,,ii  #aad? ,,congress  #a/ ,session    
,s4 #acif  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,may #bj1 #bjae ,mr4   
,?une 7= himself & ,ms4 ,/ab5[7         
introduc$ ! foll[+ bill2 :i* 0 read     
twice & ref]r$ to ! ,committee on       
,f9ance  ,a ,,bill  ,to e/abli% a       
demon/ration program requir+ !          
utilization ( ,value-,bas$ ,insurance   
,design 9 ord] to demon/rate t r$uc+ !  
copaym5ts or co9surance *>g$ to ,m$ic>e 
b5efici>ies = select$ high-value        
prescription m$ications & cl9ical       
s]vices c increase _! utilization &     
ultimately improve cl9ical outcomes1    
enhance b5efici>y satisfaction1 & l[]   
heal? c>e exp5ditures4  #a4 ,%ort title 
,?is ,act may be cit$ z ! ,value-,bas$  
,insurance ,design ,s5iors ,copaym5t    
,r$uction ,act ( #bjae4  #b4 ,f9d+s     
,congress makes ! foll[+ f9d+s3 7#a7 ,a 
gr[+ body ( evid5ce demon/rates t       
increases 9 pati5t-level f9ancial b>ri]s
 7includ+ d$uctibles1 copaym5ts1 &      
co9surance7 = high-value m$ical s]vices 

7su* z prescription m$ications1 cl9ician
 visits1 diagno/ic te/s1 & proc$ures7   
sy/ematically r$uces ! use ( su*        
s]vices4 ,sav+s attributable to         
co/-relat$1 decreas$ utilization (      
specific s]vices may lead to an increase
 9 total m$ical exp5ditures due to      
increas$ use ( o!r relat$ cl9ical       
s]vices1 su* z hospitalizations &       
em]g5cy room visits4  7#b7 ,empirical   
rese>* /udies demon/rate t r$uctions 9  
b5efici>y out-(-pocket exp5ses =        
high-value prescription m$ications &    
cl9ical s]vices c mitigate ! adv]se     
heal? & f9ancial consequ5ces            
attributable to co/-relat$ decreas$     
utilization ( high-value s]vices4  7#c7 
,f9ancial b>ri]s to prescription        
m$ications & cl9ical s]vices t are deem$
 to be high-value %\ld be r$uc$ or      
elim9at$ to increase _! use4  7#d7      
,value-,bas$ ,insurance ,design is a    
me?odology t adju/s pati5t out-(-pocket 
co/s = prescription m$ications & cl9ical
 s]vices accord+ to ! cl9ical value1 n  

exclusively ! co/4 ,value-,bas$         
,insurance ,design is bas$ on ! concept 
( cl9ical nuance t recognizes--  7,a7   
prescription m$ications & cl9ical       
s]vices diff] 9 ! cl9ical b5efit        
provid$2 &  7,b7 ! cl9ical b5efit d]iv$ 
f a specific prescription m$ication or  
cl9ical s]vice dep5ds on ! cl9ical      
situation1 ! provid]1 & :]e ! c>e is    
deliv]$4  7#e7 ,! curr5t                
"o-size-fits-all copaym5t or co9surance 
design = prescription m$ications &      
cl9ical s]vices provid$ "u ! ,m$ic>e    
program does n recognize ! well-e/abli%$
 value diff]5ces 9 heal? outcomes       
produc$ by v>i\s m$ical int]v5tions4    
7#f7 ,! e/abli%m5t by ,m$ic>e ( copaym5t
 & co9surance requirem5ts us+           
,value-,bas$ ,insurance ,design         
me?odologies w improve pati5t-c5t]$     
heal? outcomes1 enhance p]sonal         
responsibility1 & af=d a m effici5t use 
( taxpay] doll>s4  #c4 ,demon/ration    
program  7a7 ,9 g5]al ,n lat] ?an #a ye>
 aft] ! date ( enactm5t ( ?is ,act1 !   

,secret>y ( ,heal? & ,human ,s]vices 79 
?is section ref]r$ to z ! ,secret>y7    
%all e/abli% a demon/ration program to  
te/ ,value-,bas$ ,insurance ,design     
me?odologies 9 ,m$ic>e ,advantage plans 
"u "p ,c ( title ,,xviii ( ! ,social    
,security ,act = b5efici>ies ) *ronic   
cl9ical conditions4  7b7 ,demon/ration  
program design  7#a7 ,9 g5]al ,!        
,secret>y %all select n less ?an #b     
,m$ic>e ,advantage plans to p>ticipate 9
 ! demon/ration program "u ?is section4 
7#b7 ,requirem5ts ,a ,m$ic>e ,advantage 
plan select$ to p>ticipate 9 !          
demon/ration program "u p>agraph 7#a7   
%all meet ! foll[+ requirem5ts3  7,a7 ,!
 plan (f]s a coord9at$ ,m$ic>e ,"p ,d   
drug b5efit4  7,b7 ,! plan & ! ,m$ic>e  
,advantage organization (f]+ ! plan meet
 su* o!r crit]ia z ! ,secret>y det]m9es 
appropriate4  7c7 ,expansion (          
demon/ration program ,! ,secret>y %all  
exp& ! demon/ration program by issu+    
regulations to implem5t1 on a p]man5t   
basis1 ! compon5ts ( ! demon/ration     

program t are b5eficial to ,m$ic>e      
b5efici>ies & ! ,m$ic>e program1 unless 
! report "u subsection 7e7 or 7f77#c7   
conta9s an evaluation t ! demon/ration  
program "u ?is section--  7#a7 increases
 ,m$ic>e program exp5ditures =          
b5efici>ies p>ticipat+ 9 ! demon/ration 
program2 or  7#b7 decreases ! quality ( 
heal? c>e s]vices provid$ to ,m$ic>e    
b5efici>ies p>ticipat+ 9 ! demon/ration 
program4  7d7 ,value-,bas$ ,insurance   
,design me?odology  7#a7 ,value-,bas$   
,insurance ,design ,= purposes ( ?is    
section1 ,value-,bas$ ,insurance ,design
 is a me?odology = id5tify+ specific    
prescription m$ications & cl9ical       
s]vices = :i* copaym5ts or co9surance   
%\ld be r$uc$ or elim9at$ due to !      
high-value & effectiv5ess ( su*         
m$ications & s]vices = specific cl9ical 
conditions4  7#b7 ,r$uction ( copaym5ts 
& co9surance ,"u ! demon/ration program1
 a ,m$ic>e ,advantage organization1 us+ 
,value-,bas$ ,insurance ,design         
me?odologies1 %all id5tify ea*          

prescription m$ication & cl9ical s]vice 
= :i* ! am\nt ( ! copaym5t or co9surance
 payable %\ld be r$uc$ or elim9at$4     
7#c7 ,r$uction ( copaym5ts & co9surance 
to enc\rage use ( specific cl9ical      
s]vices ,"u ! demon/ration program1 !   
,m$ic>e ,advantage organization1 us+    
,value-,bas$ ,insurance ,design1 may l[]
 co/-%>+ "u ! plan = ! purpose (        
enc\rag+ enrollees to use 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$ical equipm5t7 t su*          
organization has id5tifi$ z high-value =
 ! managem5t ( specifi$ cl9ical         
conditions 9 p>agraph 7#e74 ,any su*    
v>iation on copaym5t or co9surance by a 
,m$ic>e ,advantage organization mu/     
occur on an annual basis & be           
evid5ce-bas$4  7#d7 ,r$uction (         
copaym5ts & co9surance to enc\rage use (
 specific high-p]=m+ provid]s ,"u !     
demon/ration program1 ! ,m$ic>e         
,advantage organization1 us+            

,value-,bas$ ,insurance ,design1 may l[]
 co/-%>+ "u ! plan = ! purpose (        
enc\rag+ enrollees to use provid]s t su*
 organization has id5tifi$ z high-p]=m+ 
bas$ on quality metrics4 ,any su*       
v>iation on copaym5t or co9surance by a 
,m$ic>e ,advantage organization mu/     
occur on an annual basis4  7#e7         
,specific cl9ical conditions ,9 id5tify+
 cl9ical conditions = purposes (        
p>agraph 7#c71 ! ,m$ic>e ,advantage     
organization %all1 at a m9imum1 consid] 
! s]vices utiliz$ across ! spectrum (   
c>e 9 ! managem5t ( ! foll[+ cl9ical    
conditions3  7,a7 ,a/hma4  7,b7 ,atrial 
fibrillation4  7,c7 ,deep v5\s          
?rombosis4  7,d7 ,canc]4  7,e7 ,*ronic  
ob/ructive pulmon>y disease4  7,f7      
,*ronic r5al failure_/,end /age r5al    
disease4  7,g7 ,conge/ive he>t failure4 
7,h7 ,is*emic he>t disease_/,myoc>dial  
inf>ction4  7,i7 ,depression4  7,j7     
,diabetes mellitus4  7,k7               
,hyp]lipidemia4  7,l7 ,hyp]t5sion4  7,m7
 ,o/eoporosis4  7,n7 ,/roke4  7,o7      

,tobacco abuse disord]4  7#f7           
,prohibition ( increases ( copaym5ts &  
co9surance ,a ,m$ic>e ,advantage plan   
select$ to p>ticipate 9 ! demon/ration  
program "u p>agraph 7#a7 may n raise    
co/-%>+ on any item or s]vice to        
disc\rage its use4  7e7 ,report on      
implem5tation  7#a7 ,9 g5]al ,n lat] ?an
 #a ye> aft] ! date ( ! enactm5t ( ?is  
,act1 ! ,secret>y %all submit to        
,congress a report on ! implem5tation by
 ! ,secret>y ( ! demon/ration program "u
 ?is section4  7#b7 ,elem5ts ,! report  
requir$ by p>agraph 7#a7 %all include ! 
foll[+3 7,a7 ,a /atem5t sett+ =? ea*    
m$ication & cl9ical s]vice id5tifi$     
pursuant to subsection 7d77#c74  7,b7 ,=
 ea* su* m$ication or cl9ical s]vice    
id5tifi$ pursuant to subsection 7d77#c71
 a /atem5t ( ! am\nt ( ! copaym5t or    
co9surance requir$ to be paid = su*     
s]vice & ! am\nt ( ! r$uction f previ\s 
co/-%>+ levels4  7,c7 ,= ea* su*        
high-p]=m+ provid] id5tifi$ pursuant to 
subsection 7d77#d71 a /atem5t ( ! am\nt 

( ! copaym5t or co9surance requir$ to be
 paid = su* cl9ician visit & ! am\nt ( !
 r$uction f previ\s co/-%>+ levels4  7f7
 ,review & assessm5t ( utilization (    
value-,bas$ insurance design            
me?odologies  7#a7 ,9 g5]al ,! ,secret>y
 %all ent] into a contract or agreem5t )
 an indep5d5t1 nonbias$ entity hav+     
exp]tise 9 ,value-,bas$ ,insurance      
,design 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 ref]r$ 
to 9 subsection 7d74  7,b7 ,an analysis 
( :e!r r$uc+ or elim9at+ ! copaym5t or  
co9surance = ea* m$ication & cl9ical    
s]vice id5tifi$ pursuant to subsection  
7d77#c7 result$ 9 increas$ adh]5ce to   
m$ication regim5s1 increas$ s]vice      
utilization1 improvem5t 9 quality       
metrics1 bett] heal? outcomes1 or       
enhanc$ b5efici>y exp]i5ce4  7,c7 ,an   
analysis ( ! co/-sav+s result+ f r$uc+  

or elim9at+ ! copaym5t or co9surance =  
ea* m$ication or cl9ical s]vice s       
id5tifi$4  7,d7 ,an analysis ( :e!r     
r$uc+ or elim9at+ ! copaym5t or         
co9surance = ea* high-p]=m+ provid]     
id5tifi$ pursuant to subsection 7d77#d7 
result$ 9 improvem5t 9 quality metrics1 
bett] heal? outcomes1 or enhanc$        
b5efici>y exp]i5ce4  7,e7 ,an analysis (
 ! co/-sav+s result+ f r$uc+ or elim9at+
 ! copaym5t or co9surance = ea*         
high-p]=m+ provid] s id5tifi$4  7,f7    
,su* o!r matt]s z ! ,secret>y consid]s  
appropriate4  7#b7 ,report ,! contract  
or agreem5t ent]$ into "u p>agraph 7#a7 
%all require ! entity conc]n$ to submit 
to ! ,secret>y a report on ! review &   
assessm5t conduct$ by ! entity "u t     
p>agraph 9 "t = ! inclusion ( ! results 
( su* report 9 ! report requir$ by      
p>agraph 7#c74  7#c7 ,report to         
,congress ,n lat] ?an #c ye>s aft] !    
date ( ! enactm5t ( ?is ,act1 !         
,secret>y %all submit to ,congress a    
report on ! review & assessm5t conduct$ 

"u ?is subsection4 ,! report %all       
include ! foll[+3  7,a7 ,a description (
 ! results ( ! review & assessm5t4  7,b7
 ,su* recomm5dations z ! ,secret>y      
consid]s appropriate = enhanc+ !        
utilization ( ! me?odologies ref]r$ to 9
 subsection 7d77#a7 s z to r$uce        
copaym5ts & co9surance paid by ,m$ic>e  
b5efici>ies = high-value prescription   
m$ications & cl9ical s]vices furni%$ "u 
! ,m$ic>e program & to o!rwise improve !
 quality ( heal? c>e provid$ "u su*     
,m$ic>e program4  7g7 ,waiv] ,!         
,secret>y may waive su* provisions (    
titles ,,xi & ,,xviii ( ! ,social       
,security ,act z may be necess>y to c>ry
 out ! demon/ration program "u ?is      
section4  7h7 ,implem5tation fund+ ,=   
purposes ( c>ry+ out ! demon/ration     
program "u ?is section1 ! ,secret>y %all
 provide = ! transf] f ! ,f$]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