,,ii #aaeth ,,congress #ast ,session ,s4 #bjfe ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,november #b1 #bjag,mr4 ,young 7for himself1 ,mr4 ,nelson1 ,mr4 ,heller1 and ,mr4 ,bennet7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to establish a demonstration program to provide integrated care for ,medicare beneficiaries with end-stage renal disease1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,dialysis ,patient ,access ,to ,integrated-care1 ,empowerment1 ,nephrologists1 ,treatment1 and ,services ,demonstration ,act of #bjag or the ,dialysis ,,patients ,demonstration ,act of #bjag4 #b4 ,demonstration program to provide integrated care for ,medicare beneficiaries with end-stage renal disease 7a7 ,in general ,title ,,xviii of the ,social ,security ,act is amended by inserting after section #ahff;,e the following new section3 #ahff;,f4 ,demonstration program to provide integrated care for ,medicare beneficiaries with end-stage renal disease 7a7 ,establishment 7#a7 ,in general ,the ,secretary shall conduct under this section the ,,esrd ,integrated ,care ,demonstration ,program 7in this section referred to as the ,program7 which is voluntary for patients and providers to assess the effects of alternative care delivery models and payment methodologies on patient care improvements under this title for ,program-eligible beneficiaries 7as defined in paragraph 7#b774 ,under the ,program-- 7,a7 ,program-eligible beneficiaries shall be considered enrolled under the original ,medicare fee-for-service program under parts ,a and ,b2 7,b7 eligible participating providers 7as defined in such paragraph7 may form an ,,esrd ,integrated ,care ,organization 7in this section referred to as an ,organization72 and 7,c7 an ,organization shall integrate care and serve as the medical home under the original ,medicare fee-for-service program under parts ,a and ,b for ,program-eligible beneficiaries4 7#b7 ,definitions ,in this section3 7,a7 ,eligible participating provider ,the term eligible participating provider means the following3 7i7 ,a facility certified as a renal dialysis facility under this title4 7ii7 ,a dialysis organization that owns one or more of such facilities described in clause 7i74 7iii7 ,a nephrologist or nephrology practice4 7iv7 ,any other physician group practice or a group of affiliated physicians or providers4 7,b7 ,eligible participating partner ,the term eligible participating partner means1 with respect to an ,organization1 the following3 7i7 ,a ,medicare ,advantage plan described in section #ahea7;a77#b7 or a ,medicare ,advantage organization offering such a plan4 7ii7 ,a prescription drug plan 7as defined in section #ahfj;,d-#da7;a77#ad774 7iii7 ,a ,medicaid managed care organization 7as defined in section #aijc7m774 7iv7 ,an entity that is able to bear risk as deemed by a ,state1 including public medical educational institutions experienced in the care of patients receiving dialysis1 and that chooses to bear risk as a condition of partnership in such organization4 7v7 ,a third-party administrator organization4 7,c7 ,program-eligible beneficiary ,the term ,program-eligible beneficiary means1 with respect to an ,organization offering an ,,esrd ,integrated ,care ,model1 an individual entitled to benefits under part ,a and enrolled under part ,b who-- 7i7 is identified by the ,secretary or the ,organization as receiving renal dialysis services under the original ,medicare fee-for-service program under parts ,a and ,b2 7ii7 resides in the service area of such ,organization2 7iii7 receives renal dialysis services primarily from a facility that participates in such ,organization2 and 7iv7 has not received a successful kidney transplant or has experienced a failed kidney transplant4 7b7 ,,esrd integrated care organization eligibility requirements 7#a7 ,organizations 7,a7 ,in general ,one or more eligible participating providers may establish an ,organization or may enter into1 subject to subparagraph 7,b71 one or more partnership1 ownership1 or co-ownership agreements with one or more eligible participating partners to establish an ,organization4 7,b7 ,limitation on number of agreements ,the ,secretary may specify a limitation on the number of ,organizations in which an eligible participating partner may participate under agreements described in subparagraph 7,a74 7#b7 ,,esrd integrated care model 7,a7 ,benefits requirements 7i7 ,in general ,subject to clause 7iii71 an ,organization shall offer at least one ,,esrd ,integrated ,care ,model that is an open network model 7as described in subparagraph 7,b77i77 in each of its service areas and may offer one or more ,,esrd ,integrated ,care ,models that is a preferred network model 7as described in subparagraph 7,b77ii77 in each of its service areas4 ,for purposes of this section an ,,esrd ,integrated ,care ,model 7in this section referred to as the ,model71 subject to subsection 7f77#c77;,b7-- 7,i7 shall cover all benefits under parts ,a and ,b 7other than hospice care7 and include benefits for transition 7particularly including education7 into transplantation1 palliative care1 or hospice2 and 7,,ii7 may1 through a partnership or other agreement with an ,,ma-,,pd plan under part ,c or prescription drug plan under part ,d1 cover all prescription drug benefits under such part ,d4 7ii7 ,treatment of savings 7,i7 ,in general ,any ,organization offering an ,,esrd ,integrated ,care ,model shall provide for the return under subclause 7,,iv7 to a ,program-eligible beneficiary enrolled in the ,organization of the amount1 if any1 by which the payment amount described in subclause 7,,iii7 with respect to the ,program-eligible beneficiary for a year exceeds the revenue amount described in subclause 7,,ii7 with respect to the ,program-eligible beneficiary for the year4 7,,ii7 ,revenue amount described ,the revenue amount described in this subclause1 with respect to an ,organization offering an ,,esrd ,integrated ,care ,model and a ,program-eligible beneficiary enrolled in such ,organization1 is the ,organization's estimated average revenue requirements1 including administrative costs and return on investment1 for the ,organization to provide the benefits described in clause 7i7 under the ,model for the ,program-eligible beneficiary for the year4 7,,iii7 ,payment amount described ,the payment amount described in this subclause1 with respect to an ,organization offering an ,,esrd ,integrated ,care ,model and a ,program-eligible beneficiary enrolled in such ,organization1 is the payment amount to the ,organization under subsection 7f77#a7 made with respect to the ,program-eligible beneficiary for the year4 7,,iv7 ,means of returning savings to program-eligible beneficiaries enrolled in ,organizations ,an ,organization shall return the amount under subclause 7,i7 to a ,program-eligible beneficiary enrolled in the ,organization in a manner specified by the ,organization1 which may include1 as applicable1 cost-sharing lower than otherwise applicable1 benefits not covered under the original ,medicare fee-for-service program 7including preventive services related to chronic kidney disease and education surrounding the importance of transplantation71 or financial incentives 7such as reduced cost sharing7 for ,program-eligible beneficiaries enrolled in the ,organization to promote the delivery of high-value and efficient care and services4 7iii7 ,benefit requirements for dual eligibles ,in the case of a ,program-eligible beneficiary who is eligible for benefits under this title and title ,,xix1 an ,organization1 in accordance with an agreement entered into under subsection 7f77#d7-- 7,i7 may be responsible for providing1 or arranging for the provision of1 all benefits 7other than long-term services and supports7 for which the ,program-eligible beneficiary is eligible for under the ,state ,medicaid program under title ,,xix in which the ,program-eligible beneficiary is enrolled2 and 7,,ii7 may elect to provide1 or arrange for the provision of1 long-term services and supports available to the ,program-eligible beneficiary under the ,state ,medicaid program1 including services related to the transition into palliative care or hospice4 7,b7 ,requirements for open network and preferred network models 7i7 ,open network model ,under an ,,esrd ,integrated ,care ,model offered by an ,organization that is an open network model1 the ,organization shall-- 7,i7 allow ,program-eligible beneficiaries to receive such covered benefits from any provider of services or supplier regardless of whether such provider is within the network assembled under clause 7ii77,i72 7,,ii7 pay any ,medicare-certified provider or supplier that is not within the network assembled under subclause 7,i7 for such covered benefits an amount equal to the amount the provider or supplier would otherwise receive under this title2 and 7,,iii7 not apply any additional premium or cost sharing requirements for such covered benefits in addition to premium or cost sharing requirements1 respectively1 that would be applicable under part ,a or part ,b for such benefits4 7ii7 ,preferred network model ,under an ,,esrd ,integrated ,care ,model offered by an ,organization that is a preferred network model1 the ,organization-- 7,i7 shall assemble a network of providers of services and suppliers identified by the ,organization and confirmed by the ,secretary as including providers of services and suppliers with significant expertise in caring for individuals with end-stage renal disease through which ,program-eligible beneficiaries shall receive covered benefits as described in subparagraph 7,a7 that are required to be covered under the ,model2 7,,ii7 shall provide for payment for items and services furnished by providers of services and suppliers within such network to ,program-eligible beneficiaries enrolled in such ,organization in accordance with payment rates determined pursuant to an agreement entered into between the ,organization and such providers of services and suppliers and shall provide for payment for items and services furnished by providers of services and suppliers not within such network to such beneficiaries so enrolled in accordance that would be determined under section #ahec7;a77#a77;,h72 7,,iii7 may apply premium and cost-sharing requirements1 in addition to premium or cost-sharing requirements1 respectively1 that would be applicable under part ,b1 for benefits in addition to those required to be covered under the ,model2 and 7,,iv7 shall apply network standards as defined by the ,secretary4 7iii7 ,promoting access to high-quality providers ,an ,organization offering an ,,esrd ,integrated ,care ,model may develop and implement performance-based incentives for providers of services and suppliers to promote delivery of high quality and efficient care4 ,such incentives shall be based on clinical measures and non-clinical measures1 such as with respect to notification of patient discharge from a hospital1 patient education 7such as with respect to treatment options1 including chronic kidney disease maintenance1 and nutrition71 and the interoperability of electronic health records developed by an ,organization according to requirements and standards specified by the ,secretary pursuant to subparagraph 7,c74 7iv7 ,application of ,medicare advantage requirement with respect to ,medicare services furnished by out-of-network providers and suppliers 7,i7 ,in general ,section #aheb7k77#a7 7relating to limitations on balance billing against ,,ma organizations for noncontract physicians and other entities with respect to services covered under this title7 shall apply to ,organizations1 ,program-eligible beneficiaries enrolled in such ,organizations1 and physicians and other entities that do not have a contract or other agreement with the ,organization establishing payment amounts for services furnished to such a beneficiary in the same manner as such section applies to ,,ma organizations1 individuals enrolled with such organizations1 and physicians and other entities referred to in such section4 7,,ii7 ,reference for additional provision ,for the provision relating to limitations on balance billing against ,organizations for services covered under this title furnished by noncontract providers of services and suppliers1 see section #ahff7;a77#a77,o74 7,c7 ,quality and reporting requirements 7i7 ,clinical measures ,under the ,program1 the ,secretary shall-- 7,i7 require each participating ,organization to submit to the ,secretary data on clinical measures consistent with those measures submitted by organizations participating in the ,comprehensive ,,esrd ,care ,initiative operated by the ,center for ,medicare and ,medicaid ,innovation as of ,october #a1 #bjaf1 to assess the quality of care provided2 7,,ii7 establish requirements for participating ,organizations to report to the ,secretary1 in a form and manner specified by the ,secretary1 information on such measures2 and 7,,iii7 establish quality performance standards on such measures to assess the quality of care4 7ii7 ,requirement for stakeholder input ,in developing requirements and standards under subclauses 7,,ii7 and 7,,iii7 of clause 7i71 the ,secretary shall request and consider input from a stakeholder board1 at least one nephrologist1 other suppliers and providers of services1 renal dialysis facilities1 and beneficiary advocates4 7iii7 ,additional assessments and reporting requirements ,the ,secretary shall assess the extent to which an ,organization delivers integrated and patient-centered care through analysis of information obtained from ,program-eligible beneficiaries enrolled in the ,organization through surveys1 such as the ,in-,center ,hemodialysis ,consumer ,assessment of ,healthcare ,providers and ,systems4 7,d7 ,requirements for esrd integrated care strategy 7i7 ,in general ,an ,organization seeking a contract under this section to offer one or more ,,esrd ,integrated ,care ,models must develop and submit for the ,secretary's approval1 subject to clauses 7ii7 and 7iii71 an ,,esrd ,integrated ,care ,strategy4 7ii7 ,,esrd integrated care strategy ,in assessing an ,,esrd ,integrated ,care ,strategy under clause 7i71 the ,secretary shall consider the extent to which the ,strategy includes elements1 such as the following3 7,i7 ,interdisciplinary care teams led by at least one nephrologist1 and comprised of registered nurses1 social workers1 renal dialysis facility managers1 and other representatives from alternative settings described in subclause 7,,viii74 7,,ii7 ,a decision process for care plans and care management that includes the nephrologist and other practitioners responsible for direct delivery of care to ,program-eligible beneficiaries enrolled in the ,organization involved4 7,,iii7 ,health risk and other assessments to determine the physical1 psychosocial1 nutrition1 language1 cultural1 and other needs of ,program-eligible beneficiaries enrolled in the ,organization involved4 7,,iv7 ,development and at least annual updating of individualized care plans that incorporate at least the medical1 social1 and functional needs1 preferences1 and care goals of ,program-eligible beneficiaries enrolled in the ,organization4 7,v7 ,coordination and delivery of non-clinical services1 such as transportation1 aimed at improving the adherence of ,program-eligible beneficiaries enrolled in the ,organization with care recommendations4 7,,vi7 ,services1 such as transplant evaluation1 palliative care1 evaluation for hospice eligibility1 and vascular access care4 7,,vii7 ,in the case of an individual who1 while enrolled in the ,organization1 receives confirmation that a kidney transplant is imminent1 the provision by an interdisciplinary care team described in subclause 7,i7 of counseling services to such individual on preparation for and potential challenges surrounding such transplant4 7,,viii7 ,delivery of benefits and services in alternative settings1 such as the home of the ,program-eligible beneficiary enrolled in the ,organization1 in coordination with the provider or other appropriate stakeholder involved in such delivery serving on an interdisciplinary care team described in subclause 7,i74 7,,ix7 ,use of patient reminder systems4 7,x7 ,education programs for patients1 families1 and caregivers4 7,,xi7 ,use of health care advice resources1 such as nurse advice lines4 7,,xii7 ,use of team-based health care delivery models that provide comprehensive and continuous medical care1 such as medical homes4 7,,xiii7 ,co-location of providers and services4 7,,xiv7 ,use of a demonstrated capacity to share electronic health record information across sites of care4 7,,xv7 ,use of programs to promote better adherence to recommended treatment regimens by individuals1 including by addressing barriers to access to care by such individuals4 7,,xvi7 ,defined protocols to facilitate the transition of pediatric patients into adult end stage renal disease care1 developed in conjunction with the pediatric nephrology community4 7,,xvii7 ,other services1 strategies1 and approaches identified by the ,organization to improve care coordination and delivery4 7iii7 ,requirements ,the ,secretary may not approve an ,,esrd ,integrated ,care ,strategy of an ,organization unless under such ,strategy the ,organization-- 7,i7 provides services to ,program-eligible beneficiaries enrolled in the ,organization through a comprehensive1 multidisciplinary health and social services delivery system which integrates acute and long-term care services pursuant to regulations2 7,,ii7 specifies the covered items and services that will not be provided directly by the ,organization1 and to arrange for delivery of those items and services through contracts meeting the requirements of regulations2 and 7,,iii7 establishes a governing body that-- 7aa7 consists of representation from each eligible participating provider of such ,organization2 7bb7 includes at least one nephrologist who may be affiliated with a participating provider in the preferred network1 at least one nephrologist in the open network1 and at least one beneficiary advocate2 and 7cc7 has responsibility for the oversight of the activities of the ,organization4 7#c7 ,requirement for capital reserves 7,a7 ,in general ,the ,secretary shall enter into contracts under this section only with ,organizations that demonstrate sufficient capital reserves1 measured as a percentage of capitated payments and consistent with requirements established by the ,state in which the ,organization operates4 7,b7 ,alternative mechanism to demonstrate capacity to bear risk ,an ,organization shall be considered to meet the requirement in subparagraph 7,a7 if the ,organization includes at least one eligible participating provider or eligible participating partner that-- 7i7 is licensed as a risk-bearing entity or deemed by a ,state as able to bear risk2 and 7ii7 chooses to bear risk as a condition of partnership in such ,organization4 7#d7 ,beneficiary protections 7,a7 ,seamless access to care ,the ,secretary shall establish processes and take steps as necessary1 including educating ,medicare-certified providers and suppliers about the ,program1 to ensure that ,program-eligible beneficiaries assigned into an open network model or who elect into a preferred network model offered by an ,organization experience no disruption of access to ,medicare-certified providers or suppliers furnishing items or services to such beneficiary immediately before such assignment or election and for purposes of receipt of such items or services4 ,assignment into an open network model or election into a preferred network model under the ,program shall in no way be construed as affecting a ,program-eligible beneficiary's ability to receive covered benefits from any ,medicare-certified provider or supplier as described in subsection 7b77#b77;,a74 7,b7 ,continuity of care ,to provide for continuity of care1 each contract entered into with an ,organization under this section shall provide for a transition period during which a ,program-eligible beneficiary who is first enrolled in the ,organization or who elects to opt out of the ,program or otherwise disenroll from the ,organization maintains access to eligible participating providers furnishing items or services to such beneficiary immediately before such enrollment or election for purposes of receipt of such items or services4 ,payment for such items or services covered under this title furnished to such ,program-eligible beneficiary during such transition period shall be made in accordance with this title and in such amounts as would otherwise be determined for such items and services provided to such a beneficiary not enrolled under the ,program4 7,c7 ,antidiscrimination ,each contract entered into with an ,organization under this section shall provide that each eligible participating provider of such ,organization may not deny1 limit1 or condition the furnishing of services1 or affect the quality of services furnished1 under this title to ,program-eligible beneficiaries on whether or not such a beneficiary is enrolled with the ,organization4 7,d7 ,quality assurance2 patient safeguards ,each contract entered into with an ,organization under this section shall require that such ,organization have in effect at a minimum-- 7i7 a written plan of quality assurance and improvement1 and procedures implementing such plan1 in accordance with regulations2 and 7ii7 written safeguards of the rights of ,program-eligible beneficiaries enrolled in the ,organization 7including a patient bill of rights and procedures for grievances and appeals7 in accordance with regulations and with other requirements of this title and ,federal and ,state law that are designed for the protection of patients4 7,e7 ,oversight ,the ,secretary shall oversee the marketing and assignment practices of each ,organization entering into a contract under this section as part of the approval and renewal processes of ,organizations under this section4 7#e7 ,non-,application of certain provisions of law ,for purposes of sections #afb7m77#f7 and #dad7m7 of the ,internal ,revenue ,code of #aihf and section #ijaj of the ,patient ,protection and ,affordable ,care ,act 7#bf ,u4,s4,c4 #djja note prec471 in the case of an eligible participating provider that establishes an ,organization or that enters into a partnership1 ownership1 or co-ownership agreement to establish an ,organization1 or an ,organization with a contract under this section1 risk-based payments in exchange for providing medical care shall not be considered premiums for health insurance coverage4 7#f7 ,treatment as ,medicare advanced alternative payment model ,alternative care delivery models under the ,program shall be treated under this title as an advanced alternative payment model4 7c7 ,program operation and scope 7#a7 ,in general ,not later than one year after the date of enactment of this section1 the ,secretary shall establish a process through which an ,organization can apply to offer one or more ,,esrd ,integrated ,care ,models4 ,such application shall include information on at least the following3 7,a7 ,the estimated average revenue amount described in subsection 7b77#b77;,a77ii77,,ii7 for the ,organization to deliver benefits described in subsection 7b77#b77;,a74 7,b7 ,any benefits offered by the ,organization beyond those described in such subsection4 7,c7 ,a listing of network providers of services and supplier4 7,d7 ,information on the expertise of network providers of services and suppliers in serving ,,esrd patients4 7,e7 ,a description of the ,,esrd ,integrated ,care ,strategy of the ,organization described in subsection 7b77#b77;,d74 7#b7 ,program initiation ,the ,secretary shall initiate the ,program such that ,organizations begin serving ,program-eligible beneficiaries not later than ,january #a1 #bjai4 7#c7 ,contract award and period ,the ,secretary shall enter into contracts for an initial period of not less than #e years with all ,organizations that meet ,program requirements4 7#d7 ,allowance for larger service areas and expansion of service areas ,organizations shall demonstrate in their application that the proposed service area has the capacity to serve ,program-eligible beneficiaries through an adequate provider network and is reflective of the communities in which beneficiaries live1 work1 and obtain health care services4 7#e7 ,contract termination and suspension 7,a7 ,in general ,the ,secretary may terminate a contract with an ,organization under this section if the ,secretary determines that an ,organization has failed to meet quality requirements described in subsection 7b7 or 7e77#b77;,c77iii7 or violates other terms of the contract4 7,b7 ,insufficient beneficiary participation ,the ,secretary shall1 in the case of an ,organization with a contract under this section with respect to which1 for any period of at least #cj consecutive days during a year for which such contract applies1 fewer than #ej percent of the total number of ,program-eligible beneficiaries served by the ,organization receive benefits through the ,organization under this section-- 7i7 suspend such contract for the remainder of such year2 and 7ii7 provide for the ,organization to return any prospective payments made to the ,organization under this section for items and services not provided pursuant to clause 7i74 7,c7 ,remedy and appeals process ,prior to the ,secretary terminating or suspending a contract with an ,organization under this section1 the ,secretary shall afford such ,organization sufficient opportunity to remedy any contract violations and appeal a contract termination4 7,d7 ,program-eligible beneficiary ,notice at ,time of ,contract ,termination ,each contract under this section with an ,organization shall require the ,organization to provide 7and pay for7 written notice in advance of the contract's termination or suspension1 as well as a description of alternatives for obtaining benefits under this title1 to each ,program-eligible beneficiary assigned to or who elected to receive benefits through the ,organization under this section4 7#f7 ,program expansion ,the ,secretary may1 through rulemaking1 expand the duration and scope of the ,program under this section1 to the extent determined appropriate by the ,secretary1 if-- 7,a7 the ,secretary determines that such expansion is expected to-- 7i7 reduce spending under this title without reducing the quality of patient care2 or 7ii7 improve the quality of patient care without increasing spending under this title2 7,b7 the ,chief ,actuary of the ,centers for ,medicare ,medicaid ,services certifies that such expansion would reduce 7or would not result in any increase in7 net program spending under this title2 and 7,c7 the ,secretary determines that such expansion would not deny or limit the coverage or provision of benefits under this title for applicable individuals4 7#g7 ,study ,the ,secretary shall conduct a study on an appropriate payment adjustor under the ,program to ensure there are not disincentives in under the payment method under the ,program from providing proper transplant evaluations4 7d7 ,identification of program-,eligible beneficiaries ,the ,secretary shall establish a process for the initial and ongoing identification of ,program-eligible beneficiaries4 7e7 ,program-,eligible ,beneficiaries assigned ,into an ,,esrd ,integrated ,care ,organization ,open ,network ,model 7#a7 ,assignment 7,a7 ,in general ,under the ,program1 subject to the succeeding provisions of this paragraph1 the ,secretary shall1 upon the ,secretary identifying a beneficiary as a ,program-eligible beneficiary1 assign all such ,program-eligible beneficiary to an open network model offered by an ,organization that includes the dialysis facility at which the ,program-eligible beneficiary primarily receives renal dialysis services4 7,b7 ,program-eligible beneficiary notification of assignment 7i7 ,in general ,upon assignment of a ,program-eligible beneficiary to an ,organization1 the ,secretary shall provide to the ,organization written notification of such assignment of such ,program-eligible beneficiary and not later than #ae business days after the date of receipt of such notification1 the ,organization shall provide written notice to the ,program-eligible beneficiary-- 7,i7 of such assignment2 and 7,,ii7 including education regarding the importance of transplantation as the best health outcome1 as well as the minimum health requirements for transplant eligibility before and during dialysis treatment4 7ii7 ,opt-out period and changes upon initial assignment ,the ,secretary shall provide for a #ge-;day period beginning on the date on which the assignment of a ,program-eligible beneficiary into an open network model offered by an ,organization becomes effective during which a ,program-eligible beneficiary may-- 7,i7 opt out of the ,program2 7,,ii7 make a one-time change of assignment into an open network model offered by a different ,organization2 or 7,,iii7 elect a preferred network model offered by the same or different ,organization4 7,c7 ,additional opt-in population in case of beneficiary relocation or choice ,an individual who1 without application of clause 7iv7 of subsection 7a77#b77;,c71 would be treated as a ,program-eligible beneficiary1 may elect to enroll in an ,organization under the ,program under this section if such individual agrees to receive renal dialysis services primarily from a facility that participates in such ,organization4 ,for purposes of this section 7other than subparagraphs 7,a7 and 7,b7 of this paragraph1 paragraph 7#b71 and subsection 7d71 an individual making an election pursuant to the previous sentence shall be treated as a ,program-eligible beneficiary4 7,d7 ,deemed re-enrollment ,a ,program-eligible beneficiary assigned under this paragraph to an ,,esrd ,integrated ,care ,model offered by an ,organization with respect to a year is deemed1 unless the individual elects otherwise under this paragraph1 to have elected to continue such assignment with respect to the subsequent year4 7,e7 ,additional opportunity to opt out or elect different model or organization ,on the date that is one year after the effective date of the initial assignment of a ,program-eligible beneficiary to an open network model offered by an ,organization 7and annually thereafter71 a ,program-eligible beneficiary shall be given the opportunity to-- 7i7 opt out of the ,program2 7ii7 make a one-time change of assignment into an open network model offered by a different ,organization2 or 7iii7 elect a preferred network model offered by the same or different ,organization4 7,f7 ,change in principal diagnosis opt out ,in addition to any other period during which a ,program-eligible beneficiary may1 pursuant to this paragraph1 opt out of the ,program1 in the case of a ,program-eligible beneficiary who1 after assignment under this paragraph1 is diagnosed with a principal diagnosis 7as defined by the ,secretary7 other than end-stage renal disease1 such individual shall be given the opportunity to opt out of the ,program during such period as specified by the ,secretary4 7,g7 ,special election periods ,the ,secretary shall offer ,program-eligible beneficiaries special election periods consistent with those described in section #ahea7;e77#d74 7#b7 ,program-eligible beneficiary notification 7,a7 ,in general ,the ,secretary shall notify ,program-eligible beneficiaries about the ,program under this section and provide them with information about receiving benefits under this title through an ,organization4 7,b7 ,requirements ,notwithstanding any other provision of law1 subject to subparagraph 7,c71 such notification shall allow for eligible participating providers that are part of an ,organization to-- 7i7 inform ,program-eligible beneficiaries about the ,program2 7ii7 distribute ,program materials to ,program-eligible beneficiaries2 and 7iii7 assist ,program-eligible beneficiaries in assessing the options of such beneficiaries under the ,program4 7,c7 ,limitation on unsolicited marketing 7i7 ,in general ,under the ,program1 an eligible participating provider may not provide marketing information or materials1 including information1 materials1 and assistance described in subparagraph 7,b71 to a ,program-eligible beneficiary unless the ,program-eligible beneficiary requests such marketing information or materials4 7ii7 ,exception for providers treating beneficiaries ,an eligible participating provider that is part of an ,organization may provide information1 materials1 and assistance described in subparagraph 7,b7 to a ,program-eligible beneficiary1 without prior request of such beneficiary1 if such beneficiary is receiving renal dialysis services from such provider4 7iii7 ,parity in marketing ,in any case that an ,organization participates in any form of marketing1 such form of marketing shall be the same for all ,program-eligible beneficiaries to which1 pursuant to 7ii71 the ,organization may provide information1 materials1 and assistance described in such clause4 7#c7 ,program-eligible beneficiary appeal rights ,program-eligible beneficiaries enrolled in an ,organization shall have the same right to appeal any denial of benefits under this title as such a ,program-eligible beneficiary would have under this title if such ,program-eligible beneficiary were not so enrolled4 7f7 ,payment 7#a7 ,in general ,for each ,program-eligible beneficiary receiving care through an ,organization1 the ,secretary shall make a monthly capitated payment in accordance with payment rates that would be determined under section #ahec7;a77#a77;,h71 as adjusted pursuant to paragraph 7#b74 7#b7 ,application of health status risk adjustment methodology ,the ,secretary shall adjust the payment amount to an ,organization under this subsection in the same manner in which the payment amount to a ,medicare ,advantage plan is adjusted under section #ahec7;a77#a77;,c74 7#c7 ,treatment of kidney acquisition costs 7,a7 ,excluding costs for kidney acquisitions from ma benchmark ,the ,secretary shall adjust the payment amount to an ,organization to exclude from such payment amount the ,secretary's estimate of the standardized costs for payments for organ acquisitions for kidney transplants in the area involved for the year4 7,b7 ,,ffs coverage of kidney acquisitions ,an ,organization shall provide all benefits described in subclause 7,i7 of subsection 7b77#b77;,a77i71 except for kidney acquisition costs4 ,payment for kidney acquisition costs covered under this title furnished to a ,program-eligible beneficiary shall be made in accordance with this title and in such amounts as would otherwise be made and determined for such items and services provided to such a beneficiary not enrolled under the ,program4 7#d7 ,payment for part ,d benefits ,in the case where an ,organization elects to offer part ,d prescription drug coverage under the ,program under this section1 payments to the ,organization for such benefits provided to ,program-eligible beneficiaries by the ,organization shall be made in the same manner and amounts as those payments would be made in the case of an organization with a contract under such part4 7#e7 ,agreement with ,state ,medicaid ,agency ,in the event of an ,organization that elects to cover benefits under title ,,xix for ,program-eligible beneficiaries eligible for benefits under this title and title ,,xix such ,organization shall enter into an agreement with the ,state ,medicaid agency to provide benefits1 or arrange for benefits to be provided1 for which such beneficiaries are entitled to receive medical assistance under title ,,xix and to receive payment from the ,state for providing or arranging for the provision of such benefits4 7#f7 ,affirmation of ,state obligations to pay premium and cost-sharing amounts 7,a7 ,in general ,a ,state shall continue to make medical assistance under the ,state plan under title ,,xix available in the amount described in subparagraph 7,b7 for the duration of the ,program for cost-sharing 7as defined in section #aije7p77#c77 under this title for qualified ,medicare beneficiaries described in section #aije7p77#a7 and other individuals who are ,program-eligible beneficiaries enrolled in an ,organization and entitled to medical assistance for premiums and such cost-sharing under the ,state plan under title ,,xix4 7,b7 ,amounts made available for cost-sharing ,for purposes of subparagraph 7,a73 7i7 ,in general ,subject to clause 7ii71 the amount of medical assistance described in this clause to be made available for cost-sharing pursuant to subparagraph 7,a7 for an individual described in such subparagraph entitled to medical assistance for such cost-sharing under a ,state plan under title ,,xix shall be equal to the amount of medical assistance that would be made available under such ,state plan as in effect as of ,january #a1 #bjaf4 7ii7 ,amounts in the case of a ,state that increases payments for cost-sharing ,if a ,state increases the amount of medical assistance made available under the ,state plan under title ,,xix for cost-sharing described in subparagraph 7,a7 after such date1 such increased amounts shall be made available under subparagraph 7,a7 for the remaining duration of the ,program4 7g7 ,waiver authority 7#a7 ,in general ,in order to carry out the ,program under this section1 the ,secretary shall waive those requirements waived under section #ahii and may waive such additional requirements consistent with those waived under programs administered through the ,center for ,medicare and ,medicaid ,innovation as may be necessary4 7#b7 ,notice of waivers ,not later than #c months after the date of enactment of this section1 the ,secretary shall publish a notice of waivers that will apply in connection with the ,program4 ,the notice shall include the specific conditions that an ,organization must meet to qualify for each waiver1 and commentary explaining the waiver requirements4 7h7 ,report ,not later than ,december #ca1 #bjbd1 the ,medicare ,payment ,advisory ,commission shall submit to ,congress an interim report on the ,program4 4 7b7 ,conforming amendment relating to balanced billing ,section #ahff7;a77#a77,o7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7a77#a77,o77 is amended-- 7#a7 by inserting with an ,,esrd ,integrated ,care ,organization under section #ahff;,f1 after with a ,,pace provider under section #ahid or #aicd12 7#b7 by inserting or ,,esrd ,integrated ,care ,organization after in the case of a ,,pace provider2 7#c7 by striking or ,,pace program eligible individuals enrolled with the ,,pace provider and inserting 1 ,program-eligible beneficiaries enrolled in the ,,esrd ,integrated ,care ,organization1 or ,,pace program eligible individuals enrolled with the ,,pace provider2 and 7#d7 by inserting 7or in the case of a ,program-eligible beneficiary enrolled in the ,,esrd ,integrated ,care ,organization1 the amounts that would be made in accordance with payment rates that would be determined under section #ahec7;a77#a77;,h77 after the amounts that would be made4 7c7 ,extension of guaranteed issue rights under ,medigap 7#a7 ,in general ,section #ahhb7s77#c77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciess7s77#c77;,b77 is amended by adding at the end the following new clause3 7vii7 ,the individual is participating in the demonstration program established under section #ahff;,f1 regardless of the duration of the individual's participation in the program and regardless of any previous enrollment in1 or disenrollment from1 a ,medicare supplemental policy under this section4 4 7#b7 ,notification ,the ,secretary of ,health and ,human ,services shall develop a process to notify 7and shall notify7 individuals described in clause 7vii7 of section #ahhb7s77#c77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciess7s77#c77;,b771 as added by paragraph 7#a71 of their guaranteed issue rights under such section4