[Congressional Record (Bound Edition), Volume 160 (2014), Part 1]
[Senate]
[Pages 678-684]
[From the U.S. Government Publishing Office, www.gpo.gov]




          STATEMENT ON INTRODUCED BILLS AND JOINT RESOLUTIONS

                                 ______
                                 
      By Mr. WYDEN (for himself and Mr. Isakson):
  S. 1932. 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; 
to the Committee on Finance.
  Mr. WYDEN. Mr. President, I rise today to show my strong support for 
the Medicare Program with the introduction of the Better Care, Lower 
Cost Act with my colleague, Senator Isakson.
  The Medicare Program, treasured by millions of Americans today, is 
now dominated by cancer, diabetes, heart disease, and other chronic 
conditions. It is time for reform that offers seniors with chronic 
health challenges better quality, more affordable health care.
  Fortunately, there are several pioneering health care leaders already 
paving the way to reform. The bipartisan legislation we are offering is 
designed to remove the government's shackles on innovation so that the 
types of successful approaches discussed by health care leaders here 
this morning become the norm rather than the exception.
  The good news is that when the Senate Finance Committee recently 
approved legislation to fix Medicare's

[[Page 679]]

broken system of reimbursing doctors, the bill locked in specific 
incentives to move away from fee-for-service medicine. As part of its 
markup, the Senate Finance Committee added the foundation for improving 
chronic care for seniors: reforms that guarantee many more seniors 
access to individual care plans tailored to their unique needs.
  The Better Care, Lower Cost Act builds on that progress and 
introduces a bold new concept in Medicare: the idea that chronic care 
should come first. Here are a few things the legislation does to 
promote this idea:
  First, the legislation creates the Better Care Program, allowing 
health practices to create better care practices and health plans to 
become better health plans that care for patients with teams led by 
nurses, doctors, and physician assistants that must adhere to the 
highest quality standards. These innovators will receive one payment 
for their collective efforts to meet the chronic health needs of the 
seniors enrolled. This will give providers the flexibility to deliver 
the right care at the right time in the right place.
  Second, because most seniors lack access to coordinated, chronic care 
services today, the legislation sets aside the limiting Federal 
mandates--like the ``attribution rule''--that prevent these teams from 
actively reaching out to the seniors who would benefit most from 
specialized chronic care. Our legislation also changes Federal law so 
that participating practices and plans are able to reward seniors who 
participate in the Better Care Program by lowering their out-of-pocket 
costs when they work with their health care team.
  Third, this bill recognizes that seniors with chronic conditions live 
all over the country and sets out a plan for bringing providers and 
plans to every nook and cranny of America. And for those seniors and 
providers in rural or underserved areas, the legislation uses 
telemedicine and other technologies as resources to help to closely 
monitor and manage chronic conditions.
  Finally, a word about the private sector. This bill recognizes the 
advances that have been made that prove that better care can be 
provided at lower cost. There should not be as many barriers when 
arriving at the gates of Medicare. In fact, in my hometown of Portland, 
OR, when seniors talk about their Medicare, they are really talking 
about plans like Kaiser and Providence that are fully integrated. 
Seniors should have those care choices no matter where they live.
  In Washington, there is talk a lot about ``Medicare delivery system 
reform'' without mentioning why it is necessary or how it will actually 
help the people Medicare serves. The legislation Senator Isakson and I 
are introducing today is about giving seniors with chronic illnesses 
the focus and attention they need and deserve.
  Every day Americans hear new statistics about the impact chronic 
illness has on families, productivity, and the economy as a whole. But 
I can't recall a legislative effort where all those involved have 
remained singularly focused on solutions to this big problem.
  To be clear, this legislation is not driven by a simple desire to cut 
costs. Anyone can save money by cutting benefits, but this legislation 
would actually improve the care that seniors receive. I urge my 
colleagues to join us in this effort by cosponsoring this important 
legislation.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows:

                                S. 1932

       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, 2017, 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

[[Page 680]]

     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, 2016, 
     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, 2016, 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;

[[Page 681]]

       ``(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

[[Page 682]]

     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.

[[Page 683]]

       ``(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 2017 or 2018, 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, 2017, 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:
       ``(z) 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, 2017.
       ``(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, 2014, 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

[[Page 684]]

     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, 2016, 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 cary 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.''.

                          ____________________