,i  #aai? ,,congress  #b;d ,session  ,h4
 ,r4 #habi  ,,9 ,,! ,,h\se ,,(          
,,repres5tatives  ,m>* #bf1 #bjbf,ms4   
,t5ney 7= h]self & ,mr4 ,s*neid]7       
introduc$ ! foll[+ bill2 :i* 0 ref]r$ to
 ! ,committee on ,ways & ,means1 & 9    
addition to ! ,committee on ,en]gy &    
,comm]ce1 = a p]iod to be subsequ5tly   
det]m9$ by ! ,speak]1 9 ea* case =      
consid]ation ( su* provisions z fall )9 
! jurisdiction ( ! committee conc]n$  ,a
 ,,bill  ,to am5d title ,,xviii ( !     
,social ,security ,act to e/abli% a full
 risk ,,aco program4  #a4 ,full ,risk   
,,aco ,program ,title ,,xviii ( !       
,social ,security ,act 7#db ,u4,s4,c4   
#acie et seq47 is am5d$ by add+ at ! end
 ! foll[+ new section3  #ahii;,b4 ,full 
,risk ,acc\ntable ,c>e ,organization    
,program  7a7 ,f9d+s ,congress f9ds z   
foll[s3 7#a7 ,successful pilots ov] !   
la/ decade h demon/rat$ t full risk     
acc\ntable c>e organizations 7,a,c,os71 
includ+ full risk ,a,c,os t focus on a  
complex c>e population are successful at

 improv+ heal? outcomes :ile l[]+ co/s 9
 traditional ,m$ic>e4  7#b7 ,traditional
 ,m$ic>e lacks a p]man5t program t all[s
 provid]s flexibility to engage 9 full  
risk models outside ( "t-limit$ pilot   
projects4  7#c7 ,a wide range (         
organizations s]v+ a range ( traditional
 ,m$ic>e b5efici>ies1 includ+ rural &   
und]s]v$ areas1 w\ld b5efit f p]man5t   
options = full risk acc\ntable c>e4     
7#d7 ,full risk models c trans=m c>e by 
all[+ m flexible & div]se paym5t options
 beyond fee-=-s]vice reimbursem5t1      
impact ca% fl[1 & tailor exp]i5ces =    
cl9icians & b5efici>ies4  7#e7 ,,aco    
options mu/ enc\rage bett] c>e          
coord9ation = complex c>e b5efici>ies1  
^? ) six or m *ronic conditions4  7b7   
,e/abli%m5t ,by ,june #cj1 #bjbf1 !     
,secret>y %all e/abli% a full risk ,,aco
 program 79 ?is section ref]r$ to z !   
program7 t adopts prov5 provid]         
inc5tives to deliv] high-quality c>e to 
bett] meet ! ne$s ( ,traditional ,m$ic>e
 b5efici>ies 7z def9$ 9 subsection 7l774

 ,"u su* program-- 7#a7 gr\ps ( heal?   
c>e pr(essionals %all "w toge!r to      
manage & coord9ate c>e = ,m$ic>e        
fee-=-s]vice b5efici>ies ?r\gh a /&>d or
 complex c>e full risk ,,aco4  7#b7     
provid]s & suppli]s p>ticipat+ 9 ?is    
program %all be paid 9 a mann] t        
inc5tivizes furni%+ items & s]vices 9   
su* practice to provide high-quality c>e
 tailor$ to meet ! ne$s ( ,m$ic>e       
fee-=-s]vice b5efici>ies :ile r$uc+ !   
co/ ( c>e4  7c7 ,full risk ,,aco program
 ) /&>d & complex c>e track options     
7#a7 ,9 g5]al ,an ,,aco p>ticipat+ 9 ?is
 program is a gr\p ( provid]s & suppli]s
 focus$ on individualiz+ c>e to meet !  
specific ne$s ( ,traditional ,m$ic>e    
b5efici>ies by emphasiz+ advanc$ prim>y 
c>e1 c>e coord9ation1 & ! deliv]y ( c>e 
9 alt]nate sett+s = b5efici>ies ne$+    
m$ical & nonm$ical assi/ance 9 manag+ _!
 heal?4  7#b7  ,requirem5ts  ,9 ord] to 
p>ticipate 9 ! program "u ?is program1  
an ,,aco3 7,a7 ,mu/ be =m$ by ! foll[+  
,,aco p>ticipants or comb9ations ( ,,aco

 p>ticipants1 consi/5t ) ! ,m$ic>e ,%>$ 
,sav+s ,program3  7i7 ,,aco pr(essionals
 9 gr\p practice arrangem5ts4  7ii7     
,networks ( individual practices ( ,,aco
 pr(essionals4  7iii7 ,p>tn]%ips or jo9t
 v5ture arrangem5ts betwe5 hospitals &  
,,aco pr(essionals4  7iv7 ,hospitals    
employ+ ,,aco pr(essionals4  7v7 ,c,a,hs
 t bill "u ,me?od ,,ii 7z describ$ 9    
section #dac4gj7;b77#c7 ( ?is *apt]74   
7vi7 ,r,h,cs4  7vii7 ,f,q,h,cs4  7viii7 
,tea*+ hospitals t h elect$ "u section  
#dae4afj ( ?is sub*apt] to receive      
paym5t on a reasonable co/ basis = !    
direct m$ical & surgical s]vices ( _!   
physicians4  7,b7 ,%all be /ructur$ to  
all[ ! organization to receive &        
di/ribute paym5ts = s]vices & p]=mance  
inc5tives to p>ticipant & pref]r$       
provid]s & suppli]s4  7,c7 ,%all include
 a suffici5t numb] & type ( provid]s = !
 ,m$ic>e fee-=-s]vice b5efici>ies align$
 or assign$ to ! ,,aco1 z det]m9$ by !  
,secret>y4  7,d7 ,%all s]ve a requir$   
m9imum numb] ( align$ &_/or attribut$   

b5efici>ies4  7i7 ,a ,/&>d ,full ,risk  
,,aco %all h at lea/ #b1ejj align$ &_/or
 assign$ b5efici>ies4  7ii7 ,a complex  
c>e full risk ,,aco %all h at lea/ #bej 
align$ &_/or assign$ b5efici>ies 9 !    
fir/ ye>2 at lea/ #ejj align$ or assign$
 b5efici>ies 9 ! second ye>2 & at lea/  
#a1jjj align$ &_/or assign$ b5efici>ies 
9 ! ?ird ye> & 9 e p>ticipation ye> aft]
 t4  7,e7 ,may e/abli% pref]r$ provid]  
relation%ips1 & may pay su* provid]s a  
portion or all ( ! provid]'s            
fee-=-s]vice claims 9 lieu (            
fee-=-s]vice reimbursem5t f ,,cms4  7,f7
 ,%all h a f9ancial gu>antee me*anism 9 
place comm5surate ) ! f9ancial          
arrangem5t select$ 9 ?is program4  7,g7 
,%all ent] into an agreem5t ) !         
,secret>y to p>ticipate 9 ! program = a 
five-ye> p]iod4 ,! agreem5t may be r5ew$
 = additional p]=mance p]iods4  7,h7    
,%all p]mit p>ticipation 9 ! program at 
! ,,t9-,,npi level4  7#c7 ,cl9ical      
s]vices ,an ,,aco p>ticipat+ 9 ?is      
program %all provide individualiz$ c>e  

to meet ! specific ne$s ( ,m$ic>e       
fee-=-s]vice b5efici>ies attribut$ or   
align$ to ! ,,aco4 ,?is may include !   
foll[+3  7,a7 ,coord9at$ c>e across !   
c>e cont9uum1 includ+ transitions4  7,b7
 ,social support s]vices4  7,c7         
,behavioral heal? s]vices4  7,d7        
,nonvisit-bas$ c>e 7includ+ email1 text1
 phone1 video1 or o!r te*nology74  7,e7 
,ext5d$ c>e access options & te*nology  
plat=ms enabl+ pati5t /ratification1    
outcomes track+1 & practice-bas$        
population managem5t4  7,f7 ,9-home c>e4
  7,g7 ,palliative c>e4  7,h7 ,o!r items
 & s]vices z det]m9$ appropriate by !   
,secret>y4  7#d7 ,quality & report+     
requirem5ts ,! ,secret>y %all develop   
quality p]=mance /&>ds = full risk      
,a,c,os4  7,a7  ,/&>d ,full ,risk       
,a,c,os  ,! ,secret>y %all deploy a     
limit$ set ( quality measures t         
prioritize pati5t exp]i5ce & heal?      
outcomes :ile r$uc+ cl9ician burd54     
7,b7  ,additional ,requirem5t = ,quality
 ,p]=mance = ,complex ,c>e ,full ,risk  

,a,c,os  ,! ,secret>y %all deploy !     
quality measures 9 7c77#d77;,a7 &       
include a ,days at ,home measure4  7,c7 
,ov]lap ) ,m$ic>e ,access & ,,*ip       
,reau?orization ,act  ,all full risk    
,,aco program p>ticipants %all be exempt
 f ! ,m]it-,bas$ ,inc5tive ,paym5t      
,sy/em 7,,mips74  7#e7  ,b5efici>y      
communications  ,! ,secret>y %all       
promulgate requirem5ts = ,,aco m>ket+ to
 ,m$ic>e fee-=-s]vice b5efici>ies t     
educates & in=ms b5efici>ies ab\t _! c>e
 options4  7d7  ,paym5t arrangem5ts =   
,a,c,os1 p>ticipant & pref]r$ provid]s  
7#a7  ,9 g5]al  ,a full risk ,,aco is   
eligible to receive ! foll[+ paym5ts "u 
! program "u ?is section3  7,a7  ,prim>y
 c>e capitation  ,a p]-b5efici>y1       
p]-mon? capitat$ paym5t = prim>y c>e    
s]vices provid$ by ,p>ticipant ,provid]s
 & pref]r$ provid]s :o h opt$ into !    
capitat$ arrangem5t ) ! full risk ,,aco 
reflective ( ! pr$ict$ ,m$ic>e ,"p ,b   
co/s repres5t+ pr(essional s]vices = :i*
 ! ,,aco is directly responsible4 ,9 a  

giv5 ye>1 su* paym5t may be up to #g    
p]c5t ( ! total heal? c>e sp5d+ = !     
b5efici>y "u ?is title = ! ye>4 ,!      
program %all include a repaym5t me*anism
 = ! prim>y c>e capitation to ensure t  
?is does n result 9 additional ,m$ic>e  
sp5d+4  7,b7  ,total ,c>e ,capitation   
,a p]-b5efici>y1 p]-mon? capitat$ paym5t
 = all ,m$ic>e ,"p ,a & ,"p ,b s]vices  
provid$ to align$ b5efici>ies by all    
,p>ticipant ,provid]s & by pref]r$      
provid]s :o h opt$ into ! capitat$      
arrangem5t4 ,! ,,tcc paym5t am\nt w     
reflect ! e/imat$ total co/ ( c>e = !   
full risk ,,aco's align$ population =   
s]vices provid$ by ! provid]s p>ticipat+
 9 ! capitation me*anism4 ,provid]s t   
elect to p>ticipate 9 ,total ,c>e       
,capitation w agree to a #ajj p]c5t     
r$uction ( _! fee-=-s]vice claims4  7,c7
  ,option = ,claims ,r$uction &         
,population-,bas$ ,paym5t  ,full ,risk  
,a,c,os c ent] into arrangem5ts :]eby   
,,cms w\ld r$uce claims paym5ts = align$
 b5efici>ies = ,p>ticipant & ,pref]r$   

,provid]s & ,,cms w\ld make a mon?ly    
paym5t to ! ,,aco equival5t to ! e/imat$
 value ( ! ,,ffs claims r$uctions = ^?  
s]vices4  7#b7  ,f9ancial arrangem5ts   
7,a7  ,9 g5]al  ,?is program %all (f]   
full f9ancial risk = p>ticipant ,a,c,os4
  7,b7 ,f9ancial arrangem5ts ,!         
,secret>y %all make multiple f9ancial   
arrangem5ts available to ,a,c,os1       
reflect+ v>y+ exp]i5ce ) & ability to   
assume risk = ,m$ic>e fee-=-s]vice      
b5efici>ies4 ,! ,secret>y %all make "o  
or m f9ancial arrangem5ts available to  
,a,c,os "u bo? ( ! foll[+ solutions3    
7i7  ,full risk arrangem5t  ,a,c,os     
p>ticipat+ 9 full risk arrangem5ts %all 
%>e 9 #ajj p]c5t ( sav+s & losses1      
subject to a disc\nt & risk corridors4  
7ii7  ,disc\nt  ,! ,secret>y %all       
det]m9e & apply a disc\nt to ! full risk
 ,,aco's b5*m>k4  7,c7  ,b5*m>k = /&>d  
full risk acos  ,! b5*m>k = ,/&>d ,full 
,risk ,a,c,os %all be develop$ by-- 7i7 
calculat+ ! ,a,c,os hi/orical basel9e   
sp5d+ = its align$ b5efici>y population2

  7ii7 tr5d+ ! hi/orical basel9e        
exp5ditures =w>d bas$ on an adju/$      
v]sion ( ! ,u4,s4 ,p] ,capita ,co/ gr[? 
tr5d2  7iii7 bl5d+ ! hi/orical basel9e  
exp5ditures ) regional exp5ditures us+  
an adju/$ ,m$ic>e ,advantage rate book2 
7iv7 risk adju/ ! bl5d$ exp5ditures2 &  
7v7 apply ! disc\nt4  7,d7  ,b5*m>k =   
,complex ,c>e ,full ,risk ,a,c,os  ,!   
b5*m>k+ me?odology = ,complex ,c>e ,full
 ,risk ,a,c,os %all be develop$         
sep>ately1 tak+ into acc\nt !           
appropriate weight+ ( ! regional        
compon5t 7at lea/ half7 & remove ! ceil+
 on ! regional bl5d4  7,e7  ,risk       
,corridors  ,! ,secret>y %all develop   
risk corridors appropriate to ?is       
program4  7e7 ,risk adju/m5t  7#a7      
,prospective risk adju/m5t ,subject to  
p>agraph 7#b71 ! ,secret>y %all use     
prospective risk adju/m5t = a /&>d full 
risk ,,aco4 ,risk adju/m5t me?odologies 
%\ld be id5tical to ,m$ic>e ,advantage  
to ! ext5t practical4  7#b7 ,concurr5t  
risk adju/m5t = complex c>e full risk   

,,aco ,! ,secret>y %all use concurr5t   
risk adju/m5t to adju/ ! b5*m>k = a     
complex c>e full risk ,,aco4  7f7       
,b5efici>y assignm5t  7#a7 ,9 g5]al     
,full ,risk ,,aco program p>ticipants   
%all use ! ,m$ic>e ,%>$ ,sav+s ,program 
alignm5t & assignm5t me?odologies1      
includ+ a *oice ( prospective assignm5t 
or prospective assignm5t ) retrospective
 reconciliation4  7#b7 ,sign$ ,volunt>y 
,alignm5t ,9 addition to ! me?odology 9 
subsection 7f77#a71 ,/&>d & ,complex    
,c>e ,full ,risk ,a,c,os %all be p]mitt$
 to use sign$ volunt>y alignm5t4 ,su*   
alignm5t %all take effect on a mon?ly   
basis4  7#c7 ,opt-out ,m$ic>e           
b5efici>ies %all h ! ability to opt out 
( p>ticipat+ 9 ! full risk ,,aco        
program4  7g7 ,waiv]s ,! ,secret>y may  
waive su* provisions ( ?is title & title
 ,,xi z ! ,secret>y det]m9es necess>y 9 
ord] to implem5t ! demon/ration program4
  7h7 ,data ,! ,secret>y %all provide to
 program p>ticipants "u ?is section     
regul> reports ) up-to-date provid]     

claims data & paym5t in=mation ) respect
 to ,m$ic>e fee-=-s]vice b5efici>ies    
attribut$ or align$ 9 ! ,,aco & %all    
provide o!r data to ,a,c,os z necess>y4 
7i7 ,treatm5t "u ! m$ic>e access & ,,*ip
 ,reau?orization ,act ,an ,,aco         
p>ticipat+ 9 ?is program %all be        
consid]$ an advanc$ alt]native paym5t   
model4  7j7 ,def9itions ,9 ?is section3 
7#a7 ,concurr5t risk adju/m5t ,! t]m    
concurr5t risk adju/m5t means a risk    
adju/m5t model t uses curr5t ye>        
diagnoses1 demographics1 & o!r factors  
to pr$ict co/ 9 t same ye>4  7#b7       
,m$ic>e fee-=-s]vice b5efici>y ,! t]m   
,m$ic>e fee-=-s]vice b5efici>y means an 
individual :o is enroll$ 9 ! orig9al    
,m$ic>e fee-=-s]vice program "u p>ts ,a 
& ,b & is n enroll$ 9 a ,m$ic>e         
,advantage plan "u "p ,c1 an eligible   
organization "u section #ahgf1 or a     
,,pace program "u section #ahid4  7#c7  
,physician ,! t]m physician means a     
physician z def9$ 9 section             
#ahfa7r77#a74  7#d7 ,/&>d full risk     

,,aco ,! t]m /&>d full risk ,,aco means 
an ,,aco compos$ ( ,m$ic>e fee-=-s]vice 
b5efici>ies1 less ?an two-?irds ( :i* h 
six or m *ronic co-morbidities4  7#e7   
,complex c>e full risk ,,aco ,! t]m     
complex c>e full risk ,,aco means an    
,,aco compos$ ( ,m$ic>e fee-=-s]vices   
b5efici>ies1 at lea/ two-?irds ( :i* h  
six or m *ronic co-morbidities4  4