,,ii  #aad? ,,congress  #b;d ,session   
,s4 #cjij  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,june #bc1 #bjaf,mr4   
,hell] 7= himself & ,mr4 ,nelson7       
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 demon/ration program to       
provide integrat$ c>e = ,m$ic>e         
b5efici>ies ) end-/age r5al disease1 & =
 o!r purposes4  #a4 ,%ort title ,?is    
,act may be cit$ z ! ,dialysis ,,pati5t 
,demon/ration ,act ( #bjaf or ! ,pati5t 
,access ,to ,integrat$-c>e1 ,emp[]m5t1  
,nephrologi/s & ,treatm5t ,demon/ration 
,act ( #bjaf4  #b4 ,demon/ration program
 to provide integrat$ c>e = ,m$ic>e     
b5efici>ies ) end-/age r5al disease     
,title ,,xviii ( ! ,social ,security    
,act is am5d$ by ins]t+ aft] section    
#ahff;,e ! foll[+ new section3          
#ahff;,f4 ,demon/ration program to      
provide integrat$ c>e = ,m$ic>e         
b5efici>ies ) end-/age r5al disease  7a7

 ,e/abli%m5t  7#a7 ,9 g5]al ,! ,secret>y
 %all conduct "u ?is section ! ,,esrd   
,integrat$ ,c>e ,demon/ration ,program  
79 ?is section ref]r$ to z ! ,program7  
:i* is volunt>y = pati5ts & provid]s to 
assess ! effects ( alt]native c>e       
deliv]y models on pati5t c>e improvem5ts
 "u ?is title = ,program-eligible       
b5efici>ies 7z def9$ 9 p>agraph 7#b774  
,"u ! ,program1 eligible p>ticipat+     
provid]s 7z def9$ 9 su* p>agraph7 may =m
 an ,,esrd ,integrat$ ,c>e ,organization
 79 ?is section ref]r$ to z an          
,organization74 ,an ,organization %all  
integrate c>e & s]ve z ! m$ical home =  
,program-eligible b5efici>ies4  7#b7    
,def9itions ,9 ?is section3 7,a7        
,eligible p>ticipat+ provid] ,! t]m     
eligible p>ticipat+ provid] means !     
foll[+3  7i7 ,a facility c]tifi$ z a    
r5al dialysis facility "u ?is title4    
7ii7 ,a dialysis organization t owns "o 
or m ( su* facilities describ$ 9 clause 
7i74  7iii7 ,a nephrologi/ or nephrology
 practice4  7iv7 ,any o!r physician gr\p

 practice or a gr\p ( affiliat$         
physicians4  7,b7 ,eligible p>ticipat+  
p>tn] ,! t]m eligible p>ticipat+ p>tn]  
means ! foll[+3 7i7 ,a ,m$ic>e          
,advantage plan describ$ 9 section      
#ahea7;a77#b7 or a ,m$ic>e ,advantage   
organization (f]+ su* a plan4  7ii7 ,a  
prescription drug plan 7z def9$ 9       
section #ahfj;,d-#da7;a77#ad774  7iii7  
,a m$icaid manag$ c>e organization 7z   
def9$ 9 section #aijc7m774  7iv7 ,an    
entity able to be> risk z deem$ by a    
,/ate4  7v7 ,a ?ird p>ty-adm9i/rator    
organization4  7,c7 ,program-eligible   
b5efici>y ,! t]m ,program-eligible      
b5efici>y means1 ) respect to an        
,organization (f]+ an ,,esrd ,integrat$ 
,c>e ,model1 an individual entitl$ to   
b5efits "u "p ,a & enroll$ "u "p ,b :o--
  7i7 is #ah ye>s ( age or old]2  7ii7  
is id5tifi$ by ! ,secret>y or !         
,organization z receiv+ r5al dialysis   
s]vices "u ! orig9al m$ic>e fee-=-s]vice
 program "u p>ts ,a & ,b2  7iii7 resides
 9 ! s]vice area ( su* ,organization2   

7iv7 receives r5al dialysis s]vices     
prim>ily f a facility t p>ticipates 9   
su* ,organization2 &  7v7 has n receiv$ 
a successful kidney transplant4  7b7    
,,esrd integrat$ c>e organization       
eligibility requirem5ts  7#a7           
,organizations  7,a7 ,9 g5]al ,"o or m  
eligible p>ticipat+ provid]s may e/abli%
 an ,organization or may ent] into1     
subject to subp>agraph 7,b71 "o or m    
p>tn]%ip1 own]%ip1 or co-own]%ip        
agreem5ts ) "o or m eligible p>ticipat+ 
p>tn]s to e/abli% an ,organization4     
7,b7 ,limitation on numb] ( agreem5ts ,!
 ,secret>y may specify a limitation on !
 numb] ( ,organizations 9 :i* an        
eligible p>ticipat+ p>tn] may p>ticipate
 "u agreem5ts describ$ 9 subp>agraph    
7,a74  7#b7 ,,esrd integrat$ c>e model  
7,a7 ,b5efits requirem5ts  7i7 ,9 g5]al 
,subject to clause 7iii71 an            
,organization %all (f] at lea/ "o ,,esrd
 ,integrat$ ,c>e ,model t is an op5     
network model 7z describ$ 9 subp>agraph 
7,b77i77 9 ea* ( its s]vice areas & may 

(f] "o or m ,,esrd ,integrat$ ,c>e      
,models t is a pref]r$ network model 7z 
describ$ 9 subp>agraph 7,b77ii77 9 ea* (
 its s]vice areas4 ,= purposes ( ?is    
section an ,,esrd ,integrat$ ,c>e ,model
 79 ?is section ref]r$ to z ! ,model7-- 
7,i7 %all cov] all b5efits "u p>ts ,a & 
,b 7o!r ?an hospice c>e7 & include      
b5efits = transition 7includ+ education7
 into palliative c>e2 &  7,,ii7 may1    
?r\gh a p>tn]%ip or o!r agreem5t ) an   
,,ma-,,pd plan "u "p ,c or prescription 
drug plan "u "p ,d1 cov] all            
prescription drug b5efits "u su* "p ,d4 
7ii7 ,treatm5t ( sav+s  7,i7 ,9 g5]al   
,any ,organization (f]+ an ,,esrd       
,integrat$ ,c>e ,model %all provide = ! 
return "u subclause 7,,iv7 to a         
,program-eligible b5efici>y enroll$ 9 ! 
,organization ( ! am\nt1 if any1 by :i* 
! paym5t am\nt describ$ 9 subclause     
7,,iii7 ) respect to ! ,program-eligible
 b5efici>y = a ye> exce$s ! rev5ue am\nt
 describ$ 9 subclause 7,,ii7 ) respect  
to ! ,program-eligible b5efici>y = !    

ye>4  7,,ii7 ,rev5ue am\nt describ$ ,!  
rev5ue am\nt describ$ 9 ?is subclause1 )
 respect to an ,organization (f]+ an    
,,esrd ,integrat$ ,c>e ,model & a       
,program-eligible b5efici>y enroll$ 9   
su* ,organization1 is ! ,organization's 
e/imat$ av]age rev5ue requirem5ts1      
includ+ adm9i/rative co/s & return on   
inve/m5t1 = ! ,organization to provide !
 b5efits describ$ 9 clause 7i7 "u !     
,model = ! ,program-eligible b5efici>y =
 ! ye>4  7,,iii7 ,paym5t am\nt describ$ 
,! paym5t am\nt describ$ 9 ?is          
subclause1 ) respect to an ,organization
 (f]+ an ,,esrd ,integrat$ ,c>e ,model &
 a ,program-eligible b5efici>y enroll$ 9
 su* ,organization1 is ! paym5t am\nt to
 ! ,organization "u subsection 7f77#a7  
made ) respect to ! ,program-eligible   
b5efici>y = ! ye>4  7,,iv7 ,means (     
return+ sav+s to program-eligible       
b5efici>ies enroll$ 9 ,organizations ,an
 ,organization %all return ! am\nt "u   
subclause 7,i7 to a ,program-eligible   
b5efici>y enroll$ 9 ! ,organization 9 a 

mann] specifi$ by ! ,organization1 :i*  
may include co/-%>+ l[] ?an o!rwise     
applicable1 b5efits n cov]$ "u ! orig9al
 m$ic>e fee-=-s]vice program1 or        
f9ancial inc5tives 7su* z r$uc$ co/ %>+7
 = ,program-eligible b5efici>ies enroll$
 9 ! ,organization to promote ! deliv]y 
( high-value & effici5t c>e & s]vices4  
7iii7 ,b5efit requirem5ts = dual        
eligibles ,9 ! case ( a                 
,program-eligible b5efici>y :o is       
eligible = b5efits "u ?is title & title 
,,xix1 an ,organization1 9 accordance ) 
an agreem5t ent]$ into "u subsection    
7f77#d7--  7,i7 may be responsible =    
provid+1 or arrang+ = ! provision (1 all
 b5efits 7o!r ?an long-t]m s]vices &    
supports7 = :i* ! ,program-eligible     
b5efici>y is eligible = "u ! ,/ate      
,m$icaid program "u title ,,xix 9 :i* ! 
,program-eligible b5efici>y is enroll$2 
&  7,,ii7 may elect to provide1 or      
arrange = ! provision (1 long-t]m       
s]vices & supports available to !       
,program-eligible b5efici>y "u ! ,/ate  

,m$icaid program4  7,b7 ,requirem5ts =  
op5 network & pref]r$ network models    
7i7 ,op5 network model ,"u an ,,esrd    
,integrat$ ,c>e ,model (f]$ by an       
,organization t is an op5 network model1
 ! ,organization %all--  7,i7 all[      
,program-eligible b5efici>ies to receive
 su* cov]$ b5efits f any provid] (      
s]vices or suppli] reg>dless ( :e!r su* 
provid] is )9 ! network assembl$ "u     
subclause 7,i72  7,,ii7 pay any         
,m$ic>e-c]tifi$ provid] or suppli] t is 
n )9 ! network assembl$ "u subclause    
7,i7 = su* cov]$ b5efits an am\nt equal 
to ! am\nt ! provid] or suppli] w\ld    
o!rwise receive "u ?is title2 &  7,,iii7
 n apply any additional premium or co/  
%>+ requirem5ts = su* cov]$ b5efits 9   
addition to premium or co/ %>+          
requirem5ts1 respectively1 t w\ld be    
applicable "u "p ,a or "p ,b = su*      
b5efits4  7ii7 ,pref]r$ network model   
,"u an ,,esrd ,integrat$ ,c>e ,model    
(f]$ by an ,organization t is a pref]r$ 
network model1 ! ,organization--  7,i7  

%all assemble a network ( provid]s (    
s]vices & suppli]s id5tifi$ by !        
,organization & confirm$ by ! ,secret>y 
z includ+ provid]s ( s]vices & suppli]s 
) significant exp]tise 9 c>+ =          
individuals ) end-/age r5al disease     
?r\gh :i* ,program-eligible b5efici>ies 
%all receive cov]$ b5efits z describ$ 9 
subp>agraph 7,a7 t are requir$ to be    
cov]$ "u ! ,model2  7,,ii7 may apply    
premium & co/-%>+ requirem5ts1 9        
addition to premium or co/-%>+          
requirem5ts1 respectively1 t w\ld be    
applicable "u "p ,b1 = b5efits 9        
addition to ^? requir$ to be cov]$ "u ! 
,model2 &  7,,iii7 %all apply network   
/&>ds z def9$ by ! ,secret>y4  7iii7    
,promot+ access to high quality provid]s
 ,an ,organization (f]+ an ,,esrd       
,integrat$ ,c>e ,model may develop &    
implem5t p]=mance-bas$ inc5tives =      
provid]s ( s]vices & suppli]s to promote
 deliv]y ( high quality & effici5t c>e4 
,su* inc5tives %all be bas$ on cl9ical  
measures & non-cl9ical measures1 su* z )

 respect to notification ( pati5t       
dis*>ge f a hospital1 pati5t education  
7su* z ) respect to treatm5t options &  
nutrition71 & ! int]op]ability (        
electronic heal? records develop$ by an 
,organization accord+ to requirem5ts &  
/&>ds specifi$ by ! ,secret>y pursuant  
to subp>agraph 7,c74  7,c7 ,quality &   
report+ requirem5ts  7i7 ,cl9ical       
measures ,"u ! ,program1 ! ,secret>y    
%all-- 7,i7 require ea* p>ticipat+      
,organization to submit to ! ,secret>y  
data on cl9ical measures consi/5t ) ^?  
measures submitt$ by organizations      
p>ticipat+ 9 ! ,compreh5sive ,,esrd ,c>e
 ,initiative op]at$ by ! ,c5t] = ,m$ic>e
 & ,m$icaid ,innovation z ( ,octob] #a1 
#bjaf1 to assess ! quality ( c>e        
provid$2  7,,ii7 e/abli% requirem5ts =  
p>ticipat+ ,organizations to report to !
 ,secret>y1 9 a =m & mann] specifi$ by !
 ,secret>y1 in=mation on su* measures2 &
  7,,iii7 e/abli% quality p]=mance /&>ds
 on su* measures to assess ! quality (  
c>e4  7ii7 ,requirem5t = /akehold] input

 ,9 develop+ requirem5ts & /&>ds "u     
subclauses 7,,ii7 & 7,,iii7 ( clause    
7i71 ! ,secret>y %all reque/ & consid]  
input f a /akehold] bo>d1 at lea/ "o    
nephrologi/1 o!r suppli]s & provid]s (  
s]vices1 r5al dialysis facilities1 &    
b5efici>y advocates1 & respond 9 writ+  
to su* input4  7iii7 ,additional        
assessm5ts & report+ requirem5ts ,!     
,secret>y %all assess ! ext5t to :i* an 
,organization deliv]s integrat$ &       
pati5t-c5t]$ c>e ?r\gh analysis (       
in=mation obta9$ f ,program-eligible    
b5efici>ies enroll$ 9 ! ,organization   
?r\gh surveys1 su* z ! ,9-,c5t]         
,hemodialysis ,consum] ,assessm5t (     
,heal?c>e ,provid]s & ,sy/ems4  7,d7    
,requirem5ts = ,,esrd integrat$ c>e     
/rategy  7i7 ,9 g5]al ,an ,organization 
seek+ a contract "u ?is section to (f]  
"o or m ,,esrd ,integrat$ ,c>e ,models  
mu/ develop & submit = ! ,secret>y's    
approval1 subject to clause 7ii71 an    
,,esrd ,integrat$ ,c>e ,/rategy4  7ii7  
,,esrd integrat$ c>e /rategy ,9 assess+ 

an ,,esrd ,integrat$ ,c>e ,/rategy "u   
clause 7i71 ! ,secret>y %all consid] !  
ext5t to :i* ! ,/rategy includes        
elem5ts1 su* z ! foll[+3  7,i7          
,int]discipl9>y c>e teams l$ by at lea/ 
"o nephrologi/1 & compris$ ( regi/]$    
nurses1 social work]s1 r5al dialysis    
facility manag]s1 & o!r repres5tatives f
 alt]native sett+s describ$ 9 subclause 
7,,vi74  7,,ii7 ,heal? risk & o!r       
assessm5ts to det]m9e ! physical1       
psy*osocial1 nutrition1 language1       
cultural1 & o!r ne$s ( ,program-eligible
 b5efici>ies enroll$ 9 ! ,organization  
involv$4  7,,iii7 ,developm5t & at lea/ 
annual updat+ ( individualiz$ c>e plans 
t incorporate at lea/ ! m$ical1 social1 
& functional ne$s1 pref]5ces1 & c>e     
goals ( ,program-eligible b5efici>ies   
enroll$ 9 ! ,organization4  7,,iv7      
,coord9ation & deliv]y ( non-cl9ical    
s]vices1 su* z transportation1 aim$ at  
improv+ ! adh]5ce ( ,program-eligible   
b5efici>ies enroll$ 9 ! ,organization ) 
c>e recomm5dations4  7,v7 ,s]vices1 su* 

z transplant evaluation & vascul> access
 c>e4  7,,vi7 ,9 ! case ( an individuals
 :o1 :ile enroll$ 9 ! ,organization1    
receives confirmation t a kidney        
transplant is imm95t1 ! provision by an 
int]discipl9>y c>e team describ$ 9      
subclause 7,i7 ( c\nsel+ s]vices to su* 
individual on prep>ation = & pot5tial   
*all5ges surr\nd+ su* transplant4       
7,,vii7 ,deliv]y ( b5efits & s]vices 9  
alt]native sett+s1 su* z ! home ( !     
,program-eligible b5efici>y enroll$ 9 ! 
,organization1 9 coord9ation ) ! provid]
 or o!r appropriate /akehold] involv$ 9 
su* deliv]y s]v+ on an int]discipl9>y   
c>e team describ$ 9 subclause 7,i74     
7,,viii7 ,use ( pati5t rem9d] sy/ems4   
7,,ix7 ,education programs = pati5ts1   
families1 & c>egiv]s4  7,x7 ,use ( heal?
 c>e advice res\rces1 su* z nurse advice
 l9es4  7,,xi7 ,use ( team-bas$ heal?   
c>e deliv]y models t provide            
compreh5sive & cont9u\s m$ical c>e1 su* 
z m$ical homes4  7,,xii7 ,co-location ( 
provid]s & s]vices4  7,,xiii7 ,use ( a  

demon/rat$ capacity to %>e electronic   
heal? record in=mation across sites (   
c>e4  7,,xiv7 ,use ( programs to promote
 bett] adh]5ce to recomm5d$ treatm5t    
regim5s by individuals1 includ+ by      
address+ b>ri]s to access to c>e by su* 
individuals4  7,,xv7 ,o!r s]vices1      
/rategies1 & approa*es id5tifi$ by !    
,organization to improve c>e coord9ation
 & deliv]y4  7#c7 ,dialysis facility    
own]%ip requirem5t ,! ,secret>y %all    
ent] into contracts "u ?is section only 
) ,organizations t h at lea/ "o eligible
 p>ticipat+ provid] ) an own]%ip int]e/ 
9 a r5al dialysis facility 9 !          
,organization's s]vice area4  7#d7      
,requirem5t = capital res]ves  7,a7 ,9  
g5]al ,! ,secret>y %all ent] into       
contracts "u ?is section only )         
,organizations t demon/rate suffici5t   
capital res]ves1 measur$ z a p]c5tage ( 
capitat$ paym5ts & consi/5t )           
requirem5ts e/abli%$ by ! ,/ate 9 :i* ! 
,organization op]ates4  7,b7 ,alt]native
 me*anism to demon/rate capacity to be> 

risk ,an ,organization %all be consid]$ 
to meet ! requirem5t 9 subp>agraph 7,a7 
if ! ,organization includes at lea/ "o  
eligible p>ticipat+ provid] or eligible 
p>ticipat+ p>tn] t is lic5s$ z a        
risk-be>+ entity or deem$ by a ,/ate z  
able to be> risk4  7#e7                 
,non-,application ( c]ta9 provisions (  
law ,= purposes ( sections #afb7m77#f7 &
 #dad7m7 ( ! ,int]nal ,rev5ue ,code (   
#aihf & section #ijaj ( ! ,pati5t       
,protection & ,af=dable ,c>e ,act 7#bf  
,u4,s4,c4 #djja note prec471 9 ! case ( 
an eligible p>ticipat+ provid] t        
e/abli%es an ,organization or t ent]s   
into a p>tn]%ip1 own]%ip1 or co-own]%ip 
agreem5t to e/abli% an ,organization1 or
 an ,organization ) a contract "u ?is   
section1 risk-bas$ paym5ts 9 ex*ange =  
provid+ m$ical c>e %all n be consid]$   
premiums = heal? insurance cov]age4     
7#f7 ,treatm5t z ,m$ic>e advanc$        
alt]native paym5t model ,alt]native c>e 
deliv]y models "u ! ,program %all be    
treat$ "u ?is title z an advanc$        

alt]native paym5t model4  7c7 ,program  
op]ation & scope  7#a7 ,9 g5]al ,n lat] 
?an #f mon?s aft] ! date ( enactm5t (   
?is section1 ! ,secret>y %all e/abli% a 
process ?r\gh :i* an ,organization c    
apply to (f] "o or m ,,esrd ,integrat$  
,c>e ,models4 ,su* application %all     
include in=mation on at lea/ ! foll[+3  
7,a7 ,! e/imat$ av]age rev5ue am\nt     
describ$ 9 subsection                   
7b77#b77;,a77ii77,,ii7 = ! ,organization
 to deliv] b5efits describ$ 9 subsection
 7b77#b77;,a74  7,b7 ,any b5efits (f]$  
by ! ,organization beyond ^? describ$ 9 
su* subsection4  7,c7 ,a li/+ ( network 
provid]s ( s]vices & suppli]4  7,d7     
,in=mation on ! exp]tise ( network      
provid]s ( s]vices & suppli]s 9 s]v+    
,,esrd pati5ts4  7,e7 ,a description ( !
 ,,esrd ,integrat$ ,c>e ,/rategy ( !    
,organization describ$ 9 subsection     
7b77#b77;,d74  7#b7 ,program initiation 
,! ,secret>y %all initiate ! ,program   
su* t ,organizations beg9 s]v+          
,program-eligible b5efici>ies n lat] ?an

 ,janu>y #a1 #bjah4  7#c7 ,contract aw>d
 & p]iod ,! ,secret>y %all ent] into    
contracts = an initial p]iod ( n less   
?an #e ye>s ) all ,organizations t meet 
,program requirem5ts4  7#d7 ,program    
expansion ,! ,secret>y may exp& !       
duration & scope ( ! ,program "u ?is    
section1 to ! ext5t det]m9$ appropriate 
by ! ,secret>y1 if ! ,secret>y det]m9es 
t su* expansion w result 9 improv$      
quality ( c>e "u ! ,m$ic>e program "u   
?is title4  7#e7 ,all[ance = l>g] s]vice
 areas & expansion ( s]vice areas       
,organizations %all demon/rate 9 _!     
application t ! propos$ s]vice area has 
! capacity to s]ve ,program-eligible    
b5efici>ies ?r\gh an adequate provid]   
network & is reflective ( ! communities 
9 :i* b5efici>ies live1 "w1 & obta9     
heal? c>e s]vices4  7#f7 ,contract      
t]m9ation  7,a7 ,9 g5]al ,! ,secret>y   
may t]m9ate a contract ) an             
,organization "u ?is section if !       
,secret>y det]m9es t an ,organization   
has fail$ to meet quality requirem5ts   

describ$ 9 subsection 7b7 or violates   
o!r t]ms ( ! contract4  7,b7 ,rem$y &   
appeals process ,prior to ! ,secret>y   
t]m9at+ a contract ) an ,organization "u
 ?is section1 ! ,secret>y %all af=d su* 
,organization suffici5t opportunity to  
rem$y any contract violations & appeal a
 contract t]m9ation4  7,c7              
,program-eligible b5efici>y ,notice at  
,"t ( ,contract ,t]m9ation ,ea* contract
 "u ?is section ) an ,organization %all 
require ! ,organization to provide 7&   
pay =7 writt5 notice 9 advance ( !      
contract's t]m9ation1 z well z a        
description ( alt]natives = obta9+      
b5efits "u ?is title1 to ea*            
,program-eligible b5efici>y assign$ to  
or :o elect$ to receive b5efits ?r\gh ! 
,organization "u ?is section4  7d7      
,id5tification ( program-,eligible      
b5efici>ies ,! ,secret>y %all e/abli% a 
process = ! initial & ongo+             
id5tification ( ,program-eligible       
b5efici>ies t provides = ! id5tification
 ( ,program-eligible b5efici>ies by     

,organizations4  7e7 ,program-,eligible 
,b5efici>ies assign$ ,into an ,,esrd    
,integrat$ ,c>e ,organization ,op5      
,network ,model  7#a7 ,assignm5t  7,a7  
,9 g5]al ,"u ! ,program1 subject to !   
succe$+ provisions ( ?is p>agraph1 !    
,secret>y %all1 ^u ! ,secret>y or an    
,organization id5tify+ a b5efici>y z a  
,program-eligible b5efici>y1 assign su* 
,program-eligible b5efici>y to an op5   
network model (f]$ by an ,organization t
 includes ! dialysis facility at :i* !  
,program-eligible b5efici>y prim>ily    
receives r5al dialysis s]vices4  7,b7   
,program-eligible b5efici>y notification
 ( assignm5t  7i7 ,9 g5]al ,^u assignm5t
 ( a ,program-eligible b5efici>y to an  
,organization1 ! ,secret>y %all provide 
to ! ,organization writt5 notification (
 su* assignm5t ( su* ,program-eligible  
b5efici>y & n lat] ?an #ae bus9ess days 
aft] ! date ( receipt ( su*             
notification1 ! ,organization %all      
provide writt5 notice ( su* assignm5t to
 ! ,program-eligible b5efici>y4  7ii7   

,opt-out p]iod & *anges ^u initial      
assignm5t ,! ,secret>y %all provide = a 
#ge-;day p]iod beg9n+ on ! date on :i* !
 assignm5t ( a ,program-eligible        
b5efici>y into an op5 network model (f]$
 by an ,organization becomes effective  
dur+ :i* a ,program-eligible b5efici>y  
may--  7,i7 opt out ( ! ,program2       
7,,ii7 make a "o-"t *ange ( assignm5t   
into an op5 network model (f]$ by a     
diff]5t ,organization2 or  7,,iii7 elect
 a pref]r$ network model (f]$ by ! same 
or diff]5t ,organization4  7,c7 ,deem$  
re-enrollm5t ,a ,program-eligible       
b5efici>y assign$ "u ?is p>agraph to an 
,,esrd ,integrat$ ,c>e ,model (f]$ by an
 ,organization ) respect to a ye> is    
deem$1 unless ! individual elects       
o!rwise "u ?is p>agraph1 to h elect$ to 
cont9ue su* assignm5t ) respect to !    
subsequ5t ye>4  7,d7 ,additional        
opportunity to opt out or elect diff]5t 
model or organization ,on ! date t is "o
 ye> aft] ! effective date ( ! initial  
assignm5t ( a ,program-eligible         

b5efici>y to an op5 network model (f]$  
by an ,organization 7& annually         
!reaft]71 a ,program-eligible b5efici>y 
%all be giv5 ! opportunity to--  7i7 opt
 out ( ! ,program2  7ii7 make a "o-"t   
*ange ( assignm5t into an op5 network   
model (f]$ by a diff]5t ,organization2  
or  7iii7 elect a pref]r$ network model 
(f]$ by ! same or diff]5t ,organization4
  7,e7 ,*ange 9 pr9cipal diagnosis opt  
out ,9 addition to any o!r p]iod dur+   
:i* a ,program-eligible b5efici>y may1  
pursuant to ?is p>agraph1 opt out ( !   
,program1 9 ! case ( a ,program-eligible
 b5efici>y :o1 aft] assignm5t "u ?is    
p>agraph1 is diagnos$ ) a pr9cipal      
diagnosis 7z def9$ by ! ,secret>y7 o!r  
?an end-/age r5al disease1 su*          
individual %all be giv5 ! opportunity to
 opt out ( ! ,program dur+ su* p]iod z  
specifi$ by ! ,secret>y4  7,f7 ,special 
election p]iods ,! ,secret>y %all (f]   
,program-eligible b5efici>ies special   
election p]iods consi/5t ) ^? describ$ 9
 section #ahea7;e77#d74  7#b7           

,program-eligible b5efici>y notification
  7,a7 ,9 g5]al ,! ,secret>y %all notify
 ,program-eligible b5efici>ies ab\t !   
,program "u ?is section & provide !m )  
in=mation ab\t receiv+ b5efits "u ?is   
title ?r\gh an ,organization4  7,b7     
,requirem5ts ,not)/&+ any o!r provision 
( law1 subject to subp>agraph 7,c71 su* 
notification %all all[ = eligible       
p>ticipat+ provid]s t are "p ( an       
,organization to--  7i7 in=m            
,program-eligible b5efici>ies ab\t !    
,program2  7ii7 di/ribute ,program      
mat]ials to ,program-eligible           
b5efici>ies2 &  7iii7 assi/             
,program-eligible b5efici>ies 9 assess+ 
! options ( su* b5efici>ies "u !        
,program4  7,c7 ,limitation on          
unsolicit$ m>ket+  7i7 ,9 g5]al ,"u !   
,program1 an eligible p>ticipat+ provid]
 may n provide m>ket+ in=mation or      
mat]ials1 includ+ in=mation1 mat]ials1 &
 assi/ance describ$ 9 subp>agraph 7,b71 
to a ,program-eligible b5efici>y unless 
! ,program-eligible b5efici>y reque/s   

su* m>ket+ in=mation or mat]ials4  7ii7 
,exception = provid]s treat+ b5efici>ies
 ,an eligible p>ticipat+ provid] t is "p
 ( an ,organization may provide         
in=mation1 mat]ials1 & assi/ance        
describ$ 9 subp>agraph 7,b7 to a        
,program-eligible b5efici>y1 )\t prior  
reque/ ( su* b5efici>y1 if su* b5efici>y
 is receiv+ r5al dialysis s]vices f su* 
provid]4  7#c7 ,program-eligible        
b5efici>y protections ,program-eligible 
b5efici>ies enroll$ 9 an ,organization  
%all h ! same "r to appeal any d5ial (  
b5efits "u ?is title z su* a            
,program-eligible b5efici>y w\ld h "u   
?is title if su* ,program-eligible      
b5efici>y 7 n s enroll$4  7f7 ,paym5t   
7#a7 ,9 g5]al ,= ea* ,program-eligible  
b5efici>y receiv+ c>e ?r\gh an          
,organization1 ! ,secret>y %all make a  
mon?ly capitat$ paym5t equal to ! am\nt 
t w\ld be det]m9$ "u section            
#ahec7;a77#a77;,h74  7#b7 ,application (
 heal? /atus risk adju/m5t me?odology ,!
 ,secret>y %all adju/ ! paym5t am\nt to 

an ,organization "u ?is subsection 9 !  
same mann] 9 :i* ! paym5t am\nt to a    
,m$ic>e ,advantage plan is adju/$ "u    
section #ahec7;a77#a77;,c74  7#c7       
,paym5t = "p ,d b5efits ,9 ! case :]e an
 ,organization elects to (f] "p ,d      
prescription drug cov]age "u ! ,program 
"u ?is section1 paym5ts to !            
,organization = su* b5efits provid$ to  
,program-eligible b5efici>ies by !      
,organization %all be made 9 ! same     
mann] & am\nt z ^? paym5ts w\ld be made 
9 ! case ( an ,organization ) a contract
 "u su* "p4  7#d7 ,agreem5t ) ,/ate     
,m$icaid ,ag5cy ,9 ! ev5t ( an          
,organization t elects to cov] b5efits  
"u title ,,xix = ,program-eligible      
b5efici>ies eligible = b5efits "u ?is   
title & title ,,xix su* ,organization   
%all ent] into an agreem5t ) ! ,/ate    
,m$icaid ag5cy to provide b5efits1 or   
arrange = b5efits to be provid$1 = :i*  
su* b5efici>ies are entitl$ to receive  
m$ical assi/ance "u title ,,xix & to    
receive paym5t f ! ,/ate = provid+ or   

arrang+ = ! provision ( su* b5efits4    
7#e7 ,affirmation ( ,/ate obligations to
 pay premium & co/-%>+ am\nts  7,a7 ,9  
g5]al ,a ,/ate %all cont9ue to make     
m$ical assi/ance "u ! ,/ate plan "u     
title ,,xix available 9 ! am\nt describ$
 9 subp>agraph 7,b7 = ! duration ( !    
,program = co/-%>+ 7z def9$ 9 section   
#aije7p77#c77 "u ?is title = qualifi$   
m$ic>e b5efici>ies describ$ 9 section   
#aije7p77#a7 & o!r individuals :o are   
,program-eligible b5efici>ies enroll$ 9 
an ,organization & entitl$ to m$ical    
assi/ance = premiums & su* co/-%>+ "u ! 
,/ate plan "u title ,,xix4  7,b7 ,am\nts
 made available = co/-%>+ ,= purposes ( 
subp>agraph 7,a73 7i7 ,9 g5]al ,subject 
to clause 7ii71 ! am\nt ( m$ical        
assi/ance describ$ 9 ?is clause to be   
made available = co/-%>+ pursuant to    
subp>agraph 7,a7 = an individual        
describ$ 9 su* subp>agraph entitl$ to   
m$ical assi/ance = su* co/-%>+ "u a     
,/ate plan "u title ,,xix %all be equal 
to ! am\nt ( m$ical assi/ance t w\ld be 

made available "u su* ,/ate plan z 9    
effect z ( ,janu>y #a1 #bjaf4  7ii7     
,am\nts 9 ! case ( a ,/ate t increases  
paym5ts = co/-%>+ ,if a ,/ate increases 
! am\nt ( m$ical assi/ance made         
available "u ! ,/ate plan "u title ,,xix
 = co/-%>+ describ$ 9 subp>agraph 7,a7  
aft] su* date1 su* increas$ am\nts %all 
be made available "u subp>agraph 7,a7 = 
! rema9+ duration ( ! ,program4  7g7    
,waiv] au?ority  7#a7 ,9 g5]al ,9 ord]  
to c>ry out ! ,program "u ?is section1 !
 ,secret>y %all waive ^? requirem5ts    
waiv$ "u section #ahii & may waive su*  
additional requirem5ts consi/5t ) ^?    
waiv$ "u programs adm9i/]$ ?r\gh ! ,c5t]
 = ,m$ic>e & ,m$icaid ,innovation z may 
be necess>y4  7#b7 ,notice ( waiv]s ,n  
lat] ?an #c mon?s aft] ! date ( enactm5t
 ( ?is section1 ! ,secret>y %all publi% 
a notice ( waiv]s t w apply 9 connection
 ) ! ,program4 ,! notice %all include ! 
specific conditions t an ,organization  
mu/ meet to qualify = ea* waiv]1 &      
comm5t>y expla9+ ! waiv] requirem5ts4  4