,,ii  #aaf? ,,congress  #b;d ,session   
,s4 #degd  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,septemb] #ae1         
#bjbj,mr4 ,"y 7= himself & ,ms4 ,s9ema7 
introduc$ ! foll[+ bill2 :i* 0 read     
twice & ref]r$ to ! ,committee on       
,f9ance  ,a ,,bill  ,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 ! ,br++ ,enhanc$ ,treatm5ts & ,!rapies
 to ,,esrd ,recipi5ts 7,,bett]7 ,kidney 
,c>e ,act4  #b4 ,f9d+s ,congress f9ds ! 
foll[+3 7#a7 ,al?\gh ! relative rate (  
end-/age r5al disease 7ref]r$ to 9 ?is  
section z ,,esrd7 among ! ,nation's     
m9ority populations has decl9$1         
significant disp>ities rema94 ,comp>$ to
 ,:ites1 ,black ,am]icans are #b4f times
 m likely to h kidney failure1 :ile     
,native ,am]icans & ,alaska ,natives are
 #a4b times m likely4 ,hispanics are    
#a4c times m likely to h kidney failure 
comp>$ to non-,hispanics4  7#b7         

,disp>ities also exi/ ) respect to      
treatm5t modalities4 ,specifically1     
al?\gh home dialysis c (f] advantages1  
,black1 ,hispanic1 & ,native ,am]ican & 
,alaska ,native ,,esrd pati5ts are less 
likely to initiate home treatm5t ?an    
,:ite ,,esrd pati5ts4  7#c7 ,num]\s     
/udies %[ t individuals ) l[ incomes & 9
 l[-income communities are at great]    
risk = ,,esrd4  7#d7 ,9 addition to _!  
kidney disease1 ,,esrd pati5ts across   
all races & e?nicities (t5 suff] f "o or
 m comorbidities4 ,eighty-eight p]c5t ( 
,,esrd pati5ts h a hi/ory ( hyp]t5sion1 
#db p]c5t h diabetes1 & ne>ly #cj p]c5t 
h conge/ive he>t failure4  7#e7 ,ea*    
mon?1 ,,esrd pati5ts see multiple       
provid]s & take sev]al m$ications to    
manage _! kidney disease & comorbid     
conditions4 ,( all pati5ts1 ^? ) ,,esrd 
/& to b5efit greatly f bett] coord9at$  
c>e4  7#f7 ,! ,executive ,ord] on       
,advanc+ ,am]ican ,kidney ,heal?        
recognizes ! ne$ to develop & implem5t  
new ,,esrd c>e deliv]y models to improve

 quality & value = ,,esrd pati5ts & !   
,m$ic>e program4  7#g7 ,9 alignm5t ) t  
goal1 x is imp]ative t ,m$ic>e te/ new  
models t h at _! core an int]discipl9>y 
c>e team1 among o!r /ructural           
requirem5ts1 to-- 7,a7 help ,,esrd      
pati5ts bett] navigate ! heal? c>e      
sy/em2  7,b7 emp[] su* pati5ts to manage
 _! plan ( c>e & m$ication regim52  7,c7
 support su* pati5ts 9 receiv+ !        
treatm5t modality1 includ+ a kidney     
transplant1 z prescrib$ by _!           
nephrologi/2  7,d7 access s]vices to    
meet ! noncl9ical ne$s ( su* pati5ts t c
 affect c>e outcomes2 &  7,e7 receive   
additional s]vices1 su* z transplant    
evaluation1 palliative c>e1 evaluation =
 hospice eligibility1 & vascul> access  
c>e4  #c4 ,demon/ration program to      
provide integrat$ c>e = ,m$ic>e         
b5efici>ies ) end-/age r5al disease  7a7
 ,9 g5]al ,title ,,xviii ( ! ,social    
,security ,act is am5d$ by ins]t+ aft]  
section #ahff;,f ! foll[+ new section3  
#ahff;,g4 ,demon/ration program to      

provide integrat$ c>e = ,m$ic>e         
b5efici>ies ) end-/age r5al disease  7a7
 ,e/abli%m5t  7#a7 ,9 g5]al ,! ,secret>y
 %all conduct "u ?is section ! ,,esrd   
,fee-,=-,s]vice ,integrat$ ,c>e         
,demon/ration ,program 79 ?is section   
ref]r$ to z ! ,program71 :i* is volunt>y
 = ,program-eligible b5efici>ies &      
eligible p>ticipat+ provid]s1 to assess 
! effects ( alt]native c>e deliv]y      
models & paym5t me?odologies on pati5t  
c>e improvem5ts "u ?is title = su*      
b5efici>ies4 ,"u ! ,program-- 7,a7      
,program-eligible b5efici>ies %all be   
consid]$ orig9al ,m$ic>e fee-=-s]vice   
b5efici>ies 7z def9$ 9 section          
#ahii7;h77#c77 = ! duration ( !         
p>ticipation ( su* b5efici>ies "u !     
,program2  7,b7 eligible p>ticipat+     
provid]s may =m an ,,esrd               
,fee-,=-,s]vice ,integrat$ ,c>e         
,organization 79 ?is section ref]r$ to z
 an ,organization72 &  7,c7 an          
,organization %all integrate c>e "u !   
orig9al ,m$ic>e fee-=-s]vice program "u 

p>ts ,a & ,b = ,program-eligible        
b5efici>ies4  7#b7 ,def9itions ,9 ?is   
section3 7,a7 ,eligible p>ticipat+      
provid] ,! t]m eligible p>ticipat+      
provid] means any ( ! foll[+3 7i7 ,a    
facility c]tifi$ z a r5al dialysis      
facility "u ?is title4  7ii7 ,an entity 
t owns "o or m ( su* facilities describ$
 9 clause 7i74  7iii7 ,a nephrologi/    
7includ+ a p$iatric nephrologi/7 or     
nephrology practice4  7iv7 ,any o!r     
physician or physician gr\p practice4   
7v7 ,a nurse practition]1 physician     
assi/ant1 or cl9ical nurse speciali/ 7z 
su* t]ms are def9$ 9 section            
#ahfa7;aa77#e77 or a cl9ical social     
work] 7z def9$ 9 section #ahfa7;hh77#a77
 work+ 9 conjunction ) su* a nurse      
practition]1 physician assi/ant1 or     
cl9ical nurse speciali/4  7,b7 ,eligible
 p>ticipat+ p>tn] ,! t]m eligible       
p>ticipat+ p>tn] means1 ) respect to an 
,organization1 any ( ! 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 m$icaid manag$ c>e            
organization 7z def9$ 9 section         
#aijc7m774  7iii7 ,a hospital or an     
academic m$ical c5t] exp]i5c$ 9 ! c>e ( 
pati5ts receiv+ dialysis4  7iv7 ,any o!r
 entity det]m9$ appropriate by !        
,secret>y4  7,c7 ,program-eligible      
b5efici>y  7i7 ,9 g5]al ,! t]m          
,program-eligible b5efici>y means1 )    
respect to an ,organization (f]+ an     
,,esrd ,fee-,=-,s]vice ,integrat$ ,c>e  
,model1 an individual entitl$ to b5efits
 "u "p ,a & enroll$ "u "p ,b 7includ+   
su* an individual entitl$ to m$ical     
assi/ance "u a ,/ate plan "u title      
,,xix7 :o-- 7,i7 is id5tifi$ by !       
,secret>y z hav+ end-/age r5al disease &
 :o is receiv+ r5al dialysis s]vices "u 
! orig9al ,m$ic>e fee-=-s]vice program  
"u p>ts ,a & ,b1 & is n enroll$ 9 a     
,m$ic>e ,advantage plan "u "p ,c or gr\p
 heal? insurance cov]age or individual  
heal? insurance cov]age 7z def9$ 9      
section #bgia7;b7 ( ! ,public ,heal?    

,s]vice ,act 7#db ,u4,s4,c4             
#cjj;gg-#ia7;b777 t is prim>y to cov]age
 "u ?is title2  7,,ii7 receives r5al    
dialysis s]vices prim>ily f an eligible 
p>ticipat+ provid] ( su* ,organization1 
includ+ su* r5al dialysis s]vices       
receiv$ aft] be+ id5tifi$ z a suitable  
c&idate = transplantation2 &  7,,iii7   
has atta9$ ! age ( #ah ye>s4  7ii7      
,affirmation ( program eligibility ^u   
hospice election or kidney transplant ,a
 ,program-eligible b5efici>y :o 0       
assign$ to or elect$ an ,,esrd          
,fee-,=-,s]vice ,integrat$ ,c>e ,model  
(f]$ by an ,organization & :o-- 7,i7    
elects to receive hospice b5efits "u    
section #aheb7;d77#a72 or  7,,ii7       
receives a kidney transplant z cov]$ "u 
?is title & ma9ta9s entitlem5t to       
b5efits "u "p ,a & enrollm5t 9 "p ,b on 
! basis ( end-/age r5al disease1  %all  
cont9ue to meet ! def9ition (           
,program-eligible b5efici>y e/abli%$ "u 
?is subp>agraph4  7b7 ,,esrd            
fee-=-,s]vice 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 & 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 ,organization or to
 (f] "o or m ,,esrd ,fee-=-,s]vice      
,integrat$ ,c>e ,models 9 accordance )  
p>agraph 7#b74  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 =       
purposes ( (f]+ "o or m ,,esrd          
,fee-=-,s]vice ,integrat$ ,c>e ,models  
"u p>tn]%ip1 own]%ip1 or co-own]%ip     
agreem5ts describ$ 9 subp>agraph 7,a74  
7,c7 ,m9imum ,program ,eligible         
,b5efici>y ,p>ticipation ,requirem5t    
7i7 ,9 g5]al ,subject to clause 7ii71 ! 
,secret>y may n ent] into or cont9ue an 
agreem5t ) an ,organization unless !    
,organization has at lea/ #cej          

,program-eligible b5efici>ies1 or at    
lea/ #fj p]c5t ( ,program-eligible      
b5efici>ies receiv+ c>e f !             
,organization's facilities1 :o are      
assign$ to or elect an ,,esrd           
,fee-,=-,s]vice ,integrat$ ,model (f]$  
by ! ,organization & :o cont9ue _!      
assignm5t to or election ( !            
,organization4  7ii7 ,all[+ transition  
,! ,secret>y may waive ! requirem5t "u  
clause 7i7 = an ,organization dur+ !    
fir/ agreem5t ye> ) respect to !        
,organization4  7,d7 ,fiscal s\ndness   
requirem5ts  7i7 ,9 g5]al ,! ,secret>y  
%all ent] into appropriate agreem5ts "u 
?is section only ) ,organizations t     
demon/rate suffici5t capital res]ves1   
measur$ z a p]c5tage ( mon?ly           
prospective paym5ts describ$ 9          
subsection 7e7 & consi/5t ) capital     
res]ve requirem5ts e/abli%$ by ea* ,/ate
 9 :i* ! ,organization op]ates1 subject 
to clause 7ii74  7ii7 ,alt]native       
,me*anism to ,demon/rate ,risk-,be>+    
,capacity ,an ,organization %all be     

consid]$ to meet ! requirem5t 9 clause  
7i7 if ! ,organization includes at lea/ 
"o eligible p>ticipat+ provid] or       
eligible p>ticipat+ p>tn] t-- 7,i7 7aa7 
is lic5s$ "u ,/ate law z a risk-be>+    
entity eligible to (f] heal? insurance  
or heal? b5efits cov]age 9 ea* ,/ate 9  
:i* ! ,organization p>ticipates 9 !     
demon/ration "u ?is section2 or  7bb7 is
 o!rwise au?oriz$ by ea* ,/ate 9 :i* !  
,organization p>ticipates 9 !           
demon/ration "u ?is section to be> risk 
= (f]+ heal? insurance or heal? b5efits2
  7,,ii7 agrees to be> risk "u !        
,organization2 &  7,,iii7 has ! capacity
 to be> risk comm5surate ) !            
,organization's expect$ exp5ditures "u  
an agreem5t "u ?is section4  7iii7      
,disclosure ,ea* ,organization ) an     
agreem5t "u ?is section %all1 9         
accordance ) curr5t regulations ( !     
,secret>y t gov]n simil> disclosures1   
report to ! ,secret>y f9ancial in=mation
 consi/5t ) su* in=mation requir$ to be 
report$ by a ,m$ic>e ,advantage         

organization "u "p ,c to demon/rate t ! 
,organization has a fiscally s\nd       
op]ation4  7,e7 ,gov]nance requirem5ts  
,ea* ,organization ) an agreem5t "u ?is 
section %all e/abli% a gov]n+ body )    
ov]sight responsibility = !             
,organization's compliance ) ,program   
requirem5ts t includes-- 7i7            
repres5tation f ea* eligible p>ticipat+ 
provid] ( su* ,organization2  7ii7 at   
lea/ two nephrologi/s1 "o ( :i* may be  
affiliat$ ) an eligible p>ticipat+      
provid]2 &  7iii7 at lea/ "o b5efici>y  
advocate4  7#b7 ,,esrd ,fee-,=-,s]vice  
,integrat$ ,c>e ,model  7,a7 ,b5efit    
requirem5ts  7i7 ,9 g5]al ,subject to   
clause 7iii71 an ,organization %all (f] 
an ,,esrd ,fee-,=-,s]vice ,integrat$    
,c>e ,model t %all-- 7,i7 cov] all      
b5efits "u p>ts ,a & ,b 7subject to     
paym5t rules reg>d+ ! treatm5t ( &      
paym5t = kidney organ acquisitions &    
hospice describ$ 9 subsections 7e77#c7 &
 7#d772 &  7,,ii7 include s]vices =     
transition 7p>ticul>ly includ+          

education7 into transplantation1        
palliative c>e1 & hospice4  7ii7        
,det]m9ation & treatm5t ( sav+s  7,i7 ,9
 g5]al ,! ,secret>y %all require any    
,organization (f]+ an ,,esrd            
,fee-,=-,s]vice ,integrat$ ,c>e ,model  
to provide = ! return "u subclause      
7,,vi7 to a ,program-eligible b5efici>y 
assign$ to or :o elects an ,organization
 sav+s equal to ! am\nt1 if any1 by :i* 
! paym5t am\nt describ$ 9 subclause 7,v7
 ) respect to ! ,program-eligible       
b5efici>y = a ye> exce$s ! av]age rev5ue
 am\nt describ$ 9 subclause 7,,iv7 )    
respect to ! ,program-eligible b5efici>y
 = ! ye>4  7,,ii7 ,sav+s det]m9ation    
process ,! ,secret>y %all det]m9e !     
sav+s describ$ 9 subclause 7,i7 9 ! same
 mann] z ! rebate calculation =         
individuals ) end-/age r5al disease     
enroll$ 9 ,m$ic>e ,advantage            
organizations "u section                
#ahei7;b77#f77;,b77iii74  7,,iii7       
,application ( m$ical loss ratio        
requirem5ts ,no?+ %all preclude !       

,secret>y f apply+ m$ical loss ratio    
requirem5ts describ$ 9 section          
#aheg7;e77#d7 "u ?is section4  7,,iv7   
,av]age rev5ue am\nt describ$ ,! rev5ue 
am\nt describ$ 9 ?is subclause1 )       
respect to an ,organization (f]+ an     
,,esrd ,fee-,=-,s]vice ,integrat$ ,c>e  
,model & a ,program-eligible b5efici>y  
assign$ to or :o elects 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,v7 ,paym5t am\nt describ$ ,! 
paym5t am\nt describ$ 9 ?is subclause1 )
 respect to an ,organization (f]+ an    
,,esrd ,fee-,=-,s]vice ,integrat$ ,c>e  
,model & a ,program-eligible b5efici>y  
assign$ to or :o elects su*             
,organization1 is ! paym5t am\nt to !   
,organization "u subsection 7e77#a7     
7adju/$ pursuant to subsection 7e77#b7 &
 subject to ! treatm5t ( paym5ts =      

kidney acquisitions & hospice c>e       
describ$ 9 p>agraphs 7#c7 & 7#d7 (      
subsection 7e71 respectively7 made )    
respect to ! ,program-eligible b5efici>y
 = ! ye>4  7,,vi7 ,return+ sav+s to     
program-eligible b5efici>ies ,an        
,organization %all1 9 a mann] specifi$  
by ! ,secret>y & consi/5t ) return+     
,m$ic>e ,advantage rebates to           
individuals "u "p ,c1 return ! am\nt "u 
subclause 7,i7 to a ,program-eligible   
b5efici>y ?r\gh (f]+ b5efits n cov]$ "u 
! orig9al ,m$ic>e ,fee-,=-,s]vice       
program consi/5t ) ! types ( b5efits1   
includ+ non-heal? relat$ b5efits1 t     
,m$ic>e ,advantage organizations may    
(f]4  7iii7 ,b5efit requirem5ts = dual  
eligibles ,9 ! case ( a                 
,program-eligible b5efici>y :o is       
entitl$ to m$ical assi/ance "u a ,/ate  
plan "u title ,,xix1 an ,organization1 9
 accordance ) a mutual agreem5t ent]$   
into betwe5 ! ,/ate & ,organization "u  
subsection 7e77#g7-- 7,i7 %all provide1 
or arrange = ! provision (1 all b5efits 

7o!r ?an long-t]m s]vices & supports7 = 
:i* ! ,program-eligible b5efici>y is    
entitl$ to "u a ,/ate plan "u title     
,,xix2 &  7,,ii7 may elect to provide1  
or arrange = ! provision (1 long-t]m    
s]vices & supports = :i* !              
,program-eligible b5efici>y is entitl$  
"u a ,/ate plan "u title ,,xix1 includ+ 
s]vices relat$ to ! transition into     
palliative c>e or hospice4  7iv7        
,application ( ,m$ic>e ,,ffs provid]    
*oice & co/-%>+ requirem5ts ,"u an      
,,esrd ,fee-,=-,s]vice ,integrat$ ,c>e  
,model (f]$ by an ,organization1 !      
,organization %all-- 7,i7 all[          
,program-eligible b5efici>ies to receive
 b5efits z describ$ 9 subsection        
7b77#b77;,a77i77,i7 f any provid] (     
s]vices or suppli] enroll$ "u ?is title 
& :o o!rwise meets all applicable       
requirem5ts "u ?is title2 &  7,,ii7 n   
apply any co/-%>+ requirem5ts = b5efits 
describ$ 9 subsection                   
7b77#b77;,a77i77,i7 9 addition to       
premium & co/-%>+ requirem5ts1          

respectively1 t w\ld be applicable "u "p
 ,a or "p ,b = su* b5efits4  7v7        
,promot+ access to high-quality provid]s
 ,an ,organization (f]+ an ,,esrd       
,fee-,=-,s]vice ,integrat$ ,c>e ,model  
%all develop & implem5t p]=mance-bas$   
inc5tives1 includ+ f9ancial inc5tives   
fund$ ?r\gh paym5ts made to an          
,organization "u subsection 7e71 =      
provid]s ( s]vices & suppli]s to promote
 deliv]y ( high quality & effici5t c>e4 
,su* inc5tives %all comply ) section    
#aheb7;j77#d7 & section #dbb4bjh ( title
 #db1 ,code ( ,f$]al regulations 7z 9   
effect on ! date ( enactm5t ( ?is       
section7 & be bas$ on cl9ical measures  
or non-cl9ical measures1 su* z ) respect
 to notification ( pati5t dis*>ge f a   
hospital1 pati5t education 7su* z )     
respect to treatm5t options1 includ+    
disease ma9t5ance1 & nutrition71 rates (
 completion ( pati5t education          
categoriz$ by race1 rates ( completion (
 transplant evaluation = pati5ts :o are 
cl9ically eligible = transplant1 rates (

 completion ( transplant evaluation     
categoriz$ by race1 & ! int]op]ability (
 electronic heal? records develop$ by an
 ,organization accord+ to requirem5ts & 
/&>ds specifi$ by ! ,secret>y pursuant  
to subp>agraph 7,b74  7,b7 ,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 develop$ us+1 z
 a ref]5ce1 measures submitt$ by        
organizations p>ticipat+ 9 !            
,compreh5sive ,,esrd ,c>e ,initiative   
op]at$ by ! ,c5t] = ,m$ic>e & ,m$icaid  
,innovation to assess ! quality ( c>e   
provid$2  7,,ii7 e/abli% requirem5ts =  
p>ticipat+ ,organizations to submit to !
 ,secret>y1 9 a =m & mann] specifi$ by !
 ,secret>y1 in=mation on su* measures2 &
  7,,iii7 e/abli% /&>ds = mak+ in=mation
 on quality "u ! ,program e/abli%$ "u   
?is section z assess$ us+ cl9ical       
measures describ$ 9 subclause 7,i7      
available to ! public4  ,z "p ( ! /&>ds 

describ$ 9 subclause 7,,iii7 ! ,secret>y
 %all1 9 consultation ) relevant        
/akehold]s1 develop /&>ds t w\ld e/abli%
 a m9imum ?re%old = ! volume (          
individual pati5ts to be li/$ =         
transplant 9 an ,organ ,procurem5t &    
,transplant ,network "u contract ) !    
,secret>y & t w\ld measure ! numb] (    
individuals t an ,organization mov$ on  
to1 kept on1 or remov$ f ! transplant   
li/ & ! numb] ( individuals t receive a 
transplant aft] p>ticipat+ 9 !          
,organization4 ,! numb] (               
,program-eligible b5efici>ies assign$ to
 an ,organization on ! transplant li/ t 
h n opt$ out at ! "t ( ! agreem5t betwe5
 ! ,secret>y & an ,organization %all be 
not$ z "p ( su* agreem5t4 ,organizations
 %all submit su* measures z a condition 
( paym5t & ,program-eligible b5efici>y  
assignm5t "u ?is subsection4  7ii7      
,requirem5t = /akehold] input ,9        
develop+ measures & requirem5ts "u      
subclauses 7,i7 & 7,,ii7 ( clause 7i71 !
 ,secret>y %all reque/ & consid] input f

 a /akehold] bo>d t includes at lea/ "o 
nephrologi/1 a p$iatric nephrologi/1 o!r
 suppli]s & provid]s ( s]vices z det]m9$
 appropriate by ! ,secret>y1 r5al       
dialysis facilities1 b5efici>y          
advocates1 a heal? equity exp]t1 a m5tal
 heal? provid]1 a transplant surgeon1 & 
,m$ic>e-approv$ transplant programs4    
,section #ad ( ! ,f$]al ,advisory       
,committee ,act %all n apply to !       
/akehold] bo>d4  7iii7 ,additional      
assessm5ts & report+ requirem5ts ,!     
,secret>y %all assess ! ext5t to :i* an 
,organization (f]s integrat$ &          
pati5t-c5t]$ c>e ?r\gh analysis (       
in=mation obta9$ f ,program-eligible    
b5efici>ies assign$ to or :o elect !    
,organization ?r\gh surveys1 su* z !    
,9-,c5t] ,hemodialysis ,consum]         
,assessm5t ( ,heal?c>e ,provid]s &      
,sy/ems4  7iv7 ,no effect on o!r r5al   
dialysis facility quality requirem5ts   
,no?+ 9 ?is section %all be con/ru$ z   
affect+ ! requirem5ts e/abli%$ "u       
section #ahha7;h74  7,c7 ,requirem5ts = 

esrd fee-=-s]vice integrat$ c>e /rategy 
7i7 ,9 g5]al ,an ,organization seek+ a  
contract "u ?is section to (f] "o or m  
,,esrd ,fee-,=-,s]vice ,integrat$ ,c>e  
,models %all develop & submit = !       
,secret>y's approval z "p ( !           
application ( ! ,organization to        
p>ticipate 9 ! ,program "u ?is section1 
subject to clauses 7ii7 & 7iii71 an     
,,esrd ,fee-,=-,s]vice ,integrat$ ,c>e  
,/rategy4  7ii7 ,,esrd fee-=-s]vice     
integrat$ c>e /rategy ,9 assess+ an     
,,esrd ,fee-,=-,s]vice ,integrat$ ,c>e  
,/rategy "u clause 7i71 ! ,secret>y %all
 consid] ! ext5t to :i* ! ,/rategy      
includes elem5ts su* z ! foll[+3 7,i7   
,use ( int]discipl9>y c>e teams l$ by at
 lea/ "o nephrologi/1 & compris$ (      
regi/]$ nurses1 social work]s1 r5al     
dialysis facility manag]s1 & z          
appropriate o!r repres5tatives f        
alt]native sett+s describ$ 9 subclause  
7,,viii74  7,,ii7 ,use ( a decision     
process = c>e plans & c>e managem5t t   
includes ! nephrologi/1 a memb] ( !     

transplant evaluation team1 & o!r       
practition]s responsible = direct       
deliv]y ( c>e to ,program-eligible      
b5efici>ies assign$ to or :o elect !    
,organization involv$4  7,,iii7 ,use (  
heal? risk & o!r assessm5ts to det]m9e !
 physical1 psy*osocial1 nutrition1      
language1 cultural1 & o!r ne$s (        
,program-eligible b5efici>ies assign$ to
 or :o elect ! ,organization involv$4   
7,,iv7 ,developm5t & at lea/ annual     
updat+ ( individualiz$ c>e plans t      
incorporate at lea/ ! m$ical1 social1 & 
functional ne$s1 pref]5ces1 & c>e goals 
( ,program-eligible b5efici>ies assign$ 
to or :o elect ! ,organization1 includ+ 
a discussion on reconsid]ation ( ! me?od
 & location ( dialysis4  7,v7           
,coord9ation & furni%+ ( non-cl9ical    
coord9ation b5efits1 su* z              
transportation1 aim$ at improv+ !       
adh]5ce ( ,program-eligible b5efici>ies 
assign$ to or :o elect ! ,organization )
 c>e recomm5dations4  7,,vi7 ,z         
appropriate1 coord9ation s]vices1 su* z 

transplant evaluation1 palliative c>e1  
evaluation = hospice eligibility1 &     
vascul> access c>e4  7,,vii7 ,9 ! case (
 an individual :o1 dur+ an assignm5t to1
 or an election ( an ,,esrd             
,fee-,=-,s]vice ,integrat$ ,c>e model   
(f]$ by an ,organization1 receives      
confirmation t a kidney transplant is   
imm95t1 ! provision ( c\nsel+ s]vices by
 an int]discipl9>y c>e team describ$ 9  
subclause 7,i7 to su* individual on     
prep>ation = & pot5tial b5efits & risks 
associat$ ) su* transplant4  7,,viii7   
,deliv]y ( b5efits & s]vices 9 sett+s   
alt]native to traditional cl9ical       
sett+s1 su* z ! home ( !                
,program-eligible b5efici>y4  7,,ix7    
,use ( pati5t rem9d] sy/ems4  7,x7      
,education programs = pati5ts1 families1
 & c>egiv]s4  7,,xi7 ,use ( heal? c>e   
advice res\rces1 su* z nurse advice     
l9es4  7,,xii7 ,use ( team-bas$ heal?   
c>e deliv]y models t provide            
compreh5sive & cont9u\s m$ical c>e1 su* 
z m$ical homes4  7,,xiii7 ,co-location (

 provid]s & s]vices4  7,,xiv7 ,use ( a  
demon/rat$ capacity to %>e electronic   
heal? record in=mation across sites (   
c>e4  7,,xv7 ,use ( programs to promote 
bett] adh]5ce to recomm5d$ treatm5t     
regim5s1 includ+ prescription drug1 by  
individuals1 includ+ by address+ b>ri]s 
to access to c>e by su* individuals1    
includ+ /rategies to coord9ate any      
prescription drug b5efits "u any        
prescription drug plan "u "p ,d 9 :i* a 
,program-eligible b5efici>y is enroll$4 
7,,xvi7 ,use ( def9$ protocols1 develop$
 9 conjunction ) ! p$iatric nephrology  
community1 to facilitate ! transition ( 
p$iatric individuals into adult end-/age
 r5al disease c>e4  7,,xvii7 ,use (     
heal? equity exp]ts to implem5t programs
 & protocols :i* seek to decrease g5d]1 
racial1 e?nic1 & language inequities4   
7,,xviii7 ,o!r s]vices1 /rategies1 &    
approa*es id5tifi$ by ! ,organization to
 improve c>e coord9ation & deliv]y4     
7#c7 ,b5efici>y protections  7,a7       
,seamless access to c>e ,! ,secret>y    

%all ensure t ! ,organization e/abli%es 
processes & takes /eps necess>y1 includ+
 educat+ relevant provid]s ( s]vices &  
suppli]s ab\t ! ,program1 to ensure t   
,program-eligible b5efici>ies assign$ to
 or :o elect$ an ,,esrd ,fee-,=-,s]vice 
,integrat$ ,c>e ,model (f]$ by an       
,organization d n exp]i5ce any          
disruption 9 access to provid]s (       
s]vices & suppli]s furni%+ b5efits "u   
?is title due to su* assignm5t or       
election4 ,assignm5t to or an election (
 an ,,esrd ,fee-,=-,s]vice ,integrat$   
,c>e ,model (f]$ by an ,organization    
%all n be con/ru$ z affect+ a           
,program-eligible b5efici>y's ability to
 receive b5efits describ$ 9 subsection  
7b77#b77;,a77i77,i7 f any provid] (     
s]vices or suppli]s enroll$ & :o o!rwise
 meets requirem5ts "u ?is title1 z      
describ$ 9 subsection 7b77#b77;,a77iv74 
7,b7 ,anti-discrim9ation ,ea* agreem5t  
betwe5 ! ,secret>y & an ,organization "u
 ?is section %all-- 7i7 provide t ea*   
eligible p>ticipat+ provid] ( su*       

,organization may n d5y1 limit1 or      
condition ! furni%+ ( s]vices1 or affect
 ! quality ( s]vices furni%$1 "u ?is    
title to ,program-eligible b5efici>ies  
on :e!r or n su* a b5efici>y is assign$ 
to or elects ! ,organization2 &  7ii7   
prohibit ! ,organization f engag+ 9 any 
activity t c\ld reasonably be expect$ to
 h ! effect ( d5y+ or disc\rag+         
assignm5t to or an election ( an ,,esrd 
,fee-,=-,s]vice ,integrat$ ,c>e ,model  
(f]$ by an ,organization by a           
,program-eligible b5efici>y ^: m$ical   
condition or hi/ory indicates a ne$ =   
sub/antial future m$ical s]vices4  7,c7 
,quality assurance2 pati5t safegu>ds    
,ea* agreem5t betwe5 ! ,secret>y & an   
,organization "u ?is section %all       
require t su* ,organization h 9 effect  
at a m9imum-- 7i7 a writt5 plan (       
quality assurance & improvem5t1 &       
proc$ures implem5t+ su* plan1 9         
accordance ) regulations2 &  7ii7 writt5
 safegu>ds ( ! rights (                 
,program-eligible b5efici>ies assign$ to

 or :o elect ! ,organization 7includ+ a 
pati5t bill ( rights & proc$ures =      
grievances & appeals7 9 accordance )    
regulations & ) o!r requirem5ts ( ?is   
title & applicable ,f$]al & ,/ate laws  
design$ to protect ,program-eligible    
b5efici>ies 7includ+ ^? :o are entitl$  
to m$ical assi/ance "u a ,/ate plan "u  
title ,,xix74  7,d7 ,ov]sight ,!        
,secret>y %all develop & implem5t an    
ov]sight program to monitor an          
,organization's compliance ) ,program   
requirem5ts "u an agreem5t "u ?is       
section4  7#d7 ,treatm5t z alt]native   
paym5t model & eligible alt]native      
paym5t entity  7,a7 ,treatm5t ( program 
,! ,,esrd ,fee-=-,s]vice ,integrat$ ,c>e
 ,demon/ration ,program e/abli%$ "u ?is 
section %all meet ! def9ition ( an      
alt]native paym5t model describ$ 9      
section #ahcc7z77#c77;,c77iv74  7,b7    
,treatm5t ( organization ,an            
,organization (f]+ "o or m ,,esrd       
,fee-=-,s]vice ,integrat$ ,c>e ,models  
%all be treat$ "u ?is section z an      

eligible alt]native paym5t entity z     
describ$ 9 clauses 7i7 & 7ii77,i7 (     
section #ahcc7z77#c77;,d74  7c7 ,program
 op]ation & scope  7#a7 ,9 g5]al ,!     
,secret>y %all develop a process su* t  
an ,organization c apply to (f] "o or m 
,,esrd ,fee-,=-,s]vice ,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 cov] b5efits describ$ 9
 subsection 7b77#b77;,a77i77,i74  7,b7  
,any b5efits (f]$ by ! ,organization    
beyond ^? describ$ 9 su* subsection4    
7,c7 ,a description ( ! ,organization's 
,,esrd ,fee-,=-,s]vice integrat$ c>e    
/rategy specifi$ 9 subsection           
7b77#b77;,d71 includ+ a detail$         
explanation ( ! ,organization's approa* 
to fulfill ! requirem5t to coord9ate !  
deliv]y ( multidiscipl9>y heal? & social
 s]vices t1 pursuant to a mutual        
agreem5t betwe5 a ,/ate & ,organization1
 integrates acute & long-t]m c>e s]vices

 & supports4  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 #bjbd4  7#c7 ,initial      
agreem5t p]iod ,! ,secret>y %all ent]   
into agreem5ts = an initial p]iod ( n   
less ?an #e ye>s ) all ,organizations t 
meet all ,program requirem5ts e/abli%$  
"u ?is section1 z det]m9$ by ! ,secret>y
 ?r\gh ! application process describ$ 9 
p>agraph 7#a74  7#d7 ,all[ance = s]vice 
area expansions ,dur+ ea* ye> ( !       
,program's op]ation1 ! ,secret>y %all   
all[ an ,organization ) an agreem5t "u  
?is section to exp& its s]vice area dur+
 ! initial agreem5t p]iod ^u !          
,secret>y's det]m9ation1 ?r\gh !        
application process describ$ 9 p>agraph 
7#a71 t ! ,organization meets all       
,program requirem5ts e/abli%$ "u ?is    
section4  7#e7 ,contract susp5sion &    
t]m9ation process  7,a7 ,9 g5]al        
,subject to subp>agraph 7,b77ii71 !     
,secret>y may susp5d assignm5t to or an 

election ( an ,,esrd ,fee-,=-,s]vice    
,integrat$ ,c>e ,model (f]$ by an       
,organization if ! ,organization fails  
to comply ) any ,program requirem5ts    
specifi$ 9 an agreem5t "u ?is section4  
,an ,organization also %all be consid]$ 
n 9 compliance if1 = any cal5d> mon?    
dur+ an agreem5t ye>1 m ?an #ej p]c5t ( 
! total numb] ( ,program-eligible       
b5efici>ies assign$ to or :o elect an   
,,esrd ,fee-,=-,s]vice ,integrat$ ,c>e  
,model (f]$ by ! ,organization opt out (
 ! ,program4  7,b7 ,opportunity =       
corrective action plan & appeal  7i7 ,9 
g5]al ,prior to susp5d+ assignm5t to or 
an election ( an ,,esrd ,fee-,=-,s]vice 
,integrat$ ,c>e ,model (f]$ by an       
,organization or t]m9at+ an agreem5t "u 
?is section1 ! ,secret>y %all af=d an   
,organization suffici5t opportunity to  
rem$y any defici5cies 9 comply+ ) any   
,program requirem5ts "u ?is section by  
implem5t+ a corrective action plan4 ,any
 corrective action plan implem5t$ "u ?is
 subp>agraph %all specify a date by :i* 

! ,organization %all resolve su*        
defici5cies & %all rema9 9 effect until 
su* "t t ! ,secret>y confirms t !       
,organization has a*iev$ compliance4    
7ii7 ,imposition ( agreem5t susp5sion or
 t]m9ation ,9 ! case ( an ,organization 
t fails to a*ieve compliance by ! date  
specifi$ 9 corrective action plan1      
subject to clause 7iii7 & dep5d+ on !   
sev]ity ( a compliance defici5cy1 !     
,secret>y 9 a mann] consi/5t ) processes
 e/abli%$ "u "p ,c ( ?is title may--    
7,i7 susp5d ,program-eligible           
b5efici>ies' assignm5ts to or an        
election ( an ,,esrd ,fee-,=-,s]vice    
,integrat$ ,c>e ,model (f]$ by an       
,organization2 or  7,,ii7 t]m9ate an    
agreem5t ) an ,organization "u ?is      
section4  7iii7 ,imm$iate agreem5t      
t]m9ation = violat+ ! prohibition on    
discrim9ation ,not)/&+ ! corrective     
action plan process e/abli%$ "u clause  
7i71 ! ,secret>y may1 9 addition to !   
circum/ances "u :i* a contract "u "p ,c 
may be imm$iately t]m9at$1 imm$iately   

t]m9ate an agreem5t "u ?is section ) an 
,organization if ! ,secret>y-- 7,i7     
notifies ! ,organization ( ! int5t to   
inve/igate allegations ( sy/ematic      
activities ) ! int5t ( violat+ !        
prohibition on discrim9ation e/abli%$ "u
 subsection 7b77#c77;,b77ii72  7,,ii7   
det]m9es1 aft] conduct+ a rigor\s       
analysis ( all available data bas$ on a 
suffici5t sample size1 t ! ,organization
 engag$ 9 sy/ematic activities ) ! int5t
 ( violat+ ! prohibition on             
discrim9ation e/abli%$ 9 subsection     
7b77#c77;,b77ii72 &  7,,iii7 discloses  
cr$ible evid5ce to ! ,organization      
reg>d+ a det]m9ation made "u subclause  
7,,ii74  7iv7 ,recov]y ( mon?ly         
prospective paym5ts ,! ,secret>y may    
recov] ! prorat$ %>e ( any mon?ly       
prospective paym5ts describ$ 9          
subsection 7e7 cov]+ ! p]iod ( ! mon?   
foll[+ an agreem5t t]m9ation if su*     
agreem5t t]m9ation is effective 9 !     
middle ( a cal5d> mon?4  7v7            
,notification ( program-eligible        

b5efici>y ^u agreem5t t]m9ation ,ea*    
agreem5t "u ?is section betwe5 !        
,secret>y & an ,organization %all       
require ! ,organization to provide & pay
 = writt5 notice 9 advance ( an         
agreem5t's t]m9ation1 z well z a        
description ( alt]natives = obta9+      
b5efits "u ?is title1 9 a mann] consi/5t
 ) b5efici>y notification requirem5ts 9 
! ev5t ( a contract t]m9ation "u "p ,c4 
7#f7 ,program evaluation ,! ,secret>y   
%all conduct an evaluation ( ! ,program 
"u ?is section to in=m a det]m9ation    
reg>d+ a ,program expansion "u p>agraph 
7#g74 ,su* evaluation %all include an   
analysis (-- 7,a7 ! quality ( c>e       
furni%$ "u ! ,program1 includ+ !        
measurem5t ( pati5t-level outcomes &    
pati5t exp]i5ce & pati5t-report$ outcome
 measures det]m9$ appropriate by !      
,secret>y2 &  7,b7 ! *anges 9 sp5d+ "u  
p>ts ,a & ,b by reason ( ! ,program4    
7#g7 ,program expansion  7,a7 ,9 g5]al  
,! ,secret>y may1 ?r\gh rulemak+1 exp& !
 duration & scope ( ! ,program "u ?is   

section1 to ! ext5t det]m9$ appropriate 
by ! ,secret>y1 if-- 7i7 ! ,secret>y    
det]m9es t su* expansion is expect$ to--
 7,i7 r$uce sp5d+ "u ?is title )\t r$uc+
 ! quality ( pati5t c>e2 or  7,,ii7     
improve ! quality ( pati5t c>e )\t      
increas+ sp5d+ "u ?is title2  7ii7 !    
,*ief ,actu>y ( ! ,c5t]s = ,m$ic>e      
,m$icaid ,s]vices c]tifies t su*        
expansion w\ld r$uce 7or w\ld n result 9
 any increase 97 net program sp5d+ "u   
?is title2 &  7iii7 ! ,secret>y det]m9es
 t su* expansion w\ld n d5y or limit !  
cov]age or provision ( b5efits "u ?is   
title = applicable individuals4  7,b7   
,ensur+ program cont9uity ,! ,secret>y  
%all implem5t any ,program expansion    
made 9 accordance ) ?is p>agraph 9 a    
mann] t ensures t ,program-eligible     
b5efici>ies & ,organizations ) an       
agreem5t "u ?is section d n exp]i5ce any
 disruptions 9 ! ,program4  7#h7 ,"p ,d 
data %>+ arrangem5t ,! ,secret>y on a   
mon?ly basis %all1 9 accordance ) !     
regulations promulgat$ "u section       

#bfd7;c7 ( ! ,heal? ,insurance          
,portability & ,acc\ntability ,act (    
#aiif1 provide access to ,organizations 
to "p ,d data claims t include "p ,d    
data on ,program-eligible b5efici>ies   
assign$ to or an election ( an ,,esrd   
,fee-,=-,s]vice ,integrat$ ,c>e ,model  
(f]$ by an ,organization unless a       
,program-eligible b5efici>y opts out (  
su* data %>+4  7#i7 ,fund+ ,! ,secret>y 
%all allocate funds made available "u   
section #aaae;,a7f77#a7 to implem5t &   
evaluate ! demon/ration program e/abli%$
 "u ?is section4  7d7 ,id5tification &  
assignm5t ( program-,eligible           
b5efici>ies  7#a7 ,9 g5]al ,! ,secret>y 
%all e/abli% a process = ! initial &    
ongo+ id5tification ( ,program-eligible 
b5efici>ies4  7#b7 ,assignm5t (         
program-,eligible ,b5efici>ies to an    
organization's ,,esrd ,fee-,=-,s]vice   
,integrat$ ,c>e ,model  7,a7 ,9 g5]al   
,"u ! ,program1 ! ,secret>y %all assign 
all ,program-eligible b5efici>ies to an 
,,esrd ,fee-,=-,s]vice ,integrat$ ,c>e  

,model (f]$ by an ,organization t       
includes ! dialysis facility at :i* !   
,program-eligible b5efici>y prim>ily    
receives r5al dialysis s]vices4  7,b7   
,opt-out p]iod & *anges ^u initial      
assignm5t or election ,! ,secret>y %all 
provide = a #ij-;day p]iod beg9n+ on !  
date on :i* ! assignm5t ( or election   
made by a ,program-eligible b5efici>y   
into an ,,esrd ,fee-,=-,s]vice          
,integrat$ ,c>e ,model (f]$ by an       
,organization becomes effective dur+ :i*
 a ,program-eligible b5efici>y may-- 7i7
 opt out ( ! ,program2 or  7ii7 make a  
"o-"t *ange ( assignm5t or election into
 an ,,esrd ,fee-,=-,s]vice ,integrat$   
,c>e ,model (f]$ by a diff]5t           
,organization4  7,c7 ,deem$ re-assignm5t
 & re-election ,! ,secret>y %all e/abli%
 a process ?r\gh :i* a ,program-eligible
 b5efici>y assign$ to or :o elects an   
,,esrd ,fee-,=-,s]vice ,integrat$ ,c>e  
,model (f]$ by an ,organization )       
respect to a ye> is deem$1 unless !     
,program-eligible b5efici>y o!rwise     

*anges su* assignm5t or election "u ?is 
p>agraph1 to h elect$ to cont9ue su*    
assignm5t or election ) respect to !    
subsequ5t ye>4  7,d7 ,annual opportunity
 to opt out or elect an ,,esrd          
,fee-,=-,s]vice ,integrat$ ,c>e ,model  
(f]$ by a diff]5t organization  7i7 ,9  
g5]al ,annually1 a ,program-eligible    
b5efici>y %all be giv5 a #ij-;day p]iod 
to-- 7,i7 opt out ( ! ,program2 or      
7,,ii7 make a "o-"t *ange ( assignm5t or
 election into an ,,esrd ,fee-,=-,s]vice
 ,integrat$ ,c>e ,model (f]$ by a       
diff]5t ,organization4  7ii7 ,alignm5t )
 ,m$ic>e ,advantage op5 enrollm5t p]iod 
,to ! ext5t practicable1 ! ,secret>y    
%all align ! annual #ij-;day p]iod      
describ$ 9 clause 7i7 ) ! ,m$ic>e       
,advantage op5 enrollm5t p]iod4  7,e7   
,opt out = *ange 9 pr9cipal diagnosis or
 ent]+ home dialysis treatm5t ,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 disease or ent]s into 
home dialysis treatm5t1 su* individual  
%all be giv5 ! opportunity to opt out ( 
! ,program dur+ su* p]iod z specifi$ by 
! ,secret>y4  7#c7 ,program-eligible    
b5efici>y notification  7,a7 ,9 g5]al ,!
 ,secret>y %all ensure t an             
,organization notifies ,program-eligible
 b5efici>ies ab\t ! ,program "u ?is     
section & provides !m ) mat]ials expla9+
 ! ,program1 includ+-- 7i7 in=mation    
ab\t receiv+ b5efits "u ?is title ?r\gh 
su* ,organization2 &  7ii7 an           
explanation t !y reta9 ! "r to receive  
c>e f any ,m$ic>e provid]4  7,b7 ,tim+ (
 notification ,^u assignm5t to or       
election ( an ,,esrd ,fee-,=-,s]vice    
,integrat$ ,c>e ,model (f]$ by an       
,organization1 ! ,secret>y %all provide 
! ,organization writt5 notification     
confirm+ ! b5efici>y's assignm5t or     
election & n lat] ?an #ae bus9ess days  

aft] ! date ( receipt ( su*             
notification1 ! ,organization %all      
provide writt5 notice to !              
,program-eligible b5efici>y ( su*       
assignm5t or election4  7,c7 ,cont5t (  
writt5 notice ,subject to subp>agraph   
7,d71 su* notification %all-- 7i7 in=m  
,program-eligible b5efici>ies ab\t !    
,program us+ an in=mation guide develop$
 by ! ,organization & approv$ by !      
,secret>y2  7ii7 include ! di/ribution (
 o!r ,program mat]ials develop$ by !    
,organization & approv$ by ! ,secret>y2 
7iii7 in=m ,program-eligible b5efici>ies
 ab\t ! importance ( transplantation z !
 be/ outcome1 z well z m9imum           
requirem5ts = transplant eligibility    
be=e & dur+ dialysis treatm5t2 &  7iv7  
provide contact in=mation =             
repres5tatives ( ! ,organization to     
respond to ,program-eligible            
b5efici>ies' que/ions4  7,d7 ,limitation
 on unsolicit$ notification  7i7 ,9     
g5]al ,"u ! ,program1 no p]son or entity
 7o!r ?an ! ,secret>y1 an employee ( !  

,secret>y1 or an employee or volunte] ( 
a f$]ally au?oriz$ ,/ate ,heal?         
,insurance ,assi/ance ,program 7,,%ip771
 subject to clause 7ii71 may provide any
 in=mation ab\t ! ,program1 includ+     
in=mation1 mat]ials1 & assi/ance        
describ$ 9 subp>agraph 7,b71 to a       
,program-eligible b5efici>y unless su*  
,program-eligible b5efici>y reque/s su* 
in=mation1 mat]ials1 or assi/ance4  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 a   
facility t p>ticipates 9 su*            
,organization4  7iii7 ,p>ity 9          
notification ,9 ! case t an eligible    
p>ticipat+ provid] t is "p ( an         
,organization p>ticipates 9 notify+     
,program-eligible b5efici>ies ab\t !    
,program "u ?is subp>agraph1 su*        

notification %all be provid$ 9 ! same   
mann] to all ,program-eligible          
b5efici>ies to :i*1 pursuant to clause  
7ii71 su* eligible p>ticipat+ provid]   
may provide in=mation1 mat]ials1 &      
assi/ance describ$ 9 su* clause4  7,e7  
,program-eligible b5efici>y grievance & 
appeal rights ,program-eligible         
b5efici>ies p>ticipat+ 9 ! ,program "u  
?is section %all h grievance & appeal   
rights & proc$ures consi/5t ) ^? rights 
& proc$ures e/abli%$ "u subsections 7f7 
& 7g7 ( section #aheb4  7e7 ,,esrd      
fee-=-,s]vice integrat$ c>e program     
mon?ly paym5t & claims process+ me*anism
  7#a7 ,9 g5]al ,= ea* ,program-eligible
 b5efici>y receiv+ c>e ?r\gh an         
,organization1 ! ,secret>y %all make a  
mon?ly prospective paym5t 9 accordance )
 paym5t rates 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/ !   
mon?ly prospective paym5t 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 ,treatm5t ( & 
paym5t = kidney acquisition co/s  7,a7  
,exclud+ co/s = kidney acquisitions f ma
 b5*m>k ,! ,secret>y %all adju/ ! paym5t
 am\nt to an ,organization to exclude f 
su* paym5t am\nt ! ,secret>y's e/imate (
 ! /&>diz$ co/s = paym5ts = organ       
acquisitions = kidney transplants 9 !   
area involv$ = ! ye>4  7,b7 ,,ffs       
treatm5t ( & paym5t = kidney            
acquisitions ,an ,organization %all     
provide all b5efits describ$ 9          
subsection 7b77#b77;,a77i71 except =    
kidney acquisition co/s4 ,paym5t =      
kidney acquisition co/s cov]$ "u ?is    
title furni%$ to a ,program-eligible    
b5efici>y %all be made 9 accordance )   
?is title & 9 su* am\nts z w\ld o!rwise 
be made & det]m9$ = su* items & s]vices 
provid$ to su* a b5efici>y n p>ticipat+ 
9 ! ,program "u ?is section4  7#d7      
,treatm5t ( & paym5t = hospice c>e  7,a7
 ,9 g5]al ,an agreem5t "u ?is section   

%all require an ,organization to in=m   
ea* ,program-eligible b5efici>y :o is   
assign$ to or elects an ,,esrd          
,fee-,=-,s]vice ,integrat$ ,c>e ,model  
(f]$ by ! ,organization ab\t !          
availability ( hospice c>e if-- 7i7 a   
hospice program p>ticipat+ "u ?is title 
is locat$ )9 ! ,organization's s]vice   
area2 or  7ii7 x is common practice to  
ref] pati5ts to hospice programs outside
 su* s]vice area4  7,b7 ,paym5t ,if a   
,program-eligible b5efici>y :o is       
assign$ to or elects an ,,esrd          
,fee-,=-,s]vice ,integrat$ ,c>e ,model  
(f]$ by an ,organization ) an agreem5t  
"u ?is section makes an election "u     
section #ahab7;d77#a7 to receive hospice
 c>e f a p>ticul> hospice program-- 7i7 
paym5t = ! c>e furni%$ to !             
,program-eligible b5efici>y %all be made
 by ! ,secret>y to ! hospice program    
elect$ by ! ,program-eligible b5efici>y2
  7ii7 paym5t = o!r s]vices = :i* !     
,program-eligible b5efici>y individual  
is eligible not)/&+ ! ,program-eligible 

b5efici>y's election ( hospice c>e "u   
section #ahab7;d77#a71 includ+ s]vices n
 relat$ to ! ,program-eligible          
b5efici>y's t]m9al illness1 %all be made
 by ! ,secret>y to ! ,organization or ! 
provid] or suppli] ( ! s]vice in/ead ( !
 mon?ly prospective paym5t det]m9$ "u   
subsection 7f72 &  7iii7 ! ,secret>y    
%all cont9ue to make mon?ly paym5ts to !
 ,organization 9 an am\nt equal to !    
value ( b5efits & s]vices det]m9$ "u    
subsection 7b77#b77;,a77ii77,,iv74  7#e7
 ,application ( ,,cmi claims process+   
framework  7,a7 ,9 g5]al ,"u ! ,program1
 ! ,secret>y %all apply a claims        
process+ framework bas$ on ^? t ! ,c5t] 
= ,m$ic>e & ,m$icaid ,innovation applies
 "u v>i\s direct contract+ models "u    
section #aaae;,a su* t-- 7i7 provid]s ( 
s]vices & suppli]s s]v+                 
,program-eligible b5efici>ies cont9ue to
 submit claims to a ,m$ic>e adm9i/rative
 contractor2  7ii7 ! ,secret>y =w>ds    
claims to ! ,organization = paym5t2 &   
7iii7 ! ,organization pays provid]s (   

s]vices & suppli]s an am\nt equal to !  
am\nt t !y w\ld o!rwise receive "u !    
orig9al ,m$ic>e ,fee-,=-,s]vice program 
plus any additional am\nt to :i* !      
provid] may be eligible "u subsection   
7b77#b77;,a77v7 ( ?is section4  7,b7    
,application ( balance bill+ limitations
 ,section #aheb7;a77#b77;,a7 7relat+ to 
paym5ts made by an ,,ma organization to 
a non-contract provid] ( s]vices71      
section #aheb7k77#a7 7relat+ to         
limitations on balance bill+71 & section
 #ahff7;a77#a77o7 7relat+ to paym5ts    
made by an ,,ma organization to a       
non-contract suppli]7 %all apply to !   
,program4  7,c7 ,paym5ts = graduate     
m$ical education ,section #ahhf7;d77#aa7
 & section #ahhf7;h77#c77;,d7 7relat+ to
 paym5ts = graduate m$ical education7   
%all apply to ,organizations & provid]s 
( s]vices "u ! ,program4  7#f7 ,no      
effect on ma esrd rate sett+ or risk    
adju/m5t model ,to ensure ! integrity ( 
! ,m$ic>e ,advantage end-/age r5al      
disease rate sett+ process & risk       

adju/m5t factors appli$ to ,m$ic>e      
,advantage end-/age r5al disease rates1 
claims paid on behalf (                 
,program-eligible b5efici>ies %all n be 
includ$ 9 nei!r ! det]m9ation ( su*     
rates nor ! developm5t ( su* risk       
adju/m5t factors4  7#g7 ,agreem5t betwe5
 a /ate & organization = ,m$icaid       
b5efits ,9 ! case t a ,/ate &           
,organization ent] into a mutual        
agreem5t "u :i* ! ,organization         
coord9ates b5efits "u title ,,xix =     
,program-eligible b5efici>ies eligible =
 b5efits "u ?is title & title ,,xix su* 
mutual agreem5t %all specify ! paym5t f 
! ,/ate = provid+ or arrang+ = !        
provision ( su* b5efits4  7#h7          
,affirmation ( ,/ate obligations to pay 
premium & co/-%>+ am\nts ,a ,/ate %all  
cont9ue to make m$ical assi/ance "u !   
,/ate plan "u title ,,xix available = ! 
duration ( ! ,program = ,m$ic>e co/-%>+ 
7z def9$ 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 assign$ to or :o elect an   
,organization & entitl$ to m$ical       
assi/ance = premiums & su* co/-%>+ "u ! 
,/ate plan "u title ,,xix 9 an am\nt    
equal to ! am\nt ( m$ical assi/ance t   
w\ld be made available by su* ,/ate if  
su* ,program-eligible b5efici>ies 7 n   
p>ticipat+ 9 ! ,program "u ?is section4 
7f7 ,waiv] au?ority  7#a7 ,9 g5]al ,!   
,secret>y %all waive ^? requirem5ts     
waiv$ "u section #ahii det]m9$ by !     
,secret>y to be relevant & necess>y = ! 
op]ation ( ! ,program "u ?is section &  
may waive1 z necess>y1 su* additional   
requirem5ts t h be5 or may be waiv$ bas$
 on au?ority e/abli%$ "u section        
#aaae;,a = purposes ( models te/$ by !  
,c5t]s = ,m$ic>e & ,m$icaid ,innovation 
9 ord] to c>ry out ! ,program "u ?is    
section4  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   
7g7 ,report ,n lat] ?an ,decemb] #ca1   
#bjbe1 ! ,m$ic>e ,paym5t ,advisory      
,commission %all submit to ,congress an 
int]im report on ! ,program4  4  7b7    
,rules ( con/ruction  7#a7 ,use ( m$ic>e
 supplem5tal policy "u an ,,esrd        
,fee-,=-,s]vice ,integrat$ ,c>e ,model  
,no?+ 9 ! provisions (1 or am5dm5ts made
 by1 ?is ,act %all be con/ru$ to prev5t 
a ,program-eligible b5efici>y assign$   
to1 or :o elects1 an ,,esrd             
,fee-,=-,s]vice ,integrat$ ,c>e ,model  
(f]$ by an ,organization ) an agreem5t  
"u ?is section f enroll+ 9 or cont9u+   
enrollm5t 9 a ,m$ic>e supplem5tal policy
 available to su* ,program-eligible     
b5efici>y or receiv+ b5efits "u su*     
,m$ic>e supplem5tal policy ?r\gh\t !    
duration ( ! ,program-eligible          
b5efici>y's p>ticipation 9 an ,,esrd    
,fee-,=-,s]vice ,integrat$ ,c>e model   
(f]$ by an ,organizations ) an agreem5t 

"u ?is section4  7#b7 ,application (    
,/ate rules reg>d+ issuance ( m$ic>e    
supplem5tal policies to individual "u   
age #fe ,no?+ 9 ! provisions (1 or      
am5dm5ts made by1 ?is ,act %all be      
con/ru$ to e/abli% a ,f$]al requirem5t  
on an issu] ( a ,m$ic>e supplem5tal     
policy to (f] su* ,m$ic>e supplem5tal   
policy to individuals "u age #fe4  7#c7 
,cont9u$ availability ( m$ic>e          
supplem5tal policies to individuals "u  
age #fe ,no?+ 9 ! provisions (1 or      
am5dm5ts made by1 ?is ,act %all be      
con/ru$ to affect a ,/ate's au?ority to 
require an issu] ( a ,m$ic>e supplem5tal
 policy to (f] su* ,m$ic>e supplem5tal  
policy to individual4  7c7 ,,gao ,/udy &
 ,report on ,paym5t ,adequacy =         
,p$iatric ,,esrd ,s]vices  7#a7 ,/udy on
 ,paym5t = ,p$iatric ,,esrd ,s]vices ,! 
,comptroll] ,g5]al ( ! ,unit$ ,/ates    
%all conduct a /udy to exam9e ! accuracy
 ( p$iatric data report$ to ! ,c5t]s =  
,m$ic>e  ,m$icaid ,s]vices z "p ( !     
,,esrd prospective paym5t sy/em4 ,! /udy

 %all evaluate :e!r ! organizations     
describ$ 9 section #ahff;,g ( ! ,social 
,security ,act1 z add$ by subsection    
7a71 & ! exi/+ prospective paym5t sy/em 
accurately capture & reimburse co/s (   
p$iatric dialysis c>e & include an      
analysis ( ! foll[+ factors t influ5ce  
su* co/s3 7,a7 ,increas$ acuity ( nurs+ 
c>e comp>$ to adult dialysis pati5ts1   
especially = small] & y\ng] p$iatric    
hemodialysis pati5ts4  7,b7 ,ne$ =      
developm5tal & behavioral speciali/s1   
includ+ *ild life speciali/s4  7,c7 ,ne$
 = m frequ5t assessm5t by p$iatric      
dieticians to adju/ =mulas & diet = !   
specializ$ gr[? & nutrition requirem5ts 
( *ildr5 treat$ ) dialysis4  7,d7 ,ne$ =
 social work]s1 s*ool liaisons1 & o!r   
tra9$ individuals designat$ to help     
families navigate *all5g+ psy*osocial   
situations & to coord9ate ) s*ools to   
ensure s*ool att5dance & optimize s*ool 
p]=mance among p$iatric dialysis        
pati5ts4  7,e7 ,ne$ = a broad] array (  
dialysis supplies1 includ+ diff]5t-siz$ 

dialyz]s1 tub+1 & p]itoneal fluid bags  
to accommodate c>e provid$ infants ?r\gh
 "y adults4  7#b7 ,report ,n lat] ?an   
#ah mon?s aft] ! date ( ! enactm5t ( ?is
 ,act1 ! ,comptroll] ,g5]al %all submit 
to ,congress a report conta9+ ! results 
( ! /udy conduct$ "u p>agraph 7#a71     
toge!r ) recomm5dations = su*           
legislation & adm9i/rative action z !   
,comptroll] ,g5]al det]m9es appropriate4
  7d7 ,,gao ,/udy & ,report on ! ,impact
 ( ,race-,bas$ ,correction ( e,g,f,r on 
,ref]ral ( ,,esrd ,pati5ts = ,transplant
 ,evaluation  7#a7 ,/udy on ,impact (   
,race-bas$ ,correction ( e,g,f,r on     
,ref]ral ( ,,esrd ,pati5ts = ,transplant
 ,evaluation ,! ,comptroll] ,g5]al ( !  
,unit$ ,/ates %all conduct a /udy to    
exam9e ! impact ( race-bas$ correction (
 ! e/imat$ glom]ul> filtration rate     
7ref]r$ to 9 ?is subsection z e,g,f,r7  
on ! ref]ral ( ,,esrd pati5ts =         
transplant evaluation4  7#b7 ,report ,n 
lat] ?an #ah mon?s aft] ! date (        
enactm5t ( ?is ,act1 ! ,comptroll]      

,g5]al %all submit to ,congress a report
 conta9+ ! results ( ! /udy conduct$ "u 
p>agraph 7#a71 toge!r ) recomm5dations =
 su* legislation & adm9i/rative action z
 ! ,comptroll] ,g5]al det]m9es          
appropriate4