[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4878 Introduced in House (IH)]
<DOC>
114th CONGRESS
2d Session
H. R. 4878
To amend title XVIII of the Social Security Act to establish a Medicare
Better Care Program to provide integrated care for Medicare
beneficiaries with chronic conditions, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
March 23, 2016
Mr. Paulsen (for himself and Mr. Welch) introduced the following bill;
which was referred to the Committee on Energy and Commerce, and in
addition to the Committee on Ways and Means, 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 Medicare
Better Care Program to provide integrated care for Medicare
beneficiaries with chronic conditions, 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; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Better Care, Lower
Cost Act''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
Sec. 2. Findings.
Sec. 3. Medicare Better Care Program.
Sec. 4. Chronic special needs plans.
Sec. 5. Improvements to welcome to Medicare visit and annual wellness
visits.
Sec. 6. Chronic care innovation centers.
Sec. 7. Curricula requirements for direct and indirect graduate medical
education payments.
SEC. 2. FINDINGS.
Congress makes the following findings:
(1) The field of medicine is ever-evolving and we need a
highly skilled, team-oriented workforce that can meet the
health care needs of today as well as the health care
challenges of tomorrow.
(2) The Medicare program should recognize the growing uses
and benefits of health technology in delivering quality and
cost-efficient care by encouraging the use of telemedicine and
remote patient monitoring.
SEC. 3. MEDICARE BETTER CARE PROGRAM.
(a) In General.--Title XVIII of the Social Security Act (42 U.S.C.
1395 et seq.) is amended by adding at the end the following new
section:
``medicare better care program
``Sec. 1899B. (a) Establishment.--
``(1) In general.--Not later than January 1, 2019, the
Secretary shall establish an integrated chronic care delivery
program (in this section referred to as the `program') that
promotes accountability and better care management for
chronically ill patient populations and coordinates items and
services under parts A, B, and D, while encouraging investment
in infrastructure and redesigned care processes that result in
high quality and efficient service delivery for the most
vulnerable and costly populations. The program shall--
``(A) focus on long-term cost containment and
better overall health of the Medicare population by
implementing through qualified BCPs (as described in
paragraph (2)(A)) strategies that prevent, delay, or
minimize the progression of illness or disability
associated with chronic conditions; and
``(B) include the program elements described in
paragraph (2).
``(2) Program elements.--The following program elements are
described in this paragraph:
``(A) A health plan or group of providers of
services and suppliers, or a health plan working with
such a group, that the Secretary certifies in
accordance with subsection (e) as meeting criteria
developed by the Secretary to recognize the challenges
of managing a chronically ill population, including
patient satisfaction and engagement, quality
measurement developed specifically for a chronically
ill population, and effective use of resources and
providers, may manage and coordinate care for BCP
eligible individuals through an integrated care
network, or Better Care Program (referred to in this
section as a `qualified BCP'). A group of providers of
services and suppliers described in the preceding
sentence may also be participating in another
alternative payment model (as defined in subsection
(k)).
``(B) Payments to a qualified BCP shall be made in
accordance with subsection (g).
``(C) Implementation of the program shall focus on
physical, behavioral, and psychosocial needs of BCP
eligible individuals.
``(D) Quality and cost containment are considered
interdependent goals of the program.
``(E) The calculation of long-term cost savings is
dependent on qualified BCPs delivering the full
continuum of covered primary, post-acute care, and
social services using capitated financing.
``(3) Targeted participation.--
``(A) In general.--In certifying qualified BCPs
throughout the country, the Secretary shall give
priority to areas--
``(i) that do not have a concentration of
accountable care organizations under section
1899; and
``(ii) with a high burden of chronic
conditions.
``(B) Initial requirement.--In the first 5 years of
the program, at least 50 percent of all new qualified
BCPs certified nationwide by the Secretary shall be
from counties or regions, as determined by the
Secretary, where the prevalence of the most costly
chronic conditions is at or greater than 125 percent of
the national average.
``(C) Restricting the number of participating
bcps.--
``(i) In general.--The Secretary shall take
into account geography, urban and rural
designations, and the population case mix that
will be served, when selecting BCPs for
participation.
``(ii) Limitation during the first four
program years.--During the first four years of
the program, the total number of qualified BCPs
certified by the Secretary shall not exceed
250.
``(iii) No limitation during fifth and
subsequent program years.--During the fifth
year and any subsequent year of the program,
the Secretary may certify any BCP that meets
the requirements to be certified as a qualified
BCP.
``(4) Alignment with approved state plan waivers.--In
certifying qualified BCPs, the Secretary shall ensure alignment
with other approved waivers of State plans under title XIX.
``(b) Definition of BCP Eligible Individuals.--
``(1) Definition.--For purposes of this section, the term
`BCP eligible individual' means an individual who--
``(A) is entitled to benefits under part A and
enrolled under parts B and D, including an individual
who is enrolled in a Medicare Advantage plan under part
C, an eligible organization under section 1876, or a
PACE program under section 1894; and
``(B) is medically complex given the prevalence of
chronic disease that actively and persistently affects
their health status, and absent appropriate care
interventions, causes them to be at enhanced risk for
hospitalization, limitations on activities of daily
living, or other significant health outcomes.
``(2) Dual eligible individuals.--An individual who is
dually eligible for Medicare and Medicaid shall not be excluded
from enrolling in a qualified BCP. Dually eligible
beneficiaries enrolled in a qualified BCP will see the full
scope of their benefits under this title and title XIX (other
than long-term care) managed by the qualified BCP.
``(c) Notification and Enrollment.--
``(1) Notification.--Not later than October 1 of each year,
the Secretary shall use all available tools, including the
notice mailed annually under section 1804(a) and State health
insurance assistance programs, to notify BCP eligible
individuals of qualified BCPs in their area for the upcoming
plan year. Such information shall also be easily accessible on
the Internet website of the Centers for Medicare & Medicaid
Services.
``(2) Enrollment.--The Secretary shall establish procedures
under which BCP eligible individuals may voluntarily enroll in
a qualified BCP at the following times:
``(A) During the annual, coordinated election
period under section 1851(e)(3)(B).
``(B) During or following (for a length of time
determined by the Secretary)--
``(i) an initial preventive physical
examination (as defined in section 1861(ww));
or
``(ii) any subsequent visit where a chronic
condition is identified or a previous condition
is identified as having escalated to the level
of a chronic condition.
``(d) Patient Assessment.--
``(1) Standardized functional and health risk assessment.--
``(A) Minimum guidelines.--Not later than January
1, 2018, the Secretary shall publish minimum guidelines
for qualified BCPs to furnish to enrollees a health
information technology-compatible, standardized, and
multidimensional risk assessment that--
``(i) assesses and quantifies the medical,
psychosocial, and functional status of an
enrollee; and
``(ii) includes a mechanism to determine
the level of patient activation and ability to
engage in self-care of an enrollee.
``(B) Updating.--Not less frequently than once
every 3 years, the Secretary shall, through rulemaking,
update such minimum guidelines to reflect new clinical
standards and practices, as appropriate.
``(2) Individual patient-centered chronic care plan.--
``(A) Model plan.--Not later than January 1, 2018,
the Secretary shall publish minimum guidelines for
qualified BCPs to develop individual patient-centered
chronic care plans for enrollees. Such a plan shall--
``(i) allow health professionals to
incorporate the medical, psychosocial, and
functional components identified in the risk
assessment described in paragraph (1)(A)(i);
``(ii) provide a framework that can be
easily integrated into electronic health
records, allowing clinicians to make timely,
accurate, evidence-based decisions at the point
of care; and
``(iii) allow for the provider to describe
how services will be provided to the enrollee.
``(B) Use of technology for patient self care.--
``(i) In general.--Whenever appropriate,
the individual patient-centered chronic care
plan of an enrollee shall include the use of
technologies that enhance communication between
patients, providers, and communities of care,
such as telehealth, remote patient monitoring,
Smartphone applications, and other such
enabling technologies, that promote patient
engagement and self care while maintaining
patient safety.
``(ii) Coordination and development of
streamlined pathway.--The Secretary shall work
with the Office of the National Coordinator for
Health Information Technology and the
Department of Health and Human Services Chief
Technology Officer to develop a streamlined
pathway for the use of mobile applications and
communications devices that effectively enhance
the experience of the patient while maintaining
patient safety and cost-effectiveness. Such
pathway shall not duplicate existing efforts.
``(e) Qualified BCP Providers.--
``(1) Criteria.--
``(A) In general.--Any health plan, provider of
services, or group of providers of services and
suppliers, who agrees to meet the requirements
described in paragraph (2) and is specified in
subparagraph (C) may form a multidisciplinary team of
health professionals to be certified as a qualified
BCP. Those providers may also choose to partner with a
qualified insurer to become a qualified BCP.
``(B) No preemption of state licensure laws.--
Nothing in this section shall preempt State licensure
laws.
``(C) Groups of providers and suppliers
specified.--
``(i) In general.--As determined
appropriate by the Secretary, the following
health plans, providers of services, or groups
of providers of services and suppliers, that
meet the criteria described in clause (ii) may
be certified as qualified BCPs under the
program:
``(I) Health professionals acting
as part of a multidisciplinary team.
``(II) Networks of individual
practices of health professionals that
may include community health centers,
Federally qualified health centers,
rural health clinics, and partnerships
or affiliations with hospitals.
``(III) Health plans that meet
appropriate network adequacy standards,
as determined by the Secretary, and
that include providers with experience
and interest in managing a population
with chronic conditions.
``(IV) Independent health
professionals partnering with an
independent risk manager.
``(V) Such other groups of
providers of services or suppliers as
the Secretary determines appropriate.
``(ii) Criteria described.--The following
criteria are described in this clause:
``(I) Demonstrated capacity to
manage the full continuum of care
(other than long-term care) for the
specialized population of BCP eligible
individuals.
``(II) Having a high rate of
Medicare customer satisfaction, when
applicable, or partnering with
providers of services or suppliers with
such a demonstrated high satisfaction
rate.
``(2) Requirements.--A qualified BCP shall meet the
following requirements:
``(A) The qualified BCP shall be accountable for
the quality, cost, and overall care of enrolled BCP
eligible individuals and agree to be at financial risk
for that enrolled population. A qualified BCP shall be
established with the objective of serving BCP eligible
individuals.
``(B) The qualified BCP shall be responsible for
the full continuum of care (other than long-term care)
for enrollees. This continuum shall include medical
care, skilled nursing and home health services,
behavioral health care, and social services. The
qualified BCP may not actively restrict an enrollee's
access to providers based on a practitioner's license
or medical specialty based on cost alone.
``(C) The qualified BCP shall primarily consist of
a care team tasked with responding to, treating, and
actively supporting the needs of BCP eligible
individuals. The care team shall also develop a care
plan for each eligible BCP enrollee and use it as a
tool to execute effective care management and
transitions.
``(D) The qualified BCP shall include physicians,
nurse practitioners, registered nurses, social workers,
pharmacists, and behavioral health providers who commit
to caring for BCP eligible individuals.
``(E) The qualified BCP shall enter into an
agreement with the Secretary to participate in the
program under this section for not less than a 3-year
period.
``(F) The qualified BCP shall include adequate
numbers of primary care and other relevant
professionals that can effectively care for the number
of BCP eligible individuals enrolled in the qualified
BCP.
``(G) The qualified BCP shall provide the Secretary
with such information regarding qualified BCP
professionals participating in the qualified BCP
necessary to support the enrollment of BCP eligible
individuals in a qualified BCP, including evidence
relating to high patient satisfaction when available,
the implementation of quality reporting and other
reporting requirements, and evidence to support a
determination of capitated payments in accordance with
subsection (g).
``(H) The qualified BCP shall have in place a
structure that includes clinical and administrative
systems, including health information technology, that
supports the integration of services and providers
across sites of care.
``(I) The qualified BCP may develop a collaborative
partnership that supports the mission of the BCP with
each of the following:
``(i) A regional or national Chronic Care
Innovation Center under section 6 of the Better
Care, Lower Cost Act.
``(ii) A regional or national Center of
Innovation (COIN) of the Department of Veterans
Affairs Health Services Research and
Development Service to identify and implement
best practices--
``(I) to increase access to, and
implementation of, prevention and
wellness tools;
``(II) to integrate physical and
behavior health care with social
services;
``(III) to promote evidence-based
medicine and patient engagement;
``(IV) to coordinate care across
providers and care settings;
``(V) to allow more patients to be
cared for in their homes and
communities;
``(VI) to reduce hospital
readmissions;
``(VII) to improve health outcomes
for patients with chronic conditions;
and
``(VIII) to report on quality
improvement and cost measures.
``(iii) A regional or national Telehealth
Resource Center of the Health Resources and
Services Administration (HRSA) Office for the
Advancement of Telehealth to create an
interactive, online resource for qualified BCP
professionals who may need additional training
or assistance in managing the needs of a
complex patient population, including--
``(I) continuing training and
education and mentoring for qualified
BCP professionals at any level of
licensure;
``(II) clinician support for
complex patients by an expert panel;
``(III) remote access to regional,
national, and international experts in
the field;
``(IV) forums for best practices to
be discussed among qualified BCP
professionals;
``(V) inter-professional education
supporting optimal communication
between members of a chronic care team;
and
``(VI) continuing training on the
use of telehealth, remote patient
monitoring, and other such enabling
technologies.
``(J) The qualified BCP shall demonstrate to the
Secretary that it meets person-centeredness criteria
specified by the Secretary in collaboration with
accreditation organizations, including the use of
patient and caregiver assessments and the use of
individual patient-centered chronic care plans for each
enrollee (as described in subsection (d)(2)).
``(K) The qualified BCP may identify and respond to
unique cultural, social, and economic needs of a
community that impact access to, and quality of,
healthcare.
``(L) The qualified BCP shall provide care across
settings, including in the home as needed.
``(M) The qualified BCP shall demonstrate financial
solvency (as determined by the Secretary).
``(N) The qualified BCP shall demonstrate the
ability to partner with providers of social and
behavioral health services within the community.
``(O) The qualified BCP shall engage in continuing
education on chronic care, on an ongoing basis (as
determined necessary by the Chronic Care Innovation
Center under the partnership under subparagraph
(J)(i)), in collaboration with the Agency for
Healthcare Research and Quality, the Health Resources
and Services Administration, and the Department of
Veterans Affairs.
``(f) Implementing Value-Based Insurance Design.--
``(1) In general.--
``(A) Election.--A qualified BCP may elect to
provide value-based Medicare coverage in accordance
with this subsection.
``(B) Inclusion of original medicare fee-for-
service program benefits.--Subject to subparagraph (C),
enrollees in a qualified BCP that elects to provide
value-based Medicare coverage under this subsection
shall receive such coverage that includes items and
services for which benefits are available under parts A
and B to individuals entitled to benefits under part A
and enrolled under part B, with cost-sharing for those
items and services as described in subparagraph (C).
``(C) Cost-sharing.--Cost-sharing described in this
subparagraph, with respect to an enrollee in a
qualified BCP that makes such an election, is varied
cost-sharing approved by the Secretary to incentivize
the use of high-value, high-quality services that have
been clinically proven to benefit BCP eligible
individuals.
``(D) Changes in coverage.--The Secretary, in
consultation with experts in the field, shall establish
a process for qualified BCPs to submit value-based
Medicare coverage changes that encourage and
incentivize the use of evidence-based practices that
will drive better outcomes while ensuring patient
protections and access are maintained.
``(E) No requirement for coverage of long-term care
services.--In no case shall a qualified BCP be required
to provide to enrollees coverage for long-term care
services.
``(2) Qualified bcp participation.--
``(A) Continued access.--Subject to subparagraph
(B), enrollees in a qualified BCP shall continue to
have access to all providers of services and suppliers
under this title.
``(B) No application of varied cost-sharing for
nonparticipating providers of services and suppliers.--
``(i) In general.--The varied cost-sharing
under paragraph (1)(B) shall only apply to
items and services furnished by qualified BCP
professionals of a qualified BCP that makes an
election under paragraph (1). In the case where
items and services are furnished by a provider
of services or supplier who is not such a
qualified BCP professional, the cost-sharing
applicable for those items and services will be
the cost-sharing as required under parts A and
B, or an actuarially equivalent level of cost-
sharing as determined by the Secretary.
``(ii) Notification.--A BCP eligible
individual shall be notified and counseled
prior to the time of enrollment on potential
changes in out-of-pocket costs that may occur
if care is provided by a provider of services
or supplier that is not a qualified BCP
professional.
``(3) Limitations on out-of-pocket expenses outside a
qualified bcp.--
``(A) In general.--Out-of-pocket costs, including
individual beneficiary copayments, with respect to
items and services furnished by a provider of services
or supplier who is not a qualified BCP professional
shall not exceed what would otherwise have been paid
with respect to the item or service under the original
Medicare fee-for-service program under parts A and B
for the same services or an actuarially equivalent
level of cost-sharing as determined by the Secretary,
or, in the case of a dual eligible individual, under
the Medicaid program under title XIX.
``(B) Prohibition on coverage of cost-sharing for
certain items and services furnished to an enrollee
outside of a qualified bcp under medigap policies.--For
provisions relating to prohibition on coverage of cost-
sharing for items and services (other than emergent
services, as defined by the Secretary) furnished to an
enrollee outside of a qualified BCP under Medigap
policies, see section 1882(z).
``(4) Prescription drug coverage.--
``(A) Drug plan option.--
``(i) In general.--A health plan certified
as a qualified BCP may provide enrollees with a
drug plan option specifically designed to
reflect the medication needs of enrollees.
``(ii) Application of part d provisions.--
``(I) In general.--Except as
otherwise provided in this section, the
provisions of part D shall apply to a
drug plan option offered by a qualified
BCP under clause (i) in the same manner
as such provisions apply to a
prescription drug plan offered by a PDP
sponsor under such part.
``(II) Limitation of enrollment.--A
qualified BCP offering such a drug plan
option may limit enrollment in the drug
plan option to enrollees in the
qualified BCP.
``(III) Waiver.--The Secretary may
waive such provisions of part D as are
necessary to carry out this section.
``(B) Agreement with prescription drug plans.--A
qualified BCP managed by a group of providers of
services may enter into an agreement with a PDP sponsor
of a prescription drug plan under part D to establish
and encourage individuals enrolled in the qualified BCP
to enroll in a prescription drug plan under such part
that is better suited to the needs of chronically ill
individuals.
``(C) Limitation.--A drug plan option offered by a
qualified BCP under subparagraph (A)(i) shall not have
the authority to increase out-of-pocket limits
otherwise applicable under part D.
``(g) Payments and Treatment of Savings.--
``(1) Payments to qualified bcps on a capitated basis.--
``(A) In general.--In the case of a qualified BCP
under this section, the Secretary shall make
prospective monthly payments of a capitation amount for
each BCP eligible individual enrolled in the qualified
BCP in the same manner and from the same sources as
payments are made to a Medicare Advantage organization
under section 1853. Such payments shall be subject to
adjustment in the manner described in section
1853(a)(2) or section 1876(a)(1)(E), as the case may
be.
``(B) Capitation amount.--The capitation amount to
be applied under this paragraph for a qualified BCP for
each enrollee for a year shall be \1/12\ of the
benchmark rate under subparagraph (C)(ii) for the year
(or the relevant rate under subparagraph (C)(i) for the
first year of the program under this section) (referred
to in this paragraph as the `per member per month
payment'), as adjusted under clause (iii).
``(C) Determining the rate using risk relevant
control group.--
``(i) Relevant rate.--
``(I) Identification of beneficiary
grouping.--Using claims data, the
Secretary shall identify a group of
beneficiaries who have similar health
risk characteristics, and have sought
care in the same county, multi-county,
or State level (as determined
appropriate by the Secretary to
establish a payment area) to the
population the qualified BCP is tasked
with serving. To the extent feasible
for a statistically valid control
group, the health risk of such group
shall reflect social characteristics,
such as income, as well as medical
risk.
``(II) Determination of relevant
rate.--The per capita spending amounts
under this title and, as appropriate,
title XIX, of the group of
beneficiaries identified under
subclause (I) shall determine the
`relevant rate' that will serve as the
basis of the benchmark for
participating qualified BCPs.
``(ii) Benchmark rate.--The Secretary shall
establish the benchmark rate for a qualified
BCP service area for each year of the program
by updating the relevant rate determined under
clause (i) with the projected change in per
capita spending for the group of beneficiaries
identified under clause (i)(I) for the payment
area described in such clause, as determined by
the Chief Actuary of the Centers for Medicare &
Medicaid Services.
``(iii) Adjustment for health status.--
``(I) Comparison of health
status.--The Secretary shall establish
a risk score mechanism to compare the
health status of an enrollee in a
qualified BCP to the average health
risk of group of beneficiaries
identified under clause (i)(I).
``(II) Inclusion of number of
conditions.--The Secretary shall
provide that a risk score under the
mechanism under this clause, with
respect to an individual, includes an
indicator for the number of chronic
conditions with which the individual
has been diagnosed.
``(III) Use of 2 years of diagnosis
data.--The Secretary shall ensure that
such risk score, with respect to an
individual reflects not less than 2
years of diagnosis data, to the extent
available.
``(IV) Adjustment for health
status.--The per member per month
payment to the qualified BCP for each
enrollee shall be adjusted depending on
how the individual risk profile of the
enrollee compares to the average health
status of such group of beneficiaries.
If an enrollee has a risk profile that
is not as severe as the average health
status of such group of beneficiaries,
then the per member per month shall be
decreased to reflect the `healthier'
status of the enrollee. If an enrollee
has a risk profile that is more severe,
then the per member per month payment
to the qualified BCP shall be increased
to reflect the more acutely ill status
of the enrollee.
``(D) Shared risk payments for certain qualified
bcps during first 3 years of the program.--
``(i) In general.--This subparagraph shall
only apply to qualified BCPs offered by a group
of providers of services and suppliers during
the first 3 years of the program under this
section.
``(ii) Sharing of risk to alleviate
outliers.--The Secretary shall determine shared
risk payments and recoupments under this
subparagraph for a qualified BCP described in
clause (i) as follows:
``(I) Determination of gain or
loss.--The Secretary shall, for each of
the first 3 years of the program under
this section, determine the percentage
of gain or loss for the qualified BCP
in providing benefits to enrollees
under this section.
``(II) Gain or loss greater than 5
percent.--If the Secretary determines
the qualified BCP has a gain or loss
for the year of greater than 5 percent,
the qualified BCP shall bear 100
percent of the risk or reward of such
loss or gain.
``(III) Gain or loss of not less
than 2 and not greater than 5
percent.--If the Secretary determines
the qualified BCP has a gain or loss
for the year of not less than 2 percent
but not greater than 5 percent--
``(aa) the qualified BCP
shall bear 80 percent of the
risk or reward, as applicable,
of such loss or gain; and
``(bb) the Secretary shall
bear 20 percent of the risk or
reward, as applicable, of such
loss or gain.
``(IV) Gain or loss between 0 and 2
percent.--If the Secretary determines
the qualified BCP has a gain or loss
for the year of greater than 0 percent
but less than 2 percent--
``(aa) the qualified BCP
shall bear 50 percent of the
risk or reward, as applicable,
of such loss or gain; and
``(bb) the Secretary shall
bear 50 percent of the risk or
reward, as applicable, of such
loss or gain.
``(iii) Provision of information.--A
qualified BCP shall provide to the Secretary
such information as the Secretary determines is
necessary to carry out this subparagraph.
``(E) Bid submission.--Beginning with the fourth
year of the program, a qualified BCP shall submit a bid
for participation in the program for the year that
reflects the experience of the qualified BCP--
``(i) in managing the care of the enrolled
population; and
``(ii) in managing such care given the
relevant rate determined under subparagraph
(C).
``(F) Quality bonus system.--
``(i) In general.--The Secretary shall
establish a quality bonus system whereby the
Secretary distributes bonus payments to
qualified BCPs that meet the requirements
described in clause (iii) and other standards
specified by the Secretary, which may include a
focus on quality measurement and improvement,
delivering patient-centered care, and
practicing in integrated health systems,
including training in community-based settings.
In developing such standards, the Secretary
shall collaborate with relevant stakeholders,
including program accrediting bodies,
certifying boards, training programs, health
care organizations, health care purchasers, and
patient and consumer groups.
``(ii) Determination of quality bonuses.--
Quality bonuses to the BCP shall be based on a
comparison of the quality of care provided by
the qualified BCP to enrollees to the quality
of care provided to beneficiaries not enrolled
in a qualified BCP or a Medicare Advantage plan
under part C in the same region. For not less
than the first 5 years of the program under
this section, quality measures for the
geographic region shall be based on local
standards of care, and not on a national
standard. For subsequent years, appropriate
national standards shall be considered for
inclusion in the comparison of the quality of
care under this subparagraph.
``(iii) Requirements.--A qualified BCP is
eligible for quality bonuses under this
subparagraph if--
``(I) the qualified BCP meets
quality performance standards under
subsection (h)(3); and
``(II) the qualified BCP meets the
requirements under subsection (e)(2).
``(h) Quality and Other Reporting Requirements.--
``(1) In general.--The Secretary shall develop and
implement, with assistance and input of relevant experts in the
field and the National Strategy for Quality Improvement in
Health Care, appropriate measures for BCP eligible individuals.
The Secretary shall determine appropriate measures under this
title and title XIX to assess the quality of care furnished by
a qualified BCP, as well as those measures that are no longer
appropriate and shall be removed from use. Such measures shall
include measures--
``(A) of clinical processes and outcomes;
``(B) of patient and, where practicable, caregiver
experience of care, including measurement that enhances
patient activation and engagement;
``(C) of utilization (such as rates of hospital
admissions for ambulatory care sensitive conditions);
``(D) of care coordination, management, and
transitions; and
``(E) that appropriately align with the National
Strategy for Quality Improvement in Health Care.
The Secretary may use existing measures under this title, title
XIX, or any other health care program, as appropriate, under
this paragraph.
``(2) Reporting requirements.--A qualified BCP shall submit
data in a form and manner specified by the Secretary which is
not overly burdensome to the qualified BCP, on measures the
Secretary determines necessary for the qualified BCP to report
in order to evaluate the quality of care furnished by the
qualified BCP. Such data reporting shall emphasize `patient-
centered measurement' and may include the functional status of
patients, case management and care transitions across health
care settings, including hospital discharge planning and post-
hospital discharge follow-up by qualified BCP professionals, as
the Secretary determines appropriate.
``(3) Quality performance standards.--The Secretary shall
establish quality performance standards to assess the quality
of care furnished by qualified BCPs. The Secretary shall seek
to improve the quality of care furnished by qualified BCPs over
time by specifying higher standards, new measures, or both for
purposes of assessing such quality of care. The Secretary shall
also include a process for retiring measures that are no longer
adequately contributing to improving standards of care at the
greatest possible value.
``(4) Other reporting requirements and call for
alignment.--The Secretary shall, as the Secretary determines
appropriate, incorporate and align reporting requirements and
incentive payments related to the physician quality reporting
system under section 1848, including those related to reporting
on quality measures under subsection (m) of that section,
reporting requirements under subsection (o) of that section
relating to meaningful use of electronic health records, the
establishment of a value-based payment modifier under
subsection (p) of that section, and other similar initiatives
under that section, and may use alternative criteria than would
otherwise apply under section 1848 for determining whether to
make such payments to qualified BCP professionals. The
incentive payments described in the preceding sentence shall
not be taken into consideration when calculating any payments
otherwise made under subsection (g).
``(i) Beneficiary Protections.--The Secretary shall ensure that, to
the extent consistent with this section, a qualified BCP offers
beneficiary protections applicable to beneficiaries under this title
and, as applicable, title XIX.
``(j) Payment of Medicare Cost-Sharing for Dual Eligible
Individuals.--In the case of a dual eligible individual enrolled in a
qualified BCP, the Secretary may provide for the payment of medicare
cost-sharing (as defined in section 1905(p)(3)) that would otherwise be
available under the State plan under title XIX if the individual was
not enrolled in the qualified BCP.
``(k) Definitions.--In this section:
``(1) Alternative payment model (apm).--The term
`alternative payment model' means any of the following:
``(A) A model under section 1115A (other than a
health care innovation award).
``(B) An accountable care organization under
section 1899.
``(C) A demonstration under section 1866C.
``(D) A demonstration required by Federal law.
``(E) A qualified BCP.
``(2) Hospital.--The term `hospital' means a subsection (d)
hospital (as defined in section 1886(d)(1)(B)).
``(3) Qualified bcp professional.--The term `qualified BCP
professional' means a certified and licensed professional of
medical or behavioral health services that is participating in
a qualified BCP.''.
(b) Federal Assumption of Medicaid Costs for Full Benefit Dual
Eligible Individuals Enrolled in a Qualified BCP.--Title XIX of the
Social Security Act is amended by inserting after section 1943 the
following new section:
``federal assumption of medicaid costs for full benefit eligible
individuals enrolled in a qualified bcp
``Sec. 1944. (a) State Contribution.--
``(1) In general.--The State shall provide for payment to
the Secretary for each month in an amount determined under
paragraph (2)(A) for each applicable dual eligible BCP enrollee
for such State.
``(2) State contribution amount.--
``(A) In general.--Subject to subparagraph (C), the
amount determined under this paragraph for a State for
a month in a year is equal to the product described in
subparagraph (A) of section 1935(c)(1) for the State
for the month, except that the reference in such
subparagraph to the total number of full-benefit dual
eligible individuals shall be deemed a reference to the
total number of applicable dual eligible BCP enrollees.
``(B) Form and manner of payment.--The provisions
of subparagraphs (B) through (D) of section 1935(c)(1)
shall apply to payment by a State to the Secretary
under this paragraph in the same manner as such
subparagraphs apply to payment under section
1935(c)(1)(A).
``(C) Application of different factors.--In
applying subparagraph (A), the following shall be
substituted under paragraphs (2) and (3) of section
1935(c):
``(i) The base year State Medicaid per
capita expenditures for covered part D drugs
described in subparagraph (A)(i)(I) of such
paragraph (2) shall be deemed to be the per
capita expenditures for health care items and
services that would apply (including any
medicare cost-sharing), with respect to an
applicable dual eligible BCP enrollee, if such
an individual received benefits only under
title XVIII (and not the State plan under this
title).
``(ii) Any reference to expenditures for
covered part D drugs or for prescription drug
benefits shall be deemed a reference to the
expenditures for health care items and services
described in clause (i).
``(iii) Any reference to 2003 or 2004 shall
be deemed a reference to 2019 or 2020,
respectively.
``(iv) Any reference to a full-benefit dual
eligible individual shall be deemed a reference
to an applicable dual eligible BCP enrollee.
``(v) The applicable growth factor under
section 1935(c)(4) for a year, with respect to
a State, shall be the average annual percentage
change (to that year from the previous year) of
the expenditures of the State under the State
plan under title XIX.
``(vi) The factor described in section
1935(c)(5) is deemed to be 90 percent.
``(3) Applicable dual eligible bcp enrollee.--For purposes
of this section, the term `applicable dual eligible BCP
enrollee' means, with respect to a State, an individual
described in subparagraph (A)(ii) of section 1935(c)(6) (taking
into account the application of subparagraph (B) of such
section) for such State who is enrolled in a qualified BCP
under section 1899B. Such term includes, in the case of medical
assistance for medicare cost-sharing under a State plan under
this title, an individual who is a qualified medicare
beneficiary (as defined in section 1905(p)(1)), a qualified
disabled and working individual (described in section 1905(s)),
an individual described in section 1902(a)(10)(E)(iii), or
otherwise entitled to such medicare cost-sharing and who is
enrolled in such a qualified BCP.
``(b) Coordination of Benefits.--
``(1) Medicare as primary payor.--In the case of an
applicable dual eligible BCP enrollee, notwithstanding any
other provision of this title, medical assistance is not
available under this title for health care items or services
(or for any cost-sharing respecting such health care items and
services), and the rules under this title relating to the
provision of medical assistance for such health care items and
services shall not apply. The provision of benefits with
respect to such health care items and services shall not be
considered as the provision of care or services under the plan
under this title. No payment may be made under section 1903(a)
for health care items and services for which medical assistance
is not available pursuant to this paragraph.
``(2) Coverage of long-term care services.--In the case of
medical assistance under this title with respect to coverage of
long-term care services furnished to an applicable dual
eligible BCP enrollee, the State may elect to provide such
medical assistance in the manner otherwise provided in the case
of individuals who are not full-benefit dual eligible
individuals or through an arrangement with such qualified BCP.
In no case shall a qualified BCP be required to provide to
enrollees coverage of long-term care services.''.
(c) State Marketing Materials for Dually Eligible Individuals.--
(1) State plan requirement.--Section 1902(a) of the Social
Security Act (42 U.S.C. 1396a(a)) is amended--
(A) in paragraph (80), by striking ``and'' at the
end;
(B) in paragraph (81), by striking the period at
the end and inserting ``; and''; and
(C) by inserting after paragraph (81) the
following:
``(82) provide that any marketing materials distributed by
the State that are directed at dual eligible individuals (as
defined in section 1915(h)(2)(B)) include information on
qualified BCPs offered under section 1899B.''.
(2) Effective date.--The amendments made by this section
shall apply to calendar quarters beginning on or after January
1, 2019, without regard to whether or not final regulations to
carry out such amendments have been promulgated by such date.
(d) Prohibition on Coverage of Cost-Sharing for Certain Items and
Services Furnished to an Enrollee Outside of a Qualified BCP Under
Medigap Policies.--Section 1882 of the Social Security Act (42 U.S.C.
1395ss) is amended by adding at the end the following new subsection:
``(aa) Prohibition on Coverage of Cost-Sharing for Certain Items
and Services Furnished to an Enrollee Outside of a Qualified BCP and
Development of New Standards for Medicare Supplemental Policies.--
``(1) Development.--The Secretary shall request the
National Association of Insurance Commissioners to review and
revise the standards for benefit packages under subsection
(p)(1), taking into account the changes in benefits resulting
from the enactment of the Better Care, Lower Cost Act and to
otherwise update standards to include the requirements for
cost-sharing described in paragraph (2). Such revisions shall
be made consistent with the rules applicable under subsection
(p)(1)(E) with the reference to the `1991 NAIC Model
Regulation' deemed a reference to the NAIC Model Regulation as
published in the Federal Register on December 4, 1998, and as
subsequently updated by the National Association of Insurance
Commissioners to reflect previous changes in law and the
reference to `date of enactment of this subsection' deemed a
reference to the date of enactment of the Better Care, Lower
Cost Act. To the extent practicable, such revision shall
provide for the implementation of revised standards for benefit
packages as of January 1, 2019.
``(2) Cost-sharing requirements.--The cost-sharing
requirements described in this paragraph are that,
notwithstanding any other provision of law, no medicare
supplemental policy may provide for coverage of cost-sharing
with respect to items and services (other than emergent
services, as defined by the Secretary) furnished to an
individual enrolled in a qualified BCP under section 1899B by a
provider of services or supplier that is not a qualified BCP
professional (as defined in section 1899B(k)).
``(3) Renewability.--The renewability requirement under
subsection (q)(1) shall be satisfied with the renewal of the
revised package under paragraph (1) that most closely matches
the policy in which the individual was enrolled prior to such
revision.''.
SEC. 4. CHRONIC SPECIAL NEEDS PLANS.
Section 1859 of the Social Security Act (42 U.S.C. 1395w-28) is
amended--
(1) in subsection (f)(4)--
(A) by striking ``In the case of'' and inserting
``Subject to subsection (h), in the case of''; and
(B) by adding at the end the following flush text:
``Notwithstanding any other provision of this section, on or
after January 1, 2019, the Secretary shall establish procedures
for the transition of those individuals to a Medicare Advantage
plan qualified BCP in accordance with subsection (h).''; and
(2) by adding at the end the following new subsection:
``(h) Medicare Advantage Plan Qualified BCPs.--
``(1) In general.--A Medicare Advantage plan that is
certified as a qualified BCP (referred to in this subsection as
a `Medicare Advantage plan qualified BCP')--
``(A) is deemed to be a specialized MA plan for
special needs individuals described in subsection
(b)(6)(B)(iii); and
``(B) may enroll such special needs individuals.
``(2) Specialized benefit packages.--A Medicare Advantage
plan qualified BCP shall have the flexibility to offer
specialized benefit packages to enrollees described in
subsection (b)(6)(B)(iii), consistent with the value-based
insurance requirements under section 1899B(f).
``(3) Application of bcp requirements.--A Medicare
Advantage plan qualified BCP shall be subject to all
requirements applicable to a qualified BCP under section 1899B,
including enrollment periods under subsection (c) of that
section, applicable criteria relating to network adequacy,
requirements with respect to individual patient-centered
chronic care plans under subsection (d)(2) of that section,
applicable criteria with respect to care management processes,
and quality reporting under subsection (h) of that section.
``(4) Application of part c requirements.--The provisions
of this part, including the provisions relating to specialized
MA plans for special needs individuals described in subsection
(b)(6)(B)(iii), shall apply to a Medicare Advantage plan
qualified BCP to the extent they are consistent with the
provisions of section 1899B.''.
SEC. 5. IMPROVEMENTS TO WELCOME TO MEDICARE VISIT AND ANNUAL WELLNESS
VISITS.
(a) Welcome to Medicare Visit.--Section 1861(ww)(1) of the Social
Security Act (42 U.S.C. 1395x(ww)(1)) is amended by adding at the end
the following new sentence: ``In the case of a BCP eligible individual
(as defined in section 1899B(b)), such term includes a standardized
functional and health risk assessment (as described in section
1899B(d)(1)) furnished by a qualified BCP professional (as defined in
section 1899B(k)).''.
(b) Annual Wellness Visit.--Section 1861(hhh)(1) of the Social
Security Act (42 U.S.C. 1395x(h)(1)) is amended--
(1) in subparagraph (A), by striking ``and'' at the end;
(2) in subparagraph (B), by striking the period at the end
and inserting ``; and''; and
(3) by adding at the end the following new subparagraph:
``(C) in the case of a BCP eligible individual (as
defined in section 1899B(b)), that includes a
standardized functional and health risk assessment (as
described in section 1899B(d)(1)) furnished by a
qualified BCP professional (as defined in section
1899B(k)).''.
(c) Effective Date.--The amendments made by this section shall
apply to services furnished on or after the date that is one year after
the date of enactment of this Act.
SEC. 6. CHRONIC CARE INNOVATION CENTERS.
(a) Designation.--Not later than October 1, 2018, the Secretary,
acting through the Agency for Healthcare Research and Quality, shall
designate and provide core funding for not less than three Chronic Care
Innovation Centers. The Secretary shall develop a process for entities
seeking to become a Chronic Care Innovation Center, and shall ensure
sufficient geographic representation among those entities selected. The
main objectives of such Centers shall include the following:
(1) Improving the understanding of how to measure, monitor,
and understand quality and efficiency for a patient population
with substantial disease burden.
(2) Rigorously examining alternative and innovative systems
and strategies for efficiently improving quality and outcomes
for common, serious, and chronic illnesses.
(3) Developing and applying improved methodologies for
informing policymakers regarding heterogeneity in the
effectiveness and safety of proposed interventions, and
assessing barriers to the implementation of high-priority care.
(4) Studying organization and management practices that
result in higher quality of care.
(5) Defining and improving quality of care for patients
with the chronic diseases prevalent in primary care settings.
(6) Understanding the influence of race, ethnicity, and
cultural factors on access, quality, and outcomes (such as
clinical, patient-centered, health care utilization, and
costs).
(7) Evaluating new technology to enhance access to, and
quality of care (such as telemedicine).
(8) Assessing the use of patient self-management and
behavioral interventions as a means of improving outcomes for
Medicare beneficiaries with complex chronic conditions.
(9) Understanding how management of care is affected when
patients have multiple chronic conditions in which evidence or
recommended guidelines are lacking, conflict with, or
complicate overall care management.
(10) Characterizing coordination of care within and across
healthcare systems, including the Department of Veterans
Affairs, the Medicare program under title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.), the Medicaid program
under title XIX of such Act, and private sector programs for
veterans with complex chronic conditions.
(b) Requirements.--In order to be designated a Chronic Care
Innovation Center under this section, each eligible entity must meet
the following requirements:
(1) Develop and implement a sustained research agenda in
the field of chronic care.
(2) Collaborate with local schools of public health and
universities to carry out its mission.
(3) Actively engage in the development of new, best
practices for the delivery of care to the chronically ill.
(4) Actively engage in the development and routine updating
of quality measures for the chronically ill.
(5) Have the ability to convene experts practiced in the
needs of a chronically ill patient, including pharmacologists,
psychiatrists, cardiologists, pulmonologists, rheumatologists,
nutritionists and dieticians, social workers, and physical
therapists.
(6) Partner with the Secretary of Health and Human Services
and the Secretary of Veterans Affairs (including the Center for
Health Services Research in Primary Care of the Department of
Veterans Affairs Health Services Research and Development
Service), the medical community, medical schools, and public
health departments through the Agency for Healthcare Research
and Quality, the Health Resources and Services Administration,
and the Association of American Medical Colleges to routinely
develop new, forward thinking, and evidence-based curricula
that addresses the tremendous need for team-based care and
chronic care management. Such curricula shall include
palliative medicine, chronic care management, leadership and
team-based skills and planning, and leveraging technology as a
care tool.
(c) Oversight and Evaluation.--
(1) In general.--The Agency for Healthcare Research and
Quality shall be responsible for oversight and evaluation of
all Chronic Care Innovation Centers under this section.
(2) Reports.--Not less frequently than every 3 years, the
Agency for Healthcare Research and Quality shall submit to the
Secretary of Health and Human Services and to Congress a report
containing the findings of oversight and evaluations conducted
under paragraph (1).
(d) Contract Authority.--In order to carry out this section, the
Secretary may contract with existing Centers of Innovation (COINs) of
the Department of Veterans Affairs Health Services Research and
Development Service that meet the requirements described in subsection
(c).
(e) Authorization.--There are authorized to be appropriated such
sums as are necessary to carry out this section.
SEC. 7. CURRICULA REQUIREMENTS FOR DIRECT AND INDIRECT GRADUATE MEDICAL
EDUCATION PAYMENTS.
(a) Direct Graduate Medical Education Payments.--Section 1886(h) of
the Social Security Act (42 U.S.C. 1395ww(h)) is amended by adding at
the end the following new paragraph:
``(9) New curricula requirements.--
``(A) Development.--The Secretary shall engage with
the medical community and medical schools in developing
curricula that meets the following requirements:
``(i) The curricula is new, forward
thinking, and evidence-based.
``(ii) The curricula addresses the need for
team-based care and chronic care management.
``(iii) The curricula includes palliative
medicine, chronic care management, leadership
and team-based skills and planning, and
leveraging technology as a care tool.
``(B) Rural areas.--The curricula developed under
subparagraph (A) shall include appropriate focus on
care practices required for rural and underserved
areas.
``(C) Limitation.--Notwithstanding the preceding
provisions of this subsection, for cost reporting
periods beginning on or after the date that is 5 years
after the date of enactment of the Better Care, Lower
Cost Act, if a hospital has not begun to implement
curricula that meets the requirements described in
subparagraph (A), payments otherwise made to a hospital
under this subsection may be reduced by a percentage
determined appropriate by the Secretary. For purposes
of the preceding sentence, successful development and
implementation of such curricula shall be determined by
program accrediting bodies.''.
(b) Indirect Graduate Medical Education Payments.--Section
1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is
amended--
(1) by redesignating clause (x), as added by section
5505(b) of the Patient Protection and Affordable Care Act
(Public Law 111-148), as clause (xi) and moving such clause 6
ems to the left; and
(2) by adding at the end the following new clause:
``(xii) Notwithstanding the preceding provisions of this
subparagraph, effective for discharges occurring on or after the date
that is 5 years after the date of enactment of the Better Care, Lower
Cost Act, if a hospital has not begun to implement curricula that meets
the requirements described in subsection (h)(9)(A), as determined in
accordance with subsection (h)(9)(C), payments otherwise made to a
hospital under this subparagraph may be reduced by a percentage
determined appropriate by the Secretary.''.
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