,i #aaith ,,congress #b;d ,session ,h4 ,r4 #habi ,,in ,,the ,,house ,,of ,,representatives ,march #bf1 #bjbf,ms4 ,tenney 7for herself and ,mr4 ,schneider7 introduced the following bill2 which was referred to the ,committee on ,ways and ,means1 and in addition to the ,committee on ,energy and ,commerce1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to amend title ,,xviii of the ,social ,security ,act to establish a full risk ,,aco program4 #a4 ,full ,risk ,,aco ,program ,title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq47 is amended by adding at the end the following new section3 #ahii;,b4 ,full ,risk ,accountable ,care ,organization ,program 7a7 ,findings ,congress finds as follows3 7#a7 ,successful pilots over the last decade have demonstrated that full risk accountable care organizations 7,a,c,os71 including full risk ,a,c,os that focus on a complex care population are successful at improving health outcomes while lowering costs in traditional ,medicare4 7#b7 ,traditional ,medicare lacks a permanent program that allows providers flexibility to engage in full risk models outside of time-limited pilot projects4 7#c7 ,a wide range of organizations serving a range of traditional ,medicare beneficiaries1 including rural and underserved areas1 would benefit from permanent options for full risk accountable care4 7#d7 ,full risk models can transform care by allowing more flexible and diverse payment options beyond fee-for-service reimbursement1 impact cash flow1 and tailor experiences for clinicians and beneficiaries4 7#e7 ,,aco options must encourage better care coordination for complex care beneficiaries1 those with six or more chronic conditions4 7b7 ,establishment ,by ,june #cj1 #bjbf1 the ,secretary shall establish a full risk ,,aco program 7in this section referred to as the program7 that adopts proven provider incentives to deliver high-quality care to better meet the needs of ,traditional ,medicare beneficiaries 7as defined in subsection 7l774 ,under such program-- 7#a7 groups of health care professionals shall work together to manage and coordinate care for ,medicare fee-for-service beneficiaries through a standard or complex care full risk ,,aco4 7#b7 providers and suppliers participating in this program shall be paid in a manner that incentivizes furnishing items and services in such practice to provide high-quality care tailored to meet the needs of ,medicare fee-for-service beneficiaries while reducing the cost of care4 7c7 ,full risk ,,aco program with standard and complex care track options 7#a7 ,in general ,an ,,aco participating in this program is a group of providers and suppliers focused on individualizing care to meet the specific needs of ,traditional ,medicare beneficiaries by emphasizing advanced primary care1 care coordination1 and the delivery of care in alternate settings for beneficiaries needing medical and nonmedical assistance in managing their health4 7#b7 ,requirements ,in order to participate in the program under this program1 an ,,aco3 7,a7 ,must be formed by the following ,,aco participants or combinations of ,,aco participants1 consistent with the ,medicare ,shared ,savings ,program3 7i7 ,,aco professionals in group practice arrangements4 7ii7 ,networks of individual practices of ,,aco professionals4 7iii7 ,partnerships or joint venture arrangements between hospitals and ,,aco professionals4 7iv7 ,hospitals employing ,,aco professionals4 7v7 ,c,a,hs that bill under ,method ,,ii 7as described in section #dac4gj7;b77#c7 of this chapter74 7vi7 ,r,h,cs4 7vii7 ,f,q,h,cs4 7viii7 ,teaching hospitals that have elected under section #dae4afj of this subchapter to receive payment on a reasonable cost basis for the direct medical and surgical services of their physicians4 7,b7 ,shall be structured to allow the organization to receive and distribute payments for services and performance incentives to participant and preferred providers and suppliers4 7,c7 ,shall include a sufficient number and type of providers for the ,medicare fee-for-service beneficiaries aligned or assigned to the ,,aco1 as determined by the ,secretary4 7,d7 ,shall serve a required minimum number of aligned and_/or attributed beneficiaries4 7i7 ,a ,standard ,full ,risk ,,aco shall have at least #b1ejj aligned and_/or assigned beneficiaries4 7ii7 ,a complex care full risk ,,aco shall have at least #bej aligned and_/or assigned beneficiaries in the first year2 at least #ejj aligned or assigned beneficiaries in the second year2 and at least #a1jjj aligned and_/or assigned beneficiaries in the third year and in every participation year after that4 7,e7 ,may establish preferred provider relationships1 and may pay such providers a portion or all of the provider's fee-for-service claims in lieu of fee-for-service reimbursement from ,,cms4 7,f7 ,shall have a financial guarantee mechanism in place commensurate with the financial arrangement selected in this program4 7,g7 ,shall enter into an agreement with the ,secretary to participate in the program for a five-year period4 ,the agreement may be renewed for additional performance periods4 7,h7 ,shall permit participation in the program at the ,,tin-,,npi level4 7#c7 ,clinical services ,an ,,aco participating in this program shall provide individualized care to meet the specific needs of ,medicare fee-for-service beneficiaries attributed or aligned to the ,,aco4 ,this may include the following3 7,a7 ,coordinated care across the care continuum1 including transitions4 7,b7 ,social support services4 7,c7 ,behavioral health services4 7,d7 ,nonvisit-based care 7including email1 text1 phone1 video1 or other technology74 7,e7 ,extended care access options and technology platforms enabling patient stratification1 outcomes tracking1 and practice-based population management4 7,f7 ,in-home care4 7,g7 ,palliative care4 7,h7 ,other items and services as determined appropriate by the ,secretary4 7#d7 ,quality and reporting requirements ,the ,secretary shall develop quality performance standards for full risk ,a,c,os4 7,a7 ,standard ,full ,risk ,a,c,os ,the ,secretary shall deploy a limited set of quality measures that prioritize patient experience and health outcomes while reducing clinician burden4 7,b7 ,additional ,requirement for ,quality ,performance for ,complex ,care ,full ,risk ,a,c,os ,the ,secretary shall deploy the quality measures in 7c77#d77;,a7 and include a ,days at ,home measure4 7,c7 ,overlap with ,medicare ,access and ,,chip ,reauthorization ,act ,all full risk ,,aco program participants shall be exempt from the ,merit-,based ,incentive ,payment ,system 7,,mips74 7#e7 ,beneficiary communications ,the ,secretary shall promulgate requirements for ,,aco marketing to ,medicare fee-for-service beneficiaries that educates and informs beneficiaries about their care options4 7d7 ,payment arrangements for ,a,c,os1 participant and preferred providers 7#a7 ,in general ,a full risk ,,aco is eligible to receive the following payments under the program under this section3 7,a7 ,primary care capitation ,a per-beneficiary1 per-month capitated payment for primary care services provided by ,participant ,providers and preferred providers who have opted into the capitated arrangement with the full risk ,,aco reflective of the predicted ,medicare ,part ,b costs representing professional services for which the ,,aco is directly responsible4 ,in a given year1 such payment may be up to #g percent of the total health care spending for the beneficiary under this title for the year4 ,the program shall include a repayment mechanism for the primary care capitation to ensure that this does not result in additional ,medicare spending4 7,b7 ,total ,care ,capitation ,a per-beneficiary1 per-month capitated payment for all ,medicare ,part ,a and ,part ,b services provided to aligned beneficiaries by all ,participant ,providers and by preferred providers who have opted into the capitated arrangement4 ,the ,,tcc payment amount will reflect the estimated total cost of care for the full risk ,,aco's aligned population for services provided by the providers participating in the capitation mechanism4 ,providers that elect to participate in ,total ,care ,capitation will agree to a #ajj percent reduction of their fee-for-service claims4 7,c7 ,option for ,claims ,reduction and ,population-,based ,payment ,full ,risk ,a,c,os can enter into arrangements whereby ,,cms would reduce claims payments for aligned beneficiaries for ,participant and ,preferred ,providers and ,,cms would make a monthly payment to the ,,aco equivalent to the estimated value of the ,,ffs claims reductions for those services4 7#b7 ,financial arrangements 7,a7 ,in general ,this program shall offer full financial risk for participant ,a,c,os4 7,b7 ,financial arrangements ,the ,secretary shall make multiple financial arrangements available to ,a,c,os1 reflecting varying experience with and ability to assume risk for ,medicare fee-for-service beneficiaries4 ,the ,secretary shall make one or more financial arrangements available to ,a,c,os under both of the following solutions3 7i7 ,full risk arrangement ,a,c,os participating in full risk arrangements shall share in #ajj percent of savings and losses1 subject to a discount and risk corridors4 7ii7 ,discount ,the ,secretary shall determine and apply a discount to the full risk ,,aco's benchmark4 7,c7 ,benchmark for standard full risk acos ,the benchmark for ,standard ,full ,risk ,a,c,os shall be developed by-- 7i7 calculating the ,a,c,os historical baseline spending for its aligned beneficiary population2 7ii7 trending the historical baseline expenditures forward based on an adjusted version of the ,u4,s4 ,per ,capita ,cost growth trend2 7iii7 blending the historical baseline expenditures with regional expenditures using an adjusted ,medicare ,advantage rate book2 7iv7 risk adjust the blended expenditures2 and 7v7 apply the discount4 7,d7 ,benchmark for ,complex ,care ,full ,risk ,a,c,os ,the benchmarking methodology for ,complex ,care ,full ,risk ,a,c,os shall be developed separately1 taking into account the appropriate weighting of the regional component 7at least half7 and remove the ceiling on the regional blend4 7,e7 ,risk ,corridors ,the ,secretary shall develop risk corridors appropriate to this program4 7e7 ,risk adjustment 7#a7 ,prospective risk adjustment ,subject to paragraph 7#b71 the ,secretary shall use prospective risk adjustment for a standard full risk ,,aco4 ,risk adjustment methodologies should be identical to ,medicare ,advantage to the extent practical4 7#b7 ,concurrent risk adjustment for complex care full risk ,,aco ,the ,secretary shall use concurrent risk adjustment to adjust the benchmark for a complex care full risk ,,aco4 7f7 ,beneficiary assignment 7#a7 ,in general ,full ,risk ,,aco program participants shall use the ,medicare ,shared ,savings ,program alignment and assignment methodologies1 including a choice of prospective assignment or prospective assignment with retrospective reconciliation4 7#b7 ,signed ,voluntary ,alignment ,in addition to the methodology in subsection 7f77#a71 ,standard and ,complex ,care ,full ,risk ,a,c,os shall be permitted to use signed voluntary alignment4 ,such alignment shall take effect on a monthly basis4 7#c7 ,opt-out ,medicare beneficiaries shall have the ability to opt out of participating in the full risk ,,aco program4 7g7 ,waivers ,the ,secretary may waive such provisions of this title and title ,,xi as the ,secretary determines necessary in order to implement the demonstration program4 7h7 ,data ,the ,secretary shall provide to program participants under this section regular reports with up-to-date provider claims data and payment information with respect to ,medicare fee-for-service beneficiaries attributed or aligned in the ,,aco and shall provide other data to ,a,c,os as necessary4 7i7 ,treatment under the medicare access and ,,chip ,reauthorization ,act ,an ,,aco participating in this program shall be considered an advanced alternative payment model4 7j7 ,definitions ,in this section3 7#a7 ,concurrent risk adjustment ,the term concurrent risk adjustment means a risk adjustment model that uses current year diagnoses1 demographics1 and other factors to predict cost in that same year4 7#b7 ,medicare fee-for-service beneficiary ,the term ,medicare fee-for-service beneficiary means an individual who is enrolled in the original ,medicare fee-for-service program under parts ,a and ,b and is not enrolled in a ,medicare ,advantage plan under part ,c1 an eligible organization under section #ahgf1 or a ,,pace program under section #ahid4 7#c7 ,physician ,the term physician means a physician as defined in section #ahfa7r77#a74 7#d7 ,standard full risk ,,aco ,the term standard full risk ,,aco means an ,,aco composed of ,medicare fee-for-service beneficiaries1 less than two-thirds of which have six or more chronic co-morbidities4 7#e7 ,complex care full risk ,,aco ,the term complex care full risk ,,aco means an ,,aco composed of ,medicare fee-for-services beneficiaries1 at least two-thirds of which have six or more chronic co-morbidities4 4