,,ib ,union ,cal5d> ,no4 #aag #aad? ,,congress #a/ ,session ,h4 ,r4 #beha ,report ,no4 #aad-afa1 ,"p ,i ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,may #bi1 #bjae ,mr4 ,brady ( ,texas introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,ways & ,means1 & 9 addition to ! ,committee on ,en]gy & ,comm]ce1 = a p]iod to be subsequ5tly det]m9$ by ! ,speak]1 9 ea* case = consid]ation ( su* provisions z fall )9 ! jurisdiction ( ! committee conc]n$ ,june #af1 #bjae ,report$ f ! ,committee on ,ways & ,means ) an am5dm5t ,/rike out all aft] ! enact+ clause & ins]t ! "p pr9t$ 9 italic ,june #af1 #bjae ,! ,committee on ,en]gy & ,comm]ce dis*>g$2 committ$ to ! ,committee ( ! ,:ole ,h\se on ! ,/ate ( ! ,union & ord]$ to be pr9t$ ,= text ( introduc$ bill1 see copy ( bill z introduc$ on ,may #bi1 #bjae ,a ,,bill ,to am5d title ,,xviii ( ! ,social ,security ,act to e/abli% a #c-ye> demon/ration program to te/ ! use ( value-bas$ insurance design me?odologies "u eligible ,m$ic>e ,advantage plans1 to pres]ve ,m$ic>e b5efici>y *oice "u ,m$ic>e ,advantage1 to revise ! treatm5t "u ! ,m$ic>e program ( infusion drugs furni%$ ?r\gh durable m$ical equipm5t1 & = o!r purposes4 #a4 ,%ort title ,?is ,act may be cit$ z ! ,pres]vation ( ,access = ,s5iors 9 ,m$ic>e ,advantage ,act ( #bjae4 #b4 ,demon/ration program 7a7 ,9 g5]al ,! ,secret>y ( ,heal? & ,human ,s]vices 79 ?is section ref]r$ to z ! ,secret>y7 %all e/abli% a #c-ye> demon/ration program to te/ ! use ( value-bas$ insurance design me?odologies 7z def9$ 9 subsection 7c77#a77 "u eligible ,m$ic>e ,advantage plans (f]$ by ,m$ic>e ,advantage organizations "u "p ,c ( title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba et seq474 ,! ,secret>y may ext5d ! program to a duration ( #d or #e ye>s1 z det]m9$ necess>y by ! ,secret>y 9 coord9ation ) ! ,c5t]s = ,m$ic>e & ,m$icaid ,innovation4 7b7 ,demon/ration program design 7#a7 ,selection ( ,m$ic>e ,advantage sites & eligible ,m$ic>e ,advantage plans ,n lat] ?an two ye>s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y %all-- 7,a7 select at lea/ two ,m$ic>e ,advantage sites ) respect to :i* to conduct ! demon/ration program "u ?is section2 & 7,b7 approve eligible ,m$ic>e ,advantage plans to p>ticipate 9 su* demon/ration program4 ,9 select+ ,m$ic>e ,advantage sites "u subp>agraph 7,a71 ! ,secret>y %all take into acc\nt area diff]5ces z well z ! availability ( heal? ma9t5ance organization plans & pref]r$ provid] organization plans (f]$ 9 su* sites4 7#b7 ,/>t ( demon/ration ,! demon/ration program %all beg9 n lat] ?an ! ?ird plan ye> beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 7#c7 ,eligible ,m$ic>e ,advantage plans ,= purposes ( ?is section1 ! t]m eligible ,m$ic>e ,advantage plan means a ,m$ic>e ,advantage plan "u "p ,c ( title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba et seq47 t meets ! foll[+ requirem5ts3 7,a7 ,! plan is an ,m$ic>e ,advantage regional plan 7z def9$ 9 p>agraph 7#d7 ( section #ahei7;b7 ( su* ,act 7#db ,u4,s4,c4 #aciew-#bh7;b777 or ,m$ic>e ,advantage local plan 7z def9$ 9 p>agraph 7#e7 ( su* section7 (f]$ 9 ! ,m$ic>e ,advantage region select$ "u p>agraph 7#a77;,a74 7,b7 ,! plan has-- 7i7 7,i7 a quality rat+ "u section #ahec7o7 ( su* ,act 7#db ,u4,s4,c4 #aciew-#bc7o77 ( #d />s or high] bas$ on ! mo/ rec5t data available = su* ye>1 or 7,,ii7 9 ! case ( a specializ$ ,m$ic>e ,advantage plan = special ne$s individuals1 z def9$ 9 section #ahei7;b77#f77;,a7 ( su* ,act 7#db ,u4,s4,c4 #aciew-#bh7;b77#f77;,a771 a quality rat+ "u section #ahec7o7 ( su* ,act 7#db ,u4,s4,c4 #aciew-#bc7o77 equal to or high] ?an ! national av]age = special ne$s plans 7exclud+ ,in/itutional-,special ne$s plans7 bas$ on ! mo/ rec5t data available = su* ye>2 & 7ii7 at lea/ #bj p]c5t ( ! population to :om ! plan is (f]$ 9 a s]vice area consi/s ( subsidy eligible individuals 7z def9$ 9 section #ahfj;,d-#ad7;a77#c77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aad7;a77#c77;,a7774 7#d7 ,disclosure to b5efici>ies ,! ,secret>y %all provide to ea* individual eligible to enroll "u a ,m$ic>e ,advantage plan approv$ to p>ticipate "u ! demon/ration program dur+ a plan ye> = :i* ! plan is s select$-- 7,a7 notification t ! plan is p>ticipat+ 9 su* demon/ration program2 7,b7 backgr\nd in=mation on ! demon/ration program2 7,c7 cl9ical data d]iv$ f ! /udies result+ f ! demon/ration program2 & 7,d7 notification ( ! pot5tial b5efits t ! individual w receive1 & ( ! o!r pot5tial impacts t ! individual w exp]i5ce1 on acc\nt ( ! p>ticipation ( ! plan 9 ! demon/ration program4 7c7 ,value-,bas$ insurance design me?odologies 7#a7 ,def9ition ,= purposes ( ?is section1 ! t]m value-bas$ insurance design me?odology means a me?odology = id5tify+ specific prescription m$ications1 & cl9ical s]vices t are payable "u title ,,xviii ( ! ,social ,security ,act1 = :i* ! r$uction ( copaym5ts1 co9surance1 or bo?1 w\ld improve ! managem5t ( specific *ronic cl9ical conditions because ( ! high value & effectiv5ess ( su* m$ications & s]vices = su* specific *ronic cl9ical conditions1 z approv$ by ! ,secret>y4 7#b7 ,use ( me?odologies to r$uce copaym5ts & co9surance ,a ,m$ic>e ,advantage organization (f]+ an eligible ,m$ic>e ,advantage plan approv$ to p>ticipate "u ! demon/ration program1 = ea* plan ye> = :i* ! plan is s select$ & us+ value-bas$ insurance design me?odologies-- 7,a7 %all id5tify ea* prescription m$ication & cl9ical s]vice cov]$ "u su* plan = :i* ! plan proposes to r$uce or elim9ate ! copaym5t or co9surance1 ) respect to ! managem5t ( specific *ronic cl9ical conditions 7z specifi$ by ! ,secret>y7 ( ,m$ic>e ,advantage eligible individuals 7z def9$ 9 section #ahea7;a77#c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba7;a77#c777 enroll$ "u su* plans1 = su* plan ye>2 7,b7 may1 = su* plan ye>1 r$uce or elim9ate copaym5ts1 co9surance1 or bo? = su* prescription m$ication & cl9ical s]vices s id5tifi$ ) respect to ! managem5t ( su* conditions ( su* individuals-- 7i7 if su* r$uction or elim9ation is evid5ce-bas$ & = ! purpose ( enc\rag+ su* individuals 9 su* plan to use su* prescription m$ications & cl9ical s]vices 7su* z prev5tive c>e1 prim>y c>e1 specialty visits1 diagno/ic te/s1 proc$ures1 & durable m$ical equipm5t7 ) respect to su* conditions2 & 7ii7 = ! purpose ( enc\rag+ su* individuals 9 su* plan to use heal? c>e provid]s t su* organization has id5tifi$ ) respect to su* plan ye> z be+ high value provid]s2 & 7,c7 if a r$uction or elim9ation is appli$ pursuant to subp>agraph 7,b71 ) respect to su* m$ication & cl9ical s]vices1 %all1 = su* plan ye>1 c\nt t[>d ! d$uctible applicable to su* individual "u su* plan am\nts t w\ld h be5 payable by ! individual z copaym5t or co9surance = su* m$ication & s]vices if ! r$uction or elim9ation _h n be5 appli$4 7#c7 ,prohibition ( increases ( copaym5ts & co9surance ,9 no case may any ,m$ic>e ,advantage plan p>ticipat+ 9 ! demon/ration program increase1 = any plan ye> = :i* ! plan is s p>ticipat+1 ! am\nt ( copaym5ts or co9surance = any item or s]vice cov]$ "u su* plan = purposes ( disc\rag+ ! use ( su* item or s]vice4 7d7 ,report on implem5tation 7#a7 ,9 g5]al ,n lat] ?an #a ye> aft] ! date on :i* ! demon/ration program "u ?is section beg9s "u subsection 7b77#b71 ! ,secret>y %all submit to ,congress a report on ! /atus ( ! implem5tation ( ! demon/ration program4 7#b7 ,elem5ts ,! report requir$ by p>agraph 7#a7 %all1 ) respect to eligible ,m$ic>e ,advantage plans p>ticipat+ 9 ! demon/ration program = ! fir/ plan ye> ( su* program1 include ! foll[+3 7,a7 ,a li/ ( ea* m$ication & s]vice id5tifi$ pursuant to subsection 7c77#b77;,a7 = su* plan ) respect to su* plan ye>4 7,b7 ,= ea* su* m$ication or s]vice s id5tifi$1 ! am\nt ( ! copaym5t or co9surance requir$ "u su* plan ) respect to su* plan ye> = su* m$ication or s]vice & ! am\nt ( ! r$uction ( su* copaym5t or co9surance f a previ\s plan ye>4 7,c7 ,= ea* provid] id5tifi$ pursuant to subsection 7c77#b77;,b77ii7 = su* plan ) respect to su* plan ye>1 a /atem5t ( ! am\nt ( ! copaym5t or co9surance requir$ "u su* plan ) respect to su* plan ye> & ! am\nt ( ! r$uction ( su* copaym5t or co9surance f ! previ\s plan ye>4 7e7 ,review & assessm5t ( utilization ( value-,bas$ insurance design me?odologies 7#a7 ,9 g5]al ,! ,secret>y %all ent] into a contract or agreem5t ) an indep5d5t entity to review & assess ! implem5tation ( ! demon/ration program "u ?is section4 ,! review & assessm5t %all include ! foll[+3 7,a7 ,an assessm5t ( ! utilization ( value-bas$ insurance design me?odologies by ,m$ic>e ,advantage plans p>ticipat+ "u su* program4 7,b7 ,an analysis ( :e!r r$uc+ or elim9at+ ! copaym5t or co9surance = ea* m$ication & cl9ical s]vice id5tifi$ pursuant to subsection 7c77#b77;,a7 result$ 9 increas$ adh]5ce to m$ication regim5s1 increas$ s]vice utilization1 improvem5t 9 quality metrics1 bett] heal? outcomes1 & enhanc$ b5efici>y exp]i5ce4 7,c7 ,an analysis ( ! ext5t to :i* co/s to ,m$ic>e ,advantage plans "u "p ,c ( title ,,xviii ( ! ,social ,security ,act p>ticipat+ 9 ! demon/ration program is less ?an co/s to ,m$ic>e ,advantage plans "u su* "p t are n p>ticipat+ 9 ! demon/ration program4 7,d7 ,an analysis ( :e!r r$uc+ or elim9at+ ! copaym5t or co9surance = provid]s id5tifi$ pursuant to subsection 7c77#b77;,b77ii7 result$ 9 improvem5t 9 quality metrics1 bett] heal? outcomes1 & enhanc$ b5efici>y exp]i5ce4 7,e7 ,an analysis1 = ea* provid] s id5tifi$1 ! ext5t to :i* co/s to ,m$ic>e ,advantage plans "u "p ,c ( title ,,xviii ( ! ,social ,security ,act p>ticipat+ 9 ! demon/ration program is less ?an co/s to ,m$ic>e ,advantage plans "u su* "p t are n p>ticipat+ 9 ! demon/ration program4 7,f7 ,su* o!r matt]s z ! ,secret>y consid]s appropriate4 7#b7 ,report ,! contract or agreem5t ent]$ into "u p>agraph 7#a7 %all require su* entity to submit to ! ,secret>y a report on ! review & assessm5t conduct$ by ! entity "u su* p>agraph 9 "t = ! inclusion ( ! results ( su* report 9 ! report requir$ by p>agraph 7#c74 ,su* report %all include a description1 9 cle> language1 ( ! mann] 9 :i* ! entity conduct$ ! review & assessm5t4 7#c7 ,report to ,congress ,n lat] ?an #d ye>s aft] ! date on :i* ! demon/ration program beg9s "u subsection 7b77#b71 ! ,secret>y %all submit to ,congress a report on ! review & assessm5t ( ! demon/ration program conduct$ "u ?is subsection4 ,! report %all include ! foll[+3 7,a7 ,a description ( ! results ( ! review & assessm5t includ$ 9 ! report submitt$ pursuant to p>agraph 7#b74 7,b7 ,su* recomm5dations z ! ,secret>y consid]s appropriate = enhanc+ ! utilization ( ! me?odologies appli$ "u ! demon/ration program to all ,m$ic>e ,advantage plans "u "p ,c ( title ,,xviii ( ! ,social ,security ,act s z to r$uce copaym5ts & co9surance "u su* plans paid by ,m$ic>e b5efici>ies = high-value prescription m$ications & cl9ical s]vices = :i* cov]age is provid$ "u su* plans & to o!rwise improve ! quality ( heal? c>e provid$ "u su* plans4 7#d7 ,ov]sight report ,n lat] ?an ?ree ye>s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ,congress a report on ! demon/ration program t includes an assessm5t1 ) respect to individuals enroll$ "u ,m$ic>e ,advantage plans approv$ to p>ticipate "u ! demon/ration program1 ( ! impact t ! age1 co-morbidities1 & geographic regions ( su* individuals _h ^u ! implem5tation ( ! demon/ration program by ! plans ) respect to su* individuals4 7f7 ,sav+s ,9 no case may any r$uction 9 b5efici>y copaym5ts or co9surance result+ f ! implem5tation ( ! demon/ration program "u ?is section result 9 exp5ditures "u p>ts ,a1 ,b1 & ,d ( ! title ,,xviii ( ! ,social ,security ,act t are great] ?an su* exp5ditures )\t application ( ?is section4 7g7 ,expansion ( demon/ration program ,tak+ into acc\nt ! review & assessm5t conduct$ "u subsection 7e71 ! ,secret>y may1 ?r\gh notice & comm5t rulemak+1 exp& 7includ+ implem5tation on a nationwide basis7 ! duration & scope ( ! demon/ration program "u title ,,xviii ( ! ,social ,security ,act1 o!r ?an "u ! orig9al m$ic>e fee-=-s]vice program "u p>ts ,a & ,b ( su* title1 to ! ext5t det]m9$ appropriate by ! ,secret>y1 if ! requirem5ts ( p>agraphs 7#a71 7#b7 & 7#c7 ( subsection 7c7 ( section #aaae;,a ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acae;a71 z appli$ to ! te/+ ( a model "u subsection 7b7 ( su* section1 appli$ to ! demon/ration "u ?is section4 7h7 ,waiv] au?ority ,! ,secret>y may waive su* provisions ( titles ,,xi & ,,xviii ( ! ,social ,security ,act z may be necess>y to c>ry out ! demon/ration program "u ?is section4 7i7 ,implem5tation fund+ ,= purposes ( c>ry+ out ! demon/ration program "u ?is section1 ! ,secret>y %all provide = ! transf] f ! ,f$]al ,hospital ,insurance ,tru/ ,fund "u section #ahag ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;i7 & ! ,f$]al ,supplem5t>y ,insurance ,tru/ ,fund "u section #ahda ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciet71 includ+ ! ,m$ic>e ,prescription ,drug ,acc\nt 9 su* ,tru/ ,fund1 9 su* proportion z det]m9$ appropriate by ! ,secret>y1 ( su* sums z may be necess>y4 #c4 ,pres]vation ( ,m$ic>e b5efici>y *oice "u ,m$ic>e ,advantage ,section #ahea7;e77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba7;e77#b77 is am5d$-- 7#a7 9 subp>agraph 7,c7-- 7,a7 9 ! head+1 by ins]t+ f #bjaa ?r\gh #bjae aft] #de-;day p]iod2 & 7,b7 by ins]t+ & end+ ) #bjae aft] beg9n+ ) #bjaa2 & 7#b7 by add+ at ! end ! foll[+ new subp>agraph3 7,g7 ,cont9u\s op5 enrollm5t & dis5rollm5t = fir/ #c mon?s 9 #bjaf & subsequ5t ye>s 7i7 ,9 g5]al ,subject to clause 7ii7 & subp>agraph 7,d7-- 7,i7 9 ! case ( an ,,ma eligible individual :o is enroll$ 9 an ,,ma plan1 at any "t dur+ ! fir/ #c mon?s ( a ye> 7beg9n+ ) #bjaf72 or 7,,ii7 9 ! case ( an individual :o fir/ becomes an ,,ma eligible individual dur+ a ye> 7beg9n+ ) #bjaf7 & enrolls 9 an ,,ma plan1 dur+ ! fir/ #c mon?s dur+ su* ye> 9 :i* ! individual is an ,,ma eligible individual2 su* ,,ma eligible individual may *ange ! election "u subsection 7a77#a74 7ii7 ,limitation ( "o *ange dur+ op5 enrollm5t p]iod ea* ye> ,an individual may *ange ! election pursuant to clause 7i7 only once dur+ ! applicable #c-mon? p]iod describ$ 9 su* clause 9 ea* ye>4 ,! limitation "u ?is clause %all n apply to *anges 9 elections effect$ dur+ an annual1 coord9at$ election p]iod "u p>agraph 7#c7 or dur+ a special enrollm5t p]iod "u p>agraph 7#d74 7iii7 ,limit$ application to "p ,d ,clauses 7i7 & 7ii7 ( ?is subp>agraph %all only apply ) respect to *anges 9 enrollm5t 9 a prescription drug plan "u "p ,d 9 ! case ( an individual :o1 previ\s to su* *ange 9 enrollm5t1 is enroll$ 9 a ,m$ic>e ,advantage plan4 7iv7 ,limitations on m>ket+ ,pursuant to subsection 7j71 no unsolicit$ m>ket+ or m>ket+ mat]ials may be s5t to an individual describ$ 9 clause 7i7 dur+ ! cont9u\s op5 enrollm5t & dis5rollm5t p]iod e/abli%$ = ! individual "u su* clause1 not)/&+ m>ket+ guidel9es e/abli%$ by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices4 4 #d4 ,treatm5t ( infusion drugs furni%$ ?r\gh durable m$ical equipm5t ,section #ahdb7o77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieu7o77#a77 is am5d$-- 7#a7 9 subp>agraph 7,c71 by ins]t+ 7& includ+ a drug or biological describ$ 9 subp>agraph 7,d77i7 furni%$ on or aft] ,janu>y #a1 #bjag7 aft] #bjje2 & 7#b7 9 subp>agraph 7,d7-- 7,a7 by /rik+ infusion drugs & ins]t+ infusion drugs or biologicals ea* place x appe>s2 & 7,b7 9 clause 7i7-- 7i7 by /rik+ #bjjd & ins]t+ #bjjd1 & be=e ,janu>y #a1 #bjag2 & 7ii7 by /rik+ = su* drug4 #e4 ,s5se ( ,congress reg>d+ ! implem5tation & di/ribution ( quality inc5tive paym5ts to ,m$ic>e ,advantage plans ,x is ! s5se ( ,congress t-- 7#a7 ! ,secret>y ( ,heal? & ,human ,s]vices has incorrectly int]pret$ subsection 7n7 ( section #ahec ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7 z prohibit+ ! provision ( any ,m$ic>e quality inc5tive paym5ts "u subsection 7o7 ( su* section ) respect to ,m$ic>e ,advantage plans t exce$ ! paym5t b5*m>k cap "u su* subsection 7n7 = ! area s]v$ by su* plans2 & 7#b7 ! ,secret>y %\ld imm$iately apply quality inc5tive paym5ts "u su* subsection 7o7 ) respect to su* ,m$ic>e ,advantage plans )\t reg>d to ! limits set =? 9 su* subsection 7n74 ,june #af1 #bjae ,report$ f ! ,committee on ,ways & ,means ) an am5dm5t ,june #af1 #bjae ,! ,committee on ,en]gy & ,comm]ce dis*>g$2 committ$ to ! ,committee ( ! ,:ole ,h\se on ! ,/ate ( ! ,union & ord]$ to be pr9t$