provide assistance to the individual in obtaining necessary care through appropriate referrals and making the individual’s medical records available to new providers.(8)

Rule of construction

Nothing is this subsection shall be construed as preventing the eligible CCRC from assessing typical and appropriate fees to eligible CCRC residents.(g)

Secretary's oversight; enforcement authority

(1)

Oversight

(A)

In general

During the duration of the demonstration project, with respect to an eligible CCRC operating a residential care coordination program under a program agreement under subsection (f), the Secretary (acting in cooperation with the State Medicaid agency) shall conduct a comprehensive annual review of the operation of the eligible CCRC in order to ensure compliance with the requirements of this section. Such review shall include—(i)an onsite visit to the eligible CCRC;(ii)a comprehensive assessment of the community’s fiscal soundness;(iii)a comprehensive assessment of the eligible CCRC’s capacity to provide all comprehensive coordinated health care services to participating CCRC residents;(iv)detailed analysis of the community’s substantial compliance with the requirements of this section; and(v)any other elements that the Secretary or the State Medicaid agency considers necessary or appropriate.(B)

Disclosure

The results of reviews under this paragraph shall be reported promptly to the eligible CCRC, along with any recommendations for changes to the community’s program, and shall be made available to the public through a public Web site of the Department of Health and Human Services.(2)

Sanctions

(A)

In general

If the Secretary determines (after consultation with the State Medicaid agency) that an eligible CCRC operating a residential care coordination program under a program agreement under subsection (f) is failing substantially to comply with the requirements of this section, the Secretary (and the State Medicaid agency) may take any or all of the following actions:(i)Condition the continuation of the program agreement upon timely execution of a corrective action plan.(ii)Withhold some or all further payments under the program agreement under this section with respect to services furnished by such community until the deficiencies have been corrected.(iii)Terminate such agreement under subsection (f)(3)(B).(B)

Application of intermediate sanctions

The Secretary may, by regulation, provide for the application against an eligible CCRC operating a residential care coordination program under a program agreement under this section of remedies described in section 1857(g)(2) of the Social Security Act (42 U.S.C. 1395w–27(g)(2)) or section 1903(m)(5)(B) of such Act (42 U.S.C. 1396b(m)(5)(B)) in the case of violations by the community of the type described in section 1857(g)(1) or 1903(m)(5)(A) of such Act, respectively (in relation to agreements, enrollees, and requirements under this section).(C)

Procedures for termination or imposition of sanctions

The provisions of section 1857(h) of the Social Security Act (42 U.S.C. 1395w–27(h)) shall apply, by regulation, to termination and sanctions respecting a program agreement and an eligible CCRC operating a residential care coordination program under a program agreement under this subsection in the same manner as they apply to a termination and sanctions with respect to a contract and a Medicare Advantage organization under part C of title XVIII of such Act.(h)

Waiver

Notwithstanding section 1115(a) of the Social Security Act (42 U.S.C. 1315(a)), the Secretary may waive such provisions of titles XI, XVIII, and XIX of that Act as may be necessary to—(1)accomplish the goals of the demonstration project under this section; and(2)maximize the quality of life of eligible CCRC beneficiaries, as determined using the measures established under subsection (f)(5)(B).(i)

Duration of 10 years

(1)

In general

Subject to paragraph (2) and subsection (f)(3)(B), the demonstration project shall terminate 10 years after the date on which the demonstration project is first implemented under subsection (a)(2)(B).(2)

Extension

The Secretary, acting through the Center for Medicare and Medicaid Innovation, may extend the use of capitated payments for eligible CCRCs for residential care coordination programs under this section if, by the termination date that would otherwise apply under paragraph (1), the Secretary has demonstrated that the demonstration project has improved the coordination, quality, and efficiency of health care services furnished to Medicare beneficiaries.(j)

Study and report to congress

(1)

Interim evaluation and report

Not later than 3 years after the date on which the demonstration project is first implemented under subsection (a)(2)(B), the Secretary shall submit to Congress a report that contains the following:(A)An interim evaluation of the costs and benefits of providing comprehensive coordinated health care services to Medicare beneficiaries (including dual-eligible individuals) through residential care coordination programs, including the costs and benefits of using payments under title XIX of the Social Security Act to provide continuity of care by permitting certain individuals to continue to participate in such programs after qualifying for enrollment in the Medicaid program under this section due to reduced income and assets.(B)An analysis of the appropriateness of implementing a new payment methodology under titles XVIII and XIX of the Social Security Act for such services in the future.(2)

Final evaluation and report

Not later than 10 years after the date on which the demonstration project is first so implemented, the Secretary shall submit to Congress a report that contains a final evaluation of the impact of the demonstration project.