,i  #aac? ,,congress  #a/ ,session  ,h4 
,r4 #cefg  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,novemb] #bj1         
#bjac,mr4 ,s*rad] 7= himself & ,mr4     
,ribble7 introduc$ ! foll[+ bill2 :i* 0 
ref]r$ to ! ,committee on ,ways &       
,means1 & 9 addition to ! ,committee on 
,en]gy & ,comm]ce1 = a p]iod to be      
subsequ5tly det]m9$ by ! ,speak]1 9 ea* 
case = consid]ation ( su* provisions z  
fall )9 ! jurisdiction ( ! committee    
conc]n$  ,a ,,bill  ,to am5d title      
,,xviii ( ! ,social ,security ,act to   
provide = additional cov]age options =  
b5efici>ies "u ! orig9al ,m$ic>e        
fee-=-s]vice program ?r\gh a ,m$ic>e    
,l9k program4  #a4 ,%ort title ,?is ,act
 may be cit$ z ! ,m$ic>e ,l9k ,act (    
#bjac4  #b4 ,e/abli%m5t ( ,m$ic>e ,l9k  
program  7a7 ,9 g5]al ,title ,,xviii ( !
 ,social ,security ,act is am5d$ by add+
 aft] section #ahii;,a 7#db ,u4,s4,c4   
#aciekkk7 ! foll[+ new section3         
#ahii;,b4 ,m$ic>e ,l9k program option   
7a7 ,9 g5]al ,! ,secret>y %all e/abli%  

"u ?is section a program 7to be kn[n z !
 ,m$ic>e ,l9k ,program & 9 ?is section  
ref]r$ to z ! ,program7 ?r\gh :i*       
individuals :o are entitl$ to enroll 9 a
 ,m$ic>e ,advantage plan "u "p ,c b :o  
are n enroll$ 9 su* a plan "u su* "p are
 eligible to enroll ) a ,m$ic>e ,l9k    
contractor "u ?is section4  7b7         
,enrollm5t2 dis5rollm5t ,! ,secret>y    
%all e/abli% a process = ! enrollm5t 7& 
dis5rollm5t7 ( eligible individuals )   
,m$ic>e ,l9k contractors "u ! ,program  
:i* process %all be1 to ! maximum ext5t 
practicable1 ! same z 7& coord9at$ )7 ! 
process = enrollm5t 7& dis5rollm5t7 (   
individuals 9 ,m$ic>e ,advantage plans  
"u "p ,c4  7c7 ,qualification (         
contractors2 aw>d+ ( contracts  7#a7 ,9 
g5]al ,9 ?is section1 ! t]m ,m$ic>e ,l9k
 contractor means a nongov]nm5tal       
entity1 t may be a ,m$ic>e ,advantage   
organization1 heal? plan1 heal?         
insurance issu]1 m$ic>e adm9i/rative    
contractor1 or o!r qualifi$ ?ird-p>ty   
entity1 t has ent]$ into a contract ) ! 

,secret>y ) respect to "o or m ,m$ic>e  
,l9k regions 7z specifi$ by ! ,secret>y 
"u p>agraph 7#c77 = ! (f]+ ( ,m$ic>e    
,l9k s]vices 7describ$ 9 subsection 7d77
 to individuals resid+ 9 ! region :o    
enroll ) ! contractor "u ! ,program4    
7#b7 ,limitation2 requirem5ts ,= ea* su*
 ,m$ic>e ,l9k region1 ! ,secret>y %all  
select 7& contract )7 at lea/ #a1 & n m 
?an #c1 ,m$ic>e ,l9k contractors = !    
(f]+ ( plans 79 ?is section ref]r$ to z 
,m$ic>e ,l9k plans7 "u ?is section4 ,!  
,secret>y %all seek to contract ) at    
lea/ #b ,m$ic>e ,l9k contractors )9 ea* 
,m$ic>e ,l9k region4 ,a contract ) a    
,m$ic>e ,l9k contractor may cov] a      
multi-ye> p]iod4  7#c7 ,specification ( 
,m$ic>e ,l9k regions ,! ,secret>y %all  
def9e & specify ,m$ic>e ,l9k regions    
7ea* 9 ?is section ref]r$ to z a ,m$ic>e
 ,l9k region7 t1 across all su* regions1
 encompass all #ej ,/ates1 ! ,di/rict ( 
,columbia1 & ! t]ritories4  7#d7        
,qualification ( contractors ,!         
,secret>y %all e/abli% uni=m            

qualifications = ,m$ic>e ,l9k           
contractors bas$ on _! exp]i5ce &       
qualifications to (f] ,m$ic>e ,l9k plans
 "u ?is section & to provide additional 
s]vices to individuals enroll$ "u su*   
plans "u ?is section & to provide =     
r$uc$ exp5ditures "u p>ts ,a & ,b4      
,contracts ) ,m$ic>e ,l9k contractors "u
 ?is section %all be = p]iods simil> to 
! contracts ) ,,ma organizations "u "p  
,c & %all conta9 su* t]ms & conditions z
 ! ,secret>y %all specify4  7#e7        
,contract+ au?ority ,no?+ 9 ?is section 
%all be con/ru$ z prev5t+ a ,m$ic>e ,l9k
 contractor f contract+ ) o!r entities 9
 c>ry+ out activities "u ?is section1   
includ+ ! (f]+ ( ,m$ic>e ,l9k plans "u  
?is section4  7#f7 ,bidd+ process ,9    
select+ ,m$ic>e ,l9k contractors1 !     
,secret>y %all e/abli% a bidd+ process  
simil> to ! process ( bidd+ by m$ic>e   
adm9i/rative contractors "u section     
#ahgd;,a4  7#g7 ,contractor paym5ts     
,m$ic>e ,l9k contractors ) contracts "u 
?is section %all be paid1 on a mon?ly   

basis1 a p] enrollee mon?ly s]vice fee =
 ! provision ( s]vices "u ! contract    
consi/5t ) ! provisions ( p>agraph 7#h74
 ,a portion ( su* fee 7n to exce$ #e    
p]c5t7 may be subject to adju/m5t bas$  
on a contractor's p]=mance on f9ancial &
 quality b5*m>ks bas$ ^u pre-e/abli%$   
measures specifi$ by ! ,secret>y4  7#h7 
,requirem5t = f$]al sav+s "u contract   
7,a7 ,9 g5]al ,be=e ent]+ into or r5ew+ 
a contract ) a ,m$ic>e ,l9k contractor1 
! ,secret>y mu/ det]m9e 7& ! ,*ief      
,actu>y ( ! ,c5t]s = ,m$ic>e  ,m$icaid  
,s]vices mu/ c]tify7 t ! t]ms ( !       
contract are expect$ to yield av]age1   
net sav+s to ! ,m$ic>e program "u ?is   
title ( n less ?an #e p]c5t p] program  
enrollee 9 ! ,m$ic>e ,l9k region cov]$  
"u ! contract4  7,b7 ,computation ,su*  
sav+s %all be comput$ tak+ into acc\nt  
all effects on sp5d+ "u ?is title1      
includ+ any r$uctions 9 premiums & co/  
%>+ or o!r inc5tives = enrollees "u     
subsection 7d71 paym5ts to ,m$ic>e ,l9k 
contractors "u ! contract1 & r$uctions 9

 paym5ts to m$ic>e adm9i/rative         
contractors t w\ld o!rwise h be5 made "u
 section #ahgd;,a4  7,c7 ,paym5ts bas$  
on %>$ sav+s1 adju/$ = quality ,!       
contract %all be /ructur$ 9 a mann] s   
t-- 7i7 subject to clause 7ii71 !       
paym5ts to ! contractor "u p>agraph 7#g7
 are comput$ to repres5t a proportion 7z
 specifi$ 9 ! contract7 ( ! net sav+s 9 
excess ( ! m9imum sav+s requir$ "u      
subp>agraph 7,a72 &  7ii7 su* proportion
 may be increas$ "u ! contract bas$ on a
 contractor's p]=mance on quality       
b5*m>ks1 bas$ ^u pre-e/abli%$ measures  
specifi$ by ! ,secret>y4  7,d7 ,gu>ante$
 ,f$]al sav+s ,if ! ,secret>y det]m9es t
 a ,m$ic>e ,l9k contractor1 aft] a p]iod
 ( ?ree consecutive ye>s1 does n ma9ta9 
an av]age net sav+s to ! ,m$ic>e program
 ( at lea/ #e p]c5t p] program enrollee 
z requir$ "u subp>agraph 7,a71 ! ,m$ic>e
 ,l9k contractor %all remit to !        
,secret>y a sum specifi$ by ! ,secret>y 
& relat$ to ! am\nt ( ! %ortfall4  7#i7 
,sav+s validation audit ,! ,secret>y    

%all provide = ! annual audit+ ( !      
f9ancial records 7includ+ data relat+ to
 ,m$ic>e utilization & co/s7 (          
organizations (f]+ ,m$ic>e ,l9k plans "u
 ?is section  7#aj7 ,,gao audit ,e #c   
ye>s ! ,comptroll] ,g5]al ( ! ,unit$    
,/ates %all conduct an audit ( ! ,m$ic>e
 ,l9k program co/s & program sav+s4 ,su*
 report %all be submitt$ to ! committees
 ( ! ,h\se ( ,repres5tatives & ( !      
,s5ate ) jurisdiction ov] ,m$ic>e4  7d7 
,s]vices "u a ,m$ic>e ,l9k plan  7#a7 ,9
 g5]al ,ea* ,m$ic>e ,l9k plan (f]$ "u   
?is section-- 7,a7 %all provide = c>e   
managem5t s]vices 7describ$ 9 p>agraph  
7#b77 & pr$ictive model+ & risk         
prioritization 7describ$ 9 p>agraph     
7#c77 = individuals enroll$ "u ! plan   
consi/5t ) ?is subsection2  7,b7 %all   
c>ry out ! functions ( m$ic>e           
adm9i/rative contractors describ$ 9     
p>agraph #ahgd;,a7a77#d72  7,c7 %all    
provide a r$uction or rebate 9 ! premium
 o!rwise applicable "u "p ,b 7z det]m9$ 
)\t reg>d to section #ahci7;i77 to      

individuals s enroll$2 &  7,d7 may      
provide = a r$uction 9 co/-%>+ o!rwise  
applicable to su* individuals :o use    
provid]s )9 a plan network4  7#b7 ,c>e  
managem5t s]vices  7,a7 ,requir$ ,!     
requir$ c>e managem5t s]vices %all      
include cl9ical int]v5tions to help     
coord9ate c>e4  7,b7 ,optional ,optional
 c>e managem5t s]vices may include      
int]v5tions su* z ! foll[+3 7i7         
,prev5tion & wellness4  7ii7            
,transitional & case managem5t & o!r    
cl9ical programs4  7iii7 ,*ronic disease
 managem5t4  7iv7 ,advanc$ illness c>e  
initiatives4  7v7 ,diabetes prev5tion   
programs4  7vi7 ,transitional case      
managem5t1 = individuals dis*>g$ f a    
hospital or o!r heal? c>e in/itution4   
7vii7 ,nurse practition]-l$ int]v5tions 
7consi/5t ) re/rictions "u applicable   
,/ate law74  7viii7 ,po/-acute          
transition programs4  7ix7 ,high-risk   
case managem5t4  7x7 ,home-bas$ prim>y  
c>e4  7xi7 ,advanc$ illness transitional
 c>e4  7xii7 ,op]ation ( cl9ical        

managem5t programs4  7xiii7 ,managem5t &
 developm5t ( provid] networks4  7xiv7  
,consum] engagem5t ) decision support4  
7#c7 ,pr$ictive model+ & risk           
prioritization ,! pr$ictive model+ &    
risk prioritization s]vices describ$ 9  
?is p>agraph %all include ! foll[+3 7,a7
 ,pr$ictive model+ & high risk          
id5tification ,! use ( claims data &    
tr5d data to pr$ict :i* enrollees c\ld  
b5efit f ! application ( a cl9ical      
int]v5tion or :i* might be high risk & 9
 ne$ ( a c>e plan4  7,b7 ,prioritization
 ( int]v5tions ,programs to id5tify1    
prioritize1 & p]sonalize c>e            
opportunities ?r\gh a compreh5sive      
pr(ile ( ea* enrollee4  7#d7 ,optional  
inc5tives & enrollee emp[]m5t  7,a7 ,9  
g5]al ,a ,m$ic>e ,l9k contractor may use
 appropriate inc5tives to manage ov]all 
c>e = enrollees4 ,! ,secret>y %all      
e/abli% t]ms & conditions "u :i* a      
,m$ic>e ,l9k contractor may elect to use
 optional inc5tives = its memb]s4  7,b7 
,types ( inc5tives ,! types ( inc5tives 

t may be us$ include ! foll[+3 7i7      
,heal?y rew>ds ,premium rebates & o!r   
inc5tives approv$ by ! ,secret>y =      
enrollees to make heal?i] *oices &      
actively engage 9 _! heal? c>e4  7ii7   
,memb] inc5tives to use quality network 
provid]s ,r$uctions 9 b5efici>y co/-%>+ 
7& o!r inc5tives approv$ by ! ,secret>y7
 = enrollees :o use provid]s 7:i* may be
 acc\ntable c>e organizations7 )9 a plan
 network 9 ord] to rew>d quality1       
effici5t c>e4  7iii7 ,co/ e/imator tools
 ,provid+ b5efici>ies ) tools design$ to
 help !m simplify ! evaluation ( heal?  
c>e co/s ?r\gh co/ e/imates = diff]5t   
treatm5t options4  7#e7 ,application (  
,,ma grievance & appeals proc$ures ,9   
accordance ) regulations1 ! provisions (
 "p ,c ins(> z !y apply to grievances & 
appeals1 %all apply to ,m$ic>e ,l9k     
plans & enrollees "u ?is section 9 a    
mann] simil> to h[ su* provisions apply 
to ,,ma plans "u su* "p4  7e7 ,ma9t5ance
 ( curr5t b5efits2 contractor n at      
f9ancial risk = orig9al fee-=-,s]vice   

b5efits  7#a7 ,no *ange 9 ,m$ic>e cov]$ 
items & s]vices or limitation on        
supplem5tal plans ,m$ic>e ,l9k plans    
%all provide = cov]age ( ! same items & 
s]vices t are cov]$ "u p>ts ,a & ,b4    
,no?+ 9 ?is section %all be con/ru$ z   
prev5t+ an individual enroll$ "u a      
,m$ic>e ,l9k plan f pur*as+ a m$ic>e    
supplem5tal policy 7describ$ 9 section  
#ahha7 or o!r supplem5tal cov]age       
outside ( a ,m$ic>e ,l9k plan4  7#b7 ,no
 *ange 9 paym5ts to provid]s  7,a7 ,9   
g5]al ,subject to subp>agraph 7,b71 no?+
 9 ?is section %all be con/ru$ z        
au?oriz+ a paym5t level to a provid] (  
s]vices or suppli] = ,m$ic>e cov]$      
s]vices t is o!r ?an ! paym5t level     
o!rwise applicable "u "p ,a or ,b = su* 
s]vices4  7,b7 ,negotiation ( rates     
p]mitt$ ,a ,m$ic>e ,l9k contractor may  
negotiate ) provid]s ( s]vices &        
suppli]s paym5t rates t are less or     
great] ?an ! paym5t rates ref]r$ to 9   
subp>agraph 7,a74  7#c7 ,contractor n at
 f9ancial risk ,a ,m$ic>e ,l9k          

contractor %all n be at f9ancial risk ) 
respect to ! cov]age or paym5t = ,m$ic>e
 s]vices cov]$ "u p>ts ,a & ,b4 ,b !    
,secret>y may provide f9ancial inc5tives
 = contractors t are able to r$uce      
,m$ic>e exp5ditures = su* s]vices bel[  
b5*m>k levels 7specifi$ by ! ,secret>y7 
t reasonably repres5t ! levels ( paym5ts
 t w\ld be made 7) respect to           
individuals enroll$ "u a ,m$ic>e ,l9k   
plan7 if su* individuals 7 n s enroll$4 
4