,,ii #aagth ,,congress #b;d ,session ,s4 #cfbf ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,february #aj1 #bjbb ,mr4 ,casey 7for himself and ,mr4 ,scott of ,south ,carolina7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to improve access to the ,program of ,all-,inclusive ,care for the ,elderly1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,program of ,all-inclusive ,care for the ,elderly ,expanded ,act or the ,,pace ,expanded ,act4 #b4 ,improving access to and affordability of ,,pace programs for ,medicare beneficiaries who are not dual eligible beneficiaries through flexibility in rate setting for services not covered by ,medicare 7a7 ,in general ,section #ahid of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;eee7 is amended by adding at the end the following new subsection3 7j7 ,flexibility in establishing premiums for ,medicare ,,pace participants who are not also entitled to benefits under a ,state ,medicaid program 7#a7 ,codification of authority to charge a monthly capitation amount for non-,medicare services ,subject to the succeeding provisions of this subsection1 a ,,pace program operated by a ,,pace provider under a ,,pace program agreement in any ,state may charge a ,medicare-only ,,pace program eligible individual 7as defined in paragraph 7#d77;,a77 who is enrolled in such ,,pace program a monthly capitation payment amount for the provision of non-,medicare services 7as defined in paragraph 7#d77;,b77 under the ,,pace program4 7#b7 ,determination of monthly capitation payment amount 7,a7 ,in general ,notwithstanding section #dfj4ahf of title #db1 ,code of ,federal ,regulations 7or any successor regulation71 the monthly capitation payment amount that may be charged under paragraph 7#a7 shall be determined by the ,,pace provider operating the ,,pace program4 ,such monthly capitation payment amount shall be based on assessments conducted on the ,medicare-only ,,pace program eligible individual who is enrolled in such ,,pace program by the ,,pace program interdisciplinary team and shall take into account the health status of such individual4 ,in determining the monthly capitation amount for a ,medicare-only ,,pace program eligible individual under this paragraph1 a ,,pace provider may take into account the services determined necessary for the individual by the ,,pace program interdisciplinary team based upon their assessment of the individual4 ,a determination described in the preceding sentence shall not be construed as limiting the responsibility of the ,,pace provider to meet any unforeseen needs or provide for any required services for such individual4 7,b7 ,authority to adjust monthly capitation amount 7i7 ,in general ,subject to clause 7ii7 and paragraph 7#c71 the monthly capitation payment amount that may be charged under paragraph 7#a7 to a ,medicare-only ,,pace program eligible individual enrolled in a ,,pace program for non-,medicare services may increase or decrease based on assessments conducted on such individual4 ,any change in the monthly capitation payment amount charged to such an individual shall take effect beginning with the first day of the first month that begins after the month during which the plan of care is developed for such individual based on such an assessment4 7ii7 ,limitation on frequency of increase ,the monthly capitation payment amount that may be charged under paragraph 7#a7 to such an individual may not increase more frequently than once per calendar quarter4 7#c7 ,beneficiary protections 7,a7 ,disclosure of premium rate structure ,a ,,pace provider shall disclose to ,medicare-only ,,pace program eligible individuals the capitation payment amounts that may be charged under this section to such individuals for non-,medicare services under the ,,pace program operated by such ,,pace provider under this section-- 7i7 prior to enrollment of such individual in such ,,pace program1 and 7ii7 periodically1 and upon request of such individual1 after enrollment4 7,b7 ,assessment instrument 7i7 ,in general ,the ,secretary shall develop an assessment instrument for use by ,,pace programs with respect to ,medicare-only ,,pace program eligible individuals under this subsection4 7ii7 ,requirement for disclosure of assessment instrument ,the monthly capitation payment amount charged under paragraph 7#a7 to a ,medicare-only ,,pace program eligible individual for non-,medicare services shall be based on an assessment of such individual conducted by the ,,pace provider 7using the assessment instrument developed by the ,secretary under clause 7i771 accounting for health status and corresponding needs4 7iii7 ,requirement for disclosure of assessment instrument ,the assessment instrument used by the interdisciplinary team of the ,,pace program to evaluate the health and social status of ,,pace participants shall be disclosed to the individual prior to the assessment4 7,c7 ,process to seek review of assessments ,the ,secretary shall establish a process for a ,medicare-only ,,pace program eligible individual to seek review of any assessment conducted on the individual under this subsection4 7#d7 ,rule of construction ,nothing in this subsection shall be construed to preclude the testing under section #aaae;,a of a model to permit a ,,pace provider operating a ,,pace program to establish and charge monthly capitation payment amounts for the provision of non-,medicare services under the ,,pace program to ,medicare-only ,,pace program eligible individuals under a rate structure established by such ,,pace provider for such purpose1 including the use of an assessment instrument developed by the ,,pace program to assign such individuals to an appropriate rate category under such rate structure4 7#e7 ,definitions ,in this subsection-- 7,a7 the term ,medicare-only ,,pace program eligible individual means an individual who is described in subsection 7a77#a7 and who is not entitled to medical assistance under title ,,xix1 and includes the designated representative of the individual as appropriate2 and 7,b7 the term non-,medicare services means items and services covered under title ,,xix that are not covered under this title and items and services described in subsection 7b77#a77;,a77ii74 4 7b7 ,effective date ,the amendment made by subsection 7a7 shall take effect on the date of the enactment of this ,act1 and apply with respect to capitation amounts that may be charged for months beginning on or after ,january #a1 #bjbc4 7c7 ,rule of construction ,nothing in this section1 or the amendments made by this section1 shall be construed to modify or otherwise impact the following ,medicare capitation rates that may be charged by ,,pace plans for ,,pace participants who are ,medicare beneficiaries who are not both entitled to 7or enrolled for7 benefits under part ,a of title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq47 and enrolled for benefits under part ,b of such title3 7#a7 ,part ,a only medicare beneficiary ,in the case of a ,medicare beneficiary who is a ,,pace participant who is entitled to 7or enrolled for7 benefits under part ,a of such title ,,xviii but who is not enrolled for benefits under part ,b of such title1 the ,medicare ,part ,b capitation rate under paragraph 7b7 of section #dfj4ahf of title #db1 ,code of ,federal ,regulations 7or any successor regulations74 7#b7 ,part ,b only medicare beneficiary ,in the case of a ,medicare beneficiary who is a ,,pace participant who is enrolled for benefits under part ,b of such title ,,xviii but who is not entitled to 7or enrolled for7 benefits under part ,a of such title1 the ,medicare ,part ,a capitation rate under paragraph 7c7 of such section #dfj4ahf 7or any successor regulations74 #c4 ,anytime enrollment in ,,pace 7a7 ,in general 7#a7 ,any time enrollment and effective date ,section #ahid7;c77#e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;eee7c77#e77 is amended by adding at the end the following new subparagraph3 7,c7 ,any time enrollment and effective date of enrollment 7i7 ,any time enrollment ,a ,,pace program eligible individual may enroll in a ,,pace program at any time during a month4 7ii7 ,effective date ,subject to clause 7iii71 the enrollment of a ,,pace program eligible individual in a ,,pace program shall be effective on the date the ,,pace provider operating the ,,pace program receives an enrollment agreement signed by such ,,pace program eligible individual with respect to such ,,pace program4 7iii7 ,special rule in the case of dual eligible beneficiaries ,in the case of a ,,pace program eligible individual who is eligible for benefits under this title and title ,,xix1 clause 7i7 shall only apply if the ,state in which such individual resides has made an election under section #aicd7;c77#e77;,c7 to permit ,,pace program eligible individuals enroll in a ,,pace program at any time during a month in such ,state4 4 7#b7 ,prorated payments ,section #ahid7;d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;eee7d77 is amended by adding at the end the following new paragraph3 7#d7 ,prorated payments ,in the case of a ,,pace program eligible individual enrolled in a ,,pace program operated by a ,,pace provider with an enrollment effective date that is not the first day of a month1 the capitation amount that would otherwise be made under this subsection to the ,,pace provider for such individual for the first month in which such individual is so enrolled shall be prorated accordingly4 4 7b7 ,conforming amendments 7#a7 ,anytime enrollment and effective date ,section #aicd7;c77#e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#d7;c77#e77 is amended by adding at the end the following new subparagraph3 7,c7 ,state option to permit any time enrollment and effective date of enrollment 7i7 ,any time enrollment ,a ,state may elect to permit a ,,pace program eligible individual to enroll in a ,,pace program at any time during a month4 7ii7 ,effective date ,pursuant to a ,state election made under clause 7i71 the enrollment of a ,,pace program eligible individual in a ,,pace program shall be effective on the date the ,,pace provider operating the ,,pace program receives an enrollment agreement signed by such ,,pace program eligible individual with respect to such ,,pace program4 4 7#b7 ,prorated payments ,section #aicd7;d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#d7;d77 is amended by adding at the end the following new paragraph3 7#c7 ,prorated payments ,if a ,state elects under subsection 7c77#e77;,c7 to permit enrollment at any time during a month1 in the case of a ,,pace program eligible individual enrolled in a ,,pace program operated by a ,,pace provider with an enrollment effective date that is not the first day of a month1 the ,state shall prorate the capitation amount that would otherwise be made under this subsection to the ,,pace provider for such individual for the first month in which such individual is so enrolled4 4 7c7 ,effective date ,the amendments made by this section shall take effect on ,january #a1 #bjbc4 #d4 ,,pace site approval and expansion 7a7 ,in general ,sections #ahid7;e7 and #aicd7;e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;eee7e71 #acifu-#d7;e77 are each amended by striking paragraph 7#h7 and inserting the following3 7#h7 ,authority to submit applications at any time2 timely consideration of applications 7,a7 ,authority to submit applications at any time 7i7 ,new ,,pace provider status ,an entity that seeks to become a ,,pace provider may submit an application for ,,pace provider status at any time4 7ii7 ,service area expansion and addition of ,,pace center site ,to the extent the ,secretary requires a ,,pace provider to submit an application to expand its service area or to add a ,,pace center site1 a ,,pace provider may submit such an application at any time1 subject to the requirements of section #dfj4ab7;d7 of title #db1 ,code of ,federal ,regulations 7relating to the first trial period audit71 or any successor regulation4 7iii7 ,assurances ,an application for ,,pace provider status under clause 7i7 or to add a ,,pace center site under clause 7ii7 shall include the following assurances3 7,i7 ,an assurance that the required members of the interdisciplinary team are employees or contractors of the proposed ,,pace center or will be employees or contractors of the proposed ,,pace center by the time the ,,pace center becomes operational4 7,,ii7 ,an assurance that-- 7aa7 the ,,pace provider's contracts for all contractors and contracted personnel will be executed by the time the proposed ,,pace center becomes operational2 and 7bb7 executed contracts may include provisions for staffing levels commensurate with enrollment to full projected census4 7,b7 ,deemed approval ,an application described in subparagraph 7,a7 shall be deemed approved unless the ,secretary1 within #de days after the date of the submission of the application to the ,secretary1 either denies such request in writing or informs the applicant in writing with respect to any additional information that is needed in order to make a final determination with respect to the application4 ,after the date the ,secretary receives such additional information1 the application shall be deemed approved unless the ,secretary1 within #de days of such date1 denies such request4 4 7b7 ,effective date ,the amendments made by subsection 7a7 shall take effect on ,january #a1 #bjbc4 #e4 ,,pace pilot ,section #aaae;,a7b77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7b77#b77 is amended-- 7#a7 in subparagraph 7,b71 by adding at the end the following new clause3 7xxviii7 ,national testing of a model for expanded eligibility for the ,program of ,all-,inclusive ,care for the ,elderly as described in subparagraph 7,d74 2 and 7#b7 by adding at the end the following new subparagraph3 7,d7 ,national testing of model for expanded eligibility for the program of all-inclusive care for the elderly ,in the case where the ,secretary selects the model described in clause 7ii7 of this subparagraph for testing pursuant to clause 7xxviii7 of subparagraph 7,b71 the following shall apply3 7i7 ,national testing 7,i7 ,in general ,subject to subclause 7,,ii71 the ,secretary shall design a demonstration that allows each ,,pace provider with an executed ,,pace agreement to develop and submit to the ,secretary an application to begin testing expanded ,,pace eligibility for high-need and high-cost populations that are not otherwise eligible to participate in a ,,pace program within #a year of the date on which the model is selected4 7,,ii7 ,no effect on ongoing models or demonstration projects ,nothing in this subparagraph shall affect the testing of any model under this subsection or any demonstration project under this ,act that is implemented prior to the date of the enactment of this subparagraph4 7ii7 ,model described ,the model described in this clause seeks to increase access to quality1 integrated1 care for high-need1 high-cost individuals who are not otherwise eligible to participate in a ,,pace program in order to improve health and reduce cost4 ,under this model1 participating ,,pace providers would-- 7,i7 be paid fixed1 monthly capitated rates from both ,medicare and the applicable ,state ,medicaid agency for all services provided to each enrollee fitting the criteria of the ,,pace provider's designated population2 7,,ii7 partner with non-,,pace providers1 such as ,area ,agencies on ,aging1 ,centers for ,independent ,living1 local hospitals1 and non-hospital providers such as physicians1 behavioral health providers and other community-based organizations to effectively reach the ,,pace provider's selected population2 7,,iii7 adapt the ,,pace program model of care to appropriately serve the ,,pace provider's selected population to integrate care and meet the unique needs of said population2 and 7,,iv7 if the ,,pace provider is located in a ,state that has not yet served the selected population through a ,,pace program under section #aicd1 receive an up-front fixed payment to coordinate with the ,state to develop a capitated payment rate1 with appropriate risk adjustment1 for the ,,pace provider's selected population4 7iii7 ,requirements for participating ,,pace organizations ,in order to participate in the model1 a ,,pace provider must-- 7,i7 conduct a survey or needs assessment of their service area to determine the most appropriate population with which to expand their services2 7,,ii7 receive prior approval from the applicable ,state ,medicaid agency to submit an application to participate in the model2 and 7,,iii7 following such survey or needs assessment and approval from the applicable ,state ,medicaid agency1 submit and receive approval of an application of expansion from the ,secretary4 7iv7 ,application ,a ,,pace provider's application to participate in this model shall include the following information3 7,i7 ,results of the survey or needs assessment of their service area under clause 7iii77,i7 and an explanation of the expanded population the ,,pace organization will serve4 7,,ii7 ,the types of services that the expanded population will require and the ,,pace provider's plan to implement these services4 7,,iii7 ,how the ,,pace provider will achieve engagement and enrollment of the new population in the model1 including how it will partner with non-,,pace providers in the applicable service area4 7,,iv7 ,how the expanded population's participation in the ,,pace program is intended to improve quality of care and health outcomes under the model4 7,v7 ,certification that the applicable ,state ,medicaid agency has approved the ,,pace provider's application to participate in the model4 7,,vi7 ,plans to coordinate with the ,state ,medicaid agency to develop an initial capitated rate with appropriate risk adjustment4 7,,vii7 ,plans for the ,,pace provider and the ,state ,medicaid agency to review and adjust the ,medicaid capitated rate on a biennial basis1 as needed4 7,,viii7 ,any other information required by the ,secretary4 7v7 ,technical assistance ,the ,secretary shall provide1 or designate an entity to provide1 technical assistance to participating ,,pace providers as they apply for and implement the model4 7vi7 ,accounting for uncertainty ,in order for implementing ,,pace providers to receive unanticipated additional resources needed to implement the model1 the ,secretary shall establish procedures for the implementing ,,pace providers to submit to the ,secretary a request for additional resources4 7vii7 ,monitoring outcomes ,the ,secretary1 in conjunction with ,,pace providers and in consultation with ,states that have elected to expand ,,pace program eligibility under section #aicd7l71 shall develop a plan to-- 7,i7 annually monitor outcomes under the model1 which may include financial1 quality1 access1 and utilization outcomes2 7,,ii7 annually monitor the health outcomes of the ,,pace provider's expanded population2 and 7,,iii7 any other outcomes as determined by the ,secretary4 7viii7 ,reporting requirements 7,i7 ,report to congress ,not less frequently than every #c years 7for the duration of the implementation of the model under this subparagraph71 the ,secretary shall submit to ,congress a report on the implementation of the model under this subparagraph4 ,the report shall include demographic information on the populations served under the demonstration1 best practices for future implementation efforts and any other information the ,secretary determines appropriate together with recommendations for such legislation and administrative action as the ,secretary determines appropriate4 7ix7 ,funding ,the ,secretary shall allocate funds made available under subsection 7f77#a7 to design1 implement1 evaluate1 and report on the model described in clause 7ii7 in accordance with this subparagraph4 4 #f4 ,coordination with the ,federal ,coordinated ,health ,care ,office ,section #aicd of the ,social ,security ,act 7#db ,u4,s4,c4 #acifu-#d71 as amended by sections #c and #h1 is amended by adding at the end the following new subsection3 7m7 ,coordination with the ,federal ,coordinated ,health ,care ,office 7#a7 ,state coordination with ,,fchco ,the ,director of the ,federal ,coordinated ,health ,care ,office established under section #bfjb of the ,patient ,protection and ,affordable ,care ,act shall serve as a point of contact between ,state administering agencies and the ,federal ,government for purposes of implementing and operating a ,,pace program in a ,state1 and shall coordinate with other relevant offices and staff of the ,centers for ,medicare ,medicaid ,services involved in carrying out this section4 7#b7 ,annual report ,not later than ,january #a1 #bjbc1 and annually thereafter1 the ,director of the ,federal ,coordinated ,health ,care ,office shall submit to ,congress a report on the demographics of the populations served by ,,pace programs operated under this section and section #ahid4 4 #g4 ,evaluation of effectiveness of ,,pace program in rural and underserved areas 7a7 ,in general ,the ,assistant ,secretary for ,planning and ,evaluation of the ,department of ,health and ,human ,services 7referred to in this section as the ,assistant ,secretary7 shall conduct an evaluation of the effectiveness of the program for all-inclusive care for the elderly under sections #ahid and #aicd of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;eee1 #acifu-#d7 in rural and underserved areas1 including with respect to the following factors3 7#a7 ,reductions in hospitalizations and re-hospitalizations among program beneficiaries4 7#b7 ,reductions in emergency department use among program beneficiaries4 7#c7 ,reductions in long-term nursing facility use among program beneficiaries4 7#d7 ,reductions in mortality among program beneficiaries4 7#e7 ,achieving lower rates of functional decline1 and improvements in reported health status and quality of life among program beneficiaries4 7#f7 ,reductions in the total cost of care among program beneficiaries4 7#g7 ,the effect of activities supported under the program on the local area serviced by the program1 including on the health and well-being of unpaid and family caregivers of program beneficiaries4 7#h7 ,improvements in quality of life among program beneficiaries4 7b7 ,report ,not later than #fj months after the date of enactment of this ,act1 the ,assistant ,secretary shall submit a report containing the results of the evaluation required under subsection 7a71 an analysis of which elements of the program for all-inclusive care for the elderly under sections #ahid and #aicd of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;eee1 #acifu-#d7 should be replicated and scaled by governmental or non-governmental entities1 and such recommendations for legislation and administrative action as the ,assistant ,secretary determines appropriate to the chairs and ranking members of the following committees3 7#a7 ,the ,special ,committee on ,aging of the ,senate4 7#b7 ,the ,committee on ,finance of the ,senate4 7#c7 ,the ,committee on ,health1 ,education1 ,labor1 and ,pensions of the ,senate4 7#d7 ,the ,committee on ,ways and ,means of the ,house of ,representatives4 7#e7 ,the ,committee on ,energy and ,commerce of the ,house of ,representatives4 7c7 ,partners ,in conducting the evaluation and completing the report required under this section1 the ,assistant ,secretary shall provide an opportunity for partners and persons that have participated in the program for all-inclusive care for the elderly under sections #ahid and #aicd of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;eee1 #acifu-#d7 on every level1 especially individuals who receive care through the program and their unpaid or family caregivers1 to have an opportunity to contribute their expertise to evaluating the strategy and outcomes of the program4