,,ii #aadth ,,congress #b;d ,session ,s4 #bdih ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,february #d1 #bjaf,mr4 ,bennet 7for himself and ,mr4 ,portman7 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 pilot program to improve care for the most costly ,medicare fee-for-service beneficiaries through the use of comprehensive and effective care management while reducing costs to the ,federal ,government for these beneficiaries1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,medicare ,program ,linking ,uncoordinated ,services 7,,plus7 ,act4 #b4 ,program to improve care for highest cost ,medicare fee-for-service beneficiaries ,title ,,xviii of the ,social ,security ,act is amended by inserting after section #ahff;,e 7#db ,u4,s4,c4 #acie;cc-#e7 the following new section3 #ahff;,f4 ,program to improve care for highest cost ,medicare fee-for-service beneficiaries 7a7 ,establishment ,the ,secretary shall conduct under this section a pilot program 7in this section referred to as the program7 to demonstrate improvements in patient care and cost savings for the highest cost ,medicare fee-for-service beneficiaries through enrollment of such beneficiaries with participating organizations4 ,under the program1 the ,secretary shall1 through a competitive process1 enter into a contract with one or two selected organizations to offer benefits for items and services in service areas identified under subsection 7b77#a77;,a7 to the highest cost ,medicare fee-for-service beneficiaries 7identified under subsection 7c77#a77 in the service area involved4 ,the program shall be designed in a manner to provide comprehensive and integrated care management and services through a network of health care providers to meet the specialized needs of such identified beneficiaries4 7b7 ,conduct of program 7#a7 ,period of operation and scope 7,a7 ,initial conduct ,the program shall initially be conducted over a #c-year period1 beginning not later than #a year after the date of the enactment of this section1 in at least #d service areas1 each identified by the ,secretary and each including at least #c contiguous counties4 7,b7 ,expansion and extension ,the ,secretary may expand the program to additional service areas and extend its duration if the ,secretary determines1 in consultation with the ,chief ,actuary of the ,centers for ,medicare ,medicaid ,services1 that such expansion and extension will result in additional savings to the ,medicare program and will meet the quality performance standards established under subsection 7d77#c77;,a77iii74 7,c7 ,relation to part ,d 7i7 ,in general ,the ,secretary shall design and implement the program in such manner as to preserve the operation of part ,d1 including payment1 noninterference1 and beneficiary protections under such part4 7ii7 ,coordination mechanisms ,the ,secretary shall identify mechanisms that may be used1 in the case of a highest cost ,medicare fee-for-service beneficiary who is enrolled with a participating organization under the program and in a prescription drug plan offered by a ,,pdp sponsor under part ,d or a qualified retiree prescription drug plan offered by a sponsor under section #ahfj;,d-#bb1 in order to enhance coordination of the individual's care between the organization and the respective sponsor4 7#b7 ,number of participating organizations per service area ,under the program the ,secretary shall enter into a contract with at least one selected organization 7and no more than #b selected organizations7 in each service area identified and covered under the program4 7c7 ,identification and enrollment of highest cost ,medicare fee-for-,service beneficiaries 7#a7 ,identification 7,a7 ,in general ,for purposes of the program1 the ,secretary shall develop criteria to identify1 subject to subparagraph 7,b71 ,medicare fee-for-service beneficiaries with projected total costs under parts ,a and ,b in the highest #aeth percentile of all ,medicare fee-for-service beneficiaries on an ongoing basis4 ,such criteria shall be developed in a manner so as to identify such beneficiaries using the most recent national data available for a #b-year period4 7,b7 ,refinement of eligibility criteria ,in identifying highest cost ,medicare fee-for-service beneficiaries under this paragraph1 the ,secretary shall develop such criteria in a manner that eliminates1 to the extent practicable1 the identification of individuals who otherwise appear to meet such criteria only because of a single1 isolated high-cost incident1 item1 or service4 7#b7 ,eligible beneficiary initial outreach ,the ,secretary shall inform the highest cost ,medicare fee-for-service beneficiaries residing in an area covered by the program and provide them with information about the program and the process for enrollment and disenrollment from participating organizations in such area4 ,such information shall include information about such organizations1 about rights and protections under the program1 a contact telephone number where beneficiaries can obtain additional information about the program1 and the use of an advance directive 7as defined in section #ahff7;f77#c77 in connection with participation in the program4 7#c7 ,auto-enrollment and disenrollment procedures 7,a7 ,in general ,under the program1 the highest cost ,medicare fee-for-service beneficiaries residing in a service area covered under the program-- 7i7 shall be enrolled1 in a form and manner specified by the ,secretary1 with a participating organization offered under the program to such a resident in such area2 and 7ii7 may change or terminate such enrollment in a form and manner so specified4 ,in specifying such form and manner1 the ,secretary shall take into account the form and manner in which individuals may change or terminate an enrollment under a ,medicare ,advantage plan under part ,c1 including permitting special disenrollment periods described in section #ahea7;e77#d74 7,b7 ,default organization selection ,in carrying out subparagraph 7,a71 if there are two participating organizations in a service area1 the ,secretary shall identify1 to the extent possible1 and enroll the beneficiary in the participating organization which has providers in its network from whom the beneficiary has received services under the ,medicare fee-for-service program in the previous year4 7,c7 ,timeframes ,in carrying out subparagraph 7,a71 there shall be an initial enrollment period of #ab months1 during which a highest cost ,medicare fee-for-service beneficiary may also opt out of participation in the program4 7#d7 ,extension of certain guaranteed issuance rights to ,medigap coverage in case of disenrollment ,subparagraph 7,a7 of section #ahhb7s77#c7 shall apply to a ,medicare beneficiary enrolled with a participating organization under this section who had previous coverage under a medicare supplemental insurance policy and who terminates enrollment with the participating organization in the same manner as such section applies to an individual described in subparagraph 7,b77v7 of such section with respect to enrollment with a health plan1 regardless of the time period of participation in the program and without regard to subparagraph 7,e77ii7 of such section4 7#e7 ,treatment of ,medicare fee-for-service benefits to enrollees through program ,the provisions of section #ahea7;i7 shall apply to individuals enrolled with a participating organization under the program in the same manner as they apply to an individual enrolled in a ,medicare ,advantage plan under part ,c4 7#f7 ,relation to part ,d1 employer-based prescription drug coverage1 and medicare supplemental coverage ,except as specifically provided1 nothing in this section shall be construed as intended to impact benefits or coverage furnished under a prescription drug plan under part ,d1 under a group health plan 7including under a qualified retiree prescription drug plan as defined in section #ahfj;,d-#bb7;a77#b771 or under a medicare supplemental policy4 7d7 ,participating organization requirements 7#a7 ,in general ,for purposes of participating in the program1 except as provided in this subsection1 a participating organization must meet the same requirements that apply to a ,medicare ,advantage organization and an ,,ma plan that is not an ,,ma-,,pd plan under part ,c1 including requirements relating to-- 7,a7 coverage of items and services under parts ,a and ,b2 and 7,b7 beneficiary protections under part ,c4 7#b7 ,waiver authority ,under the program1 the ,secretary may waive the requirements of this title and title ,,xi but only to the extent necessary to permit participating organizations-- 7,a7 to provide care management1 custodial care1 transportation1 in-home assistance1 and other services that are not otherwise covered under this title2 7,b7 to structure patient incentives1 such as a reduction or elimination of cost-sharing1 for services and benefits under parts ,a and ,b and the use of in-home technology1 to improve beneficiary adherence to treatment protocols and the effectiveness of treatment for enrolled beneficiaries with chronic clinical conditions2 and 7,c7 to maintain provider and pharmacy networks that do not otherwise meet network adequacy standards4 7#c7 ,quality and reporting requirements 7,a7 ,in general ,under the program1 the ,secretary shall-- 7i7 determine appropriate measures 7including1 to the extent feasible1 outcome measures7 to assess the quality of care being provided under the program2 7ii7 establish requirements for participating organizations to report1 in a form and manner specified by the ,secretary1 information on such measures2 7iii7 establish quality performance standards on such measures to assess the quality of care being provided by such organizations under the program2 and 7iv7 seek the input of stakeholders 7in a manner similar to that provided for under section #ahdh7r77 in determining such measures1 requirements1 and standards4 7,b7 ,termination of participation for failure to meet quality performance standards ,the ,secretary may terminate participation of an organization under the program for failure to meet the quality performance standards established under subparagraph 7,a77iii74 7,c7 ,quality performance standards ,in establishing quality performance standards under subparagraph 7,a77iii7 in the case of-- 7i7 a provider-based organization 7such as an accountable care organization71 the ,secretary may apply the quality measurement system used under the ,medicare shared savings program under section #ahii7;b77#c72 and 7ii7 an ,,ma organization1 the ,secretary may require that only an organization with a rating 7under the star quality rating system under section #ahec7o77#d77 of #d stars or higher be permitted to participate in the program4 7#d7 ,use of integrated model of care ,the ,secretary shall develop care management requirements for participating organizations that provides an integrated care model and that includes the following elements3 7,a7 ,provision of person-centered1 comprehensive1 and integrated care management and services4 7,b7 ,provision of services through-- 7i7 the use of a network of providers characterized as best-in-class1 such as centers of excellence2 and 7ii7 the use of an interdisciplinary management team that includes a nurse coordinator 7or other appropriate health care professional7 assigned to each enrolled beneficiary and that shares a common health information technology platform4 7,c7 ,an evidence-based model of care with appropriate networks of providers and specialists4 7,d7 ,for each beneficiary enrolled with the organization under the program1 the organization-- 7i7 conducts an initial assessment and an annual reassessment of the beneficiary's physical1 psychosocial1 and functional needs1 including an evaluation and plan with respect to the beneficiary's chronic conditions2 7ii7 provides for regular in-person visits to the beneficiary by a care provider and provides the beneficiary with access to a specialized team1 including a hospitalist physician2 and 7iii7 develops a plan1 in consultation with the beneficiary as feasible1 that identifies goals and objectives with respect to the beneficiary1 including measurable outcomes as well as specific services and benefits to be provided4 7e7 ,payments 7#a7 ,in general ,for each individual enrolled with a participating organization under the program1 the ,secretary shall make a monthly capitated payment to the organization in the same manner as such a payment would be made under part ,c for an individual enrolled in an ,,ma-plan 7that was not an ,,ma-,,pd plan7 offered by a ,medicare ,advantage organization1 except that-- 7,a7 notwithstanding section #ahec1 the amount of the payment shall be determined1 subject to subparagraph 7,b71 in an amount equivalent to #ih percent of the projected cost1 under the ,medicare fee-for-service program under parts ,a and ,b for the highest cost ,medicare fee-for-service beneficiaries2 and 7,b7 the amount of such payment shall be adjusted1 in a manner specified by the ,secretary1 to take into account differences in costs among different geographic areas and among high cost ,medicare fee-for-service beneficiaries 7including outlier costs for the most costly of such beneficiaries74 7#b7 ,projection based upon historical data ,in applying paragraph 7#a77;,a71 the ,secretary shall use historical fee-for-service spending and enrollment data for the highest cost ,medicare fee-for-service beneficiaries1 trended forward to the first year of the program1 and1 for subsequent years of the program1 increased by projected growth in such spending for such beneficiaries4 7#c7 ,relationship to payment for covered part ,d drugs ,in the case of an individual who is enrolled with a participating organization under the program-- 7,a7 if the individual is enrolled with a prescription drug plan under part ,d1 payment for covered part ,d drugs for such individual is made under such prescription drug plan under such part and not under the program2 and 7,b7 if the individual is covered under a qualified retiree prescription drug plan under section #ahfj;,d-#bb1 payment for covered part ,d drugs for such individual is made under such plan and not under the program4 7f7 ,evaluation and report to ,congress 7#a7 ,evaluation ,the ,secretary shall conduct an independent evaluation of the program4 ,such evaluation shall include an analysis of the impact of the program on coordination of care1 expenditures by participating organizations and plans1 the program's impact on reducing expenditures under this title1 beneficiary access to services and providers1 the quality of health care services furnished to beneficiaries1 and beneficiary experiences with auto-enrollment and disenrollment under the program4 7#b7 ,report ,not later than #b years after the date that ,medicare beneficiaries are first enrolled under the program1 the ,secretary shall submit to ,congress a report on the performance of the program4 ,such report shall include the results of the evaluation conducted under paragraph 7#a7 and the program's impact on reducing expenditures under this title and on improving the quality of care for the highest cost ,medicare fee-for-service beneficiaries enrolled under the program4 7g7 ,definitions ,in this section3 7#a7 ,highest cost ,medicare fee-for-service beneficiary ,the term highest cost ,medicare fee-for-service beneficiary means a ,medicare fee-for-service beneficiary who has been identified under subsection 7c74 7#b7 ,medicare fee-for-service beneficiary defined ,the term ,medicare fee-for-service beneficiary means an individual who-- 7,a7 is entitled to benefits under part ,a1 and enrolled under part ,b1 regardless of the basis for entitlement or eligibility to benefits under any such part2 and 7,b7 is not enrolled in a ,medicare ,advantage plan under part ,c4 7#c7 ,program ,unless the context indicates otherwise1 the term program means the program under this section4 7#d7 ,participating organization ,the term participating organization means a selected organization that has entered into a contract to participate in the program4 7#e7 ,selected organization ,the term selected organization means a provider-based organization 7such as an accountable care organization7 or ,,ma organization 7as defined for purposes of part ,c7 that the ,secretary determines-- 7,a7 meets the requirements to provide services to the highest cost ,medicare fee-for-services beneficiaries under the program2 and 7,b7 is accredited by the ,national ,committee for ,quality ,assurance or otherwise is certified as meeting quality standards4 4