[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3244 Introduced in House (IH)]

114th CONGRESS
  1st Session
                                H. R. 3244

 To amend title XVIII of the Social Security Act to establish a pilot 
 program to improve care for the most costly Medicare fee-for-service 
   beneficiaries through the use of comprehensive and effective care 
  management while reducing costs to the Federal Government for these 
                 beneficiaries, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             July 28, 2015

  Mrs. McMorris Rodgers (for herself, Mr. Larson of Connecticut, Mr. 
   Reed, and Mr. Schrader) 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 establish a pilot 
 program to improve care for the most costly Medicare fee-for-service 
   beneficiaries through the use of comprehensive and effective care 
  management while reducing costs to the Federal Government for these 
                 beneficiaries, and for other purposes.

    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 ``Providing Innovative Care for 
Complex Cases Demonstration Act of 2015''.

SEC. 2. PROGRAM TO IMPROVE CARE FOR HIGHEST COST MEDICARE FEE-FOR-
              SERVICE BENEFICIARIES.

    Title XVIII of the Social Security Act is amended by inserting 
after section 1866E (42 U.S.C. 1395cc-5) the following new section:

  ``program to improve care for highest cost medicare fee-for-service 
                             beneficiaries

    ``Sec. 1866F.  (a) Establishment.--The Secretary shall conduct 
under this section a pilot program (in this section referred to as the 
`program') to demonstrate improvements in patient care and cost savings 
for the highest cost Medicare fee-for-service beneficiaries through 
enrollment of such beneficiaries with participating organizations. 
Under the program, the Secretary shall, through a competitive process, 
enter into a contract with one or two selected organizations to offer 
benefits for items and services in service areas identified under 
subsection (b)(1)(A) to the highest cost Medicare fee-for-service 
beneficiaries (identified under subsection (c)(1)) in the service area 
involved. The program shall be designed in a manner to provide 
comprehensive and integrated care management and services through a 
network of health care providers to meet the specialized needs of such 
identified beneficiaries.
    ``(b) Conduct of Program.--
            ``(1) Period of operation and scope.--
                    ``(A) Initial conduct.--The program shall initially 
                be conducted over a 3-year period, beginning not later 
                than 1 year after the date of the enactment of this 
                section, in at least 4 service areas, each identified 
                by the Secretary and each including at least 3 
                contiguous counties.
                    ``(B) Expansion and extension.--The Secretary may 
                expand the program to additional service areas and 
                extend its duration if the Secretary determines, in 
                consultation with the Chief Actuary of the Centers for 
                Medicare & Medicaid Services, that such expansion and 
                extension will result in additional savings to the 
                Medicare program and will meet the quality performance 
                standards established under subsection (d)(3)(A)(iii).
                    ``(C) Relation to part d.--
                            ``(i) In general.--The Secretary shall 
                        design and implement the program in such manner 
                        as to preserve the operation of part D, 
                        including payment, noninterference, and 
                        beneficiary protections under such part.
                            ``(ii) Coordination mechanisms.--The 
                        Secretary shall identify mechanisms that may be 
                        used, in the case of a highest cost Medicare 
                        fee-for-service beneficiary who is enrolled 
                        with a participating organization under the 
                        program and in a prescription drug plan offered 
                        by a PDP sponsor under part D or a qualified 
                        retiree prescription drug plan offered by a 
                        sponsor under section 1860D-22, in order to 
                        enhance coordination of the individual's care 
                        between the organization and the respective 
                        sponsor.
            ``(2) Number of participating organizations per service 
        area.--Under the program the Secretary shall enter into a 
        contract with at least one selected organization (and no more 
        than 2 selected organizations) in each service area identified 
        and covered under the program.
    ``(c) Identification and Enrollment of Highest Cost Medicare Fee-
for-Service Beneficiaries.--
            ``(1) Identification.--
                    ``(A) In general.--For purposes of the program, the 
                Secretary shall develop criteria to identify, subject 
                to subparagraph (B), Medicare fee-for-service 
                beneficiaries with projected total costs under parts A 
                and B in the highest 10th percentile of all Medicare 
                fee-for-service beneficiaries on an ongoing basis. Such 
                criteria shall be developed in a manner so as to 
                identify such beneficiaries using the most recent 
                national data available for a 2-year period.
                    ``(B) Refinement of eligibility criteria.--In 
                identifying highest cost Medicare fee-for-service 
                beneficiaries under this paragraph, the Secretary shall 
                develop such criteria in a manner that eliminates, to 
                the extent practicable, the identification of 
                individuals who otherwise appear to meet such criteria 
                only because of a single, isolated high-cost incident, 
                item, or service.
            ``(2) Eligible beneficiary initial outreach.--The Secretary 
        shall inform the highest cost Medicare fee-for-service 
        beneficiaries residing in an area covered by the program of the 
        program and provide them with information about the program and 
        the process for enrollment and disenrollment from participation 
        organizations in such area. Such information shall include 
        information about such organizations, about rights and 
        protections under the program, a contact telephone number where 
        beneficiaries can obtain additional information about the 
        program, and the use of an advance directive (as defined in 
        section 1866(f)(3)) in connection with participation in the 
        program.
            ``(3) Auto-enrollment and disenrollment procedures.--
                    ``(A) In general.--Under the program, the highest 
                cost Medicare fee-for-service beneficiaries residing in 
                a service area covered under the program--
                            ``(i) shall be enrolled, in a form and 
                        manner specified by the Secretary, with a 
                        participating organization offered under the 
                        program to such a resident in such area; and
                            ``(ii) may change or terminate such 
                        enrollment in a form and manner so specified.
                In specifying such form and manner, the Secretary shall 
                take into account the form and manner in which 
                individuals may change or terminate an enrollment under 
                a Medicare Advantage plan under part C, including 
                permitting special disenrollment periods described in 
                section 1851(e)(4).
                    ``(B) Default organization selection.--In carrying 
                out subparagraph (A), if there are two participating 
                organizations in a service area, the Secretary shall 
                identify, to the extent possible, and enroll the 
                beneficiary in the participating organization which has 
                providers in its network from whom the beneficiary has 
                received services under the Medicare fee-for-service 
                program in the previous year.
                    ``(C) Timeframes.--In carrying out subparagraph 
                (A), there shall be an initial enrollment period of 12 
                months, during which a highest cost Medicare fee-for-
                service beneficiary may also opt out of participation 
                in the program.
            ``(4) Extension of certain guaranteed issuance rights to 
        medigap coverage in case of disenrollment.--Subparagraph (A) of 
        section 1882(s)(3) shall apply to a Medicare beneficiary 
        enrolled with a participating organization under this section 
        who had previous coverage under a medicare supplemental 
        insurance policy and who terminates enrollment with the 
        participating organization in the same manner as such section 
        applies to an individual described in subparagraph (B)(v) of 
        such section with respect to enrollment with a health plan, 
        regardless of the time period of participation in the program 
        and without regard to subparagraph (E)(ii) of such section.
            ``(5) Treatment of medicare fee-for-service benefits to 
        enrollees through program.--The provisions of section 1851(i) 
        shall apply to individuals enrolled with a participating 
        organization under the program in the same manner as they apply 
        to an individual enrolled in a Medicare Advantage plan under 
        part C.
            ``(6) Relation to part d, employer-based prescription drug 
        coverage, and medicare supplemental coverage.--Except as 
        specifically provided, nothing in this section shall be 
        construed as intending to impact on benefits or coverage 
        furnished under a prescription drug plan under part D, under a 
        group health plan (including under a qualified retiree 
        prescription drug plan as defined in section 1860D-22(a)(2)), 
        or under a medicare supplemental policy.
    ``(d) Participating Organization Requirements.--
            ``(1) In general.--For purposes of participating in the 
        program, except as provided in this subsection, a participating 
        organization must meet the same requirements that apply to a 
        Medicare Advantage organization and an MA plan that is not an 
        MA-PD plan under part C, including requirements relating to--
                    ``(A) coverage of items and services under parts A 
                and B; and
                    ``(B) beneficiary protections under part C.
            ``(2) Waiver authority.--Under the program, the Secretary 
        may waive the requirements of this title and title XI but only 
        to the extent necessary to permit participating organizations--
                    ``(A) to provide care management, custodial care, 
                transportation, in-home assistance, and other services 
                that are not otherwise covered under this title;
                    ``(B) to structure patient incentives, such as a 
                reduction or elimination of cost-sharing, for services 
                and benefits under parts A and B and the use of in-home 
                technology, to improve beneficiary adherence to 
                treatment protocols and the effectiveness of treatment 
                for enrolled beneficiaries with chronic clinical 
                conditions; and
                    ``(C) to maintain provider and pharmacy networks 
                that do not otherwise meet network adequacy standards.
            ``(3) Quality and reporting requirements.--
                    ``(A) In general.--Under the program, the Secretary 
                shall--
                            ``(i) determine appropriate measures 
                        (including, to the extent feasible, outcome 
                        measures) to assess the quality of care being 
                        provided under the program;
                            ``(ii) establish requirements for 
                        participating organizations to report, in a 
                        form and manner specified by the Secretary, 
                        information on such measures;
                            ``(iii) establish quality performance 
                        standards on such measures to assess the 
                        quality of care being provided by such 
                        organizations under the program; and
                            ``(iv) seek the input of stakeholders (in a 
                        manner similar to that provided for under 
                        section 1848(r)) in determining such measures, 
                        requirements, and standards.
                    ``(B) Termination of participation for failure to 
                meet quality performance standards.--The Secretary may 
                terminate participation of an organization under the 
                program for failure to meet the quality performance 
                standards established under subparagraph (A)(iii).
                    ``(C) Quality performance standards.--In 
                establishing quality performance standards under 
                subparagraph (A)(iii) in the case of--
                            ``(i) a provider-based organization (such 
                        as an accountable care organization), the 
                        Secretary may apply the quality measurement 
                        system used under the Medicare shared savings 
                        program under section 1899(b)(3); and
                            ``(ii) an MA organization, the Secretary 
                        may require that only an organization with a 
                        rating (under the star quality rating system 
                        under section 1853(o)(4)) of 4 stars or higher 
                        be permitted to participate in the program.
            ``(4) Use of integrated model of care.--The Secretary shall 
        develop care management requirements for participating 
        organizations that provides an integrated care model and that 
        includes the following elements:
                    ``(A) Provision of person-centered, comprehensive, 
                and integrated care management and services.
                    ``(B) Provision of services through--
                            ``(i) the use of a network of providers 
                        characterized as best-in-class, such as centers 
                        of excellence; and
                            ``(ii) the use of an interdisciplinary 
                        management team that includes a nurse 
                        coordinator (or other appropriate health care 
                        professional) assigned to each enrolled 
                        beneficiary and that shares a common health 
                        information technology platform.
                    ``(C) An evidence-based model of care with 
                appropriate networks of providers and specialists.
                    ``(D) For each beneficiary enrolled with the 
                organization under the program, the organization--
                            ``(i) conducts an initial assessment and an 
                        annual reassessment of the beneficiary's 
                        physical, psychosocial, and functional needs, 
                        including an evaluation and plan with respect 
                        to the beneficiary's chronic conditions;
                            ``(ii) provides for regular in-person 
                        visits to the beneficiary by a care provider 
                        and provides the beneficiary with access to a 
                        specialized team, including a hospitalist 
                        physician; and
                            ``(iii) develops a plan, in consultation 
                        with the beneficiary as feasible, that 
                        identifies goals and objectives with respect to 
                        the beneficiary, including measurable outcomes 
                        as well as specific services and benefits to be 
                        provided.
    ``(e) Payments.--
            ``(1) In general.--For each individual enrolled with a 
        participating organization under the program, the Secretary 
        shall make a monthly capitated payment to the organization in 
        the same manner as such a payment would be made under part C 
        for an individual enrolled in an MA-plan (that was not an MA-PD 
        plan) offered by a Medicare Advantage organization, except 
        that--
                    ``(A) notwithstanding section 1853, the amount of 
                the payment shall be determined, subject to 
                subparagraph (B), in an amount equivalent to 98 percent 
                of the projected cost, under the Medicare fee-for-
                service program under parts A and B for the highest 
                cost Medicare fee-for-service beneficiaries; and
                    ``(B) the amount of such payment shall be adjusted, 
                in a manner specified by the Secretary, to take into 
                account differences in costs among different geographic 
                areas and among high cost Medicare fee-for-service 
                beneficiaries (including outlier costs for the most 
                costly such beneficiaries).
            ``(2) Projection based upon historical data.--In applying 
        paragraph (1)(A), the Secretary shall use historical fee-for-
        service spending and enrollment data for the highest cost 
        Medicare fee-for-service beneficiaries, trended forward to the 
        first year of the program, and, for subsequent years of the 
        program, increased by projected growth in such spending for 
        such beneficiaries.
            ``(3) Relationship to payment for covered part d drugs.--In 
        the case of an individual who is enrolled with a participating 
        organization under the program--
                    ``(A) if the individual is enrolled with a 
                prescription drug plan under part D, payment for 
                covered part D drugs for such individual is made under 
                such prescription drug plan under such part and not 
                under the program; and
                    ``(B) if the individual is covered under a 
                qualified retiree prescription drug plan under section 
                1860D-22, payment for covered part D drugs for such 
                individual is made under such plan and not under the 
                program.
    ``(f) Evaluation and Report to Congress.--
            ``(1) Evaluation.--The Secretary shall conduct an 
        independent evaluation of the program. Such evaluation shall 
        include an analysis of the impact of the program on 
        coordination of care, expenditures by participating 
        organizations and plans, the program's impact on reducing 
        expenditures under this title, beneficiary access to services 
        and providers, the quality of health care services furnished to 
        beneficiaries, and beneficiary experiences with auto-enrollment 
        and disenrollment under the program.
            ``(2) Report.--Not later than 2 years after the date that 
        Medicare beneficiaries are first enrolled under the program, 
        the Secretary shall submit to Congress a report on the 
        performance of the program. Such report shall include the 
        results of the evaluation conducted under paragraph (1) and the 
        program's impact on reducing expenditures under this title and 
        on improving the quality of care for the highest cost Medicare 
        fee-for-service beneficiaries enrolled under the program.
    ``(g) Definitions.--In this section:
            ``(1) Highest cost medicare fee-for-service beneficiary.--
        The term `highest cost Medicare fee-for-service beneficiary' 
        means a Medicare fee-for-service beneficiary who has been 
        identified under subsection (c).
            ``(2) Medicare fee-for-service beneficiary defined.--The 
        term `Medicare fee-for-service beneficiary' means an individual 
        who--
                    ``(A) is entitled to benefits under part A, and 
                enrolled under part B, regardless of the basis for 
                entitlement or eligibility to benefits under any such 
                part; and
                    ``(B) is not enrolled in a Medicare Advantage plan 
                under part C.
            ``(3) Program.--Unless the context indicates otherwise, the 
        term `program' means the program under this section.
            ``(4) Participating organization.--The term `participating 
        organization' means a selected organization that has entered 
        into a contract to participate in the program.
            ``(5) Selected organization.--The term `selected 
        organization' means a provider-based organization (such as an 
        accountable care organization) or MA organization (as defined 
        for purposes of part C) that the Secretary determines--
                    ``(A) meets the requirements to provide services to 
                the highest cost Medicare fee-for-services 
                beneficiaries under the program; and
                    ``(B) is accredited by the National Committee for 
                Quality Assurance or otherwise is certified as meeting 
                quality standards.''.
                                 <all>