,i #aacth ,,congress #ast ,session ,h4 ,r4 #bcgf ,,in ,,the ,,house ,,of ,,representatives ,june #ad1 #bjac ,mr4 ,fitzpatrick introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committee on ,ways and ,means1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to implement a demonstration project under titles ,,xviii and ,,xix of the ,social ,security ,act to examine the costs and benefits of providing payments for comprehensive coordinated health care services provided by purpose-built1 continuing care retirement communities to ,medicare beneficiaries4 #a4 ,short title ,this ,act may be cited as the ,medicare ,residential ,care ,coordination ,act of #bjac4 #b4 ,medicare and ,medicaid residential care coordination demonstration project 7a7 ,establishment and implementation 7#a7 ,in general ,the ,secretary of ,health and ,human ,services 7in this section referred to as the ,secretary7 shall establish and implement a demonstration project 7in this section referred to as the demonstration project7 under titles ,,xviii and ,,xix of the ,social ,security ,act to evaluate the use of capitated payments made to eligible continuing care retirement communities for residential care coordination programs4 7#b7 ,timetable for implementation ,in carrying out this section-- 7,a7 not later than #a year after the date of the enactment of this ,act the ,secretary shall complete the design for the demonstration project and enter into one or more agreements with eligible ,c,c,r,cs for the implementation of the project with respect to such ,c,c,r,cs2 and 7,b7 not later than #d years after the date of entering into such agreements1 first provide for implementation of the project through such ,c,c,r,cs4 7b7 ,budget neutrality ,with respect to the period of the demonstration project under this section1 the aggregate expenditures under titles ,,xviii and ,,xix of the ,social ,security ,act for such period shall not exceed the aggregate expenditures that would have been expended under such titles if the demonstration project had not been implemented4 7c7 ,state election required 7#a7 ,in general ,the ,secretary may only implement the demonstration project in a ,state that elects to participate in the demonstration project4 7#b7 ,benefits and payments ,a ,state that elects to participate in the demonstration project shall provide medical assistance through title ,,xix of the ,social ,security ,act for each eligible ,,ccrc resident who is eligible for medical assistance under the ,state plan under such title 7including such residents who are made eligible under subsection 7d77#c77;,b77iii77 and who is enrolled in a residential care coordination program in a manner that is consistent with the requirements of this section1 including making the payments under subsection 7e74 7#c7 ,limitation ,a ,state may establish a numerical limit on-- 7,a7 the number of eligible ,,ccrc residents who may be enrolled in residential care coordination programs in the ,state2 and 7,b7 the number of eligible ,c,c,r,cs that may operate residential care coordination programs in the ,state4 7d7 ,residential care coordination program 7,,rccp72 eligible continue care retirement community 7,,ccrc72 eligible ,,ccrc residents2 comprehensive coordinated health care services defined 7#a7 ,residential care coordination program2 ,,rccp ,for purposes of this section1 the terms residential care coordination program and ,,rccp mean a program that-- 7,a7 is operated within one or more eligible continuing care retirement communities 7as defined in paragraph 7#b772 7,b7 is designed with a capacity of serving at least #a1jjj1 but not more than #a1ejj1 eligible ,,ccrc residents 7as defined in paragraph 7#c77 at any one time2 and 7,c7 provides comprehensive coordinated health care services 7as defined in paragraph 7#d77 to participating ,,ccrc residents enrolled in the program in accordance with the program agreement under subsection 7f7 and the requirements of this section4 7#b7 ,eligible continuing care retirement community2 eligible ,,ccrc ,in this section1 the terms eligible continuing care retirement community and eligible ,,ccrc mean an entity that is a continuing care retirement community 7as defined in section #aheb7l77#d77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7l77#d77;,b777 that-- 7,a7 is built for the purposes of participating in the demonstration project2 7,b7 provides onsite-- 7i7 housing accommodations for eligible ,,ccrc residents1 including apartments for independent living2 and 7ii7 additional services to facilitate aging in place for such residents1 including assisted living and skilled nursing facilities or alternatives2 and 7,c7 has entered into a program agreement with the ,secretary and the ,state with respect to its operation of the residential care coordination program and such agreement is consistent with the requirements of this section4 7#c7 ,eligible ,,ccrc resident2 participating ,,ccrc resident 7,a7 ,in general ,for purposes of this section3 7i7 ,eligible ,,ccrc resident ,the term eligible ,,ccrc resident means an individual who-- 7,i7 is entitled to1 or enrolled for1 benefits under part ,a of title ,,xviii of the ,social ,security ,act1 and enrolled for benefits under part ,b of such title2 and 7,,ii7 resides in an eligible ,,ccrc4 7ii7 ,participating ,,ccrc resident ,the term participating ,,ccrc resident means1 with respect to a resident care coordination program1 an eligible ,,ccrc resident who is enrolled in that program4 7,b7 ,participation by dual-eligible individuals2 expanded eligibility 7i7 ,in general ,an eligible ,,ccrc resident may be1 but is not required to be1 a dual-eligible individual4 7ii7 ,dual-eligible individual defined ,in this section1 the term dual-eligible individual means any individual who is-- 7,i7 a full-benefit dual eligible individual 7as defined in section #aice7;c77#f7 of the ,social ,security ,act72 or 7,,ii7 is described in clause 7iii74 7iii7 ,qualification of participating ,,ccrc residents for ,medicaid benefits ,an individual who is a participating ,,ccrc resident1 regardless of the level of care1 who meets income and resource eligibility criteria established under the ,state ,medicaid plan for an individual to obtain coverage for nursing facility services on the basis of the individual's requirement for the level of care for such services1 shall be treated as a dual-eligible individual under this section and under title ,,xix of the ,social ,security ,act so long as the individual remains a participating ,,ccrc resident4 7,c7 ,enrollment and disenrollment rules 7i7 ,deemed enrollment at time of initial residency ,an individual who is described in subclause 7,i7 of subparagraph 7,a77i7 is deemed1 at the time of becoming a resident in an eligible ,,ccrc1 to have voluntarily consented to enroll in the ,,rccp operated by that ,,ccrc for purposes of subparagraph 7,a77ii74 7ii7 ,disenrollment process ,the demonstration project shall provide a method for the disenrollment from the project of participating ,,ccrc residents1 which method shall take into account the unique circumstances of residents who are required to leave the ,,ccrc and shall permit disenrollment at least in the same circumstances as would permit an individual to disenroll from a ,medicare ,advantage plan under part ,c of title ,,xviii of the ,social ,security ,act for cause4 7,d7 ,relation to ,medicare ,advantage and prescription drug program 7i7 ,supercedes enrollment ,a participating ,,ccrc resident is not eligible to enroll in an ,,ma plan under part ,c of title ,,xviii of the ,social ,security ,act or under a prescription drug plan under part ,d of such title4 7ii7 ,coordination in case of disenrollment ,in the case of a participating ,,ccrc resident who disenrolls from the demonstration project1 the disenrollment shall be treated1 for purposes of parts ,c and ,d of such title1 as if the individual had been previously enrolled in1 and disenrolled from1 an ,,ma-,,pd plan under part ,c of such title4 7,e7 ,premium payments ,during the period in which an individual is a participating ,,ccrc resident-- 7i7 for purposes of payment of premiums under parts ,b1 ,c1 and ,d of title ,,xviii of the ,social ,security ,act1 the individual shall be treated as if the individual were enrolled under an ,,ma-,,pd plan with a premium equal to an amount specified in the program agreement2 and 7ii7 the individual shall be eligible for assistance with respect to such premiums under part ,d and ,medicare cost-sharing in the same manner and in the equivalent amounts as if the individual had not been enrolled as a participating ,,ccrc resident4 7#d7 ,comprehensive coordinated health care services defined ,for purposes of this section1 the term comprehensive coordinated health care services1 with respect to an eligible ,,ccrc resident-- 7,a7 means all items and services that are otherwise payable under title ,,xviii of the ,social ,security ,act1 including the minimum prescription drug coverage required under a prescription drug plan under part ,d of such title2 7,b7 includes in the case of a dual eligible individual all items and services that are otherwise payable under the ,state plan under title ,,xix of such ,act of the ,state in which the resident resides2 and 7,c7 also includes-- 7i7 care management services that coordinate acute and specialty services 7including inpatient hospital services1 services provided by specialty physicians1 and other necessary services7 provided to eligible ,,ccrc residents2 7ii7 wellness services1 including assistance and instruction in healthy living 7including diet and exercise72 and 7iii7 other health care items and services to manage chronic conditions1 treat subacute conditions1 and provide preventive care4 7e7 ,payment under ,medicare and ,medicaid 7#a7 ,in general ,in the case of an individual who is a participating ,,ccrc resident who is enrolled in a residential care coordination program operated by an eligible ,,ccrc-- 7,a7 the individual shall receive benefits under title ,,xviii of the ,social ,security ,act1 and1 if such individual is a dual-eligible individual 7as defined in subsection 7d77#c77;,b77ii771 under the ,state ,medicaid plan or waiver under title ,,xix of such ,act1 solely through the residential care coordination program1 which shall provide such individual with comprehensive coordinated health care services2 and 7,b7 the eligible ,,ccrc shall receive capitated payments for the provision of such services 7from the ,secretary for benefits under title ,,xviii and from the ,state for benefits under such ,state plan or waiver71 in accordance with this section4 7#b7 ,payment methodology 7,a7 ,payment under ,medicare 7i7 ,payment on monthly basis ,with respect to each eligible ,,ccrc1 the ,secretary shall make prospective monthly payments of a capitated amount1 based on the rate established under clause 7ii71 for each participating ,,ccrc resident enrolled in the residential care coordination program operated by such ,,ccrc in the same manner and from the same sources as payments are made to a ,medicare ,advantage organization under section #ahec of the ,social ,security ,act4 ,such payments shall be subject to adjustment in the manner described in paragraphs 7#b7 and 7#c7 of section #ahec7;a74 7ii7 ,establishment of payment rate 7,i7 ,in general ,the ,secretary shall establish a risk-adjusted capitated payment rate under title ,,xviii of the ,social ,security ,act for comprehensive coordinated health care services provided to eligible ,,ccrc residents through a residential care coordination program operated by an eligible ,,ccrc4 ,the payment rate shall be #ij percent of the adjusted average per capita cost described in section #ahec7;c77#a77;,d77i7 of such ,act 7#db ,u4,s4,c4 #aciew-#bc7;c77#a77;,d77i771 plus an amount equivalent to #ij percent of the amount that would have been paid to a prescription drug plan the standardized bid amount of which 7as defined in #ahfj;,d-#ac7;a77#e7 of such ,act7 was equal to the adjusted national average monthly bid amount 7as defined in section #ahfj;,d-#ac7;a77#a77;,b77iii7 of such ,act7 and taking into account low-income subsidies paid under section #ahfj;,d-#ad4 7,,ii7 ,program agreement ,the mechanism for establishing the capitated amount under this subparagraph for a specific eligible ,,ccrc shall be specified in the program agreement4 7,b7 ,payment under ,medicaid 7i7 ,payment on a monthly basis ,with respect to an eligible ,,ccrc operating an ,,rccp1 the ,state shall make prospective monthly payments of the capitated amount determined under and specified in the program agreement for each eligible ,,ccrc resident of such community who is a dual-eligible individual4 7ii7 ,relationship to ,medicare payments ,the payment made under this subparagraph shall be in addition to any payment made under subparagraph 7,a7 to an eligible ,,ccrc for eligible ,,ccrc residents who are dual-eligible individuals4 7iii7 ,program agreement ,the capitated amount under this subparagraph for a specific eligible ,,ccrc shall be specified in the program agreement4 7iv7 ,payments to the ,state ,the ,secretary shall treat the payments made under clause 7i7 as medical assistance under title ,,xix of the ,social ,security ,act for purposes of making payments to the ,state under section #aijc of such ,act 7#db ,u4,s4,c4 #acif;b74 7v7 ,payments to reflect spend down amounts and personal needs allowances ,the payments under this subparagraph shall be made in a manner that takes into account the financial contributions required of dual-eligible individuals and the personal needs allowance established under the ,state plan4 ,such personal needs allowances may vary depending upon the level of care required by such an individual4 7#c7 ,treatment of services furnished by noncontract physicians and other entities 7,a7 ,application of ,medicare ,advantage requirements ,section #aheb7k77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7k77#a77 7relating to limitations on balance billing against ,medicare ,advantage organizations for noncontract physicians and other entities with respect to services covered under title ,,xviii of such ,act7 shall apply to eligible ,c,c,r,cs1 eligible ,,ccrc residents enrolled in a residential care coordination program1 and physicians and other entities that do not have a contract or other agreement establishing payment amounts for services furnished to such a resident in the same manner as such section applies to ,medicare ,advantage organizations1 individuals enrolled with such organizations1 and physicians and other entities referred to in such section4 7,b7 ,application of balanced billing limitations ,section #ahff7;a77#a77,o7 shall apply to services that are covered under title ,,xviii of the ,social ,security ,act and are furnished to any eligible ,,ccrc residents enrolled in a residential care coordination program in the same manner that such section applies to services furnished to an individual enrolled with a ,,pace provider under section #ahid or #aicd of such ,act4 7f7 ,program agreement 7#a7 ,requirement ,the ,secretary1 in close cooperation with the single ,state agency that administers or supervises the administration of the ,state plan under title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 7in this section referred to as the ,state ,medicaid agency71 shall establish procedures for entering into1 extending1 and terminating program agreements 7each in this section referred to as a program agreement7 for the operation of residential care coordination programs by eligible ,c,c,r,cs4 7#b7 ,agreement required for payment ,in order to receive payment under subsection 7e71 each eligible ,,ccrc operating a residential care coordination program shall enter into a program agreement with the ,secretary and the ,state1 which shall contain such terms and conditions as the parties may agree to1 so long as such terms and conditions are consistent with this section4 7#c7 ,duration 7,a7 ,in general ,a program agreement under this section shall be effective for a contract year1 beginning consistent with subsection 7a77#b77;,b7 not later than the fourth calendar year to begin after the establishment of the demonstration project1 and shall be extended for additional contract years in the absence of notice by a party to terminate4 7,b7 ,termination 7i7 ,end of demonstration project ,the ,secretary and the ,state ,medicaid agency shall terminate the program agreement at the termination of the demonstration project under subsection 7i74 7ii7 ,notice of provider termination ,the eligible ,,ccrc may terminate the agreement after appropriate notice to the ,secretary1 the ,state ,medicaid agency1 and eligible ,,ccrc residents4 7iii7 ,termination for cause ,the ,secretary and the ,state ,medicaid agency may terminate the program agreement at any time for cause 7as provided under the agreement74 ,reasons for terminating an agreement under this clause include that the ,secretary or ,state administering agency determines that-- 7,i7 there are significant deficiencies in the quality of care provided to eligible ,,ccrc residents enrolled in the program or the eligible ,,ccrc has failed to comply substantially with the requirements of this section2 and 7,,ii7 the entity has failed to develop and successfully initiate1 within #cj days of the date of the receipt of written notice of such a determination1 a plan to correct the deficiencies1 or has failed to continue implementation of such a plan4 7iv7 ,right to remain ,nothing in this paragraph shall be construed1 in the case that a program agreement is terminated-- 7,i7 for a previously participating ,,ccrc resident continuing1 as affecting the individual's right to continue to reside in the ,,ccrc and to receive traditional ,,ccrc care and services in accordance with the contract between the ,,ccrc resident and the ,,ccrc2 and 7,,ii7 as relieving the ,state from continuing to provide medical assistance with respect to such services for individuals who would qualify as dual-eligible individuals if the agreement had not been terminated4 7#d7 ,scope of benefits 7,a7 ,in general ,under the agreement under paragraph 7#b71 the eligible ,,ccrc shall-- 7i7 provide to participating ,,ccrc residents of such community1 regardless of source of payment1 directly or under contracts with other entities1 at a minimum1 all comprehensive coordinated health care services1 without regard to any limitation or condition as to amount1 duration1 or scope under title ,,xviii or title ,,xix of the ,social ,security ,act2 7ii7 provide such residents with access to necessary covered items and services #bd hours a day1 every day of the year2 7iii7 provide services to such residents onsite at the eligible ,,ccrc through a multidisciplinary team that is led by a primary care physician and includes care coordinators1 case managers1 and nurses2 7iv7 has a ratio of accessible physicians to eligible ,,ccrc residents that the ,secretary determines is adequate2 and 7v7 specify the covered items and services that will not be provided directly by the eligible ,,ccrc and-- 7,i7 provide for delivery of those items and services through contracts to ensure compliance with the requirements of this section2 and 7,,ii7 provides1 on an as needed basis for those residents who cannot transport themselves1 for necessary transportation services to the providers of such items and services1 if such items and services are provided outside of the eligible ,,ccrc4 7,b7 ,application of regular cost-sharing rules ,under such agreement the eligible ,,ccrc may apply deductibles1 copayments1 coinsurance1 or other cost sharing that would otherwise apply under titles ,,xviii and ,,xix of the ,social ,security ,act in the case of a ,,ma-,,pd plan under part ,c of title ,,xviii of such ,act4 7#e7 ,quality control 7,a7 ,in general ,under the program agreement1 the eligible ,,ccrc shall-- 7i7 collect data2 7ii7 maintain1 and afford the ,secretary and the ,state ,medicaid agency access to1 the records relating to the program1 including pertinent financial1 medical1 and personnel records2 and 7iii7 submit to the ,secretary and the ,state ,medicaid agency such reports as the ,secretary finds 7in consultation with ,state ,medicaid agencies7 necessary to monitor the operation1 cost1 and effectiveness of the demonstration project1 including data relevant to the measurements established by the ,secretary under subparagraph 7,b71 to permit the ,secretary and the ,state to evaluate such demonstration project4 7,b7 ,quality and outcome measures ,the ,secretary shall establish clinical and other outcome measurements to assess the efficacy of the demonstration project in-- 7i7 improving-- 7,i7 the health status and outcomes of participating ,,ccrc residents enrolled in residential care coordination programs under this demonstration project1 compared to ,medicare beneficiaries 7including traditional dual-eligible individuals described in subsection 7d77#c77;,b77ii77,i77 who are not enrolled in such programs2 and 7,,ii7 the quality of health care provided to such participating ,,ccrc residents2 and 7ii7 controlling the overall cost of providing health care items and services to such participating ,,ccrc residents1 compared to the cost of providing such items and services to other ,medicare beneficiaries4 7#f7 ,patient safeguards ,the agreement under paragraph 7#b7 shall provide for written safeguards of the rights of participating ,,ccrc residents enrolled in a residential care coordination program 7including a patient bill of rights and procedures for grievances and appeals74 ,such safeguards shall be similar to the safeguards required under the section #ahid7;b77#b77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;eee7b77#b77;,b77 with respect to the ,,pace program4 7#g7 ,transition ,if a participating ,,ccrc resident who is enrolled in a residential care coordination program is disenrolled from such program1 the eligible ,,ccrc shall provide assistance to the individual in obtaining necessary care through appropriate referrals and making the individual's medical records available to new providers4 7#h7 ,rule of construction ,nothing is this subsection shall be construed as preventing the eligible ,,ccrc from assessing typical and appropriate fees to eligible ,,ccrc residents4 7g7 ,secretary's oversight2 enforcement authority 7#a7 ,oversight 7,a7 ,in general ,during the duration of the demonstration project1 with respect to an eligible ,,ccrc operating a residential care coordination program under a program agreement under subsection 7f71 the ,secretary 7acting in cooperation with the ,state ,medicaid agency7 shall conduct a comprehensive annual review of the operation of the eligible ,,ccrc in order to ensure compliance with the requirements of this section4 ,such review shall include-- 7i7 an onsite visit to the eligible ,,ccrc2 7ii7 a comprehensive assessment of the community's fiscal soundness2 7iii7 a comprehensive assessment of the eligible ,,ccrc's capacity to provide all comprehensive coordinated health care services to participating ,,ccrc residents2 7iv7 detailed analysis of the community's substantial compliance with the requirements of this section2 and 7v7 any other elements that the ,secretary or the ,state ,medicaid agency considers necessary or appropriate4 7,b7 ,disclosure ,the results of reviews under this paragraph shall be reported promptly to the eligible ,,ccrc1 along with any recommendations for changes to the community's program1 and shall be made available to the public through a public ,web site of the ,department of ,health and ,human ,services4 7#b7 ,sanctions 7,a7 ,in general ,if the ,secretary determines 7after consultation with the ,state ,medicaid agency7 that an eligible ,,ccrc operating a residential care coordination program under a program agreement under subsection 7f7 is failing substantially to comply with the requirements of this section1 the ,secretary 7and the ,state ,medicaid agency7 may take any or all of the following actions3 7i7 ,condition the continuation of the program agreement upon timely execution of a corrective action plan4 7ii7 ,withhold some or all further payments under the program agreement under this section with respect to services furnished by such community until the deficiencies have been corrected4 7iii7 ,terminate such agreement under subsection 7f77#c77;,b74 7,b7 ,application of intermediate sanctions ,the ,secretary may1 by regulation1 provide for the application against an eligible ,,ccrc operating a residential care coordination program under a program agreement under this section of remedies described in section #aheg7;g77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;g77#b77 or section #aijc7m77#e77;,b7 of such ,act 7#db ,u4,s4,c4 #acif;b7m77#e77;,b77 in the case of violations by the community of the type described in section #aheg7;g77#a7 or #aijc7m77#e77;,a7 of such ,act1 respectively 7in relation to agreements1 enrollees1 and requirements under this section74 7,c7 ,procedures for termination or imposition of sanctions ,the provisions of section #aheg7;h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;h77 shall apply1 by regulation1 to termination and sanctions respecting a program agreement and an eligible ,,ccrc operating a residential care coordination program under a program agreement under this subsection in the same manner as they apply to a termination and sanctions with respect to a contract and a ,medicare ,advantage organization under part ,c of title ,,xviii of such ,act4 7h7 ,waiver ,notwithstanding section #aaae7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acae7;a771 the ,secretary may waive such provisions of titles ,,xi1 ,,xviii1 and ,,xix of that ,act as may be necessary to-- 7#a7 accomplish the goals of the demonstration project under this section2 and 7#b7 maximize the quality of life of eligible ,,ccrc beneficiaries1 as determined using the measures established under subsection 7f77#e77;,b74 7i7 ,duration of #aj years 7#a7 ,in general ,subject to paragraph 7#b7 and subsection 7f77#c77;,b71 the demonstration project shall terminate #aj years after the date on which the demonstration project is first implemented under subsection 7a77#b77;,b74 7#b7 ,extension ,the ,secretary1 acting through the ,center for ,medicare and ,medicaid ,innovation1 may extend the use of capitated payments for eligible ,c,c,r,cs for residential care coordination programs under this section if1 by the termination date that would otherwise apply under paragraph 7#a71 the ,secretary has demonstrated that the demonstration project has improved the coordination1 quality1 and efficiency of health care services furnished to ,medicare beneficiaries4 7j7 ,study and report to congress 7#a7 ,interim evaluation and report ,not later than #c years after the date on which the demonstration project is first implemented under subsection 7a77#b77;,b71 the ,secretary shall submit to ,congress a report that contains the following3 7,a7 ,an interim evaluation of the costs and benefits of providing comprehensive coordinated health care services to ,medicare beneficiaries 7including dual-eligible individuals7 through residential care coordination programs1 including the costs and benefits of using payments under title ,,xix of the ,social ,security ,act to provide continuity of care by permitting certain individuals to continue to participate in such programs after qualifying for enrollment in the ,medicaid program under this section due to reduced income and assets4 7,b7 ,an analysis of the appropriateness of implementing a new payment methodology under titles ,,xviii and ,,xix of the ,social ,security ,act for such services in the future4 7#b7 ,final evaluation and report ,not later than #aj years after the date on which the demonstration project is first so implemented1 the ,secretary shall submit to ,congress a report that contains a final evaluation of the impact of the demonstration project4