[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3567 Introduced in House (IH)]

113th CONGRESS
  1st Session
                                H. R. 3567

    To amend title XVIII of the Social Security Act to provide for 
   additional coverage options for beneficiaries under the original 
   Medicare fee-for-service program through a Medicare Link program.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           November 20, 2013

  Mr. Schrader (for himself and Mr. Ribble) introduced the following 
  bill; which was referred to the Committee on Ways and Means, and in 
 addition to the Committee on Energy and Commerce, for a period to be 
subsequently determined by the Speaker, in each case for consideration 
  of such provisions as fall within the jurisdiction of the committee 
                               concerned

_______________________________________________________________________

                                 A BILL


 
    To amend title XVIII of the Social Security Act to provide for 
   additional coverage options for beneficiaries under the original 
   Medicare fee-for-service program through a Medicare Link program.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Medicare Link Act of 2013''.

SEC. 2. ESTABLISHMENT OF MEDICARE LINK PROGRAM.

    (a) In General.--Title XVIII of the Social Security Act is amended 
by adding after section 1899A (42 U.S.C. 1395kkk) the following new 
section:

                     ``medicare link program option

    ``Sec. 1899B.  (a) In General.--The Secretary shall establish under 
this section a program (to be known as the `Medicare Link Program' and 
in this section referred to as the `Program') through which individuals 
who are entitled to enroll in a Medicare Advantage plan under part C 
but who are not enrolled in such a plan under such part are eligible to 
enroll with a Medicare Link contractor under this section.
    ``(b) Enrollment; Disenrollment.--The Secretary shall establish a 
process for the enrollment (and disenrollment) of eligible individuals 
with Medicare Link contractors under the Program which process shall 
be, to the maximum extent practicable, the same as (and coordinated 
with) the process for enrollment (and disenrollment) of individuals in 
Medicare Advantage plans under part C.
    ``(c) Qualification of Contractors; Awarding of Contracts.--
            ``(1) In general.--In this section, the term `Medicare Link 
        contractor' means a nongovernmental entity, that may be a 
        Medicare Advantage organization, health plan, health insurance 
        issuer, medicare administrative contractor, or other qualified 
        third-party entity, that has entered into a contract with the 
        Secretary with respect to one or more Medicare Link regions (as 
        specified by the Secretary under paragraph (3)) for the 
        offering of Medicare Link services (described in subsection 
        (d)) to individuals residing in the region who enroll with the 
        contractor under the Program.
            ``(2) Limitation; requirements.--For each such Medicare 
        Link region, the Secretary shall select (and contract with) at 
        least 1, and not more than 3, Medicare Link contractors for the 
        offering of plans (in this section referred to as `Medicare 
        Link plans') under this section. The Secretary shall seek to 
        contract with at least 2 Medicare Link contractors within each 
        Medicare Link region. A contract with a Medicare Link 
        contractor may cover a multi-year period.
            ``(3) Specification of medicare link regions.--The 
        Secretary shall define and specify Medicare Link regions (each 
        in this section referred to as a `Medicare Link region') that, 
        across all such regions, encompass all 50 States, the District 
        of Columbia, and the territories.
            ``(4) Qualification of contractors.--The Secretary shall 
        establish uniform qualifications for Medicare Link contractors 
        based on their experience and qualifications to offer Medicare 
        Link plans under this section and to provide additional 
        services to individuals enrolled under such plans under this 
        section and to provide for reduced expenditures under parts A 
        and B. Contracts with Medicare Link contractors under this 
        section shall be for periods similar to the contracts with MA 
        organizations under part C and shall contain such terms and 
        conditions as the Secretary shall specify.
            ``(5) Contracting authority.--Nothing in this section shall 
        be construed as preventing a Medicare Link contractor from 
        contracting with other entities in carrying out activities 
        under this section, including the offering of Medicare Link 
        plans under this section.
            ``(6) Bidding process.--In selecting Medicare Link 
        contractors, the Secretary shall establish a bidding process 
        similar to the process of bidding by medicare administrative 
        contractors under section 1874A.
            ``(7) Contractor payments.--Medicare Link contractors with 
        contracts under this section shall be paid, on a monthly basis, 
        a per enrollee monthly service fee for the provision of 
        services under the contract consistent with the provisions of 
        paragraph (8). A portion of such fee (not to exceed 5 percent) 
        may be subject to adjustment based on a contractor's 
        performance on financial and quality benchmarks based upon pre-
        established measures specified by the Secretary.
            ``(8) Requirement for federal savings under contract.--
                    ``(A) In general.--Before entering into or renewing 
                a contract with a Medicare Link contractor, the 
                Secretary must determine (and the Chief Actuary of the 
                Centers for Medicare & Medicaid Services must certify) 
                that the terms of the contract are expected to yield 
                average, net savings to the Medicare program under this 
                title of not less than 5 percent per program enrollee 
                in the Medicare Link region covered under the contract.
                    ``(B) Computation.--Such savings shall be computed 
                taking into account all effects on spending under this 
                title, including any reductions in premiums and cost 
                sharing or other incentives for enrollees under 
                subsection (d), payments to Medicare Link contractors 
                under the contract, and reductions in payments to 
                medicare administrative contractors that would 
                otherwise have been made under section 1874A.
                    ``(C) Payments based on shared savings, adjusted 
                for quality.--The contract shall be structured in a 
                manner so that--
                            ``(i) subject to clause (ii), the payments 
                        to the contractor under paragraph (7) are 
                        computed to represent a proportion (as 
                        specified in the contract) of the net savings 
                        in excess of the minimum savings required under 
                        subparagraph (A); and
                            ``(ii) such proportion may be increased 
                        under the contract based on a contractor's 
                        performance on quality benchmarks, based upon 
                        pre-established measures specified by the 
                        Secretary.
                    ``(D) Guaranteed federal savings.--If the Secretary 
                determines that a Medicare Link contractor, after a 
                period of three consecutive years, does not maintain an 
                average net savings to the Medicare program of at least 
                5 percent per program enrollee as required under 
                subparagraph (A), the Medicare Link contractor shall 
                remit to the Secretary a sum specified by the Secretary 
                and related to the amount of the shortfall.
            ``(9) Savings validation audit.--The Secretary shall 
        provide for the annual auditing of the financial records 
        (including data relating to Medicare utilization and costs) of 
        organizations offering Medicare Link plans under this section
            ``(10) GAO audit.--Every 3 years the Comptroller General of 
        the United States shall conduct an audit of the Medicare Link 
        program costs and program savings. Such report shall be 
        submitted to the committees of the House of Representatives and 
        of the Senate with jurisdiction over Medicare.
    ``(d) Services Under a Medicare Link Plan.--
            ``(1) In general.--Each Medicare Link plan offered under 
        this section--
                    ``(A) shall provide for care management services 
                (described in paragraph (2)) and predictive modeling 
                and risk prioritization (described in paragraph (3)) 
                for individuals enrolled under the plan consistent with 
                this subsection;
                    ``(B) shall carry out the functions of medicare 
                administrative contractors described in paragraph 
                1874A(a)(4);
                    ``(C) shall provide a reduction or rebate in the 
                premium otherwise applicable under part B (as 
                determined without regard to section 1839(i)) to 
                individuals so enrolled; and
                    ``(D) may provide for a reduction in cost-sharing 
                otherwise applicable to such individuals who use 
                providers within a plan network.
            ``(2) Care management services.--
                    ``(A) Required.--The required care management 
                services shall include clinical interventions to help 
                coordinate care.
                    ``(B) Optional.--Optional care management services 
                may include interventions such as the following:
                            ``(i) Prevention and wellness.
                            ``(ii) Transitional and case management and 
                        other clinical programs.
                            ``(iii) Chronic disease management.
                            ``(iv) Advanced illness care initiatives.
                            ``(v) Diabetes prevention programs.
                            ``(vi) Transitional case management, for 
                        individuals discharged from a hospital or other 
                        health care institution.
                            ``(vii) Nurse practitioner-led 
                        interventions (consistent with restrictions 
                        under applicable State law).
                            ``(viii) Post-acute transition programs.
                            ``(ix) High-risk case management.
                            ``(x) Home-based primary care.
                            ``(xi) Advanced illness transitional care.
                            ``(xii) Operation of clinical management 
                        programs.
                            ``(xiii) Management and development of 
                        provider networks.
                            ``(xiv) Consumer engagement with decision 
                        support.
            ``(3) Predictive modeling and risk prioritization.--The 
        predictive modeling and risk prioritization services described 
        in this paragraph shall include the following:
                    ``(A) Predictive modeling and high risk 
                identification.--The use of claims data and trend data 
                to predict which enrollees could benefit from the 
                application of a clinical intervention or which might 
                be high risk and in need of a care plan.
                    ``(B) Prioritization of interventions.--Programs to 
                identify, prioritize, and personalize care 
                opportunities through a comprehensive profile of each 
                enrollee.
            ``(4) Optional incentives and enrollee empowerment.--
                    ``(A) In general.--A Medicare Link contractor may 
                use appropriate incentives to manage overall care for 
                enrollees. The Secretary shall establish terms and 
                conditions under which a Medicare Link contractor may 
                elect to use optional incentives for its members.
                    ``(B) Types of incentives.--The types of incentives 
                that may be used include the following:
                            ``(i) Healthy rewards.--Premium rebates and 
                        other incentives approved by the Secretary for 
                        enrollees to make healthier choices and 
                        actively engage in their health care.
                            ``(ii) Member incentives to use quality 
                        network providers.--Reductions in beneficiary 
                        cost-sharing (and other incentives approved by 
                        the Secretary) for enrollees who use providers 
                        (which may be accountable care organizations) 
                        within a plan network in order to reward 
                        quality, efficient care.
                            ``(iii) Cost estimator tools.--Providing 
                        beneficiaries with tools designed to help them 
                        simplify the evaluation of health care costs 
                        through cost estimates for different treatment 
                        options.
            ``(5) Application of ma grievance and appeals procedures.--
        In accordance with regulations, the provisions of part C 
        insofar as they apply to grievances and appeals, shall apply to 
        Medicare Link plans and enrollees under this section in a 
        manner similar to how such provisions apply to MA plans under 
        such part.
    ``(e) Maintenance of Current Benefits; Contractor Not at Financial 
Risk for Original Fee-for-Service Benefits.--
            ``(1) No change in medicare covered items and services or 
        limitation on supplemental plans.--Medicare Link plans shall 
        provide for coverage of the same items and services that are 
        covered under parts A and B. Nothing in this section shall be 
        construed as preventing an individual enrolled under a Medicare 
        Link plan from purchasing a medicare supplemental policy 
        (described in section 1881) or other supplemental coverage 
        outside of a Medicare Link plan.
            ``(2) No change in payments to providers.--
                    ``(A) In general.--Subject to subparagraph (B), 
                nothing in this section shall be construed as 
                authorizing a payment level to a provider of services 
                or supplier for Medicare covered services that is other 
                than the payment level otherwise applicable under part 
                A or B for such services.
                    ``(B) Negotiation of rates permitted.--A Medicare 
                Link contractor may negotiate with providers of 
                services and suppliers payment rates that are less or 
                greater than the payment rates referred to in 
                subparagraph (A).
            ``(3) Contractor not at financial risk.--A Medicare Link 
        contractor shall not be at financial risk with respect to the 
        coverage or payment for Medicare services covered under parts A 
        and B. But the Secretary may provide financial incentives for 
        contractors that are able to reduce Medicare expenditures for 
        such services below benchmark levels (specified by the 
        Secretary) that reasonably represent the levels of payments 
        that would be made (with respect to individuals enrolled under 
        a Medicare Link plan) if such individuals were not so 
        enrolled.''.
                                 <all>