,,ii  #aac? ,,congress  #b;d ,session   
,s4 #aicb  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,janu>y #ae1 #bjad,mr4 
,wyd5 7= himself & ,mr4 ,isakson7       
introduc$ ! foll[+ bill2 :i* 0 read     
twice & ref]r$ to ! ,committee on       
,f9ance  ,a ,,bill  ,to am5d title      
,,xviii ( ! ,social ,security ,act to   
e/abli% a ,m$ic>e ,bett] ,c>e ,program  
to provide integrat$ c>e = ,m$ic>e      
b5efici>ies ) *ronic conditions1 & = o!r
 purposes4  #a4 ,%ort title2 table (    
cont5ts  7a7 ,%ort title ,?is ,act may  
be cit$ z ! ,bett] ,c>e1 ,l[] ,co/ ,act4
  7b7 ,table ( cont5ts ,! table (       
cont5ts ( ?is ,act is z foll[s3 ,sec4   
#a4 ,%ort title2 table ( cont5ts4,sec4  
#b4 ,f9d+s4,sec4 #c4 ,m$ic>e ,bett] ,c>e
 ,program4,sec4 #d4 ,*ronic special ne$s
 plans4,sec4 #e4 ,improvem5ts to welcome
 to ,m$ic>e visit & annual wellness     
visits4,sec4 #f4 ,*ronic c>e innovation 
c5t]s4,sec4 #g4 ,curricula requirem5ts =
 direct & indirect graduate m$ical      
education paym5ts4  #b4 ,f9d+s ,congress

 makes ! foll[+ f9d+s3 7#a7 ,! field (  
m$ic9e is ev]-evolv+ & we ne$ a highly  
skill$1 team-ori5t$ work=ce t c meet !  
heal? c>e ne$s ( today z well z ! heal? 
c>e *all5ges ( tomorr[4  7#b7 ,! ,m$ic>e
 program %\ld recognize ! gr[+ uses &   
b5efits ( heal? te*nology 9 deliv]+     
quality & co/-effici5t c>e by enc\rag+ !
 use ( telem$ic9e & remote pati5t       
monitor+4  #c4 ,m$ic>e ,bett] ,c>e      
,program  7a7 ,9 g5]al ,title ,,xviii ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#acie et seq47 is am5d$ by add+ at ! end
 ! foll[+ new section3  #ahii;,b4       
,m$ic>e ,bett] ,c>e ,program  7a7       
,e/abli%m5t  7#a7 ,9 g5]al ,n lat] ?an  
,janu>y #a1 #bjag1 ! ,secret>y %all     
e/abli% an integrat$ *ronic c>e deliv]y 
program 79 ?is section ref]r$ to z !    
program7 t promotes acc\ntability &     
bett] c>e managem5t = *ronically ill    
pati5t populations & coord9ates items & 
s]vices "u p>ts ,a1 ,b1 & ,d1 :ile      
enc\rag+ inve/m5t 9 infra/ructure &     
r$esign$ c>e processes t result 9 high  

quality & effici5t s]vice deliv]y = !   
mo/ vuln]able & co/ly populations4 ,!   
program %all-- 7,a7 focus on long-t]m   
co/ conta9m5t & bett] ov]all heal? ( !  
,m$ic>e population by implem5t+ ?r\gh   
qualifi$ ,b,c,ps 7z describ$ 9 p>agraph 
7#b77;,a77 /rategies t prev5t1 delay1 or
 m9imize ! progression ( illness or     
disability associat$ ) *ronic           
conditions2 &  7,b7 include ! program   
elem5ts describ$ 9 p>agraph 7#b74  7#b7 
,program elem5ts ,! foll[+ program      
elem5ts are describ$ 9 ?is p>agraph3    
7,a7 ,a heal? plan or gr\p ( provid]s ( 
s]vices & suppli]s1 or a heal? plan     
work+ ) su* a gr\p1 t ! ,secret>y       
c]tifies 9 accordance ) subsection 7e7 z
 meet+ crit]ia develop$ by ! ,secret>y  
to recognize ! *all5ges ( manag+ a      
*ronically ill population1 includ+      
pati5t satisfaction & engagem5t1 quality
 measurem5t develop$ specifically = a   
*ronically ill population1 & effective  
use ( res\rces & provid]s1 may manage & 
coord9ate c>e = ,,bcp eligible          

individuals ?r\gh an integrat$ c>e      
network1 or ,bett] ,c>e ,program 7ref]r$
 to 9 ?is section z a qualifi$ ,,bcp74  
,a gr\p ( provid]s ( s]vices & suppli]s 
describ$ 9 ! prec$+ s5t5ce may also be  
p>ticipat+ 9 ano!r alt]native paym5t    
model 7z def9$ 9 subsection 7k774  7,b7 
,paym5ts to a qualifi$ ,,bcp %all be    
made 9 accordance ) subsection 7g74     
7,c7 ,implem5tation ( ! program %all    
focus on physical1 behavioral1 &        
psy*osocial ne$s ( ,,bcp eligible       
individuals4  7,d7 ,quality & co/       
conta9m5t are consid]$ int]dep5d5t goals
 ( ! program4  7,e7 ,! calculation (    
long-t]m co/ sav+s is dep5d5t on        
qualifi$ ,b,c,ps deliv]+ ! full cont9uum
 ( cov]$ prim>y1 po/-acute c>e1 & social
 s]vices us+ capitat$ f9anc+4  7#c7     
,t>get$ p>ticipation  7,a7 ,9 g5]al ,9  
c]tify+ qualifi$ ,b,c,ps ?r\gh\t !      
c\ntry1 ! ,secret>y %all give priority  
to areas-- 7i7 t d n h a conc5tration ( 
acc\ntable c>e organizations "u section 
#ahii2 &  7ii7 ) a high burd5 ( *ronic  

conditions4  7,b7 ,initial requirem5t ,9
 ! fir/ #e ye>s ( ! program1 at lea/ #ej
 p]c5t ( all new qualifi$ ,b,c,ps       
c]tifi$ nationwide by ! ,secret>y %all  
be f c\nties or regions1 z det]m9$ by ! 
,secret>y1 :]e ! preval5ce ( ! mo/ co/ly
 *ronic conditions is at or great] ?an  
#abe p]c5t ( ! national av]age4  7,c7   
,re/rict+ ! numb] ( p>ticipat+ ,b,c,ps  
7i7 ,9 g5]al ,! ,secret>y %all take into
 acc\nt geography1 urban & rural        
designations1 & ! population case mix t 
w be s]v$1 :5 select+ ,b,c,ps =         
p>ticipation4  7ii7 ,limitation dur+ !  
fir/ f\r program ye>s ,dur+ ! fir/ f\r  
ye>s ( ! program1 ! total numb] (       
qualifi$ ,b,c,ps c]tifi$ by ! ,secret>y 
%all n exce$ #bej4  7iii7 ,no limitation
 dur+ fif? & subsequ5t program ye>s     
,dur+ ! fif? ye> & any subsequ5t ye> ( !
 program1 ! ,secret>y may c]tify any    
,,bcp t meets ! requirem5ts to be       
c]tifi$ z a qualifi$ ,,bcp4  7#d7       
,alignm5t ) approv$ ,/ate plan waiv]s ,9
 c]tify+ qualifi$ ,b,c,ps1 ! ,secret>y  

%all ensure alignm5t ) o!r approv$      
waiv]s ( ,/ate plans "u title ,,xix4    
7b7 ,def9ition ( ,,bcp eligible         
individuals  7#a7 ,def9ition ,= purposes
 ( ?is section1 ! t]m ,,bcp eligible    
individual means an individual :o-- 7,a7
 is entitl$ to b5efits "u "p ,a &       
enroll$ "u p>ts ,b & ,d1 includ+ an     
individual :o is enroll$ 9 a ,m$ic>e    
,advantage plan "u "p ,c1 an eligible   
organization "u section #ahgf1 or a     
,,pace program "u section #ahid2 &  7,b7
 is m$ically complex giv5 ! preval5ce ( 
*ronic disease t actively & p]si/5tly   
affects _! heal? /atus1 & abs5t         
appropriate c>e int]v5tions1 causes !m  
to be at enhanc$ risk = hospitalization1
 limitations on activities ( daily liv+1
 or o!r significant heal? outcomes4     
7#b7 ,dual eligible individuals ,an     
individual :o is dually eligible =      
,m$ic>e & ,m$icaid %all n be exclud$ f  
enroll+ 9 a qualifi$ ,,bcp4 ,dually     
eligible b5efici>ies enroll$ 9 a        
qualifi$ ,,bcp w see ! full scope ( _!  

b5efits "u ?is title & title ,,xix 7o!r 
?an long-t]m c>e7 manag$ by ! qualifi$  
,,bcp4  7c7 ,notification & enrollm5t   
7#a7 ,notification ,n lat] ?an ,octob]  
#a ( ea* ye>1 ! ,secret>y %all use all  
available tools1 includ+ ! notice mail$ 
annually "u section #ahjd7;a7 & ,/ate   
heal? insurance assi/ance programs1 to  
notify ,,bcp eligible individuals (     
qualifi$ ,b,c,ps 9 _! area = ! upcom+   
plan ye>4 ,su* in=mation %all also be   
easily accessible on ! ,int]net website 
( ! ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices4
  7#b7 ,enrollm5t ,! ,secret>y %all     
e/abli% proc$ures "u :i* ,,bcp eligible 
individuals may volunt>ily enroll 9 a   
qualifi$ ,,bcp at ! foll[+ times3 7,a7  
,dur+ ! annual1 coord9at$ election p]iod
 "u section #ahea7;e77#c77;,b74  7,b7   
,dur+ or foll[+ 7= a l5g? ( "t det]m9$  
by ! ,secret>y7-- 7i7 an initial        
prev5tive physical exam9ation 7z def9$ 9
 section #ahfa7ww772 or  7ii7 any       
subsequ5t visit :]e a *ronic condition  
is id5tifi$ or a previ\s condition is   

id5tifi$ z hav+ escalat$ to ! level ( a 
*ronic condition4  7d7 ,pati5t assessm5t
  7#a7 ,/&>diz$ functional & heal? risk 
assessm5t  7,a7 ,m9imum guidel9es ,n    
lat] ?an ,janu>y #a1 #bjaf1 ! ,secret>y 
%all publi% m9imum guidel9es = qualifi$ 
,b,c,ps to furni% to enrollees a heal?  
in=mation te*nology-compatible1 /&>diz$1
 & multidim5sional risk assessm5t t--   
7i7 assesses & quantifies ! m$ical1     
psy*osocial1 & functional /atus ( an    
enrollee2 &  7ii7 includes a me*anism to
 det]m9e ! level ( pati5t activation &  
ability to engage 9 self-c>e ( an       
enrollee4  7,b7 ,updat+ ,n less         
frequ5tly ?an once e #c ye>s1 !         
,secret>y %all1 ?r\gh rulemak+1 update  
su* m9imum guidel9es to reflect new     
cl9ical /&>ds & practices1 z            
appropriate4  7#b7 ,individual          
pati5t-c5t]$ *ronic c>e plan  7,a7      
,model plan ,n lat] ?an ,janu>y #a1     
#bjaf1 ! ,secret>y %all publi% m9imum   
guidel9es = qualifi$ ,b,c,ps to develop 
individual pati5t-c5t]$ *ronic c>e plans

 = enrollees4 ,su* a plan %all-- 7i7    
all[ heal? pr(essionals to incorporate !
 m$ical1 psy*osocial1 & functional      
compon5ts id5tifi$ 9 ! risk assessm5t   
describ$ 9 p>agraph 7#a77;,a77i72  7ii7 
provide a framework t c be easily       
integrat$ into electronic heal? records1
 all[+ cl9icians to make timely1        
accurate1 evid5ce-bas$ decisions at !   
po9t ( c>e2 &  7iii7 all[ = ! provid] to
 describe h[ s]vices w be provid$ to !  
enrollee4  7,b7 ,use ( te*nology =      
pati5t self c>e  7i7 ,9 g5]al ,:5ev]    
appropriate1 ! individual pati5t-c5t]$  
*ronic c>e plan ( an enrollee %all      
include ! use ( te*nologies t enhance   
communication betwe5 pati5ts1 provid]s1 
& communities ( c>e1 su* z teleheal?1   
remote pati5t monitor+1 ,sm>tphone      
applications1 & o!r su* enabl+          
te*nologies1 t promote pati5t engagem5t 
& self c>e :ile ma9ta9+ pati5t safety4  
7ii7 ,coord9ation & developm5t (        
/reaml9$ pa?way ,! ,secret>y %all "w ) !
 ,(fice ( ! ,national ,coord9ator =     

,heal? ,in=mation ,te*nology & !        
,dep>tm5t ( ,heal? & ,human ,s]vices    
,*ief ,te*nology ,(fic] to develop a    
/reaml9$ pa?way = ! use ( mobile        
applications & communications devices t 
effectively enhance ! exp]i5ce ( !      
pati5t :ile ma9ta9+ pati5t safety &     
co/-effectiv5ess4 ,su* pa?way %all n    
duplicate exi/+ ef=ts4  7e7 ,qualifi$   
,,bcp provid]s  7#a7 ,crit]ia  7,a7 ,9  
g5]al ,any heal? plan1 provid] (        
s]vices1 or gr\p ( provid]s ( s]vices & 
suppli]s1 :o agrees to meet !           
requirem5ts describ$ 9 p>agraph 7#b7 &  
is specifi$ 9 subp>agraph 7,c7 may =m a 
multidiscipl9>y team ( heal?            
pr(essionals to be c]tifi$ z a qualifi$ 
,,bcp4 ,^? provid]s may also *oose to   
p>tn] ) a qualifi$ insur] to become a   
qualifi$ ,,bcp4  7,b7 ,no preemption (  
/ate lic5sure laws ,no?+ 9 ?is section  
%all preempt ,/ate lic5sure laws4  7,c7 
,gr\ps ( provid]s & suppli]s specifi$   
7i7 ,9 g5]al ,z det]m9$ appropriate by !
 ,secret>y1 ! foll[+ heal? plans1       

provid]s ( s]vices1 or gr\ps ( provid]s 
( s]vices & suppli]s1 t meet ! crit]ia  
describ$ 9 clause 7ii7 may be c]tifi$ z 
qualifi$ ,b,c,ps "u ! program3 7,i7     
,heal? pr(essionals act+ z "p ( a       
multidiscipl9>y team4  7,,ii7 ,networks 
( individual practices ( heal?          
pr(essionals t may include community    
heal? c5t]s1 ,f$]ally qualifi$ heal?    
c5t]s1 rural heal? cl9ics1 & p>tn]%ips  
or affiliations ) hospitals4  7,,iii7   
,heal? plans t meet appropriate network 
adequacy /&>ds1 z det]m9$ by !          
,secret>y1 & t include provid]s )       
exp]i5ce & int]e/ 9 manag+ a population 
) *ronic conditions4  7,,iv7 ,indep5d5t 
heal? pr(essionals p>tn]+ ) an indep5d5t
 risk manag]4  7,v7 ,su* o!r gr\ps (    
provid]s ( s]vices or suppli]s z !      
,secret>y det]m9es appropriate4  7ii7   
,crit]ia describ$ ,! foll[+ crit]ia are 
describ$ 9 ?is clause3 7,i7 ,demon/rat$ 
capacity to manage ! full cont9uum ( c>e
 7o!r ?an long-t]m c>e7 = ! specializ$  
population ( ,,bcp eligible individuals4

  7,,ii7 ,hav+ a high rate ( ,m$ic>e    
cu/om] satisfaction1 :5 applicable1 or  
p>tn]+ ) provid]s ( s]vices or suppli]s 
) su* a demon/rat$ high satisfaction    
rate4  7#b7 ,requirem5ts ,a qualifi$    
,,bcp %all meet ! foll[+ requirem5ts3   
7,a7 ,! qualifi$ ,,bcp %all be          
acc\ntable = ! quality1 co/1 & ov]all   
c>e ( enroll$ ,,bcp eligible individuals
 & agree to be at f9ancial risk = t     
enroll$ population4 ,a qualifi$ ,,bcp   
%all be e/abli%$ ) ! objective ( s]v+   
,,bcp eligible individuals4  7,b7 ,!    
qualifi$ ,,bcp %all be responsible = !  
full cont9uum ( c>e 7o!r ?an long-t]m   
c>e7 = enrollees4 ,?is cont9uum %all    
include m$ical c>e1 skill$ nurs+ & home 
heal? s]vices1 behavioral heal? c>e1 &  
social s]vices4 ,! qualifi$ ,,bcp may n 
actively re/rict an enrollee's access to
 provid]s bas$ on a practition]'s lic5se
 or m$ical specialty bas$ on co/ alone4 
7,c7 ,! qualifi$ ,,bcp %all prim>ily    
consi/ ( a c>e team task$ ) respond+ to1
 treat+1 & actively support+ ! ne$s (   

,,bcp eligible individuals4 ,! c>e team 
%all also develop a c>e plan = ea*      
eligible ,,bcp enrollee & use x z a tool
 to execute effective c>e managem5t &   
transitions4  7,d7 ,! qualifi$ ,,bcp    
%all include physicians1 nurse          
practition]s1 regi/]$ nurses1 social    
work]s1 ph>maci/s1 & behavioral heal?   
provid]s :o commit to c>+ = ,,bcp       
eligible individuals4  7,e7 ,! qualifi$ 
,,bcp %all ent] into an agreem5t ) !    
,secret>y to p>ticipate 9 ! program "u  
?is section = n less ?an a #c-ye> p]iod4
  7,f7 ,! qualifi$ ,,bcp %all include   
adequate numb]s ( prim>y c>e & o!r      
relevant pr(essionals t c effectively   
c>e = ! numb] ( ,,bcp eligible          
individuals enroll$ 9 ! qualifi$ ,,bcp4 
7,g7 ,! qualifi$ ,,bcp %all provide !   
,secret>y ) su* in=mation reg>d+        
qualifi$ ,,bcp pr(essionals p>ticipat+ 9
 ! qualifi$ ,,bcp necess>y to support ! 
enrollm5t ( ,,bcp eligible individuals 9
 a qualifi$ ,,bcp1 includ+ evid5ce      
relat+ to high pati5t satisfaction :5   

available1 ! implem5tation ( quality    
report+ & o!r report+ requirem5ts1 &    
evid5ce to support a det]m9ation (      
capitat$ paym5ts 9 accordance )         
subsection 7g74  7,h7 ,! qualifi$ ,,bcp 
%all h 9 place a /ructure t includes    
cl9ical & adm9i/rative sy/ems1 includ+  
heal? in=mation te*nology1 t supports ! 
integration ( s]vices & provid]s across 
sites ( c>e4  7,i7 ,! qualifi$ ,,bcp may
 develop a collaborative p>tn]%ip t     
supports ! mission ( ! ,,bcp ) ea* ( !  
foll[+3 7i7 ,a regional or national     
,*ronic ,c>e ,innovation ,c5t] "u       
section #f ( ! ,bett] ,c>e1 ,l[] ,co/   
,act4  7ii7 ,a regional or national     
,c5t] ( ,innovation 7,,co97 ( !         
,dep>tm5t ( ,vet]ans ,affairs ,heal?    
,s]vices ,rese>* & ,developm5t ,s]vice  
to id5tify & implem5t be/ practices--   
7,i7 to increase access to1 &           
implem5tation (1 prev5tion & wellness   
tools2  7,,ii7 to integrate physical &  
behavior heal? c>e ) social s]vices2    
7,,iii7 to promote evid5ce-bas$ m$ic9e &

 pati5t engagem5t2  7,,iv7 to coord9ate 
c>e across provid]s & c>e sett+s2  7,v7 
to all[ m pati5ts to be c>$ = 9 _! homes
 & communities2  7,,vi7 to r$uce        
hospital readmissions2  7,,vii7 to      
improve heal? outcomes = pati5ts )      
*ronic conditions2 &  7,,viii7 to report
 on quality improvem5t & co/ measures4  
7iii7 ,a regional or national ,teleheal?
 ,res\rce ,c5t] ( ! ,heal? ,res\rces &  
,s]vices ,adm9i/ration 7,,hrsa7 ,(fice =
 ! ,advancem5t ( ,teleheal? to create an
 int]active1 onl9e res\rce = qualifi$   
,,bcp pr(essionals :o may ne$ additional
 tra9+ or assi/ance 9 manag+ ! ne$s ( a 
complex pati5t population1 includ+--    
7,i7 cont9u+ tra9+ & education & m5tor+ 
= qualifi$ ,,bcp pr(essionals at any    
level ( lic5sure2  7,,ii7 cl9ician      
support = complex pati5ts by an exp]t   
panel2  7,,iii7 remote access to        
regional1 national1 & int]national      
exp]ts 9 ! field2  7,,iv7 =ums = be/    
practices to be discuss$ among qualifi$ 
,,bcp pr(essionals2  7,v7               

int]-pr(essional education support+     
optimal communication betwe5 memb]s ( a 
*ronic c>e team2 &  7,,vi7 cont9u+ tra9+
 on ! use ( teleheal?1 remote pati5t    
monitor+1 & o!r su* enabl+ te*nologies4 
7,j7 ,! qualifi$ ,,bcp %all demon/rate  
to ! ,secret>y t x meets p]son-c5t]$ness
 crit]ia specifi$ by ! ,secret>y 9      
collaboration ) accr$itation            
organizations1 includ+ ! use ( pati5t & 
c>egiv] assessm5ts & ! use ( individual 
pati5t-c5t]$ *ronic c>e plans = ea*     
enrollee 7z describ$ 9 subsection       
7d77#b774  7,k7 ,! qualifi$ ,,bcp may   
id5tify & respond to unique cultural1   
social1 & economic ne$s ( a community t 
impact access to1 & quality (1 heal?c>e4
  7,l7 ,! qualifi$ ,,bcp %all provide   
c>e across sett+s1 includ+ 9 ! home z   
ne$$4  7,m7 ,! qualifi$ ,,bcp %all      
demon/rate f9ancial solv5cy 7z det]m9$  
by ! ,secret>y74  7,n7 ,! qualifi$ ,,bcp
 %all demon/rate ! ability to p>tn] )   
provid]s ( social & behavioral heal?    
s]vices )9 ! community4  7,o7 ,!        

qualifi$ ,,bcp %all engage 9 cont9u+    
education on *ronic c>e1 on an ongo+    
basis 7z det]m9$ necess>y by ! ,*ronic  
,c>e ,innovation ,c5t] "u ! p>tn]%ip "u 
subp>agraph 7,j77i771 9 collaboration ) 
! ,ag5cy = ,heal?c>e ,rese>* & ,quality1
 ! ,heal? ,res\rces & ,s]vices          
,adm9i/ration1 & ! ,dep>tm5t ( ,vet]ans 
,affairs4  7f7 ,implem5t+ value-,bas$   
insurance design  7#a7 ,9 g5]al  7,a7   
,election ,a qualifi$ ,,bcp may elect to
 provide value-bas$ ,m$ic>e cov]age 9   
accordance ) ?is subsection4  7,b7      
,inclusion ( orig9al ,m$ic>e            
fee-=-s]vice program b5efits ,subject to
 subp>agraph 7,c71 enrollees 9 a        
qualifi$ ,,bcp t elects to provide      
value-bas$ ,m$ic>e cov]age "u ?is       
subsection %all receive su* cov]age t   
includes items & s]vices = :i* b5efits  
are available "u p>ts ,a & ,b to        
individuals entitl$ to b5efits "u "p ,a 
& enroll$ "u "p ,b1 ) co/-%>+ = ^? items
 & s]vices z describ$ 9 subp>agraph     
7,c74  7,c7 ,co/-%>+ ,co/-%>+ describ$ 9

 ?is subp>agraph1 ) respect to an       
enrollee 9 a qualifi$ ,,bcp t makes su* 
an election1 is v>i$ co/-%>+ approv$ by 
! ,secret>y to inc5tivize ! use (       
high-value1 high-quality s]vices t h be5
 cl9ically prov5 to b5efit ,,bcp        
eligible individuals4  7,d7 ,*anges 9   
cov]age ,! ,secret>y1 9 consultation )  
exp]ts 9 ! field1 %all e/abli% a process
 = qualifi$ ,b,c,ps to submit value-bas$
 ,m$ic>e cov]age *anges t enc\rage &    
inc5tivize ! use ( evid5ce-bas$         
practices t w drive bett] outcomes :ile 
ensur+ pati5t protections & access are  
ma9ta9$4  7,e7 ,no requirem5t = cov]age 
( long-t]m c>e s]vices ,9 no case %all a
 qualifi$ ,,bcp be requir$ to provide to
 enrollees cov]age = long-t]m c>e       
s]vices4  7#b7 ,qualifi$ ,,bcp          
p>ticipation  7,a7 ,cont9u$ access      
,subject to subp>agraph 7,b71 enrollees 
9 a qualifi$ ,,bcp %all cont9ue to h    
access to all provid]s ( s]vices &      
suppli]s "u ?is title4  7,b7 ,no        
application ( v>i$ co/-%>+ =            

nonp>ticipat+ provid]s ( s]vices &      
suppli]s  7i7 ,9 g5]al ,! v>i$ co/-%>+  
"u p>agraph 7#a77;,b7 %all only apply to
 items & s]vices furni%$ by qualifi$    
,,bcp pr(essionals ( a qualifi$ ,,bcp t 
makes an election "u p>agraph 7#a74 ,9 !
 case :]e items & s]vices are furni%$ by
 a provid] ( s]vices or suppli] :o is n 
su* a qualifi$ ,,bcp pr(essional1 !     
co/-%>+ applicable = ^? items & s]vices 
w be ! co/-%>+ z requir$ "u p>ts ,a &   
,b1 or an actu>ially equival5t level (  
co/-%>+ z det]m9$ by ! ,secret>y4  7ii7 
,notification ,a ,,bcp eligible         
individual %all be notifi$ & c\nsel$    
prior to ! "t ( enrollm5t on pot5tial   
*anges 9 out-(-pocket co/s t may occur  
if c>e is provid$ by a provid] ( s]vices
 or suppli] t is n a qualifi$ ,,bcp     
pr(essional4  7#c7 ,limitations on      
out-(-pocket exp5ses outside a qualifi$ 
,,bcp  7,a7 ,9 g5]al ,out-(-pocket co/s1
 includ+ individual b5efici>y copaym5ts1
 ) respect to items & s]vices furni%$ by
 a provid] ( s]vices or suppli] :o is n 

a qualifi$ ,,bcp pr(essional %all n     
exce$ :at w\ld o!rwise h be5 paid )     
respect to ! item or s]vice "u ! orig9al
 ,m$ic>e fee-=-s]vice program "u p>ts ,a
 & ,b = ! same s]vices or an actu>ially 
equival5t level ( co/-%>+ z det]m9$ by !
 ,secret>y1 or1 9 ! case ( a dual       
eligible individual1 "u ! ,m$icaid      
program "u title ,,xix4  7,b7           
,prohibition on cov]age ( co/-%>+ =     
c]ta9 items & s]vices furni%$ to an     
enrollee outside ( a qualifi$ ,,bcp "u  
,m$igap policies ,= provisions relat+ to
 prohibition on cov]age ( co/-%>+ =     
items & s]vices 7o!r ?an em]g5t s]vices1
 z def9$ by ! ,secret>y7 furni%$ to an  
enrollee outside ( a qualifi$ ,,bcp "u  
,m$igap policies1 see section #ahhb7z74 
7#d7 ,prescription drug cov]age  7,a7   
,drug plan option  7i7 ,9 g5]al ,a heal?
 plan c]tifi$ z a qualifi$ ,,bcp may    
provide enrollees ) a drug plan option  
specifically design$ to reflect !       
m$ication ne$s ( enrollees4  7ii7       
,application ( "p ,d provisions  7,i7 ,9

 g5]al ,except z o!rwise provid$ 9 ?is  
section1 ! provisions ( "p ,d %all apply
 to a drug plan option (f]$ by a        
qualifi$ ,,bcp "u clause 7i7 9 ! same   
mann] z su* provisions apply to a       
prescription drug plan (f]$ by a ,,pdp  
sponsor "u su* "p4  7,,ii7 ,limitation (
 enrollm5t ,a qualifi$ ,,bcp (f]+ su* a 
drug plan option may limit enrollm5t 9 !
 drug plan option to enrollees 9 !      
qualifi$ ,,bcp4  7,,iii7 ,waiv] ,!      
,secret>y may waive su* provisions ( "p 
,d z are necess>y to c>ry out ?is       
section4  7,b7 ,agreem5t ) prescription 
drug plans ,a qualifi$ ,,bcp manag$ by a
 gr\p ( provid]s ( s]vices may ent] into
 an agreem5t ) a ,,pdp sponsor ( a      
prescription drug plan "u "p ,d to      
e/abli% & enc\rage individuals enroll$ 9
 ! qualifi$ ,,bcp to enroll 9 a         
prescription drug plan "u su* "p t is   
bett] suit$ to ! ne$s ( *ronically ill  
individuals4  7,c7 ,limitation ,a drug  
plan option (f]$ by a qualifi$ ,,bcp "u 
subp>agraph 7,a77i7 %all n h ! au?ority 

to increase out-(-pocket limits o!rwise 
applicable "u "p ,d4  7g7 ,paym5ts &    
treatm5t ( sav+s  7#a7 ,paym5ts to      
qualifi$ ,b,c,ps on a capitat$ basis    
7,a7 ,9 g5]al ,9 ! case ( a qualifi$    
,,bcp "u ?is section1 ! ,secret>y %all  
make prospective mon?ly paym5ts ( a     
capitation am\nt = ea* ,,bcp eligible   
individual enroll$ 9 ! qualifi$ ,,bcp 9 
! same mann] & f ! same s\rces z paym5ts
 are made to a ,m$ic>e ,advantage       
organization "u section #ahec4 ,su*     
paym5ts %all be subject to adju/m5t 9 ! 
mann] describ$ 9 section #ahec7;a77#b7  
or section #ahgf7;a77#a77;,e71 z ! case 
may be4  7,b7 ,capitation am\nt ,!      
capitation am\nt to be appli$ "u ?is    
p>agraph = a qualifi$ ,,bcp = ea*       
enrollee = a ye> %all be #a_/ab ( !     
b5*m>k rate "u subp>agraph 7,c77ii7 = ! 
ye> 7or ! relevant rate "u subp>agraph  
7,c77i7 = ! fir/ ye> ( ! program "u ?is 
section7 7ref]r$ to 9 ?is p>agraph z !  
p] memb] p] mon? paym5t71 z adju/$ "u   
clause 7iii74  7,c7 ,det]m9+ ! ,rate    

,us+ ,risk ,relevant ,control ,gr\p  7i7
 ,relevant ,rate  7,i7 ,id5tification ( 
b5efici>y gr\p+ ,us+ claims data1 !     
,secret>y %all id5tify a gr\p (         
b5efici>ies :o h simil> heal? risk      
*>act]i/ics1 & h s\ght c>e 9 ! same     
c\nty1 multi-c\nty1 or ,/ate level 7z   
det]m9$ appropriate by ! ,secret>y to   
e/abli% a paym5t area7 to ! population !
 qualifi$ ,,bcp is task$ ) s]v+4 ,to !  
ext5t feasible = a /ati/ically valid    
control gr\p1 ! heal? risk ( su* gr\p   
%all reflect social *>act]i/ics1 su* z  
income1 z well z m$ical risk4  7,,ii7   
,det]m9ation ( relevant rate ,! p]      
capita sp5d+ am\nts "u ?is title &1 z   
appropriate1 title ,,xix1 ( ! gr\p (    
b5efici>ies id5tifi$ "u subclause 7,i7  
%all det]m9e ! relevant rate t w s]ve z 
! basis ( ! b5*m>k = p>ticipat+ qualifi$
 ,b,c,ps4  7ii7 ,b5*m>k ,rate ,!        
,secret>y %all e/abli% ! b5*m>k rate = a
 qualifi$ ,,bcp s]vice area = ea* ye> ( 
! program by updat+ ! relevant rate     
det]m9$ "u clause 7i7 ) ! project$ *ange

 9 p] capita sp5d+ = ! gr\p (           
b5efici>ies id5tifi$ "u clause 7i77,i7 =
 ! paym5t area describ$ 9 su* clause1 z 
det]m9$ by ! ,*ief ,actu>y ( ! ,c5t]s = 
,m$ic>e  ,m$icaid ,s]vices4  7iii7      
,adju/m5t = heal? /atus  7,i7 ,comp>ison
 ( heal? /atus ,! ,secret>y %all e/abli%
 a risk score me*anism to comp>e ! heal?
 /atus ( an enrollee 9 a qualifi$ ,,bcp 
to ! av]age heal? risk ( gr\p (         
b5efici>ies id5tifi$ "u clause 7i77,i74 
7,,ii7 ,inclusion ( numb] ( conditions  
,! ,secret>y %all provide t a risk score
 "u ! me*anism "u ?is clause1 ) respect 
to an individual1 includes an indicator 
= ! numb] ( *ronic conditions ) :i* !   
individual has be5 diagnos$4  7,,iii7   
,use ( #b ye>s ( diagnosis data ,!      
,secret>y %all ensure t su* risk score1 
) respect to an individual reflects n   
less ?an #b ye>s ( diagnosis data1 to ! 
ext5t available4  7,,iv7 ,adju/m5t =    
heal? /atus ,! p] memb] p] mon? paym5t  
to ! qualifi$ ,,bcp = ea* enrollee %all 
be adju/$ dep5d+ on h[ ! individual risk

 pr(ile ( ! enrollee comp>es to ! av]age
 heal? /atus ( su* gr\p ( b5efici>ies4  
,if an enrollee has a risk pr(ile t is n
 z sev]e z ! av]age heal? /atus ( su*   
gr\p ( b5efici>ies1 !n ! p] memb] p]    
mon? %all be decreas$ to reflect !      
heal?i] /atus ( ! enrollee4 ,if an      
enrollee has a risk pr(ile t is m sev]e1
 !n ! p] memb] p] mon? paym5t to !      
qualifi$ ,,bcp %all be increas$ to      
reflect ! m acutely ill /atus ( !       
enrollee4  7,d7 ,%>$ risk paym5ts =     
c]ta9 qualifi$ ,b,c,ps dur+ fir/ #c ye>s
 ( ! program  7i7 ,9 g5]al ,?is         
subp>agraph %all only apply to qualifi$ 
,b,c,ps (f]$ by a gr\p ( provid]s (     
s]vices & suppli]s dur+ ! fir/ #c ye>s (
 ! program "u ?is section4  7ii7 ,%>+ ( 
risk to alleviate outli]s ,! ,secret>y  
%all det]m9e %>$ risk paym5ts &         
rec\pm5ts "u ?is subp>agraph = a        
qualifi$ ,,bcp describ$ 9 clause 7i7 z  
foll[s3 7,i7 ,det]m9ation ( ga9 or loss 
,! ,secret>y %all1 = ea* ( ! fir/ #c    
ye>s ( ! program "u ?is section1 det]m9e

 ! p]c5tage ( ga9 or loss = ! qualifi$  
,,bcp 9 provid+ b5efits to enrollees "u 
?is section4  7,,ii7 ,ga9 or loss great]
 ?an #e p]c5t ,if ! ,secret>y det]m9es !
 qualifi$ ,,bcp has a ga9 or loss = !   
ye> ( great] ?an #e p]c5t1 ! qualifi$   
,,bcp %all be> #ajj p]c5t ( ! risk or   
rew>d ( su* loss or ga94  7,,iii7 ,ga9  
or loss ( n less ?an #b & n great] ?an  
#e p]c5t ,if ! ,secret>y det]m9es !     
qualifi$ ,,bcp has a ga9 or loss = ! ye>
 ( n less ?an #b p]c5t b n great] ?an #e
 p]c5t-- 7aa7 ! qualifi$ ,,bcp %all be> 
#hj p]c5t ( ! risk or rew>d1 z          
applicable1 ( su* loss or ga92 &  7bb7 !
 ,secret>y %all be> #bj p]c5t ( ! risk  
or rew>d1 z applicable1 ( su* loss or   
ga94  7,,iv7 ,ga9 or loss betwe5 #j & #b
 p]c5t ,if ! ,secret>y det]m9es !       
qualifi$ ,,bcp has a ga9 or loss = ! ye>
 ( great] ?an #j p]c5t b less ?an #b    
p]c5t-- 7aa7 ! qualifi$ ,,bcp %all be>  
#ej p]c5t ( ! risk or rew>d1 z          
applicable1 ( su* loss or ga92 &  7bb7 !
 ,secret>y %all be> #ej p]c5t ( ! risk  

or rew>d1 z applicable1 ( su* loss or   
ga94  7iii7 ,provision ( in=mation ,a   
qualifi$ ,,bcp %all provide to !        
,secret>y su* in=mation z ! ,secret>y   
det]m9es is necess>y to c>ry out ?is    
subp>agraph4  7,e7 ,bid submission      
,beg9n+ ) ! f\r? ye> ( ! program1 a     
qualifi$ ,,bcp %all submit a bid =      
p>ticipation 9 ! program = ! ye> t      
reflects ! exp]i5ce ( ! qualifi$ ,,bcp--
 7i7 9 manag+ ! c>e ( ! enroll$         
population2 &  7ii7 9 manag+ su* c>e    
giv5 ! relevant rate det]m9$ "u         
subp>agraph 7,c74  7,f7 ,quality ,bonus 
sy/em  7i7 ,9 g5]al ,! ,secret>y %all   
e/abli% a quality bonus sy/em :]eby !   
,secret>y di/ributes bonus paym5ts to   
qualifi$ ,b,c,ps t meet ! requirem5ts   
describ$ 9 clause 7iii7 & o!r /&>ds     
specifi$ by ! ,secret>y1 :i* may include
 a focus on quality measurem5t &        
improvem5t1 deliv]+ pati5t-c5t]$ c>e1 & 
practic+ 9 integrat$ heal? sy/ems1      
includ+ tra9+ 9 community-bas$ sett+s4  
,9 develop+ su* /&>ds1 ! ,secret>y %all 

collaborate ) relevant /akehold]s1      
includ+ program accr$it+ bodies1 c]tify+
 bo>ds1 tra9+ programs1 heal? c>e       
organizations1 heal? c>e pur*as]s1 &    
pati5t & consum] gr\ps4  7ii7           
,det]m9ation ( quality bonuses ,quality 
bonuses to ! ,,bcp %all be bas$ on a    
comp>ison ( ! quality ( c>e provid$ by !
 qualifi$ ,,bcp to enrollees to !       
quality ( c>e provid$ to b5efici>ies n  
enroll$ 9 a qualifi$ ,,bcp or a ,m$ic>e 
,advantage plan "u "p ,c 9 ! same       
region4 ,= n less ?an ! fir/ #e ye>s ( !
 program "u ?is section1 quality        
measures = ! geographic region %all be  
bas$ on local /&>ds ( c>e1 & n on a     
national /&>d4 ,= subsequ5t ye>s1       
appropriate national /&>ds %all be      
consid]$ = inclusion 9 ! comp>ison ( !  
quality ( c>e "u ?is subp>agraph4  7iii7
 ,requirem5ts ,a qualifi$ ,,bcp is      
eligible = quality bonuses "u ?is       
subp>agraph if-- 7,i7 ! qualifi$ ,,bcp  
meets quality p]=mance /&>ds "u         
subsection 7h77#c72 &  7,,ii7 ! qualifi$

 ,,bcp meets ! requirem5ts "u subsection
 7e77#b74  7h7 ,quality & o!r report+   
requirem5ts  7#a7 ,9 g5]al ,! ,secret>y 
%all develop & implem5t1 ) assi/ance &  
input ( relevant exp]ts 9 ! field & !   
,national ,/rategy = ,quality           
,improvem5t 9 ,heal? ,c>e1 appropriate  
measures = ,,bcp eligible individuals4  
,! ,secret>y %all det]m9e appropriate   
measures "u ?is title & title ,,xix to  
assess ! quality ( c>e furni%$ by a     
qualifi$ ,,bcp1 z well z ^? measures t  
are no long] appropriate & %all be      
remov$ f use4 ,su* measures %all include
 measures-- 7,a7 ( cl9ical processes &  
outcomes2  7,b7 ( pati5t &1 :]e         
practicable1 c>egiv] exp]i5ce ( c>e1    
includ+ measurem5t t enhances pati5t    
activation & engagem5t2  7,c7 (         
utilization 7su* z rates ( hospital     
admissions = ambulatory c>e s5sitive    
conditions72  7,d7 ( c>e coord9ation1   
managem5t1 & transitions2 &  7,e7 t     
appropriately align ) ! ,national       
,/rategy = ,quality ,improvem5t 9 ,heal?

 ,c>e4  ,! ,secret>y may use exi/+      
measures "u ?is title1 title ,,xix1 or  
any o!r heal? c>e program1 z            
appropriate1 "u ?is p>agraph4  7#b7     
,report+ requirem5ts ,a qualifi$ ,,bcp  
%all submit data 9 a =m & mann] specifi$
 by ! ,secret>y :i* is n ov]ly burd5some
 to ! qualifi$ ,,bcp1 on measures !     
,secret>y det]m9es necess>y = ! qualifi$
 ,,bcp to report 9 ord] to evaluate !   
quality ( c>e furni%$ by ! qualifi$     
,,bcp4 ,su* data report+ %all emphasize 
pati5t-c5t]$ measurem5t & may include ! 
functional /atus ( pati5ts1 case        
managem5t & c>e transitions across heal?
 c>e sett+s1 includ+ hospital dis*>ge   
plann+ & po/-hospital dis*>ge foll[-up  
by qualifi$ ,,bcp pr(essionals1 z !     
,secret>y det]m9es appropriate4  7#c7   
,quality p]=mance /&>ds ,! ,secret>y    
%all e/abli% quality p]=mance /&>ds to  
assess ! quality ( c>e furni%$ by       
qualifi$ ,b,c,ps4 ,! ,secret>y %all seek
 to improve ! quality ( c>e furni%$ by  
qualifi$ ,b,c,ps ov] "t by specify+     

high] /&>ds1 new measures1 or bo? =     
purposes ( assess+ su* quality ( c>e4 ,!
 ,secret>y %all also include a process =
 retir+ measures t are no long]         
adequately contribut+ to improv+ /&>ds (
 c>e at ! greate/ possible value4  7#d7 
,o!r report+ requirem5ts & call =       
alignm5t ,! ,secret>y %all1 z !         
,secret>y det]m9es appropriate1         
incorporate & align report+ requirem5ts 
& inc5tive paym5ts relat$ to ! physician
 quality report+ sy/em "u section #ahdh1
 includ+ ^? relat$ to report+ on quality
 measures "u subsection 7m7 ( t section1
 report+ requirem5ts "u subsection 7o7 (
 t section relat+ to mean+ful use (     
electronic heal? records1 ! e/abli%m5t (
 a value-bas$ paym5t modifi] "u         
subsection 7p7 ( t section1 & o!r simil>
 initiatives "u t section1 & may use    
alt]native crit]ia ?an w\ld o!rwise     
apply "u section #ahdh = det]m9+ :e!r to
 make su* paym5ts to qualifi$ ,,bcp     
pr(essionals4 ,! inc5tive paym5ts       
describ$ 9 ! prec$+ s5t5ce %all n be    

tak5 into consid]ation :5 calculat+ any 
paym5ts o!rwise made "u subsection 7g74 
7i7 ,b5efici>y protections ,! ,secret>y 
%all ensure t1 to ! ext5t consi/5t ) ?is
 section1 a qualifi$ ,,bcp (f]s         
b5efici>y protections applicable to     
b5efici>ies "u ?is title &1 z           
applicable1 title ,,xix4  7j7 ,paym5t ( 
m$ic>e co/-,%>+ = dual eligible         
individuals ,9 ! case ( a dual eligible 
individual enroll$ 9 a qualifi$ ,,bcp1 !
 ,secret>y may provide = ! paym5t (     
m$ic>e co/-%>+ 7z def9$ 9 section       
#aije7p77#c77 t w\ld o!rwise be         
available "u ! ,/ate plan "u title ,,xix
 if ! individual 0 n enroll$ 9 !        
qualifi$ ,,bcp4  7k7 ,def9itions ,9 ?is 
section3 7#a7 ,alt]native paym5t model  
7,,apm7 ,! t]m alt]native paym5t model  
means any ( ! foll[+3 7,a7 ,a model "u  
section #aaae;,a 7o!r ?an a heal? c>e   
innovation aw>d74  7,b7 ,an acc\ntable  
c>e organization "u section #ahii4  7,c7
 ,a demon/ration "u section #ahff;,c4   
7,d7 ,a demon/ration requir$ by ,f$]al  

law4  7,e7 ,a qualifi$ ,,bcp4  7#b7     
,hospital ,! t]m hospital means a       
subsection 7d7 hospital 7z def9$ 9      
section #ahhf7;d77#a77;,b774  7#c7      
,qualifi$ ,,bcp pr(essional ,! t]m      
qualifi$ ,,bcp pr(essional means a      
c]tifi$ & lic5s$ pr(essional ( m$ical or
 behavioral heal? s]vices t is          
p>ticipat+ 9 a qualifi$ ,,bcp4  4  7b7  
,f$]al assumption ( m$icaid co/s = full 
b5efit dual eligible individuals enroll$
 9 a qualifi$ ,,bcp ,title ,,xix ( !    
,social ,security ,act is am5d$ by      
ins]t+ aft] section #aidc ! foll[+ new  
section3  #aidd4 ,f$]al assumption (    
m$icaid co/s = full b5efit eligible     
individuals enroll$ 9 a qualifi$ ,,bcp  
7a7 ,/ate contribution  7#a7 ,9 g5]al ,!
 ,/ate %all provide = paym5t to !       
,secret>y = ea* mon? 9 an am\nt det]m9$ 
"u p>agraph 7#b77;,a7 = ea* applicable  
dual eligible ,,bcp enrollee = su*      
,/ate4  7#b7 ,/ate contribution am\nt   
7,a7 ,9 g5]al ,subject to subp>agraph   
7,c71 ! am\nt det]m9$ "u ?is p>agraph = 

a ,/ate = a mon? 9 a ye> is equal to !  
product describ$ 9 subp>agraph 7,a7 (   
section #aice7;c77#a7 = ! ,/ate = !     
mon?1 except t ! ref]5ce 9 su*          
subp>agraph to ! total numb] (          
full-b5efit dual eligible individuals   
%all be deem$ a ref]5ce to ! total numb]
 ( applicable dual eligible ,,bcp       
enrollees4  7,b7 ,=m & mann] ( paym5t ,!
 provisions ( subp>agraphs 7,b7 ?r\gh   
7,d7 ( section #aice7;c77#a7 %all apply 
to paym5t by a ,/ate to ! ,secret>y "u  
?is p>agraph 9 ! same mann] z su*       
subp>agraphs apply to paym5t "u section 
#aice7;c77#a77;,a74  7,c7 ,application (
 diff]5t factors ,9 apply+ subp>agraph  
7,a71 ! foll[+ %all be sub/itut$ "u     
p>agraphs 7#b7 & 7#c7 ( section         
#aice7;c73 7i7 ,! base ye> ,/ate        
,m$icaid p] capita exp5ditures = cov]$  
"p ,d drugs describ$ 9 subp>agraph      
7,a77i77,i7 ( su* p>agraph 7#b7 %all be 
deem$ to be ! p] capita exp5ditures =   
heal? c>e items & s]vices t w\ld apply  
7includ+ any m$ic>e co/-%>+71 ) respect 

to an applicable dual eligible ,,bcp    
enrollee1 if su* an individual receiv$  
b5efits only "u title ,,xviii 7& n !    
,/ate plan "u ?is title74  7ii7 ,any    
ref]5ce to exp5ditures = cov]$ "p ,d    
drugs or = prescription drug b5efits    
%all be deem$ a ref]5ce to ! exp5ditures
 = heal? c>e items & s]vices describ$ 9 
clause 7i74  7iii7 ,any ref]5ce to #bjjc
 or #bjjd %all be deem$ a ref]5ce to    
#bjag or #bjah1 respectively4  7iv7 ,any
 ref]5ce to a full-b5efit-dual-eligible 
individual %all be deem$ a ref]5ce to an
 applicable dual eligible ,,bcp         
enrollee4  7v7 ,! applicable gr[? factor
 "u section #aice7;c77#d7 = a ye>1 )    
respect to a ,/ate1 %all be ! av]age    
annual p]c5tage *ange 7to t ye> f !     
previ\s ye>7 ( ! exp5ditures ( ! ,/ate  
"u ! ,/ate plan "u title ,,xix4  7vi7 ,!
 factor describ$ 9 section #aice7;c77#e7
 is deem$ to be #ij p]c5t4  7#c7        
,applicable dual eligible ,,bcp enrollee
 ,= purposes ( ?is section1 ! t]m       
applicable dual eligible ,,bcp enrollee 

means1 ) respect to a ,/ate1 an         
individual describ$ 9 subp>agraph       
7,a77ii7 ( section #aice7;c77#f7 7tak+  
into acc\nt ! application ( subp>agraph 
7,b7 ( su* section7 = su* ,/ate :o is   
enroll$ 9 a qualifi$ ,,bcp "u section   
#ahii;,b4 ,su* t]m includes1 9 ! case ( 
m$ical assi/ance = m$ic>e co/-%>+ "u a  
,/ate plan "u ?is title1 an individual  
:o is a qualifi$ m$ic>e b5efici>y 7z    
def9$ 9 section #aije7p77#a771 a        
qualifi$ disabl$ & work+ individual     
7describ$ 9 section #aije7s771 an       
individual describ$ 9 section           
#aijb7;a77#aj77;,e77iii71 or o!rwise    
entitl$ to su* m$ic>e co/-%>+ & :o is   
enroll$ 9 su* a qualifi$ ,,bcp4  7b7    
,coord9ation ( b5efits  7#a7 ,m$ic>e z  
prim>y payor ,9 ! case ( an applicable  
dual eligible ,,bcp enrollee1 not)/&+   
any o!r provision ( ?is title1 m$ical   
assi/ance is n available "u ?is title = 
heal? c>e items or s]vices 7or = any    
co/-%>+ respect+ su* heal? c>e items &  
s]vices71 & ! rules "u ?is title relat+ 

to ! provision ( m$ical assi/ance = su* 
heal? c>e items & s]vices %all n apply4 
,! provision ( b5efits ) respect to su* 
heal? c>e items & s]vices %all n be     
consid]$ z ! provision ( c>e or s]vices 
"u ! plan "u ?is title4 ,no paym5t may  
be made "u section #aijc7;a7 = heal? c>e
 items & s]vices = :i* m$ical assi/ance 
is n available pursuant to ?is p>agraph4
  7#b7 ,cov]age ( long-t]m c>e s]vices  
,9 ! case ( m$ical assi/ance "u ?is     
title ) respect to cov]age ( long-t]m   
c>e s]vices furni%$ to an applicable    
dual eligible ,,bcp enrollee1 ! ,/ate   
may elect to provide su* m$ical         
assi/ance 9 ! mann] o!rwise provid$ 9 ! 
case ( individuals :o are n full-b5efit 
dual eligible individuals or ?r\gh an   
arrangem5t ) su* qualifi$ ,,bcp4 ,9 no  
case %all a qualifi$ ,,bcp be requir$ to
 provide to enrollees cov]age ( long-t]m
 c>e s]vices4  4  7c7 ,/ate m>ket+      
mat]ials = dually eligible individuals  
7#a7 ,/ate plan requirem5t ,section     
#aijb7;a7 ( ! ,social ,security ,act    

7#db ,u4,s4,c4 #acif;a7a77 is am5d$--   
7,a7 9 p>agraph 7#hj71 by /rik+ & at !  
end2  7,b7 9 p>agraph 7#ha71 by /rik+ ! 
p]iod at ! end & ins]t+ 2 &2 &  7,c7 by 
ins]t+ aft] p>agraph 7#ha7 ! foll[+3    
7#hb7 provide t any m>ket+ mat]ials     
di/ribut$ by ! ,/ate t are direct$ at   
dual eligible individuals 7z def9$ 9    
section #aiae7;h77#b77;,b77 include     
in=mation on qualifi$ ,b,c,ps (f]$ "u   
section #ahii;,b4  4  7#b7 ,effective   
date ,! am5dm5ts made by ?is section    
%all apply to cal5d> qu>t]s beg9n+ on or
 aft] ,janu>y #a1 #bjag1 )\t reg>d to   
:e!r or n f9al regulations to c>ry out  
su* am5dm5ts h be5 promulgat$ by su*    
date4  7d7 ,prohibition on cov]age (    
co/-,%>+ = c]ta9 items & s]vices furni%$
 to an enrollee outside ( a qualifi$    
,,bcp "u ,m$igap policies ,section #ahhb
 ( ! ,social ,security ,act 7#db        
,u4,s4,c4 #aciess7 is am5d$ by add+ at !
 end ! foll[+ new subsection3  7z7      
,prohibition on cov]age ( co/-,%>+ =    
c]ta9 items & s]vices furni%$ to an     

enrollee outside ( a qualifi$ ,,bcp &   
developm5t ( new /&>ds = m$ic>e         
supplem5tal policies  7#a7 ,developm5t  
,! ,secret>y %all reque/ ! ,national    
,association ( ,insurance ,commission]s 
to review & revise ! /&>ds = b5efit     
packages "u subsection 7p77#a71 tak+    
into acc\nt ! *anges 9 b5efits result+ f
 ! enactm5t ( ! ,bett] ,c>e1 ,l[] ,co/  
,act & to o!rwise update /&>ds to       
include ! requirem5ts = co/-%>+ describ$
 9 p>agraph 7#b74 ,su* revisions %all be
 made consi/5t ) ! rules applicable "u  
subsection 7p77#a77;,e7 ) ! ref]5ce to !
 #aiia ,,naic ,model ,regulation deem$ a
 ref]5ce to ! ,,naic ,model ,regulation 
z publi%$ 9 ! ,f$]al ,regi/] on ,decemb]
 #d1 #aiih1 & z subsequ5tly updat$ by ! 
,national ,association ( ,insurance     
,commission]s to reflect previ\s *anges 
9 law & ! ref]5ce to date ( enactm5t (  
?is subsection deem$ a ref]5ce to ! date
 ( enactm5t ( ! ,bett] ,c>e1 ,l[] ,co/  
,act4 ,to ! ext5t practicable1 su*      
revision %all provide = ! implem5tation 

( revis$ /&>ds = b5efit packages z (    
,janu>y #a1 #bjag4  7#b7 ,co/-%>+       
requirem5ts ,! co/-%>+ requirem5ts      
describ$ 9 ?is p>agraph are t1 not)/&+  
any o!r provision ( law1 no m$ic>e      
supplem5tal policy may provide = cov]age
 ( co/-%>+ ) respect to items & s]vices 
7o!r ?an em]g5t s]vices1 z def9$ by !   
,secret>y7 furni%$ to an individual     
enroll$ 9 a qualifi$ ,,bcp "u section   
#ahii;,b by a provid] ( s]vices or      
suppli] t is n a qualifi$ ,,bcp         
pr(essional 7z def9$ 9 section          
#ahii;,b7k774  7#c7 ,r5ewability ,!     
r5ewability requirem5t "u subsection    
7q77#a7 %all be satisfi$ ) ! r5ewal ( ! 
revis$ package "u p>agraph 7#a7 t mo/   
closely mat*es ! policy 9 :i* !         
individual 0 enroll$ prior to su*       
revision4  4  #d4 ,*ronic special ne$s  
plans ,section #ahei ( ! ,social        
,security ,act 7#db ,u4,s4,c4           
#aciew-#bh7 is am5d$-- 7#a7 9 subsection
 7f77#d7-- 7,a7 by /rik+ ,9 ! case ( &  
ins]t+ ,subject to subsection 7h71 9 !  

case (2 &  7,b7 by add+ at ! end !      
foll[+ flu% text3 ,not)/&+ any o!r      
provision ( ?is section1 on or aft]     
,janu>y #a1 #bjad1 ! ,secret>y %all     
e/abli% proc$ures = ! transition ( ^?   
individuals to a ,m$ic>e ,advantage plan
 qualifi$ ,,bcp 9 accordance )          
subsection 7h74 2 &  7#b7 by add+ at !  
end ! foll[+ new subsection3  7h7       
,m$ic>e ,advantage plan qualifi$ ,b,c,ps
  7#a7 ,9 g5]al ,a ,m$ic>e ,advantage   
plan t is c]tifi$ z a qualifi$ ,,bcp    
7ref]r$ to 9 ?is subsection z a ,m$ic>e 
,advantage plan qualifi$ ,,bcp7-- 7,a7  
is deem$ to be a specializ$ ,,ma plan = 
special ne$s individuals describ$ 9     
subsection 7b77#f77;,b77iii72 &  7,b7   
may enroll su* special ne$s individuals4
  7#b7 ,specializ$ b5efit packages ,a   
,m$ic>e ,advantage plan qualifi$ ,,bcp  
%all h ! flexibility to (f] specializ$  
b5efit packages to enrollees describ$ 9 
subsection 7b77#f77;,b77iii71 consi/5t )
 ! value-bas$ insurance requirem5ts "u  
section #ahii;,b7f74  7#c7 ,application 

( ,,bcp requirem5ts ,a ,m$ic>e          
,advantage plan qualifi$ ,,bcp %all be  
subject to all requirem5ts applicable to
 a qualifi$ ,,bcp "u section #ahii;,b1  
includ+ enrollm5t p]iods "u subsection  
7c7 ( t section1 applicable crit]ia     
relat+ to network adequacy1 requirem5ts 
) respect to individual pati5t-c5t]$    
*ronic c>e plans "u subsection 7d77#b7 (
 t section1 applicable crit]ia ) respect
 to c>e managem5t processes1 & quality  
report+ "u subsection 7h7 ( t section4  
7#d7 ,application ( "p ,c requirem5ts ,!
 provisions ( ?is "p1 includ+ !         
provisions relat+ to specializ$ ,,ma    
plans = special ne$s individuals        
describ$ 9 subsection 7b77#f77;,b77iii71
 %all apply to a ,m$ic>e ,advantage plan
 qualifi$ ,,bcp to ! ext5t !y are       
consi/5t ) ! provisions ( section       
#ahii;,b4  4  #e4 ,improvem5ts to       
welcome to ,m$ic>e visit & annual       
wellness visits  7a7 ,welcome to ,m$ic>e
 visit ,section #ahfa7ww77#a7 ( !       
,social ,security ,act 7#db ,u4,s4,c4   

#aciex7ww77#a77 is am5d$ by add+ at !   
end ! foll[+ new s5t5ce3 ,9 ! case ( a  
,,bcp eligible individual 7z def9$ 9    
section #ahii;,b7b771 su* t]m includes a
 /&>diz$ functional & heal? risk        
assessm5t 7z describ$ 9 section         
#ahii;,b7d77#a77 furni%$ by a qualifi$  
,,bcp pr(essional 7z def9$ 9 section    
#ahii;,b7k7744  7b7 ,annual wellness    
visit ,section #ahfa7;hhh77#a7 ( !      
,social ,security ,act 7#db ,u4,s4,c4   
#aciex7h77#a77 is am5d$-- 7#a7 9        
subp>agraph 7,a71 by /rik+ & at ! end2  
7#b7 9 subp>agraph 7,b71 by /rik+ !     
p]iod at ! end & ins]t+ 2 &2 &  7#c7 by 
add+ at ! end ! foll[+ new subp>agraph3 
7,c7 9 ! case ( a ,,bcp eligible        
individual 7z def9$ 9 section           
#ahii;,b7b771 t includes a /&>diz$      
functional & heal? risk assessm5t 7z    
describ$ 9 section #ahii;,b7d77#a77     
furni%$ by a qualifi$ ,,bcp pr(essional 
7z def9$ 9 section #ahii;,b7k774  4  7c7
 ,effective date ,! am5dm5ts made by ?is
 section %all apply to s]vices furni%$  

on or aft] ! date t is "o ye> aft] !    
date ( enactm5t ( ?is ,act4  #f4 ,*ronic
 c>e innovation c5t]s  7a7 ,designation 
,n lat] ?an ,octob] #a1 #bjaf1 !        
,secret>y1 act+ ?r\gh ! ,ag5cy =        
,heal?c>e ,rese>* & ,quality1 %all      
designate & provide core fund+ = n less 
?an ?ree ,*ronic ,c>e ,innovation       
,c5t]s4 ,! ,secret>y %all develop a     
process = entities seek+ to become a    
,*ronic ,c>e ,innovation ,c5t]1 & %all  
ensure suffici5t geographic             
repres5tation among ^? entities select$4
 ,! ma9 objectives ( su* ,c5t]s %all    
include ! foll[+3 7#a7 ,improv+ !       
und]/&+ ( h[ to measure1 monitor1 &     
und]/& quality & effici5cy = a pati5t   
population ) sub/antial disease burd54  
7#b7 ,rigor\sly exam9+ alt]native &     
innovative sy/ems & /rategies =         
effici5tly improv+ quality & outcomes = 
common1 s]i\s1 & *ronic illnesses4  7#c7
 ,develop+ & apply+ improv$ me?odologies
 = in=m+ policymak]s reg>d+ het]og5eity 
9 ! effectiv5ess & safety ( propos$     

int]v5tions1 & assess+ b>ri]s to !      
implem5tation ( high-priority c>e4  7#d7
 ,/udy+ organization & managem5t        
practices t result 9 high] quality (    
c>e4  7#e7 ,def9+ & improv+ quality (   
c>e = pati5ts ) ! *ronic diseases       
preval5t 9 prim>y c>e sett+s4  7#f7     
,und]/&+ ! influ5ce ( race1 e?nicity1 & 
cultural factors on access1 quality1 &  
outcomes 7su* z cl9ical1 pati5t-c5t]$1  
heal? c>e utilization1 & co/s74  7#g7   
,evaluat+ new te*nology to enhance      
access to1 & quality ( c>e 7su* z       
telem$ic9e74  7#h7 ,assess+ ! use (     
pati5t self-managem5t & behavioral      
int]v5tions z a means ( improv+ outcomes
 = ,m$ic>e b5efici>ies ) complex *ronic 
conditions4  7#i7 ,und]/&+ h[ managem5t 
( c>e is affect$ :5 pati5ts h multiple  
*ronic conditions 9 :i* evid5ce or      
recomm5d$ guidel9es are lack+1 conflict 
)1 or complicate ov]all c>e managem5t4  
7#aj7 ,*>act]iz+ coord9ation ( c>e )9 & 
across heal?c>e sy/ems1 includ+ !       
,dep>tm5t ( ,vet]ans ,affairs1 ! ,m$ic>e

 program "u title ,,xviii ( ! ,social   
,security ,act 7#db ,u4,s4,c4 #acie et  
seq471 ! ,m$icaid program "u title ,,xix
 ( su* ,act1 & private sector programs =
 vet]ans ) complex *ronic conditions4   
7b7 ,requirem5ts ,9 ord] to be designat$
 a ,*ronic ,c>e ,innovation ,c5t] "u ?is
 section1 ea* eligible entity mu/ meet !
 foll[+ requirem5ts3 7#a7 ,develop &    
implem5t a su/a9$ rese>* ag5da 9 ! field
 ( *ronic c>e4  7#b7 ,collaborate )     
local s*ools ( public heal? &           
univ]sities to c>ry out its mission4    
7#c7 ,actively engage 9 ! developm5t (  
new1 be/ practices = ! deliv]y ( c>e to 
! *ronically ill4  7#d7 ,actively engage
 9 ! developm5t & r\t9e updat+ ( quality
 measures = ! *ronically ill4  7#e7 ,h !
 ability to conv5e exp]ts practic$ 9 !  
ne$s ( a *ronically ill pati5t1 includ+ 
ph>macologi/s1 psy*iatri/s1 c>diologi/s1
 pulmonologi/s1 rheumatologi/s1         
nutritioni/s & dieticians1 social       
work]s1 & physical !rapi/s4  7#f7 ,p>tn]
 ) ! ,secret>y ( ,heal? & ,human        

,s]vices & ! ,secret>y ( ,vet]ans       
,affairs 7includ+ ! ,c5t] = ,heal?      
,s]vices ,rese>* 9 ,prim>y ,c>e ( !     
,dep>tm5t ( ,vet]ans ,affairs ,heal?    
,s]vices ,rese>* & ,developm5t ,s]vice71
 ! m$ical community1 m$ical s*ools1 &   
public heal? dep>tm5ts ?r\gh ! ,ag5cy = 
,heal?c>e ,rese>* & ,quality1 ! ,heal?  
,res\rces & ,s]vices ,adm9i/ration1 & ! 
,association ( ,am]ican ,m$ical         
,colleges to r\t9ely develop new1 =w>d  
?9k+1 & evid5ce-bas$ curricula t        
addresses ! trem5d\s ne$ = team-bas$ c>e
 & *ronic c>e managem5t4 ,su* curricula 
%all include palliative m$ic9e1 *ronic  
c>e managem5t1 lead]%ip & team-bas$     
skills & plann+1 & lev]ag+ te*nology z a
 c>e tool4  7c7 ,ov]sight & evaluation  
7#a7 ,9 g5]al ,! ,ag5cy = ,heal?c>e     
,rese>* & ,quality %all be responsible =
 ov]sight & evaluation ( all ,*ronic    
,c>e ,innovation ,c5t]s "u ?is section4 
7#b7 ,reports ,n less frequ5tly ?an e #c
 ye>s1 ! ,ag5cy = ,heal?c>e ,rese>* &   
,quality %all submit to ! ,secret>y (   

,heal? & ,human ,s]vices & to ,congress 
a report conta9+ ! f9d+s ( ov]sight &   
evaluations conduct$ "u p>agraph 7#a74  
7d7 ,contract au?ority ,9 ord] to c>ry  
out ?is section1 ! ,secret>y may        
contract ) exi/+ ,c5t]s ( ,innovation   
7,c,o,i,ns7 ( ! ,dep>tm5t ( ,vet]ans    
,affairs ,heal? ,s]vices ,rese>* &      
,developm5t ,s]vice t meet ! requirem5ts
 describ$ 9 subsection 7c74  7e7        
,au?orization ,!re are au?oriz$ to be   
appropriat$ su* sums z are necess>y to  
c>ry out ?is section4  #g4 ,curricula   
requirem5ts = direct & indirect graduate
 m$ical education paym5ts  7a7 ,direct  
graduate m$ical education paym5ts       
,section #ahhf7;h7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #acieww7h77 is     
am5d$ by add+ at ! end ! foll[+ new     
p>agraph3  7#i7 ,new curricula          
requirem5ts  7,a7 ,developm5t ,!        
,secret>y %all engage ) ! m$ical        
community & m$ical s*ools 9 develop+    
curricula t meets ! foll[+ requirem5ts3 
7i7 ,! curricula is new1 =w>d ?9k+1 &   

evid5ce-bas$4  7ii7 ,! curricula        
addresses ! ne$ = team-bas$ c>e & *ronic
 c>e managem5t4  7iii7 ,! curricula     
includes palliative m$ic9e1 *ronic c>e  
managem5t1 lead]%ip & team-bas$ skills &
 plann+1 & lev]ag+ te*nology z a c>e    
tool4  7,b7 ,rural areas ,! curricula   
develop$ "u subp>agraph 7,a7 %all       
include appropriate focus on c>e        
practices requir$ = rural & und]s]v$    
areas4  7,c7 ,limitation ,not)/&+ !     
prec$+ provisions ( ?is subsection1 =   
co/ report+ p]iods beg9n+ on or aft] !  
date t is #e ye>s aft] ! date ( enactm5t
 ( ! ,bett] ,c>e1 ,l[] ,co/ ,act1 if a  
hospital has n begun to implem5t        
curricula t meets ! requirem5ts describ$
 9 subp>agraph 7,a71 paym5ts o!rwise    
made to a hospital "u ?is subsection may
 be r$uc$ by a p]c5tage det]m9$         
appropriate by ! ,secret>y4 ,= purposes 
( ! prec$+ s5t5ce1 successful developm5t
 & implem5tation ( su* curricula %all be
 det]m9$ by program accr$it+ bodies4  4 
7b7 ,indirect graduate m$ical education 

paym5ts ,section #ahhf7;d77#e77;,b7 ( ! 
,social ,security ,act 7#db ,u4,s4,c4   
#acieww7d77#e77;,b77 is am5d$-- 7#a7 by 
r$esignat+ clause 7x71 z add$ by section
 #eeje7;b7 ( ! ,pati5t ,protection &    
,af=dable ,c>e ,act 7,public ,law       
#aaa-adh71 z clause 7xi7 & mov+ su*     
clause #f ems to ! left2 &  7#b7 by add+
 at ! end ! foll[+ new clause3  7xii7   
,not)/&+ ! prec$+ provisions ( ?is      
subp>agraph1 effective = dis*>ges       
occurr+ on or aft] ! date t is #e ye>s  
aft] ! date ( enactm5t ( ! ,bett] ,c>e1 
,l[] ,co/ ,act1 if a hospital has n     
begun to implem5t curricula t meets !   
requirem5ts describ$ 9 subsection       
7h77#i77;,a71 z det]m9$ 9 accordance )  
subsection 7h77#i77;,c71 paym5ts o!rwise
 made to a hospital "u ?is subp>agraph  
may be r$uc$ by a p]c5tage det]m9$      
appropriate by ! ,secret>y4  4