[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.''.
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