[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5942 Introduced in House (IH)]

<DOC>






114th CONGRESS
  2d Session
                                H. R. 5942

    To amend title XVIII of the Social Security Act to establish a 
     demonstration program to provide integrated care for Medicare 
  beneficiaries with end-stage renal disease, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           September 7, 2016

   Mr. Young of Indiana (for himself, Mr. Blumenauer, Mrs. McMorris 
  Rodgers, and Mr. Cardenas) 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 
     demonstration program to provide integrated care for Medicare 
  beneficiaries with end-stage renal disease, 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 ``Dialysis PATIENTS Demonstration Act 
of 2016'' or the ``Dialysis Patient Access To Integrated-care, 
Empowerment, Nephrologists, Treatment, and Services Demonstration Act 
of 2016''.

SEC. 2. DEMONSTRATION PROGRAM TO PROVIDE INTEGRATED CARE FOR MEDICARE 
              BENEFICIARIES WITH END-STAGE RENAL DISEASE.

    (a) In General.--Title XVIII of the Social Security Act is amended 
by inserting after section 1866E the following new section:

    ``demonstration program to provide integrated care for medicare 
               beneficiaries with end-stage renal disease

    ``Sec. 1866F.  (a) Establishment.--
            ``(1) In general.--The Secretary shall conduct under this 
        section the ESRD Integrated Care Demonstration Program (in this 
        section referred to as the `Program') which is voluntary for 
        patients and providers to assess the effects of alternative 
        care delivery models on patient care improvements under this 
        title for Program-eligible beneficiaries (as defined in 
        paragraph (2)). Under the Program, eligible participating 
        providers (as defined in such paragraph) may form an ESRD 
        Integrated Care Organization (in this section referred to as an 
        `Organization'). An Organization shall integrate care and serve 
        as the medical home for Program-eligible beneficiaries.
            ``(2) Definitions.--In this section:
                    ``(A) Eligible participating provider.--The term 
                `eligible participating provider' means the following:
                            ``(i) A facility certified as a renal 
                        dialysis facility under this title.
                            ``(ii) A dialysis organization that owns 
                        one or more of such facilities described in 
                        clause (i).
                            ``(iii) A nephrologist or nephrology 
                        practice.
                            ``(iv) Any other physician group practice 
                        or a group of affiliated physicians.
                    ``(B) Eligible participating partner.--The term 
                `eligible participating partner' means, with respect to 
                an Organization, the following:
                            ``(i) A Medicare Advantage plan described 
                        in section 1851(a)(2) or a Medicare Advantage 
                        organization offering such a plan.
                            ``(ii) A prescription drug plan (as defined 
                        in section 1860D-41(a)(14)).
                            ``(iii) A medicaid managed care 
                        organization (as defined in section 1903(m)).
                            ``(iv) An entity able to bear risk as 
                        deemed by a State and that chooses to bear risk 
                        as a condition of partnership in such 
                        organization.
                            ``(v) A third party-administrator 
                        organization.
                    ``(C) Program-eligible beneficiary.--The term 
                `Program-eligible beneficiary' means, with respect to 
                an Organization offering an ESRD Integrated Care Model, 
                an individual entitled to benefits under part A and 
                enrolled under part B who--
                            ``(i) is 18 years of age or older;
                            ``(ii) is identified by the Secretary or 
                        the Organization as receiving renal dialysis 
                        services under the original medicare fee-for-
                        service program under parts A and B;
                            ``(iii) resides in the service area of such 
                        Organization;
                            ``(iv) receives renal dialysis services 
                        primarily from a facility that participates in 
                        such Organization; and
                            ``(v) has not received a successful kidney 
                        transplant.
    ``(b) ESRD Integrated Care Organization Eligibility Requirements.--
            ``(1) Organizations.--
                    ``(A) In general.--One or more eligible 
                participating providers may establish an Organization 
                or may enter into, subject to subparagraph (B), one or 
                more partnership, ownership, or co-ownership agreements 
                with one or more eligible participating partners to 
                establish an Organization.
                    ``(B) Limitation on number of agreements.--The 
                Secretary may specify a limitation on the number of 
                Organizations in which an eligible participating 
                partner may participate under agreements described in 
                subparagraph (A).
            ``(2) ESRD integrated care model.--
                    ``(A) Benefits requirements.--
                            ``(i) In general.--Subject to clause (iii), 
                        an Organization shall offer at least one ESRD 
                        Integrated Care Model that is an open network 
                        model (as described in subparagraph (B)(i)) in 
                        each of its service areas and may offer one or 
                        more ESRD Integrated Care Models that is a 
                        preferred network model (as described in 
                        subparagraph (B)(ii)) in each of its service 
                        areas. For purposes of this section an ESRD 
                        Integrated Care Model (in this section referred 
                        to as the `Model')--
                                    ``(I) shall cover all benefits 
                                under parts A and B (other than hospice 
                                care) and include benefits for 
                                transition (including education) into 
                                palliative care; and
                                    ``(II) may, through a partnership 
                                or other agreement with an MA-PD plan 
                                under part C or prescription drug plan 
                                under part D, cover all prescription 
                                drug benefits under such part D.
                            ``(ii) Treatment of savings.--
                                    ``(I) In general.--Any Organization 
                                offering an ESRD Integrated Care Model 
                                shall provide for the return under 
                                subclause (IV) to a Program-eligible 
                                beneficiary enrolled in the 
                                Organization of the amount, if any, by 
                                which the payment amount described in 
                                subclause (III) with respect to the 
                                Program-eligible beneficiary for a year 
                                exceeds the revenue amount described in 
                                subclause (II) with respect to the 
                                Program-eligible beneficiary for the 
                                year.
                                    ``(II) Revenue amount described.--
                                The revenue amount described in this 
                                subclause, with respect to an 
                                Organization offering an ESRD 
                                Integrated Care Model and a Program-
                                eligible beneficiary enrolled in such 
                                Organization, is the Organization's 
                                estimated average revenue requirements, 
                                including administrative costs and 
                                return on investment, for the 
                                Organization to provide the benefits 
                                described in clause (i) under the Model 
                                for the Program-eligible beneficiary 
                                for the year.
                                    ``(III) Payment amount described.--
                                The payment amount described in this 
                                subclause, with respect to an 
                                Organization offering an ESRD 
                                Integrated Care Model and a Program-
                                eligible beneficiary enrolled in such 
                                Organization, is the payment amount to 
                                the Organization under subsection 
                                (f)(1) made with respect to the 
                                Program-eligible beneficiary for the 
                                year.
                                    ``(IV) Means of returning savings 
                                to program-eligible beneficiaries 
                                enrolled in organizations.--An 
                                Organization shall return the amount 
                                under subclause (I) to a Program-
                                eligible beneficiary enrolled in the 
                                Organization in a manner specified by 
                                the Organization, which may include 
                                cost-sharing lower than otherwise 
                                applicable, benefits not covered under 
                                the original medicare fee-for-service 
                                program, or financial incentives (such 
                                as reduced cost sharing) for Program-
                                eligible beneficiaries enrolled in the 
                                Organization to promote the delivery of 
                                high-value and efficient care and 
                                services.
                            ``(iii) Benefit requirements for dual 
                        eligibles.--In the case of a Program-eligible 
                        beneficiary who is eligible for benefits under 
                        this title and title XIX, an Organization, in 
                        accordance with an agreement entered into under 
                        subsection (f)(4)--
                                    ``(I) may be responsible for 
                                providing, or arranging for the 
                                provision of, all benefits (other than 
                                long-term services and supports) for 
                                which the Program-eligible beneficiary 
                                is eligible for under the State 
                                Medicaid program under title XIX in 
                                which the Program-eligible beneficiary 
                                is enrolled; and
                                    ``(II) may elect to provide, or 
                                arrange for the provision of, long-term 
                                services and supports available to the 
                                Program-eligible beneficiary under the 
                                State Medicaid program.
                    ``(B) Requirements for open network and preferred 
                network models.--
                            ``(i) Open network model.--Under an ESRD 
                        Integrated Care Model offered by an 
                        Organization that is an open network model, the 
                        Organization shall--
                                    ``(I) allow Program-eligible 
                                beneficiaries to receive such covered 
                                benefits from any provider of services 
                                or supplier regardless of whether such 
                                provider is within the network 
                                assembled under subclause (I);
                                    ``(II) pay any Medicare-certified 
                                provider or supplier that is not within 
                                the network assembled under subclause 
                                (I) for such covered benefits an amount 
                                equal to the amount the provider or 
                                supplier would otherwise receive under 
                                this title; and
                                    ``(III) not apply any additional 
                                premium or cost sharing requirements 
                                for such covered benefits in addition 
                                to premium or cost sharing 
                                requirements, respectively, that would 
                                be applicable under part A or part B 
                                for such benefits.
                            ``(ii) Preferred network model.--Under an 
                        ESRD Integrated Care Model offered by an 
                        Organization that is a preferred network model, 
                        the Organization--
                                    ``(I) shall assemble a network of 
                                providers of services and suppliers 
                                identified by the Organization and 
                                confirmed by the Secretary as including 
                                providers of services and suppliers 
                                with significant expertise in caring 
                                for individuals with end-stage renal 
                                disease through which Program-eligible 
                                beneficiaries shall receive covered 
                                benefits as described in subparagraph 
                                (A) that are required to be covered 
                                under the Model;
                                    ``(II) shall provide for payment 
                                for items and services furnished by 
                                providers of services and suppliers 
                                within such network to Program-eligible 
                                beneficiaries enrolled in such 
                                Organization in accordance with payment 
                                rates determined pursuant to an 
                                agreement entered into between the 
                                Organization and such providers of 
                                services and suppliers and shall 
                                provide for payment for items and 
                                services furnished by providers of 
                                services and suppliers not within such 
                                network to such beneficiaries so 
                                enrolled in accordance that would be 
                                determined under section 1853(a)(1)(H);
                                    ``(III) may apply premium and cost-
                                sharing requirements, in addition to 
                                premium or cost-sharing requirements, 
                                respectively, that would be applicable 
                                under part B, for benefits in addition 
                                to those required to be covered under 
                                the Model; and
                                    ``(IV) shall apply network 
                                standards as defined by the Secretary.
                            ``(iii) Promoting access to high-quality 
                        providers.--An Organization offering an ESRD 
                        Integrated Care Model may develop and implement 
                        performance-based incentives for providers of 
                        services and suppliers to promote delivery of 
                        high quality and efficient care. Such 
                        incentives shall be based on clinical measures 
                        and non-clinical measures, such as with respect 
                        to notification of patient discharge from a 
                        hospital, patient education (such as with 
                        respect to treatment options and nutrition), 
                        and the interoperability of electronic health 
                        records developed by an Organization according 
                        to requirements and standards specified by the 
                        Secretary pursuant to subparagraph (C).
                            ``(iv) Application of medicare advantage 
                        requirement with respect to medicare services 
                        furnished by out-of-network providers and 
                        suppliers.--
                                    ``(I) In general.--Section 
                                1852(k)(1) (relating to limitations on 
                                balance billing against MA 
                                organizations for noncontract 
                                physicians and other entities with 
                                respect to services covered under this 
                                title) shall apply to Organizations, 
                                Program-eligible beneficiaries enrolled 
                                in such Organizations, and physicians 
                                and other entities that do not have a 
                                contract or other agreement with the 
                                Organization establishing payment 
                                amounts for services furnished to such 
                                a beneficiary in the same manner as 
                                such section applies to MA 
                                organizations, individuals enrolled 
                                with such organizations, and physicians 
                                and other entities referred to in such 
                                section.
                                    ``(II) Reference for additional 
                                provision.--For the provision relating 
                                to limitations on balance billing 
                                against Organizations for services 
                                covered under this title furnished by 
                                noncontract providers of services and 
                                suppliers, see section 1866(a)(1)(O).
                    ``(C) Quality and reporting requirements.--
                            ``(i) Clinical measures.--Under the 
                        Program, the Secretary shall--
                                    ``(I) require each participating 
                                Organization to submit to the Secretary 
                                data on clinical measures consistent 
                                with those measures submitted by 
                                organizations participating in the 
                                Comprehensive ESRD Care Initiative 
                                operated by the Center for Medicare and 
                                Medicaid Innovation as of October 1, 
                                2016, to assess the quality of care 
                                provided;
                                    ``(II) establish requirements for 
                                participating Organizations to report 
                                to the Secretary, in a form and manner 
                                specified by the Secretary, information 
                                on such measures; and
                                    ``(III) establish quality 
                                performance standards on such measures 
                                to assess the quality of care.
                            ``(ii) Requirement for stakeholder input.--
                        In developing requirements and standards under 
                        subclauses (II) and (III) of clause (i), the 
                        Secretary shall request and consider input from 
                        a stakeholder board, at least one nephrologist, 
                        other suppliers and providers of services, 
                        renal dialysis facilities, and beneficiary 
                        advocates, and respond in writing to such 
                        input.
                            ``(iii) Additional assessments and 
                        reporting requirements.--The Secretary shall 
                        assess the extent to which an Organization 
                        delivers integrated and patient-centered care 
                        through analysis of information obtained from 
                        Program-eligible beneficiaries enrolled in the 
                        Organization through surveys, such as the In-
                        Center Hemodialysis Consumer Assessment of 
                        Healthcare Providers and Systems.
                    ``(D) Requirements for esrd integrated care 
                strategy.--
                            ``(i) In general.--An Organization seeking 
                        a contract under this section to offer one or 
                        more ESRD Integrated Care Models must develop 
                        and submit for the Secretary's approval, 
                        subject to clauses (ii) and (iii), an ESRD 
                        Integrated Care Strategy.
                            ``(ii) ESRD integrated care strategy.--In 
                        assessing an ESRD Integrated Care Strategy 
                        under clause (i), the Secretary shall consider 
                        the extent to which the Strategy includes 
                        elements, such as the following:
                                    ``(I) Interdisciplinary care teams 
                                led by at least one nephrologist, and 
                                comprised of registered nurses, social 
                                workers, renal dialysis facility 
                                managers, and other representatives 
                                from alternative settings described in 
                                subclause (VI).
                                    ``(II) Health risk and other 
                                assessments to determine the physical, 
                                psychosocial, nutrition, language, 
                                cultural, and other needs of Program-
                                eligible beneficiaries enrolled in the 
                                Organization involved.
                                    ``(III) Development and at least 
                                annual updating of individualized care 
                                plans that incorporate at least the 
                                medical, social, and functional needs, 
                                preferences, and care goals of Program-
                                eligible beneficiaries enrolled in the 
                                Organization.
                                    ``(IV) Coordination and delivery of 
                                non-clinical services, such as 
                                transportation, aimed at improving the 
                                adherence of Program-eligible 
                                beneficiaries enrolled in the 
                                Organization with care recommendations.
                                    ``(V) Services, such as transplant 
                                evaluation and vascular access care.
                                    ``(VI) In the case of an individual 
                                who, while enrolled in the 
                                Organization, receives confirmation 
                                that a kidney transplant is imminent, 
                                the provision by an interdisciplinary 
                                care team described in subclause (I) of 
                                counseling services to such individual 
                                on preparation for and potential 
                                challenges surrounding such transplant.
                                    ``(VII) Delivery of benefits and 
                                services in alternative settings, such 
                                as the home of the Program-eligible 
                                beneficiary enrolled in the 
                                Organization, in coordination with the 
                                provider or other appropriate 
                                stakeholder involved in such delivery 
                                serving on an interdisciplinary care 
                                team described in subclause (I).
                                    ``(VIII) Use of patient reminder 
                                systems.
                                    ``(IX) Education programs for 
                                patients, families, and caregivers.
                                    ``(X) Use of health care advice 
                                resources, such as nurse advice lines.
                                    ``(XI) Use of team-based health 
                                care delivery models that provide 
                                comprehensive and continuous medical 
                                care, such as medical homes.
                                    ``(XII) Co-location of providers 
                                and services.
                                    ``(XIII) Use of a demonstrated 
                                capacity to share electronic health 
                                record information across sites of 
                                care.
                                    ``(XIV) Use of programs to promote 
                                better adherence to recommended 
                                treatment regimens by individuals, 
                                including by addressing barriers to 
                                access to care by such individuals.
                                    ``(XV) Other services, strategies, 
                                and approaches identified by the 
                                Organization to improve care 
                                coordination and delivery.
                            ``(iii) Requirements.--The Secretary may 
                        not approve an ESRD Integrated Care Strategy of 
                        an Organization unless under such Strategy the 
                        Organization--
                                    ``(I) provides services to Program-
                                eligible beneficiaries enrolled in the 
                                Organization through a comprehensive, 
                                multidisciplinary health and social 
                                services delivery system which 
                                integrates acute and long-term care 
                                services pursuant to regulations; and
                                    ``(II) specifies the covered items 
                                and services that will not be provided 
                                directly by the Organization, and to 
                                arrange for delivery of those items and 
                                services through contracts meeting the 
                                requirements of regulations.
            ``(3) Requirement for capital reserves.--
                    ``(A) In general.--The Secretary shall enter into 
                contracts under this section only with Organizations 
                that demonstrate sufficient capital reserves, measured 
                as a percentage of capitated payments and consistent 
                with requirements established by the State in which the 
                Organization operates.
                    ``(B) Alternative mechanism to demonstrate capacity 
                to bear risk.--An Organization shall be considered to 
                meet the requirement in subparagraph (A) if the 
                Organization includes at least one eligible 
                participating provider or eligible participating 
                partner that--
                            ``(i) is licensed as a risk-bearing entity 
                        or deemed by a State as able to bear risk; and
                            ``(ii) chooses to bear risk as a condition 
                        of partnership in such Organization.
            ``(4) Beneficiary protections.--
                    ``(A) Continuity of care.--To provide for 
                continuity of care, each contract entered into with an 
                Organization under this section shall provide for a 
                transition period during which a Program-eligible 
                beneficiary who is first enrolled in the Organization 
                or who elects to opt out of the Program or otherwise 
                disenroll from the Organization maintains access to 
                eligible participating providers furnishing items or 
                services to such beneficiary immediately before such 
                enrollment or election for purposes of receipt of such 
                items or services. Payment for such items or services 
                covered under this title furnished to such Program-
                eligible beneficiary during such transition period 
                shall be made in accordance with this title and in such 
                amounts as would otherwise be determined for such items 
                and services provided to such a beneficiary not 
                enrolled under the Program.
                    ``(B) Antidiscrimination.--Each contract entered 
                into with an Organization under this section shall 
                provide that each eligible participating provider of 
                such Organization may not deny, limit, or condition the 
                furnishing of services, or affect the quality of 
                services furnished, under this title to Program-
                eligible beneficiaries on whether or not such a 
                beneficiary is enrolled with the Organization.
                    ``(C) Quality assurance; patient safeguards.--Each 
                contract entered into with an Organization under this 
                section shall require that such Organization have in 
                effect at a minimum--
                            ``(i) a written plan of quality assurance 
                        and improvement, and procedures implementing 
                        such plan, in accordance with regulations; and
                            ``(ii) written safeguards of the rights of 
                        Program-eligible beneficiaries enrolled in the 
                        Organization (including a patient bill of 
                        rights and procedures for grievances and 
                        appeals) in accordance with regulations and 
                        with other requirements of this title and 
                        Federal and State law that are designed for the 
                        protection of patients.
                    ``(D) Oversight.--The Secretary shall oversee the 
                marketing and assignment practices of each Organization 
                entering into a contract under this section as part of 
                the approval process of Organizations under this 
                section.
            ``(5) Non-application of certain provisions of law.--For 
        purposes of sections 162(m)(6) and 414(m) of the Internal 
        Revenue Code of 1986 and section 9010 of the Patient Protection 
        and Affordable Care Act (26 U.S.C. 4001 note prec.), in the 
        case of an eligible participating provider that establishes an 
        Organization or that enters into a partnership, ownership, or 
        co-ownership agreement to establish an Organization, or an 
        Organization with a contract under this section, risk-based 
        payments in exchange for providing medical care shall not be 
        considered premiums for health insurance coverage.
            ``(6) Treatment as medicare advanced alternative payment 
        model.--Alternative care delivery models under the Program 
        shall be treated under this title as an advanced alternative 
        payment model.
    ``(c) Program Operation and Scope.--
            ``(1) In general.--Not later than 6 months after the date 
        of enactment of this section, the Secretary shall establish a 
        process through which an Organization can apply to offer one or 
        more ESRD Integrated Care Models. Such application shall 
        include information on at least the following:
                    ``(A) The estimated average revenue amount 
                described in subsection (b)(2)(A)(ii)(II) for the 
                Organization to deliver benefits described in 
                subsection (b)(2)(A).
                    ``(B) Any benefits offered by the Organization 
                beyond those described in such subsection.
                    ``(C) A listing of network providers of services 
                and supplier.
                    ``(D) Information on the expertise of network 
                providers of services and suppliers in serving ESRD 
                patients.
                    ``(E) A description of the ESRD Integrated Care 
                Strategy of the Organization described in subsection 
                (b)(2)(D).
            ``(2) Program initiation.--The Secretary shall initiate the 
        Program such that Organizations begin serving Program-eligible 
        beneficiaries not later than January 1, 2018.
            ``(3) Contract award and period.--The Secretary shall enter 
        into contracts for an initial period of not less than 5 years 
        with all Organizations that meet Program requirements.
            ``(4) Allowance for larger service areas and expansion of 
        service areas.--Organizations shall demonstrate in their 
        application that the proposed service area has the capacity to 
        serve Program-eligible beneficiaries through an adequate 
        provider network and is reflective of the communities in which 
        beneficiaries live, work, and obtain health care services.
            ``(5) Contract termination and suspension.--
                    ``(A) In general.--The Secretary may terminate a 
                contract with an Organization under this section if the 
                Secretary determines that an Organization has failed to 
                meet quality requirements described in subsection (b) 
                or (e)(2)(C)(iii) or violates other terms of the 
                contract.
                    ``(B) Insufficient beneficiary participation.--The 
                Secretary shall, in the case of an Organization with a 
                contract under this section with respect to which, for 
                any period of at least 30 consecutive days during a 
                year for which such contract applies, fewer than 50 
                percent of the total number of Program-eligible 
                beneficiaries served by the Organization receive 
                benefits through the Organization under this section--
                            ``(i) suspend such contract for the 
                        remainder of such year; and
                            ``(ii) provide for the Organization to 
                        return any prospective payments made to the 
                        Organization under this section for items and 
                        services not provided pursuant to clause (i).
                    ``(C) Remedy and appeals process.--Prior to the 
                Secretary terminating or suspending a contract with an 
                Organization under this section, the Secretary shall 
                afford such Organization sufficient opportunity to 
                remedy any contract violations and appeal a contract 
                termination.
                    ``(D) Program-eligible beneficiary notice at time 
                of contract termination.--Each contract under this 
                section with an Organization shall require the 
                Organization to provide (and pay for) written notice in 
                advance of the contract's termination or suspension, as 
                well as a description of alternatives for obtaining 
                benefits under this title, to each Program-eligible 
                beneficiary assigned to or who elected to receive 
                benefits through the Organization under this section.
            ``(6) Program expansion.--The Secretary may, through 
        rulemaking, expand the duration and scope of the Program under 
        this section, to the extent determined appropriate by the 
        Secretary, if--
                    ``(A) the Secretary determines that such expansion 
                is expected to--
                            ``(i) reduce spending under this title 
                        without reducing the quality of patient care; 
                        or
                            ``(ii) improve the quality of patient care 
                        without increasing spending under this title;
                    ``(B) the Chief Actuary of the Centers for Medicare 
                & Medicaid Services certifies that such expansion would 
                reduce (or would not result in any increase in) net 
                program spending under this title; and
                    ``(C) the Secretary determines that such expansion 
                would not deny or limit the coverage or provision of 
                benefits under this title for applicable individuals.
    ``(d) Identification of Program-Eligible Beneficiaries.--The 
Secretary shall establish a process for the initial and ongoing 
identification of Program-eligible beneficiaries.
    ``(e) Program-Eligible Beneficiaries Assigned Into an ESRD 
Integrated Care Organization Open Network Model.--
            ``(1) Assignment.--
                    ``(A) In general.--Under the Program, subject to 
                the succeeding provisions of this paragraph, the 
                Secretary shall, upon the Secretary identifying a 
                beneficiary as a Program-eligible beneficiary, assign 
                all such Program-eligible beneficiary to an open 
                network model offered by an Organization that includes 
                the dialysis facility at which the Program-eligible 
                beneficiary primarily receives renal dialysis services.
                    ``(B) Program-eligible beneficiary notification of 
                assignment.--
                            ``(i) In general.--Upon assignment of a 
                        Program-eligible beneficiary to an 
                        Organization, the Secretary shall provide to 
                        the Organization written notification of such 
                        assignment of such Program-eligible beneficiary 
                        and not later than 15 business days after the 
                        date of receipt of such notification, the 
                        Organization shall provide written notice of 
                        such assignment to the Program-eligible 
                        beneficiary.
                            ``(ii) Opt-out period and changes upon 
                        initial assignment.--The Secretary shall 
                        provide for a 75-day period beginning on the 
                        date on which the assignment of a Program-
                        eligible beneficiary into an open network model 
                        offered by an Organization becomes effective 
                        during which a Program-eligible beneficiary 
                        may--
                                    ``(I) opt out of the Program;
                                    ``(II) make a one-time change of 
                                assignment into an open network model 
                                offered by a different Organization; or
                                    ``(III) elect a preferred network 
                                model offered by the same or different 
                                Organization.
                    ``(C) Additional opt-in population.--An individual 
                who, without application of clause (iv) of subsection 
                (a)(2)(C), would be treated as a Program-eligible 
                beneficiary, may elect to enroll in an Organization 
                under the Program under this section if such individual 
                agrees to receive renal dialysis services primarily 
                from a facility that participates in such Organization. 
                For purposes of this section (other than subparagraphs 
                (A) and (B) of this paragraph, paragraph (2), and 
                subsection (d)), an individual making an election 
                pursuant to the previous sentence shall be treated as a 
                Program-eligible beneficiary.
                    ``(D) Deemed re-enrollment.--A Program-eligible 
                beneficiary assigned under this paragraph to an ESRD 
                Integrated Care Model offered by an Organization with 
                respect to a year is deemed, unless the individual 
                elects otherwise under this paragraph, to have elected 
                to continue such assignment with respect to the 
                subsequent year.
                    ``(E) Additional opportunity to opt out or elect 
                different model or organization.--On the date that is 
                one year after the effective date of the initial 
                assignment of a Program-eligible beneficiary to an open 
                network model offered by an Organization (and annually 
                thereafter), a Program-eligible beneficiary shall be 
                given the opportunity to--
                            ``(i) opt out of the Program;
                            ``(ii) make a one-time change of assignment 
                        into an open network model offered by a 
                        different Organization; or
                            ``(iii) elect a preferred network model 
                        offered by the same or different Organization.
                    ``(F) Change in principal diagnosis opt out.--In 
                addition to any other period during which a Program-
                eligible beneficiary may, pursuant to this paragraph, 
                opt out of the Program, in the case of a Program-
                eligible beneficiary who, after assignment under this 
                paragraph, is diagnosed with a principal diagnosis (as 
                defined by the Secretary) other than end-stage renal 
                disease, such individual shall be given the opportunity 
                to opt out of the Program during such period as 
                specified by the Secretary.
                    ``(G) Special election periods.--The Secretary 
                shall offer Program-eligible beneficiaries special 
                election periods consistent with those described in 
                section 1851(e)(4).
            ``(2) Program-eligible beneficiary notification.--
                    ``(A) In general.--The Secretary shall notify 
                Program-eligible beneficiaries about the Program under 
                this section and provide them with information about 
                receiving benefits under this title through an 
                Organization.
                    ``(B) Requirements.--Notwithstanding any other 
                provision of law, subject to subparagraph (C), such 
                notification shall allow for eligible participating 
                providers that are part of an Organization to--
                            ``(i) inform Program-eligible beneficiaries 
                        about the Program;
                            ``(ii) distribute Program materials to 
                        Program-eligible beneficiaries; and
                            ``(iii) assist Program-eligible 
                        beneficiaries in assessing the options of such 
                        beneficiaries under the Program.
                    ``(C) Limitation on unsolicited marketing.--
                            ``(i) In general.--Under the Program, an 
                        eligible participating provider may not provide 
                        marketing information or materials, including 
                        information, materials, and assistance 
                        described in subparagraph (B), to a Program-
                        eligible beneficiary unless the Program-
                        eligible beneficiary requests such marketing 
                        information or materials.
                            ``(ii) Exception for providers treating 
                        beneficiaries.--An eligible participating 
                        provider that is part of an Organization may 
                        provide information, materials, and assistance 
                        described in subparagraph (B) to a Program-
                        eligible beneficiary, without prior request of 
                        such beneficiary, if such beneficiary is 
                        receiving renal dialysis services from such 
                        provider.
                            ``(iii) Parity in marketing.--In any case 
                        that an Organization participates in any form 
                        of marketing, such form of marketing shall be 
                        the same for all Program-eligible beneficiaries 
                        to which, pursuant to clause (ii), the 
                        Organization may provide information, 
                        materials, and assistance described in such 
                        clause.
            ``(3) Program-eligible beneficiary appeal rights.--Program-
        eligible beneficiaries enrolled in an Organization shall have 
        the same right to appeal any denial of benefits under this 
        title as such a Program-eligible beneficiary would have under 
        this title if such Program-eligible beneficiary were not so 
        enrolled.
    ``(f) Payment.--
            ``(1) In general.--For each Program-eligible beneficiary 
        receiving care through an Organization, the Secretary shall 
        make a monthly capitated payment in accordance with payment 
        rates that would be determined under section 1853(a)(1)(H), as 
        adjusted pursuant to paragraph (2).
            ``(2) Application of health status risk adjustment 
        methodology.--The Secretary shall adjust the payment amount to 
        an Organization under this subsection in the same manner in 
        which the payment amount to a Medicare Advantage plan is 
        adjusted under section 1853(a)(1)(C).
            ``(3) Payment for part d benefits.--In the case where an 
        Organization elects to offer part D prescription drug coverage 
        under the Program under this section, payments to the 
        Organization for such benefits provided to Program-eligible 
        beneficiaries by the Organization shall be made in the same 
        manner and amounts as those payments would be made in the case 
        of an organization with a contract under such part.
            ``(4) Agreement with state medicaid agency.--In the event 
        of an Organization that elects to cover benefits under title 
        XIX for Program-eligible beneficiaries eligible for benefits 
        under this title and title XIX such Organization shall enter 
        into an agreement with the State Medicaid agency to provide 
        benefits, or arrange for benefits to be provided, for which 
        such beneficiaries are entitled to receive medical assistance 
        under title XIX and to receive payment from the State for 
        providing or arranging for the provision of such benefits.
            ``(5) Affirmation of state obligations to pay premium and 
        cost-sharing amounts.--
                    ``(A) In general.--A State shall continue to make 
                medical assistance under the State plan under title XIX 
                available in the amount described in subparagraph (B) 
                for the duration of the Program for cost-sharing (as 
                defined in section 1905(p)(3)) under this title for 
                qualified medicare beneficiaries described in section 
                1905(p)(1) and other individuals who are Program-
                eligible beneficiaries enrolled in an Organization and 
                entitled to medical assistance for premiums and such 
                cost-sharing under the State plan under title XIX.
                    ``(B) Amounts made available for cost-sharing.--For 
                purposes of subparagraph (A):
                            ``(i) In general.--Subject to clause (ii), 
                        the amount of medical assistance described in 
                        this clause to be made available for cost-
                        sharing pursuant to subparagraph (A) for an 
                        individual described in such subparagraph 
                        entitled to medical assistance for such cost-
                        sharing under a State plan under title XIX 
                        shall be equal to the amount of medical 
                        assistance that would be made available under 
                        such State plan as in effect as of January 1, 
                        2016.
                            ``(ii) Amounts in the case of a state that 
                        increases payments for cost-sharing.--If a 
                        State increases the amount of medical 
                        assistance made available under the State plan 
                        under title XIX for cost-sharing described in 
                        subparagraph (A) after such date, such 
                        increased amounts shall be made available under 
                        subparagraph (A) for the remaining duration of 
                        the Program.
    ``(g) Waiver Authority.--
            ``(1) In general.--In order to carry out the Program under 
        this section, the Secretary shall waive those requirements 
        waived under section 1899 and may waive such additional 
        requirements consistent with those waived under programs 
        administered through the Center for Medicare and Medicaid 
        Innovation as may be necessary.
            ``(2) Notice of waivers.--Not later than 3 months after the 
        date of enactment of this section, the Secretary shall publish 
        a notice of waivers that will apply in connection with the 
        Program. The notice shall include the specific conditions that 
        an Organization must meet to qualify for each waiver, and 
        commentary explaining the waiver requirements.''.
    (b) Conforming Amendment Relating to Balanced Billing.--Section 
1866(a)(1)(O) of the Social Security Act (42 U.S.C. 1395cc(a)(1)(O)) is 
amended--
            (1) by inserting ``with an ESRD Integrated Care 
        Organization under section 1866F,'' after ``with a PACE 
        provider under section 1894 or 1934,'';
            (2) by inserting ``or ESRD Integrated Care Organization'' 
        after ``in the case of a PACE provider'';
            (3) by striking ``or PACE program eligible individuals 
        enrolled with the PACE provider'' and inserting ``, Program-
        eligible beneficiaries enrolled in the ESRD Integrated Care 
        Organization, or PACE program eligible individuals enrolled 
        with the PACE provider''; and
            (4) by inserting ``(or in the case of a Program-eligible 
        beneficiary enrolled in the ESRD Integrated Care Organization, 
        the amounts that would be made in accordance with payment rates 
        that would be determined under section 1853(a)(1)(H))'' after 
        ``the amounts that would be made''.
                                 <all>