,,ii #aacth ,,congress #b;d ,session ,s4 #aicb ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,january #ae1 #bjad,mr4 ,wyden 7for himself and ,mr4 ,isakson7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,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 conditions1 and for other purposes4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,better ,care1 ,lower ,cost ,act4 7b7 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4,sec4 #b4 ,findings4,sec4 #c4 ,medicare ,better ,care ,program4,sec4 #d4 ,chronic special needs plans4,sec4 #e4 ,improvements to welcome to ,medicare visit and annual wellness visits4,sec4 #f4 ,chronic care innovation centers4,sec4 #g4 ,curricula requirements for direct and indirect graduate medical education payments4 #b4 ,findings ,congress makes the following findings3 7#a7 ,the field of medicine is ever-evolving and we need a highly skilled1 team-oriented workforce that can meet the health care needs of today as well as the health care challenges of tomorrow4 7#b7 ,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 monitoring4 #c4 ,medicare ,better ,care ,program 7a7 ,in general ,title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq47 is amended by adding at the end the following new section3 #ahii;,b4 ,medicare ,better ,care ,program 7a7 ,establishment 7#a7 ,in general ,not later than ,january #a1 #bjag1 the ,secretary shall establish an integrated chronic care delivery program 7in this section referred to as the program7 that promotes accountability and better care management for chronically ill patient populations and coordinates items and services under parts ,a1 ,b1 and ,d1 while encouraging investment in infrastructure and redesigned care processes that result in high quality and efficient service delivery for the most vulnerable and costly populations4 ,the program shall-- 7,a7 focus on long-term cost containment and better overall health of the ,medicare population by implementing through qualified ,b,c,ps 7as described in paragraph 7#b77;,a77 strategies that prevent1 delay1 or minimize the progression of illness or disability associated with chronic conditions2 and 7,b7 include the program elements described in paragraph 7#b74 7#b7 ,program elements ,the following program elements are described in this paragraph3 7,a7 ,a health plan or group of providers of services and suppliers1 or a health plan working with such a group1 that the ,secretary certifies in accordance with subsection 7e7 as meeting criteria developed by the ,secretary to recognize the challenges of managing a chronically ill population1 including patient satisfaction and engagement1 quality measurement developed specifically for a chronically ill population1 and effective use of resources and providers1 may manage and coordinate care for ,,bcp eligible individuals through an integrated care network1 or ,better ,care ,program 7referred to in this section as a qualified ,,bcp74 ,a group of providers of services and suppliers described in the preceding sentence may also be participating in another alternative payment model 7as defined in subsection 7k774 7,b7 ,payments to a qualified ,,bcp shall be made in accordance with subsection 7g74 7,c7 ,implementation of the program shall focus on physical1 behavioral1 and psychosocial needs of ,,bcp eligible individuals4 7,d7 ,quality and cost containment are considered interdependent goals of the program4 7,e7 ,the calculation of long-term cost savings is dependent on qualified ,b,c,ps delivering the full continuum of covered primary1 post-acute care1 and social services using capitated financing4 7#c7 ,targeted participation 7,a7 ,in general ,in certifying qualified ,b,c,ps throughout the country1 the ,secretary shall give priority to areas-- 7i7 that do not have a concentration of accountable care organizations under section #ahii2 and 7ii7 with a high burden of chronic conditions4 7,b7 ,initial requirement ,in the first #e years of the program1 at least #ej percent of all new qualified ,b,c,ps certified nationwide by the ,secretary shall be from counties or regions1 as determined by the ,secretary1 where the prevalence of the most costly chronic conditions is at or greater than #abe percent of the national average4 7,c7 ,restricting the number of participating ,b,c,ps 7i7 ,in general ,the ,secretary shall take into account geography1 urban and rural designations1 and the population case mix that will be served1 when selecting ,b,c,ps for participation4 7ii7 ,limitation during the first four program years ,during the first four years of the program1 the total number of qualified ,b,c,ps certified by the ,secretary shall not exceed #bej4 7iii7 ,no limitation during fifth and subsequent program years ,during the fifth year and any subsequent year of the program1 the ,secretary may certify any ,,bcp that meets the requirements to be certified as a qualified ,,bcp4 7#d7 ,alignment with approved ,state plan waivers ,in certifying qualified ,b,c,ps1 the ,secretary shall ensure alignment with other approved waivers of ,state plans under title ,,xix4 7b7 ,definition of ,,bcp eligible individuals 7#a7 ,definition ,for purposes of this section1 the term ,,bcp eligible individual means an individual who-- 7,a7 is entitled to benefits under part ,a and enrolled under parts ,b and ,d1 including an individual who is enrolled in a ,medicare ,advantage plan under part ,c1 an eligible organization under section #ahgf1 or a ,,pace program under section #ahid2 and 7,b7 is medically complex given the prevalence of chronic disease that actively and persistently affects their health status1 and absent appropriate care interventions1 causes them to be at enhanced risk for hospitalization1 limitations on activities of daily living1 or other significant health outcomes4 7#b7 ,dual eligible individuals ,an individual who is dually eligible for ,medicare and ,medicaid shall not be excluded from enrolling in a qualified ,,bcp4 ,dually eligible beneficiaries enrolled in a qualified ,,bcp will see the full scope of their benefits under this title and title ,,xix 7other than long-term care7 managed by the qualified ,,bcp4 7c7 ,notification and enrollment 7#a7 ,notification ,not later than ,october #a of each year1 the ,secretary shall use all available tools1 including the notice mailed annually under section #ahjd7;a7 and ,state health insurance assistance programs1 to notify ,,bcp eligible individuals of qualified ,b,c,ps in their area for the upcoming plan year4 ,such information shall also be easily accessible on the ,internet website of the ,centers for ,medicare ,medicaid ,services4 7#b7 ,enrollment ,the ,secretary shall establish procedures under which ,,bcp eligible individuals may voluntarily enroll in a qualified ,,bcp at the following times3 7,a7 ,during the annual1 coordinated election period under section #ahea7;e77#c77;,b74 7,b7 ,during or following 7for a length of time determined by the ,secretary7-- 7i7 an initial preventive physical examination 7as defined in section #ahfa7ww772 or 7ii7 any subsequent visit where a chronic condition is identified or a previous condition is identified as having escalated to the level of a chronic condition4 7d7 ,patient assessment 7#a7 ,standardized functional and health risk assessment 7,a7 ,minimum guidelines ,not later than ,january #a1 #bjaf1 the ,secretary shall publish minimum guidelines for qualified ,b,c,ps to furnish to enrollees a health information technology-compatible1 standardized1 and multidimensional risk assessment that-- 7i7 assesses and quantifies the medical1 psychosocial1 and functional status of an enrollee2 and 7ii7 includes a mechanism to determine the level of patient activation and ability to engage in self-care of an enrollee4 7,b7 ,updating ,not less frequently than once every #c years1 the ,secretary shall1 through rulemaking1 update such minimum guidelines to reflect new clinical standards and practices1 as appropriate4 7#b7 ,individual patient-centered chronic care plan 7,a7 ,model plan ,not later than ,january #a1 #bjaf1 the ,secretary shall publish minimum guidelines for qualified ,b,c,ps to develop individual patient-centered chronic care plans for enrollees4 ,such a plan shall-- 7i7 allow health professionals to incorporate the medical1 psychosocial1 and functional components identified in the risk assessment described in paragraph 7#a77;,a77i72 7ii7 provide a framework that can be easily integrated into electronic health records1 allowing clinicians to make timely1 accurate1 evidence-based decisions at the point of care2 and 7iii7 allow for the provider to describe how services will be provided to the enrollee4 7,b7 ,use of technology for patient self care 7i7 ,in general ,whenever appropriate1 the individual patient-centered chronic care plan of an enrollee shall include the use of technologies that enhance communication between patients1 providers1 and communities of care1 such as telehealth1 remote patient monitoring1 ,smartphone applications1 and other such enabling technologies1 that promote patient engagement and self care while maintaining patient safety4 7ii7 ,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-effectiveness4 ,such pathway shall not duplicate existing efforts4 7e7 ,qualified ,,bcp providers 7#a7 ,criteria 7,a7 ,in general ,any health plan1 provider of services1 or group of providers of services and suppliers1 who agrees to meet the requirements described in paragraph 7#b7 and is specified in subparagraph 7,c7 may form a multidisciplinary team of health professionals to be certified as a qualified ,,bcp4 ,those providers may also choose to partner with a qualified insurer to become a qualified ,,bcp4 7,b7 ,no preemption of state licensure laws ,nothing in this section shall preempt ,state licensure laws4 7,c7 ,groups of providers and suppliers specified 7i7 ,in general ,as determined appropriate by the ,secretary1 the following health plans1 providers of services1 or groups of providers of services and suppliers1 that meet the criteria described in clause 7ii7 may be certified as qualified ,b,c,ps under the program3 7,i7 ,health professionals acting as part of a multidisciplinary team4 7,,ii7 ,networks of individual practices of health professionals that may include community health centers1 ,federally qualified health centers1 rural health clinics1 and partnerships or affiliations with hospitals4 7,,iii7 ,health plans that meet appropriate network adequacy standards1 as determined by the ,secretary1 and that include providers with experience and interest in managing a population with chronic conditions4 7,,iv7 ,independent health professionals partnering with an independent risk manager4 7,v7 ,such other groups of providers of services or suppliers as the ,secretary determines appropriate4 7ii7 ,criteria described ,the following criteria are described in this clause3 7,i7 ,demonstrated capacity to manage the full continuum of care 7other than long-term care7 for the specialized population of ,,bcp eligible individuals4 7,,ii7 ,having a high rate of ,medicare customer satisfaction1 when applicable1 or partnering with providers of services or suppliers with such a demonstrated high satisfaction rate4 7#b7 ,requirements ,a qualified ,,bcp shall meet the following requirements3 7,a7 ,the qualified ,,bcp shall be accountable for the quality1 cost1 and overall care of enrolled ,,bcp eligible individuals and agree to be at financial risk for that enrolled population4 ,a qualified ,,bcp shall be established with the objective of serving ,,bcp eligible individuals4 7,b7 ,the qualified ,,bcp shall be responsible for the full continuum of care 7other than long-term care7 for enrollees4 ,this continuum shall include medical care1 skilled nursing and home health services1 behavioral health care1 and social services4 ,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 alone4 7,c7 ,the qualified ,,bcp shall primarily consist of a care team tasked with responding to1 treating1 and actively supporting the needs of ,,bcp eligible individuals4 ,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 transitions4 7,d7 ,the qualified ,,bcp shall include physicians1 nurse practitioners1 registered nurses1 social workers1 pharmacists1 and behavioral health providers who commit to caring for ,,bcp eligible individuals4 7,e7 ,the qualified ,,bcp shall enter into an agreement with the ,secretary to participate in the program under this section for not less than a #c-year period4 7,f7 ,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 ,,bcp4 7,g7 ,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 ,,bcp1 including evidence relating to high patient satisfaction when available1 the implementation of quality reporting and other reporting requirements1 and evidence to support a determination of capitated payments in accordance with subsection 7g74 7,h7 ,the qualified ,,bcp shall have in place a structure that includes clinical and administrative systems1 including health information technology1 that supports the integration of services and providers across sites of care4 7,i7 ,the qualified ,,bcp may develop a collaborative partnership that supports the mission of the ,,bcp with each of the following3 7i7 ,a regional or national ,chronic ,care ,innovation ,center under section #f of the ,better ,care1 ,lower ,cost ,act4 7ii7 ,a regional or national ,center of ,innovation 7,,coin7 of the ,department of ,veterans ,affairs ,health ,services ,research and ,development ,service to identify and implement best practices-- 7,i7 to increase access to1 and implementation of1 prevention and wellness tools2 7,,ii7 to integrate physical and behavior health care with social services2 7,,iii7 to promote evidence-based medicine and patient engagement2 7,,iv7 to coordinate care across providers and care settings2 7,v7 to allow more patients to be cared for in their homes and communities2 7,,vi7 to reduce hospital readmissions2 7,,vii7 to improve health outcomes for patients with chronic conditions2 and 7,,viii7 to report on quality improvement and cost measures4 7iii7 ,a regional or national ,telehealth ,resource ,center of the ,health ,resources and ,services ,administration 7,,hrsa7 ,office for the ,advancement of ,telehealth to create an interactive1 online resource for qualified ,,bcp professionals who may need additional training or assistance in managing the needs of a complex patient population1 including-- 7,i7 continuing training and education and mentoring for qualified ,,bcp professionals at any level of licensure2 7,,ii7 clinician support for complex patients by an expert panel2 7,,iii7 remote access to regional1 national1 and international experts in the field2 7,,iv7 forums for best practices to be discussed among qualified ,,bcp professionals2 7,v7 inter-professional education supporting optimal communication between members of a chronic care team2 and 7,,vi7 continuing training on the use of telehealth1 remote patient monitoring1 and other such enabling technologies4 7,j7 ,the qualified ,,bcp shall demonstrate to the ,secretary that it meets person-centeredness criteria specified by the ,secretary in collaboration with accreditation organizations1 including the use of patient and caregiver assessments and the use of individual patient-centered chronic care plans for each enrollee 7as described in subsection 7d77#b774 7,k7 ,the qualified ,,bcp may identify and respond to unique cultural1 social1 and economic needs of a community that impact access to1 and quality of1 healthcare4 7,l7 ,the qualified ,,bcp shall provide care across settings1 including in the home as needed4 7,m7 ,the qualified ,,bcp shall demonstrate financial solvency 7as determined by the ,secretary74 7,n7 ,the qualified ,,bcp shall demonstrate the ability to partner with providers of social and behavioral health services within the community4 7,o7 ,the qualified ,,bcp shall engage in continuing education on chronic care1 on an ongoing basis 7as determined necessary by the ,chronic ,care ,innovation ,center under the partnership under subparagraph 7,j77i771 in collaboration with the ,agency for ,healthcare ,research and ,quality1 the ,health ,resources and ,services ,administration1 and the ,department of ,veterans ,affairs4 7f7 ,implementing value-,based insurance design 7#a7 ,in general 7,a7 ,election ,a qualified ,,bcp may elect to provide value-based ,medicare coverage in accordance with this subsection4 7,b7 ,inclusion of original ,medicare fee-for-service program benefits ,subject to subparagraph 7,c71 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 ,b1 with cost-sharing for those items and services as described in subparagraph 7,c74 7,c7 ,cost-sharing ,cost-sharing described in this subparagraph1 with respect to an enrollee in a qualified ,,bcp that makes such an election1 is varied cost-sharing approved by the ,secretary to incentivize the use of high-value1 high-quality services that have been clinically proven to benefit ,,bcp eligible individuals4 7,d7 ,changes in coverage ,the ,secretary1 in consultation with experts in the field1 shall establish a process for qualified ,b,c,ps 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 maintained4 7,e7 ,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 services4 7#b7 ,qualified ,,bcp participation 7,a7 ,continued access ,subject to subparagraph 7,b71 enrollees in a qualified ,,bcp shall continue to have access to all providers of services and suppliers under this title4 7,b7 ,no application of varied cost-sharing for nonparticipating providers of services and suppliers 7i7 ,in general ,the varied cost-sharing under paragraph 7#a77;,b7 shall only apply to items and services furnished by qualified ,,bcp professionals of a qualified ,,bcp that makes an election under paragraph 7#a74 ,in the case where items and services are furnished by a provider of services or supplier who is not such a qualified ,,bcp professional1 the cost-sharing applicable for those items and services will be the cost-sharing as required under parts ,a and ,b1 or an actuarially equivalent level of cost-sharing as determined by the ,secretary4 7ii7 ,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 professional4 7#c7 ,limitations on out-of-pocket expenses outside a qualified ,,bcp 7,a7 ,in general ,out-of-pocket costs1 including individual beneficiary copayments1 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 ,secretary1 or1 in the case of a dual eligible individual1 under the ,medicaid program under title ,,xix4 7,b7 ,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 7other than emergent services1 as defined by the ,secretary7 furnished to an enrollee outside of a qualified ,,bcp under ,medigap policies1 see section #ahhb7z74 7#d7 ,prescription drug coverage 7,a7 ,drug plan option 7i7 ,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 enrollees4 7ii7 ,application of part ,d provisions 7,i7 ,in general ,except as otherwise provided in this section1 the provisions of part ,d shall apply to a drug plan option offered by a qualified ,,bcp under clause 7i7 in the same manner as such provisions apply to a prescription drug plan offered by a ,,pdp sponsor under such part4 7,,ii7 ,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 ,,bcp4 7,,iii7 ,waiver ,the ,secretary may waive such provisions of part ,d as are necessary to carry out this section4 7,b7 ,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 individuals4 7,c7 ,limitation ,a drug plan option offered by a qualified ,,bcp under subparagraph 7,a77i7 shall not have the authority to increase out-of-pocket limits otherwise applicable under part ,d4 7g7 ,payments and treatment of savings 7#a7 ,payments to qualified ,b,c,ps on a capitated basis 7,a7 ,in general ,in the case of a qualified ,,bcp under this section1 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 #ahec4 ,such payments shall be subject to adjustment in the manner described in section #ahec7;a77#b7 or section #ahgf7;a77#a77;,e71 as the case may be4 7,b7 ,capitation amount ,the capitation amount to be applied under this paragraph for a qualified ,,bcp for each enrollee for a year shall be #a_/ab of the benchmark rate under subparagraph 7,c77ii7 for the year 7or the relevant rate under subparagraph 7,c77i7 for the first year of the program under this section7 7referred to in this paragraph as the per member per month payment71 as adjusted under clause 7iii74 7,c7 ,determining the ,rate ,using ,risk ,relevant ,control ,group 7i7 ,relevant ,rate 7,i7 ,identification of beneficiary grouping ,using claims data1 the ,secretary shall identify a group of beneficiaries who have similar health risk characteristics1 and have sought care in the same county1 multi-county1 or ,state level 7as determined appropriate by the ,secretary to establish a payment area7 to the population the qualified ,,bcp is tasked with serving4 ,to the extent feasible for a statistically valid control group1 the health risk of such group shall reflect social characteristics1 such as income1 as well as medical risk4 7,,ii7 ,determination of relevant rate ,the per capita spending amounts under this title and1 as appropriate1 title ,,xix1 of the group of beneficiaries identified under subclause 7,i7 shall determine the relevant rate that will serve as the basis of the benchmark for participating qualified ,b,c,ps4 7ii7 ,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 7i7 with the projected change in per capita spending for the group of beneficiaries identified under clause 7i77,i7 for the payment area described in such clause1 as determined by the ,chief ,actuary of the ,centers for ,medicare ,medicaid ,services4 7iii7 ,adjustment for health status 7,i7 ,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 7i77,i74 7,,ii7 ,inclusion of number of conditions ,the ,secretary shall provide that a risk score under the mechanism under this clause1 with respect to an individual1 includes an indicator for the number of chronic conditions with which the individual has been diagnosed4 7,,iii7 ,use of #b years of diagnosis data ,the ,secretary shall ensure that such risk score1 with respect to an individual reflects not less than #b years of diagnosis data1 to the extent available4 7,,iv7 ,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 beneficiaries4 ,if an enrollee has a risk profile that is not as severe as the average health status of such group of beneficiaries1 then the per member per month shall be decreased to reflect the healthier status of the enrollee4 ,if an enrollee has a risk profile that is more severe1 then the per member per month payment to the qualified ,,bcp shall be increased to reflect the more acutely ill status of the enrollee4 7,d7 ,shared risk payments for certain qualified ,b,c,ps during first #c years of the program 7i7 ,in general ,this subparagraph shall only apply to qualified ,b,c,ps offered by a group of providers of services and suppliers during the first #c years of the program under this section4 7ii7 ,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 7i7 as follows3 7,i7 ,determination of gain or loss ,the ,secretary shall1 for each of the first #c years of the program under this section1 determine the percentage of gain or loss for the qualified ,,bcp in providing benefits to enrollees under this section4 7,,ii7 ,gain or loss greater than #e percent ,if the ,secretary determines the qualified ,,bcp has a gain or loss for the year of greater than #e percent1 the qualified ,,bcp shall bear #ajj percent of the risk or reward of such loss or gain4 7,,iii7 ,gain or loss of not less than #b and not greater than #e percent ,if the ,secretary determines the qualified ,,bcp has a gain or loss for the year of not less than #b percent but not greater than #e percent-- 7aa7 the qualified ,,bcp shall bear #hj percent of the risk or reward1 as applicable1 of such loss or gain2 and 7bb7 the ,secretary shall bear #bj percent of the risk or reward1 as applicable1 of such loss or gain4 7,,iv7 ,gain or loss between #j and #b percent ,if the ,secretary determines the qualified ,,bcp has a gain or loss for the year of greater than #j percent but less than #b percent-- 7aa7 the qualified ,,bcp shall bear #ej percent of the risk or reward1 as applicable1 of such loss or gain2 and 7bb7 the ,secretary shall bear #ej percent of the risk or reward1 as applicable1 of such loss or gain4 7iii7 ,provision of information ,a qualified ,,bcp shall provide to the ,secretary such information as the ,secretary determines is necessary to carry out this subparagraph4 7,e7 ,bid submission ,beginning with the fourth year of the program1 a qualified ,,bcp shall submit a bid for participation in the program for the year that reflects the experience of the qualified ,,bcp-- 7i7 in managing the care of the enrolled population2 and 7ii7 in managing such care given the relevant rate determined under subparagraph 7,c74 7,f7 ,quality ,bonus system 7i7 ,in general ,the ,secretary shall establish a quality bonus system whereby the ,secretary distributes bonus payments to qualified ,b,c,ps that meet the requirements described in clause 7iii7 and other standards specified by the ,secretary1 which may include a focus on quality measurement and improvement1 delivering patient-centered care1 and practicing in integrated health systems1 including training in community-based settings4 ,in developing such standards1 the ,secretary shall collaborate with relevant stakeholders1 including program accrediting bodies1 certifying boards1 training programs1 health care organizations1 health care purchasers1 and patient and consumer groups4 7ii7 ,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 region4 ,for not less than the first #e years of the program under this section1 quality measures for the geographic region shall be based on local standards of care1 and not on a national standard4 ,for subsequent years1 appropriate national standards shall be considered for inclusion in the comparison of the quality of care under this subparagraph4 7iii7 ,requirements ,a qualified ,,bcp is eligible for quality bonuses under this subparagraph if-- 7,i7 the qualified ,,bcp meets quality performance standards under subsection 7h77#c72 and 7,,ii7 the qualified ,,bcp meets the requirements under subsection 7e77#b74 7h7 ,quality and other reporting requirements 7#a7 ,in general ,the ,secretary shall develop and implement1 with assistance and input of relevant experts in the field and the ,national ,strategy for ,quality ,improvement in ,health ,care1 appropriate measures for ,,bcp eligible individuals4 ,the ,secretary shall determine appropriate measures under this title and title ,,xix to assess the quality of care furnished by a qualified ,,bcp1 as well as those measures that are no longer appropriate and shall be removed from use4 ,such measures shall include measures-- 7,a7 of clinical processes and outcomes2 7,b7 of patient and1 where practicable1 caregiver experience of care1 including measurement that enhances patient activation and engagement2 7,c7 of utilization 7such as rates of hospital admissions for ambulatory care sensitive conditions72 7,d7 of care coordination1 management1 and transitions2 and 7,e7 that appropriately align with the ,national ,strategy for ,quality ,improvement in ,health ,care4 ,the ,secretary may use existing measures under this title1 title ,,xix1 or any other health care program1 as appropriate1 under this paragraph4 7#b7 ,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 ,,bcp1 on measures the ,secretary determines necessary for the qualified ,,bcp to report in order to evaluate the quality of care furnished by the qualified ,,bcp4 ,such data reporting shall emphasize patient-centered measurement and may include the functional status of patients1 case management and care transitions across health care settings1 including hospital discharge planning and post-hospital discharge follow-up by qualified ,,bcp professionals1 as the ,secretary determines appropriate4 7#c7 ,quality performance standards ,the ,secretary shall establish quality performance standards to assess the quality of care furnished by qualified ,b,c,ps4 ,the ,secretary shall seek to improve the quality of care furnished by qualified ,b,c,ps over time by specifying higher standards1 new measures1 or both for purposes of assessing such quality of care4 ,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 value4 7#d7 ,other reporting requirements and call for alignment ,the ,secretary shall1 as the ,secretary determines appropriate1 incorporate and align reporting requirements and incentive payments related to the physician quality reporting system under section #ahdh1 including those related to reporting on quality measures under subsection 7m7 of that section1 reporting requirements under subsection 7o7 of that section relating to meaningful use of electronic health records1 the establishment of a value-based payment modifier under subsection 7p7 of that section1 and other similar initiatives under that section1 and may use alternative criteria than would otherwise apply under section #ahdh for determining whether to make such payments to qualified ,,bcp professionals4 ,the incentive payments described in the preceding sentence shall not be taken into consideration when calculating any payments otherwise made under subsection 7g74 7i7 ,beneficiary protections ,the ,secretary shall ensure that1 to the extent consistent with this section1 a qualified ,,bcp offers beneficiary protections applicable to beneficiaries under this title and1 as applicable1 title ,,xix4 7j7 ,payment of medicare cost-,sharing for dual eligible individuals ,in the case of a dual eligible individual enrolled in a qualified ,,bcp1 the ,secretary may provide for the payment of medicare cost-sharing 7as defined in section #aije7p77#c77 that would otherwise be available under the ,state plan under title ,,xix if the individual was not enrolled in the qualified ,,bcp4 7k7 ,definitions ,in this section3 7#a7 ,alternative payment model 7,,apm7 ,the term alternative payment model means any of the following3 7,a7 ,a model under section #aaae;,a 7other than a health care innovation award74 7,b7 ,an accountable care organization under section #ahii4 7,c7 ,a demonstration under section #ahff;,c4 7,d7 ,a demonstration required by ,federal law4 7,e7 ,a qualified ,,bcp4 7#b7 ,hospital ,the term hospital means a subsection 7d7 hospital 7as defined in section #ahhf7;d77#a77;,b774 7#c7 ,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 ,,bcp4 4 7b7 ,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 #aidc the following new section3 #aidd4 ,federal assumption of medicaid costs for full benefit eligible individuals enrolled in a qualified ,,bcp 7a7 ,state contribution 7#a7 ,in general ,the ,state shall provide for payment to the ,secretary for each month in an amount determined under paragraph 7#b77;,a7 for each applicable dual eligible ,,bcp enrollee for such ,state4 7#b7 ,state contribution amount 7,a7 ,in general ,subject to subparagraph 7,c71 the amount determined under this paragraph for a ,state for a month in a year is equal to the product described in subparagraph 7,a7 of section #aice7;c77#a7 for the ,state for the month1 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 enrollees4 7,b7 ,form and manner of payment ,the provisions of subparagraphs 7,b7 through 7,d7 of section #aice7;c77#a7 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 #aice7;c77#a77;,a74 7,c7 ,application of different factors ,in applying subparagraph 7,a71 the following shall be substituted under paragraphs 7#b7 and 7#c7 of section #aice7;c73 7i7 ,the base year ,state ,medicaid per capita expenditures for covered part ,d drugs described in subparagraph 7,a77i77,i7 of such paragraph 7#b7 shall be deemed to be the per capita expenditures for health care items and services that would apply 7including any medicare cost-sharing71 with respect to an applicable dual eligible ,,bcp enrollee1 if such an individual received benefits only under title ,,xviii 7and not the ,state plan under this title74 7ii7 ,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 7i74 7iii7 ,any reference to #bjjc or #bjjd shall be deemed a reference to #bjag or #bjah1 respectively4 7iv7 ,any reference to a full-benefit-dual-eligible individual shall be deemed a reference to an applicable dual eligible ,,bcp enrollee4 7v7 ,the applicable growth factor under section #aice7;c77#d7 for a year1 with respect to a ,state1 shall be the average annual percentage change 7to that year from the previous year7 of the expenditures of the ,state under the ,state plan under title ,,xix4 7vi7 ,the factor described in section #aice7;c77#e7 is deemed to be #ij percent4 7#c7 ,applicable dual eligible ,,bcp enrollee ,for purposes of this section1 the term applicable dual eligible ,,bcp enrollee means1 with respect to a ,state1 an individual described in subparagraph 7,a77ii7 of section #aice7;c77#f7 7taking into account the application of subparagraph 7,b7 of such section7 for such ,state who is enrolled in a qualified ,,bcp under section #ahii;,b4 ,such term includes1 in the case of medical assistance for medicare cost-sharing under a ,state plan under this title1 an individual who is a qualified medicare beneficiary 7as defined in section #aije7p77#a771 a qualified disabled and working individual 7described in section #aije7s771 an individual described in section #aijb7;a77#aj77;,e77iii71 or otherwise entitled to such medicare cost-sharing and who is enrolled in such a qualified ,,bcp4 7b7 ,coordination of benefits 7#a7 ,medicare as primary payor ,in the case of an applicable dual eligible ,,bcp enrollee1 notwithstanding any other provision of this title1 medical assistance is not available under this title for health care items or services 7or for any cost-sharing respecting such health care items and services71 and the rules under this title relating to the provision of medical assistance for such health care items and services shall not apply4 ,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 title4 ,no payment may be made under section #aijc7;a7 for health care items and services for which medical assistance is not available pursuant to this paragraph4 7#b7 ,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 enrollee1 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 ,,bcp4 ,in no case shall a qualified ,,bcp be required to provide to enrollees coverage of long-term care services4 4 7c7 ,state marketing materials for dually eligible individuals 7#a7 ,state plan requirement ,section #aijb7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77 is amended-- 7,a7 in paragraph 7#hj71 by striking and at the end2 7,b7 in paragraph 7#ha71 by striking the period at the end and inserting 2 and2 and 7,c7 by inserting after paragraph 7#ha7 the following3 7#hb7 provide that any marketing materials distributed by the ,state that are directed at dual eligible individuals 7as defined in section #aiae7;h77#b77;,b77 include information on qualified ,b,c,ps offered under section #ahii;,b4 4 7#b7 ,effective date ,the amendments made by this section shall apply to calendar quarters beginning on or after ,january #a1 #bjag1 without regard to whether or not final regulations to carry out such amendments have been promulgated by such date4 7d7 ,prohibition on coverage of cost-,sharing for certain items and services furnished to an enrollee outside of a qualified ,,bcp under ,medigap policies ,section #ahhb of the ,social ,security ,act 7#db ,u4,s4,c4 #aciess7 is amended by adding at the end the following new subsection3 7z7 ,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 7#a7 ,development ,the ,secretary shall request the ,national ,association of ,insurance ,commissioners to review and revise the standards for benefit packages under subsection 7p77#a71 taking into account the changes in benefits resulting from the enactment of the ,better ,care1 ,lower ,cost ,act and to otherwise update standards to include the requirements for cost-sharing described in paragraph 7#b74 ,such revisions shall be made consistent with the rules applicable under subsection 7p77#a77;,e7 with the reference to the #aiia ,,naic ,model ,regulation deemed a reference to the ,,naic ,model ,regulation as published in the ,federal ,register on ,december #d1 #aiih1 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 ,care1 ,lower ,cost ,act4 ,to the extent practicable1 such revision shall provide for the implementation of revised standards for benefit packages as of ,january #a1 #bjag4 7#b7 ,cost-sharing requirements ,the cost-sharing requirements described in this paragraph are that1 notwithstanding any other provision of law1 no medicare supplemental policy may provide for coverage of cost-sharing with respect to items and services 7other than emergent services1 as defined by the ,secretary7 furnished to an individual enrolled in a qualified ,,bcp under section #ahii;,b by a provider of services or supplier that is not a qualified ,,bcp professional 7as defined in section #ahii;,b7k774 7#c7 ,renewability ,the renewability requirement under subsection 7q77#a7 shall be satisfied with the renewal of the revised package under paragraph 7#a7 that most closely matches the policy in which the individual was enrolled prior to such revision4 4 #d4 ,chronic special needs plans ,section #ahei of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bh7 is amended-- 7#a7 in subsection 7f77#d7-- 7,a7 by striking ,in the case of and inserting ,subject to subsection 7h71 in the case of2 and 7,b7 by adding at the end the following flush text3 ,notwithstanding any other provision of this section1 on or after ,january #a1 #bjad1 the ,secretary shall establish procedures for the transition of those individuals to a ,medicare ,advantage plan qualified ,,bcp in accordance with subsection 7h74 2 and 7#b7 by adding at the end the following new subsection3 7h7 ,medicare ,advantage plan qualified ,b,c,ps 7#a7 ,in general ,a ,medicare ,advantage plan that is certified as a qualified ,,bcp 7referred to in this subsection as a ,medicare ,advantage plan qualified ,,bcp7-- 7,a7 is deemed to be a specialized ,,ma plan for special needs individuals described in subsection 7b77#f77;,b77iii72 and 7,b7 may enroll such special needs individuals4 7#b7 ,specialized benefit packages ,a ,medicare ,advantage plan qualified ,,bcp shall have the flexibility to offer specialized benefit packages to enrollees described in subsection 7b77#f77;,b77iii71 consistent with the value-based insurance requirements under section #ahii;,b7f74 7#c7 ,application of ,,bcp requirements ,a ,medicare ,advantage plan qualified ,,bcp shall be subject to all requirements applicable to a qualified ,,bcp under section #ahii;,b1 including enrollment periods under subsection 7c7 of that section1 applicable criteria relating to network adequacy1 requirements with respect to individual patient-centered chronic care plans under subsection 7d77#b7 of that section1 applicable criteria with respect to care management processes1 and quality reporting under subsection 7h7 of that section4 7#d7 ,application of part ,c requirements ,the provisions of this part1 including the provisions relating to specialized ,,ma plans for special needs individuals described in subsection 7b77#f77;,b77iii71 shall apply to a ,medicare ,advantage plan qualified ,,bcp to the extent they are consistent with the provisions of section #ahii;,b4 4 #e4 ,improvements to welcome to ,medicare visit and annual wellness visits 7a7 ,welcome to ,medicare visit ,section #ahfa7ww77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7ww77#a77 is amended by adding at the end the following new sentence3 ,in the case of a ,,bcp eligible individual 7as defined in section #ahii;,b7b771 such term includes a standardized functional and health risk assessment 7as described in section #ahii;,b7d77#a77 furnished by a qualified ,,bcp professional 7as defined in section #ahii;,b7k7744 7b7 ,annual wellness visit ,section #ahfa7;hhh77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7h77#a77 is amended-- 7#a7 in subparagraph 7,a71 by striking and at the end2 7#b7 in subparagraph 7,b71 by striking the period at the end and inserting 2 and2 and 7#c7 by adding at the end the following new subparagraph3 7,c7 in the case of a ,,bcp eligible individual 7as defined in section #ahii;,b7b771 that includes a standardized functional and health risk assessment 7as described in section #ahii;,b7d77#a77 furnished by a qualified ,,bcp professional 7as defined in section #ahii;,b7k774 4 7c7 ,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 ,act4 #f4 ,chronic care innovation centers 7a7 ,designation ,not later than ,october #a1 #bjaf1 the ,secretary1 acting through the ,agency for ,healthcare ,research and ,quality1 shall designate and provide core funding for not less than three ,chronic ,care ,innovation ,centers4 ,the ,secretary shall develop a process for entities seeking to become a ,chronic ,care ,innovation ,center1 and shall ensure sufficient geographic representation among those entities selected4 ,the main objectives of such ,centers shall include the following3 7#a7 ,improving the understanding of how to measure1 monitor1 and understand quality and efficiency for a patient population with substantial disease burden4 7#b7 ,rigorously examining alternative and innovative systems and strategies for efficiently improving quality and outcomes for common1 serious1 and chronic illnesses4 7#c7 ,developing and applying improved methodologies for informing policymakers regarding heterogeneity in the effectiveness and safety of proposed interventions1 and assessing barriers to the implementation of high-priority care4 7#d7 ,studying organization and management practices that result in higher quality of care4 7#e7 ,defining and improving quality of care for patients with the chronic diseases prevalent in primary care settings4 7#f7 ,understanding the influence of race1 ethnicity1 and cultural factors on access1 quality1 and outcomes 7such as clinical1 patient-centered1 health care utilization1 and costs74 7#g7 ,evaluating new technology to enhance access to1 and quality of care 7such as telemedicine74 7#h7 ,assessing the use of patient self-management and behavioral interventions as a means of improving outcomes for ,medicare beneficiaries with complex chronic conditions4 7#i7 ,understanding how management of care is affected when patients have multiple chronic conditions in which evidence or recommended guidelines are lacking1 conflict with1 or complicate overall care management4 7#aj7 ,characterizing coordination of care within and across healthcare systems1 including the ,department of ,veterans ,affairs1 the ,medicare program under title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq471 the ,medicaid program under title ,,xix of such ,act1 and private sector programs for veterans with complex chronic conditions4 7b7 ,requirements ,in order to be designated a ,chronic ,care ,innovation ,center under this section1 each eligible entity must meet the following requirements3 7#a7 ,develop and implement a sustained research agenda in the field of chronic care4 7#b7 ,collaborate with local schools of public health and universities to carry out its mission4 7#c7 ,actively engage in the development of new1 best practices for the delivery of care to the chronically ill4 7#d7 ,actively engage in the development and routine updating of quality measures for the chronically ill4 7#e7 ,have the ability to convene experts practiced in the needs of a chronically ill patient1 including pharmacologists1 psychiatrists1 cardiologists1 pulmonologists1 rheumatologists1 nutritionists and dieticians1 social workers1 and physical therapists4 7#f7 ,partner with the ,secretary of ,health and ,human ,services and the ,secretary of ,veterans ,affairs 7including the ,center for ,health ,services ,research in ,primary ,care of the ,department of ,veterans ,affairs ,health ,services ,research and ,development ,service71 the medical community1 medical schools1 and public health departments through the ,agency for ,healthcare ,research and ,quality1 the ,health ,resources and ,services ,administration1 and the ,association of ,american ,medical ,colleges to routinely develop new1 forward thinking1 and evidence-based curricula that addresses the tremendous need for team-based care and chronic care management4 ,such curricula shall include palliative medicine1 chronic care management1 leadership and team-based skills and planning1 and leveraging technology as a care tool4 7c7 ,oversight and evaluation 7#a7 ,in general ,the ,agency for ,healthcare ,research and ,quality shall be responsible for oversight and evaluation of all ,chronic ,care ,innovation ,centers under this section4 7#b7 ,reports ,not less frequently than every #c years1 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 7#a74 7d7 ,contract authority ,in order to carry out this section1 the ,secretary may contract with existing ,centers of ,innovation 7,c,o,i,ns7 of the ,department of ,veterans ,affairs ,health ,services ,research and ,development ,service that meet the requirements described in subsection 7c74 7e7 ,authorization ,there are authorized to be appropriated such sums as are necessary to carry out this section4 #g4 ,curricula requirements for direct and indirect graduate medical education payments 7a7 ,direct graduate medical education payments ,section #ahhf7;h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7h77 is amended by adding at the end the following new paragraph3 7#i7 ,new curricula requirements 7,a7 ,development ,the ,secretary shall engage with the medical community and medical schools in developing curricula that meets the following requirements3 7i7 ,the curricula is new1 forward thinking1 and evidence-based4 7ii7 ,the curricula addresses the need for team-based care and chronic care management4 7iii7 ,the curricula includes palliative medicine1 chronic care management1 leadership and team-based skills and planning1 and leveraging technology as a care tool4 7,b7 ,rural areas ,the curricula developed under subparagraph 7,a7 shall include appropriate focus on care practices required for rural and underserved areas4 7,c7 ,limitation ,notwithstanding the preceding provisions of this subsection1 for cost reporting periods beginning on or after the date that is #e years after the date of enactment of the ,better ,care1 ,lower ,cost ,act1 if a hospital has not begun to implement curricula that meets the requirements described in subparagraph 7,a71 payments otherwise made to a hospital under this subsection may be reduced by a percentage determined appropriate by the ,secretary4 ,for purposes of the preceding sentence1 successful development and implementation of such curricula shall be determined by program accrediting bodies4 4 7b7 ,indirect graduate medical education payments ,section #ahhf7;d77#e77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,b77 is amended-- 7#a7 by redesignating clause 7x71 as added by section #eeje7;b7 of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh71 as clause 7xi7 and moving such clause #f ems to the left2 and 7#b7 by adding at the end the following new clause3 7xii7 ,notwithstanding the preceding provisions of this subparagraph1 effective for discharges occurring on or after the date that is #e years after the date of enactment of the ,better ,care1 ,lower ,cost ,act1 if a hospital has not begun to implement curricula that meets the requirements described in subsection 7h77#i77;,a71 as determined in accordance with subsection 7h77#i77;,c71 payments otherwise made to a hospital under this subparagraph may be reduced by a percentage determined appropriate by the ,secretary4 4