,,ii  #aad? ,,congress  #b;d ,session   
,s4 #bdih  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,febru>y #d1 #bjaf,mr4 
,b5net 7= himself & ,mr4 ,portman7      
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 pilot program to improve c>e =
 ! mo/ co/ly ,m$ic>e fee-=-s]vice       
b5efici>ies ?r\gh ! use ( compreh5sive &
 effective c>e managem5t :ile r$uc+ co/s
 to ! ,f$]al ,gov]nm5t = ^! b5efici>ies1
 & = o!r purposes4  #a4 ,%ort title ,?is
 ,act may be cit$ z ! ,m$ic>e ,program  
,l9k+ ,uncoord9at$ ,s]vices 7,,plus7    
,act4  #b4 ,program to improve c>e =    
highe/ co/ ,m$ic>e fee-=-s]vice         
b5eficiaries ,title ,,xviii ( ! ,social 
,security ,act is am5d$ by ins]t+ aft]  
section #ahff;,e 7#db ,u4,s4,c4         
#acie;cc-#e7 ! foll[+ new section3      
#ahff;,f4 ,program to improve c>e =     
highe/ co/ ,m$ic>e fee-=-s]vice         
b5efici>ies  7a7 ,e/abli%m5t ,!         

,secret>y %all conduct "u ?is section a 
pilot program 79 ?is section ref]r$ to z
 ! program7 to demon/rate improvem5ts 9 
pati5t c>e & co/ sav+s = ! highe/ co/   
,m$ic>e fee-=-s]vice b5efici>ies ?r\gh  
enrollm5t ( su* b5efici>ies ) p>ticipat+
 organizations4 ,"u ! program1 !        
,secret>y %all1 ?r\gh a competitive     
process1 ent] into a contract ) "o or   
two select$ organizations to (f] b5efits
 = items & s]vices 9 s]vice areas       
id5tifi$ "u subsection 7b77#a77;,a7 to !
 highe/ co/ ,m$ic>e fee-=-s]vice        
b5efici>ies 7id5tifi$ "u subsection     
7c77#a77 9 ! s]vice area involv$4 ,!    
program %all be design$ 9 a mann] to    
provide compreh5sive & integrat$ c>e    
managem5t & s]vices ?r\gh a network (   
heal? c>e provid]s to meet ! specializ$ 
ne$s ( su* id5tifi$ b5efici>ies4  7b7   
,conduct ( program  7#a7 ,p]iod (       
op]ation & scope  7,a7 ,initial conduct 
,! program %all initially be conduct$   
ov] a #c-ye> p]iod1 beg9n+ n lat] ?an #a
 ye> aft] ! date ( ! enactm5t ( ?is     

section1 9 at lea/ #d s]vice areas1 ea* 
id5tifi$ by ! ,secret>y & ea* includ+ at
 lea/ #c contigu\s c\nties4  7,b7       
,expansion & ext5sion ,! ,secret>y may  
exp& ! program to additional s]vice     
areas & ext5d its duration if !         
,secret>y det]m9es1 9 consultation ) !  
,*ief ,actu>y ( ! ,c5t]s = ,m$ic>e      
,m$icaid ,s]vices1 t su* expansion &    
ext5sion w result 9 additional sav+s to 
! ,m$ic>e program & w meet ! quality    
p]=mance /&>ds e/abli%$ "u subsection   
7d77#c77;,a77iii74  7,c7 ,relation to "p
 ,d  7i7 ,9 g5]al ,! ,secret>y %all     
design & implem5t ! program 9 su* mann] 
z to pres]ve ! op]ation ( "p ,d1 includ+
 paym5t1 non9t]f]5ce1 & b5efici>y       
protections "u su* "p4  7ii7            
,coord9ation me*anisms ,! ,secret>y %all
 id5tify me*anisms t may be us$1 9 !    
case ( a highe/ co/ ,m$ic>e fee-=-s]vice
 b5efici>y :o is enroll$ ) a p>ticipat+ 
organization "u ! program & 9 a         
prescription drug plan (f]$ by a ,,pdp  
sponsor "u "p ,d or a qualifi$ retiree  

prescription drug plan (f]$ by a sponsor
 "u section #ahfj;,d-#bb1 9 ord] to     
enhance coord9ation ( ! individual's c>e
 betwe5 ! organization & ! respective   
sponsor4  7#b7 ,numb] ( p>ticipat+      
organizations p] s]vice area ,"u !      
program ! ,secret>y %all ent] into a    
contract ) at lea/ "o select$           
organization 7& no m ?an #b select$     
organizations7 9 ea* s]vice area        
id5tifi$ & cov]$ "u ! program4  7c7     
,id5tification & enrollm5t ( highe/ co/ 
,m$ic>e fee-=-,s]vice b5efici>ies  7#a7 
,id5tification  7,a7 ,9 g5]al ,=        
purposes ( ! program1 ! ,secret>y %all  
develop crit]ia to id5tify1 subject to  
subp>agraph 7,b71 ,m$ic>e fee-=-s]vice  
b5efici>ies ) project$ total co/s "u    
p>ts ,a & ,b 9 ! highe/ #ae? p]c5tile ( 
all ,m$ic>e fee-=-s]vice b5efici>ies on 
an ongo+ basis4 ,su* crit]ia %all be    
develop$ 9 a mann] s z to id5tify su*   
b5efici>ies us+ ! mo/ rec5t national    
data available = a #b-ye> p]iod4  7,b7  
,ref9em5t ( eligibility crit]ia ,9      

id5tify+ highe/ co/ ,m$ic>e fee-=-s]vice
 b5efici>ies "u ?is p>agraph1 !         
,secret>y %all develop su* crit]ia 9 a  
mann] t elim9ates1 to ! ext5t           
practicable1 ! id5tification (          
individuals :o o!rwise appe> to meet su*
 crit]ia only because ( a s+le1 isolat$ 
high-co/ incid5t1 item1 or s]vice4  7#b7
 ,eligible b5efici>y initial outrea* ,! 
,secret>y %all in=m ! highe/ co/ ,m$ic>e
 fee-=-s]vice b5efici>ies resid+ 9 an   
area cov]$ by ! program & provide !m )  
in=mation ab\t ! program & ! process =  
enrollm5t & dis5rollm5t f p>ticipat+    
organizations 9 su* area4 ,su* in=mation
 %all include in=mation ab\t su*        
organizations1 ab\t rights & protections
 "u ! program1 a contact telephone numb]
 :]e b5efici>ies c obta9 additional     
in=mation ab\t ! program1 & ! use ( an  
advance directive 7z def9$ 9 section    
#ahff7;f77#c77 9 connection )           
p>ticipation 9 ! program4  7#c7         
,auto-enrollm5t & dis5rollm5t proc$ures 
7,a7 ,9 g5]al ,"u ! program1 ! highe/   

co/ ,m$ic>e fee-=-s]vice b5efici>ies    
resid+ 9 a s]vice area cov]$ "u !       
program--  7i7 %all be enroll$1 9 a =m &
 mann] specifi$ by ! ,secret>y1 ) a     
p>ticipat+ organization (f]$ "u !       
program to su* a resid5t 9 su* area2 &  
7ii7 may *ange or t]m9ate su* enrollm5t 
9 a =m & mann] s specifi$4  ,9 specify+ 
su* =m & mann]1 ! ,secret>y %all take   
into acc\nt ! =m & mann] 9 :i*          
individuals may *ange or t]m9ate an     
enrollm5t "u a ,m$ic>e ,advantage plan  
"u "p ,c1 includ+ p]mitt+ special       
dis5rollm5t p]iods describ$ 9 section   
#ahea7;e77#d74  7,b7 ,default           
organization selection ,9 c>ry+ out     
subp>agraph 7,a71 if !re are two        
p>ticipat+ organizations 9 a s]vice     
area1 ! ,secret>y %all id5tify1 to !    
ext5t possible1 & enroll ! b5efici>y 9 !
 p>ticipat+ organization :i* has        
provid]s 9 its network f :om ! b5efici>y
 has receiv$ s]vices "u ! ,m$ic>e       
fee-=-s]vice program 9 ! previ\s ye>4   
7,c7 ,timeframes ,9 c>ry+ out           

subp>agraph 7,a71 !re %all be an initial
 enrollm5t p]iod ( #ab mon?s1 dur+ :i* a
 highe/ co/ ,m$ic>e fee-=-s]vice        
b5efici>y may also opt out (            
p>ticipation 9 ! program4  7#d7         
,ext5sion ( c]ta9 gu>ante$ issuance     
rights to ,m$igap cov]age 9 case (      
dis5rollm5t ,subp>agraph 7,a7 ( section 
#ahhb7s77#c7 %all apply to a ,m$ic>e    
b5efici>y enroll$ ) a p>ticipat+        
organization "u ?is section :o _h       
previ\s cov]age "u a m$ic>e supplem5tal 
insurance policy & :o t]m9ates enrollm5t
 ) ! p>ticipat+ organization 9 ! same   
mann] z su* section applies to an       
individual describ$ 9 subp>agraph       
7,b77v7 ( su* section ) respect to      
enrollm5t ) a heal? plan1 reg>dless ( ! 
"t p]iod ( p>ticipation 9 ! program &   
)\t reg>d to subp>agraph 7,e77ii7 ( su* 
section4  7#e7 ,treatm5t ( ,m$ic>e      
fee-=-s]vice b5efits to enrollees ?r\gh 
program ,! provisions ( section         
#ahea7;i7 %all apply to individuals     
enroll$ ) a p>ticipat+ organization "u !

 program 9 ! same mann] z !y apply to an
 individual enroll$ 9 a ,m$ic>e         
,advantage plan "u "p ,c4  7#f7         
,relation to "p ,d1 employ]-bas$        
prescription drug cov]age1 & m$ic>e     
supplem5tal cov]age ,except z           
specifically provid$1 no?+ 9 ?is section
 %all be con/ru$ z int5d$ to impact     
b5efits or cov]age furni%$ "u a         
prescription drug plan "u "p ,d1 "u a   
gr\p heal? plan 7includ+ "u a qualifi$  
retiree prescription drug plan z def9$ 9
 section #ahfj;,d-#bb7;a77#b771 or "u a 
m$ic>e supplem5tal policy4  7d7         
,p>ticipat+ organization requirem5ts    
7#a7 ,9 g5]al ,= purposes ( p>ticipat+ 9
 ! program1 except z provid$ 9 ?is      
subsection1 a p>ticipat+ organization   
mu/ meet ! same requirem5ts t apply to a
 ,m$ic>e ,advantage organization & an   
,,ma plan t is n an ,,ma-,,pd plan "u "p
 ,c1 includ+ requirem5ts relat+ to--    
7,a7 cov]age ( items & s]vices "u p>ts  
,a & ,b2 &  7,b7 b5efici>y protections  
"u "p ,c4  7#b7 ,waiv] au?ority ,"u !   

program1 ! ,secret>y may waive !        
requirem5ts ( ?is title & title ,,xi b  
only to ! ext5t necess>y to p]mit       
p>ticipat+ organizations--  7,a7 to     
provide c>e managem5t1 cu/odial c>e1    
transportation1 9-home assi/ance1 & o!r 
s]vices t are n o!rwise cov]$ "u ?is    
title2  7,b7 to /ructure pati5t         
inc5tives1 su* z a r$uction or          
elim9ation ( co/-%>+1 = s]vices &       
b5efits "u p>ts ,a & ,b & ! use ( 9-home
 te*nology1 to improve b5efici>y adh]5ce
 to treatm5t protocols & ! effectiv5ess 
( treatm5t = enroll$ b5efici>ies )      
*ronic cl9ical conditions2 &  7,c7 to   
ma9ta9 provid] & ph>macy networks t d n 
o!rwise meet network adequacy /&>ds4    
7#c7 ,quality & report+ requirem5ts     
7,a7 ,9 g5]al ,"u ! program1 ! ,secret>y
 %all--  7i7 det]m9e appropriate        
measures 7includ+1 to ! ext5t feasible1 
outcome measures7 to assess ! quality ( 
c>e be+ provid$ "u ! program2  7ii7     
e/abli% requirem5ts = p>ticipat+        
organizations to report1 9 a =m & mann] 

specifi$ by ! ,secret>y1 in=mation on   
su* measures2  7iii7 e/abli% quality    
p]=mance /&>ds on su* measures to assess
 ! quality ( c>e be+ provid$ by su*     
organizations "u ! program2 &  7iv7 seek
 ! input ( /akehold]s 79 a mann] simil> 
to t provid$ = "u section #ahdh7r77 9   
det]m9+ su* measures1 requirem5ts1 &    
/&>ds4  7,b7 ,t]m9ation ( p>ticipation =
 failure to meet quality p]=mance /&>ds 
,! ,secret>y may t]m9ate p>ticipation ( 
an organization "u ! program = failure  
to meet ! quality p]=mance /&>ds        
e/abli%$ "u subp>agraph 7,a77iii74  7,c7
 ,quality p]=mance /&>ds ,9 e/abli%+    
quality p]=mance /&>ds "u subp>agraph   
7,a77iii7 9 ! case (-- 7i7 a            
provid]-bas$ organization 7su* z an     
acc\ntable c>e organization71 !         
,secret>y may apply ! quality measurem5t
 sy/em us$ "u ! ,m$ic>e %>$ sav+s       
program "u section #ahii7;b77#c72 &     
7ii7 an ,,ma organization1 ! ,secret>y  
may require t only an organization ) a  
rat+ 7"u ! /> quality rat+ sy/em "u     

section #ahec7o77#d77 ( #d />s or high] 
be p]mitt$ to p>ticipate 9 ! program4   
7#d7 ,use ( integrat$ model ( c>e ,!    
,secret>y %all develop c>e managem5t    
requirem5ts = p>ticipat+ organizations t
 provides an integrat$ c>e model & t    
includes ! foll[+ elem5ts3  7,a7        
,provision ( p]son-c5t]$1 compreh5sive1 
& integrat$ c>e managem5t & s]vices4    
7,b7 ,provision ( s]vices ?r\gh--  7i7 !
 use ( a network ( provid]s *>act]iz$ z 
be/-9-class1 su* z c5t]s ( excell5ce2 & 
7ii7 ! use ( an int]discipl9>y managem5t
 team t includes a nurse coord9ator 7or 
o!r appropriate heal? c>e pr(essional7  
assign$ to ea* enroll$ b5efici>y & t    
%>es a common heal? in=mation te*nology 
plat=m4  7,c7 ,an evid5ce-bas$ model (  
c>e ) appropriate networks ( provid]s & 
speciali/s4  7,d7 ,= ea* b5efici>y      
enroll$ ) ! organization "u ! program1 !
 organization--  7i7 conducts an initial
 assessm5t & an annual reassessm5t ( !  
b5efici>y's physical1 psy*osocial1 &    
functional ne$s1 includ+ an evaluation &

 plan ) respect to ! b5efici>y's *ronic 
conditions2  7ii7 provides = regul>     
9-p]son visits to ! b5efici>y by a c>e  
provid] & provides ! b5efici>y ) access 
to a specializ$ team1 includ+ a         
hospitali/ physician2 &  7iii7 develops 
a plan1 9 consultation ) ! b5efici>y z  
feasible1 t id5tifies goals & objectives
 ) respect to ! b5efici>y1 includ+      
measurable outcomes z well z specific   
s]vices & b5efits to be provid$4  7e7   
,paym5ts  7#a7 ,9 g5]al ,= ea*          
individual enroll$ ) a p>ticipat+       
organization "u ! program1 ! ,secret>y  
%all make a mon?ly capitat$ paym5t to ! 
organization 9 ! same mann] z su* a     
paym5t w\ld be made "u "p ,c = an       
individual enroll$ 9 an ,,ma-plan 7t 0 n
 an ,,ma-,,pd plan7 (f]$ by a ,m$ic>e   
,advantage organization1 except t--     
7,a7 not)/&+ section #ahec1 ! am\nt ( ! 
paym5t %all be det]m9$1 subject to      
subp>agraph 7,b71 9 an am\nt equival5t  
to #ih p]c5t ( ! project$ co/1 "u !     
,m$ic>e fee-=-s]vice program "u p>ts ,a 

& ,b = ! highe/ co/ ,m$ic>e fee-=-s]vice
 b5efici>ies2 &  7,b7 ! am\nt ( su*     
paym5t %all be adju/$1 9 a mann]        
specifi$ by ! ,secret>y1 to take into   
acc\nt diff]5ces 9 co/s among diff]5t   
geographic areas & among high co/       
,m$ic>e fee-=-s]vice b5efici>ies        
7includ+ outli] co/s = ! mo/ co/ly ( su*
 b5efici>ies74  7#b7 ,projection bas$ ^u
 hi/orical data ,9 apply+ p>agraph      
7#a77;,a71 ! ,secret>y %all use         
hi/orical fee-=-s]vice sp5d+ & enrollm5t
 data = ! highe/ co/ ,m$ic>e            
fee-=-s]vice b5efici>ies1 tr5d$ =w>d to 
! fir/ ye> ( ! program1 &1 = subsequ5t  
ye>s ( ! program1 increas$ by project$  
gr[? 9 su* sp5d+ = su* b5efici>ies4     
7#c7 ,relation%ip to paym5t = cov]$ "p  
,d drugs ,9 ! case ( an individual :o is
 enroll$ ) a p>ticipat+ organization "u 
! program-- 7,a7 if ! individual is     
enroll$ ) a prescription drug plan "u "p
 ,d1 paym5t = cov]$ "p ,d drugs = su*   
individual is made "u su* prescription  
drug plan "u su* "p & n "u ! program2 & 

7,b7 if ! individual is cov]$ "u a      
qualifi$ retiree prescription drug plan 
"u section #ahfj;,d-#bb1 paym5t = cov]$ 
"p ,d drugs = su* individual is made "u 
su* plan & n "u ! program4  7f7         
,evaluation & report to ,congress  7#a7 
,evaluation ,! ,secret>y %all conduct an
 indep5d5t evaluation ( ! program4 ,su* 
evaluation %all include an analysis ( ! 
impact ( ! program on coord9ation ( c>e1
 exp5ditures by p>ticipat+ organizations
 & plans1 ! program's impact on r$uc+   
exp5ditures "u ?is title1 b5efici>y     
access to s]vices & provid]s1 ! quality 
( heal? c>e s]vices furni%$ to          
b5efici>ies1 & b5efici>y exp]i5ces )    
auto-enrollm5t & dis5rollm5t "u !       
program4  7#b7 ,report ,n lat] ?an #b   
ye>s aft] ! date t ,m$ic>e b5efici>ies  
are fir/ enroll$ "u ! program1 !        
,secret>y %all submit to ,congress a    
report on ! p]=mance ( ! program4 ,su*  
report %all include ! results ( !       
evaluation conduct$ "u p>agraph 7#a7 & !
 program's impact on r$uc+ exp5ditures  

"u ?is title & on improv+ ! quality (   
c>e = ! highe/ co/ ,m$ic>e fee-=-s]vice 
b5efici>ies enroll$ "u ! program4  7g7  
,def9itions ,9 ?is section3 7#a7 ,highe/
 co/ ,m$ic>e fee-=-s]vice b5efici>y ,!  
t]m highe/ co/ ,m$ic>e fee-=-s]vice     
b5efici>y means a ,m$ic>e fee-=-s]vice  
b5efici>y :o has be5 id5tifi$ "u        
subsection 7c74  7#b7 ,m$ic>e           
fee-=-s]vice b5efici>y def9$ ,! t]m     
,m$ic>e fee-=-s]vice b5efici>y means an 
individual :o-- 7,a7 is entitl$ to      
b5efits "u "p ,a1 & enroll$ "u "p ,b1   
reg>dless ( ! basis = entitlem5t or     
eligibility to b5efits "u any su* "p2 & 
7,b7 is n enroll$ 9 a ,m$ic>e ,advantage
 plan "u "p ,c4  7#c7 ,program ,unless !
 context indicates o!rwise1 ! t]m       
program means ! program "u ?is section4 
7#d7 ,p>ticipat+ organization ,! t]m    
p>ticipat+ organization means a select$ 
organization t has ent]$ into a contract
 to p>ticipate 9 ! program4  7#e7       
,select$ organization ,! t]m select$    
organization means a provid]-bas$       

organization 7su* z an acc\ntable c>e   
organization7 or ,,ma organization 7z   
def9$ = purposes ( "p ,c7 t ! ,secret>y 
det]m9es--  7,a7 meets ! requirem5ts to 
provide s]vices to ! highe/ co/ ,m$ic>e 
fee-=-s]vices b5efici>ies "u ! program2 
&  7,b7 is accr$it$ by ! ,national      
,committee = ,quality ,assurance or     
o!rwise is c]tifi$ z meet+ quality      
/&>ds4  4