,i #aacth ,,congress #ast ,session ,h4 ,r4 #cefg ,,in ,,the ,,house ,,of ,,representatives ,november #bj1 #bjac,mr4 ,schrader 7for himself and ,mr4 ,ribble7 introduced the following bill2 which was referred to the ,committee on ,ways and ,means1 and in addition to the ,committee on ,energy and ,commerce1 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 amend title ,,xviii of the ,social ,security ,act to provide for additional coverage options for beneficiaries under the original ,medicare fee-for-service program through a ,medicare ,link program4 #a4 ,short title ,this ,act may be cited as the ,medicare ,link ,act of #bjac4 #b4 ,establishment of ,medicare ,link program 7a7 ,in general ,title ,,xviii of the ,social ,security ,act is amended by adding after section #ahii;,a 7#db ,u4,s4,c4 #aciekkk7 the following new section3 #ahii;,b4 ,medicare ,link program option 7a7 ,in general ,the ,secretary shall establish under this section a program 7to be known as the ,medicare ,link ,program and in this section referred to as the ,program7 through which individuals who are entitled to enroll in a ,medicare ,advantage plan under part ,c but who are not enrolled in such a plan under such part are eligible to enroll with a ,medicare ,link contractor under this section4 7b7 ,enrollment2 disenrollment ,the ,secretary shall establish a process for the enrollment 7and disenrollment7 of eligible individuals with ,medicare ,link contractors under the ,program which process shall be1 to the maximum extent practicable1 the same as 7and coordinated with7 the process for enrollment 7and disenrollment7 of individuals in ,medicare ,advantage plans under part ,c4 7c7 ,qualification of contractors2 awarding of contracts 7#a7 ,in general ,in this section1 the term ,medicare ,link contractor means a nongovernmental entity1 that may be a ,medicare ,advantage organization1 health plan1 health insurance issuer1 medicare administrative contractor1 or other qualified third-party entity1 that has entered into a contract with the ,secretary with respect to one or more ,medicare ,link regions 7as specified by the ,secretary under paragraph 7#c77 for the offering of ,medicare ,link services 7described in subsection 7d77 to individuals residing in the region who enroll with the contractor under the ,program4 7#b7 ,limitation2 requirements ,for each such ,medicare ,link region1 the ,secretary shall select 7and contract with7 at least #a1 and not more than #c1 ,medicare ,link contractors for the offering of plans 7in this section referred to as ,medicare ,link plans7 under this section4 ,the ,secretary shall seek to contract with at least #b ,medicare ,link contractors within each ,medicare ,link region4 ,a contract with a ,medicare ,link contractor may cover a multi-year period4 7#c7 ,specification of ,medicare ,link regions ,the ,secretary shall define and specify ,medicare ,link regions 7each in this section referred to as a ,medicare ,link region7 that1 across all such regions1 encompass all #ej ,states1 the ,district of ,columbia1 and the territories4 7#d7 ,qualification of contractors ,the ,secretary shall establish uniform qualifications for ,medicare ,link contractors based on their experience and qualifications to offer ,medicare ,link plans under this section and to provide additional services to individuals enrolled under such plans under this section and to provide for reduced expenditures under parts ,a and ,b4 ,contracts with ,medicare ,link contractors under this section shall be for periods similar to the contracts with ,,ma organizations under part ,c and shall contain such terms and conditions as the ,secretary shall specify4 7#e7 ,contracting authority ,nothing in this section shall be construed as preventing a ,medicare ,link contractor from contracting with other entities in carrying out activities under this section1 including the offering of ,medicare ,link plans under this section4 7#f7 ,bidding process ,in selecting ,medicare ,link contractors1 the ,secretary shall establish a bidding process similar to the process of bidding by medicare administrative contractors under section #ahgd;,a4 7#g7 ,contractor payments ,medicare ,link contractors with contracts under this section shall be paid1 on a monthly basis1 a per enrollee monthly service fee for the provision of services under the contract consistent with the provisions of paragraph 7#h74 ,a portion of such fee 7not to exceed #e percent7 may be subject to adjustment based on a contractor's performance on financial and quality benchmarks based upon pre-established measures specified by the ,secretary4 7#h7 ,requirement for federal savings under contract 7,a7 ,in general ,before entering into or renewing a contract with a ,medicare ,link contractor1 the ,secretary must determine 7and the ,chief ,actuary of the ,centers for ,medicare ,medicaid ,services must certify7 that the terms of the contract are expected to yield average1 net savings to the ,medicare program under this title of not less than #e percent per program enrollee in the ,medicare ,link region covered under the contract4 7,b7 ,computation ,such savings shall be computed taking into account all effects on spending under this title1 including any reductions in premiums and cost sharing or other incentives for enrollees under subsection 7d71 payments to ,medicare ,link contractors under the contract1 and reductions in payments to medicare administrative contractors that would otherwise have been made under section #ahgd;,a4 7,c7 ,payments based on shared savings1 adjusted for quality ,the contract shall be structured in a manner so that-- 7i7 subject to clause 7ii71 the payments to the contractor under paragraph 7#g7 are computed to represent a proportion 7as specified in the contract7 of the net savings in excess of the minimum savings required under subparagraph 7,a72 and 7ii7 such proportion may be increased under the contract based on a contractor's performance on quality benchmarks1 based upon pre-established measures specified by the ,secretary4 7,d7 ,guaranteed ,federal savings ,if the ,secretary determines that a ,medicare ,link contractor1 after a period of three consecutive years1 does not maintain an average net savings to the ,medicare program of at least #e percent per program enrollee as required under subparagraph 7,a71 the ,medicare ,link contractor shall remit to the ,secretary a sum specified by the ,secretary and related to the amount of the shortfall4 7#i7 ,savings validation audit ,the ,secretary shall provide for the annual auditing of the financial records 7including data relating to ,medicare utilization and costs7 of organizations offering ,medicare ,link plans under this section 7#aj7 ,,gao audit ,every #c years the ,comptroller ,general of the ,united ,states shall conduct an audit of the ,medicare ,link program costs and program savings4 ,such report shall be submitted to the committees of the ,house of ,representatives and of the ,senate with jurisdiction over ,medicare4 7d7 ,services under a ,medicare ,link plan 7#a7 ,in general ,each ,medicare ,link plan offered under this section-- 7,a7 shall provide for care management services 7described in paragraph 7#b77 and predictive modeling and risk prioritization 7described in paragraph 7#c77 for individuals enrolled under the plan consistent with this subsection2 7,b7 shall carry out the functions of medicare administrative contractors described in paragraph #ahgd;,a7a77#d72 7,c7 shall provide a reduction or rebate in the premium otherwise applicable under part ,b 7as determined without regard to section #ahci7;i77 to individuals so enrolled2 and 7,d7 may provide for a reduction in cost-sharing otherwise applicable to such individuals who use providers within a plan network4 7#b7 ,care management services 7,a7 ,required ,the required care management services shall include clinical interventions to help coordinate care4 7,b7 ,optional ,optional care management services may include interventions such as the following3 7i7 ,prevention and wellness4 7ii7 ,transitional and case management and other clinical programs4 7iii7 ,chronic disease management4 7iv7 ,advanced illness care initiatives4 7v7 ,diabetes prevention programs4 7vi7 ,transitional case management1 for individuals discharged from a hospital or other health care institution4 7vii7 ,nurse practitioner-led interventions 7consistent with restrictions under applicable ,state law74 7viii7 ,post-acute transition programs4 7ix7 ,high-risk case management4 7x7 ,home-based primary care4 7xi7 ,advanced illness transitional care4 7xii7 ,operation of clinical management programs4 7xiii7 ,management and development of provider networks4 7xiv7 ,consumer engagement with decision support4 7#c7 ,predictive modeling and risk prioritization ,the predictive modeling and risk prioritization services described in this paragraph shall include the following3 7,a7 ,predictive modeling and high risk identification ,the use of claims data and trend data to predict which enrollees could benefit from the application of a clinical intervention or which might be high risk and in need of a care plan4 7,b7 ,prioritization of interventions ,programs to identify1 prioritize1 and personalize care opportunities through a comprehensive profile of each enrollee4 7#d7 ,optional incentives and enrollee empowerment 7,a7 ,in general ,a ,medicare ,link contractor may use appropriate incentives to manage overall care for enrollees4 ,the ,secretary shall establish terms and conditions under which a ,medicare ,link contractor may elect to use optional incentives for its members4 7,b7 ,types of incentives ,the types of incentives that may be used include the following3 7i7 ,healthy rewards ,premium rebates and other incentives approved by the ,secretary for enrollees to make healthier choices and actively engage in their health care4 7ii7 ,member incentives to use quality network providers ,reductions in beneficiary cost-sharing 7and other incentives approved by the ,secretary7 for enrollees who use providers 7which may be accountable care organizations7 within a plan network in order to reward quality1 efficient care4 7iii7 ,cost estimator tools ,providing beneficiaries with tools designed to help them simplify the evaluation of health care costs through cost estimates for different treatment options4 7#e7 ,application of ,,ma grievance and appeals procedures ,in accordance with regulations1 the provisions of part ,c insofar as they apply to grievances and appeals1 shall apply to ,medicare ,link plans and enrollees under this section in a manner similar to how such provisions apply to ,,ma plans under such part4 7e7 ,maintenance of current benefits2 contractor not at financial risk for original fee-for-,service benefits 7#a7 ,no change in ,medicare covered items and services or limitation on supplemental plans ,medicare ,link plans shall provide for coverage of the same items and services that are covered under parts ,a and ,b4 ,nothing in this section shall be construed as preventing an individual enrolled under a ,medicare ,link plan from purchasing a medicare supplemental policy 7described in section #ahha7 or other supplemental coverage outside of a ,medicare ,link plan4 7#b7 ,no change in payments to providers 7,a7 ,in general ,subject to subparagraph 7,b71 nothing in this section shall be construed as authorizing a payment level to a provider of services or supplier for ,medicare covered services that is other than the payment level otherwise applicable under part ,a or ,b for such services4 7,b7 ,negotiation of rates permitted ,a ,medicare ,link contractor may negotiate with providers of services and suppliers payment rates that are less or greater than the payment rates referred to in subparagraph 7,a74 7#c7 ,contractor not at financial risk ,a ,medicare ,link contractor shall not be at financial risk with respect to the coverage or payment for ,medicare services covered under parts ,a and ,b4 ,but the ,secretary may provide financial incentives for contractors that are able to reduce ,medicare expenditures for such services below benchmark levels 7specified by the ,secretary7 that reasonably represent the levels of payments that would be made 7with respect to individuals enrolled under a ,medicare ,link plan7 if such individuals were not so enrolled4 4