PACE Provider Act of 1995

Summary: PACE Provider Act of 1995 - Directs the Secretary of Health and Human Services to grant waivers of certain requirements of titles XVIII (Medicare), XIX (Medicaid), or any other applicable title of the Social Security Act to approved community-based organizations meeting specified eligibility requirements with demonstrated capacity, following a special trial period, to provide quality, cost-effective, and comprehensive health care services to at-risk frail elderly patients. 
Requires the terms and conditions of such a waiver to be substantially equivalent to those:  (1) of the On Lok waiver under the Social Security Amendments of 1983, as extended by the Consolidated Omnibus Budget Reconciliation Act of 1985; and (2) under the Protocol for the Program of All-Inclusive Care for the Elderly (PACE), as published by On Lok, Inc. as of April 14, 1995. 
Applies Medicaid spousal impoverishment rules to individuals receiving services from such organizations under this Act.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``PACE Provider Act of 1995''.
SEC. 2. WAIVER AUTHORITY AND PROVIDER ELIGIBILITY FOR PACE PROJECTS.

    (a) Trial Periods.--
            (1) In general.--The Secretary of Health and Human Services 
        (hereafter for purposes of this Act referred to as the 
        `Secretary') shall grant waivers of certain requirements of 
        titles XVIII and XIX of the Social Security Act (42 U.S.C. 1395 
        et seq., 42 U.S.C. 1396 et seq.), or of any other applicable 
        title of such Act, to public or nonprofit community-based 
        organizations for a trial period to enable such organizations 
        to demonstrate their capacity to provide comprehensive health 
        care services of proper quality on a cost-effective capitated 
        basis to frail elderly patients at risk of 
        institutionalization. An organization shall be eligible to be a 
        provider under such titles if the organization successfully 
        completes the trial period described in the preceding sentence.
            (2) Approval of applications.--An appropriately completed 
        application for a waiver under this Act is deemed approved 
        unless the Secretary specifically disapproves it in writing--
                    (A) not later than 90 days after the date the 
                completed application is filed in proper form; or
                    (B) not later than 90 days after the date 
                additional information is provided to the Secretary if 
                the Secretary requests reasonable and substantial 
                additional information during the 90-day period 
                described in subparagraph (A).
            (3) Sole authority.--The Secretary shall have sole 
        authority to approve or disapprove the eligibility of an 
        organization for a waiver under this Act and shall make such 
        determinations in a timely manner.
            (4) Consideration of existing sites.--In reviewing an 
        application for a waiver under this Act, the Secretary shall--
                    (A) consider whether any existing organization 
                already operates under a waiver granted under this Act 
                in the proposed service area identified in the 
                application; and
                    (B) if the Secretary determines that such an 
                organization exists, assure that the potential 
                population of eligible individuals to be served under 
                the proposed waiver is reasonably sufficient to sustain 
                an additional organization without jeopardizing the 
                economic or service viability of any other organization 
                operating in that service area.
    (b) Terms and Conditions for Waivers.--
            (1) In general.--Except as otherwise provided by law or 
        regulation, the terms and conditions of a waiver granted 
        pursuant to this Act shall be substantially equivalent to--
                    (A) the terms and conditions of the On Lok waiver 
                (referred to in section 603(c) of the Social Security 
                Amendments of 1983 and extended by section 9220 of the 
                Consolidated Omnibus Budget Reconciliation Act of 
                1985), including permitting the organization to assume 
                the full financial risk progressively over the initial 
                3-year period of the waiver; and
                    (B) the terms and conditions provided under the 
                Protocol for the Program of All-inclusive Care for the 
                Elderly (PACE), as published by On Lok, Inc. as of 
                April 14, 1995, and made generally available.
            (2) Not conditioned on information.--
                    (A) In general.--The Secretary's approval of a 
                waiver for a trial period shall not be conditioned upon 
                an organization collecting information for purposes 
                other than operational purposes, including monitoring 
                of cost and quality of care provided.
                    (B) Research.--The Secretary may require 
                information from an organization operating under a 
                waiver under this Act for purposes of general research 
                or general evaluation, but only if an organization 
                agrees to participate in such research or evaluation 
                and is appropriately compensated for any expenses 
                incurred, or where such research is undertaken entirely 
                at the expense of the Secretary.
            (3) 3-year waiver limit.--
                    (A) In general.--Except as provided in subparagraph 
                (B), a waiver granted under this Act shall be for a 
                trial period not to exceed 3 years.
                    (B) Exception.--The Secretary may extend a waiver 
                granted under this Act beyond the 3-year period during 
                the consideration of an application from an 
                organization under subsection (c).
            (4) Number of organizations authorized.--
                    (A) Prior to july 1, 1998.--
                            (i) In general.--The Secretary shall grant 
                        waivers under this Act to not more than--
                                    (I) 30 organizations before July 1, 
                                1996;
                                    (II) 40 organizations before July 
                                1, 1997, and after July 1, 1996; or
                                    (III) 50 organizations before July 
                                1, 1998, and after July 1, 1997.
                            (ii) Section 9412(b) and on lok waivers 
                        included.--For purposes of clause (i), the 
                        number of organizations specified in such 
                        clause shall include any organization 
                        established and operating under a waiver 
                        granted under section 603(c) of the Social 
                        Security Amendments of 1983 or any organization 
                        established and operating under a waiver 
                        granted under section 9412(b) of the Omnibus 
                        Budget Reconciliation Act of 1986 (as such 
                        sections were in effect on the day before the 
                        date of the enactment of this Act).
                    (B) On and after july 1, 1998.--On and after July 
                1, 1998, the number of organizations operating under a 
                waiver under this Act shall no longer be limited.
    (c) Eligibility To Be a Provider.--
            (1) In general.--Upon successful completion of the trial 
        period established under this Act, an organization which 
        continues to meet the requirements of this Act shall be 
        eligible to be a provider under any applicable title of the 
        Social Security Act, including under titles XVIII and XIX of 
        such Act (42 U.S.C. 1395 et seq.; 42 U.S.C. 1396 et seq.), and 
        may apply to be recognized as such in accordance with 
        regulations promulgated by the Secretary.
            (2) Requirements.--No organization may be eligible to be a 
        provider under any applicable title of the Social Security Act 
        if--
                    (A) the Secretary specifically and formally finds 
                that projected reimbursement for such organization 
                would not, without any reimbursement modifications 
                specified in the Secretary's finding, result in 
                payments below the projected costs for a comparable 
                population under the medicare program under title XVIII 
                of the Social Security Act (42 U.S.C. 1395 et seq.) and 
                the medicaid program under title XIX of such Act (42 
                U.S.C. 1396 et seq.), or under any other applicable 
                title of such Act, or that the care provided by such 
                organization is significantly deficient; and
                    (B) such projected reimbursement costs or 
                significant deficiencies in quality of care are not 
                appropriately adjusted or corrected on a timely basis 
                (as determined by the Secretary) in accordance with the 
                specific recommendations for reimbursement adjustments 
                or corrections in the quality of service included in 
                the Secretary's formal finding under subparagraph (A).
            (3) Not conditioned on information.--The provisions of 
        subsection (b)(2) shall apply to an organization eligible to be 
        a provider under any applicable title of the Social Security 
        Act after successfully completing a trial period under this 
        Act.
    (d) Reimbursement.--
            (1) In general.--Notwithstanding any other provision of 
        law, and except as provided in paragraph (2), an organization 
        that is granted a waiver under this Act, or that is eligible to 
        be a provider under any applicable title of the Social Security 
        Act as a result of this Act, shall ordinarily be reimbursed on 
        a capitation basis. Any such organization may provide 
        additional services as deemed appropriate by the organization 
        for qualified participants without regard to whether such 
        services are specifically reimbursable through capitation 
        payments. To the extent such services, in terms of type or 
        frequency, are not reimbursable, no payments for such services 
        may be required of participants.
            (2) Exception.--In the case of an organization receiving an 
        initial waiver under this Act on or after October 1, 1995, the 
        Secretary (at the request of the organization) shall not 
        require the organization to provide services under title XVIII 
        of the Social Security Act (42 U.S.C. 1395 et seq.) on a 
        capitated or other risk basis during the first or second year 
        of the waiver, in order to allow such an organization to 
        progressively assume the financial risk and to acquire 
        experience with such a payment method.
    (e) Application to On Lok Waivers.--The provisions of this Act also 
shall apply to an organization operating under the On Lok waiver 
described in subsection (b)(1)(A).
    (f) Application of Income and Resources Standards for Certain 
Institutionalized Spouses.--Section 1924 of the Social Security Act (42 
U.S.C. 1396r-5) (relating to the treatment of income and resources for 
certain institutionalized spouses) shall apply to any individual 
receiving services from an organization operating--
            (1) under a waiver under this Act; or
            (2) as a provider under title XIX of such Act, after a 
        determination that the organization has successfully completed 
        a trial period under this Act.
    (g) Promotion of Additional Applications.--The Secretary shall 
institute an ongoing effort to promote the development of organizations 
to acquire eligibility, through participation in a trial period under 
this Act, to become providers under any applicable title of the Social 
Security Act.
    (h) Provision of Services to Additional Populations.--Nothing in 
this Act shall prevent any participating organization from 
independently developing distinct programs to provide appropriate 
services to frail populations other than the elderly under any 
provision of law other than this Act, except where the Secretary finds 
that the provision of such services impairs the ability of the 
organization to provide services required for the elderly.
    (i) Definition of Provider.--The term ``provider'' means a provider 
of services which--
            (1) has filed an agreement with the Secretary under section 
        1866 of the Social Security Act (42 U.S.C. 1395cc);
            (2) is eligible to participate in a State plan approved 
        under title XIX of the Social Security Act (42 U.S.C. 1396 et 
        seq.); or
            (3) is eligible to receive payment for such services under 
        any other applicable title of the Social Security Act.

SEC. 3. APPLICATION OF SPOUSAL IMPOVERISHMENT RULES.

    Section 1924(a)(5) of the Social Security Act (42 U.S.C. 1396r-
5(a)(5)) is amended to read as follows:
            ``(5) Application to individuals receiving services from 
        certain organizations.--This section applies to individuals 
        receiving institutional or noninstitutional services from any 
        organization--
                    ``(A) operating under a waiver under--
                            ``(i) section 603(c) of the Social Security 
                        Amendments of 1983 (as in effect on the day 
                        before the date of the enactment of the PACE 
                        Provider Act of 1995);
                            ``(ii) section 9412(b) of the Omnibus 
                        Budget Reconciliation Act of 1986 (as so in 
                        effect); or
                            ``(iii) the PACE Provider Act of 1995; or
                    ``(B) which has become a provider under this title 
                after a determination that the organization has 
                successfully completed a trial period under the PACE 
                Provider Act of 1995.''.

SEC. 4. REPEALS; EFFECTIVE DATE AND APPLICATION TO EXISTING WAIVERS.

    (a) Repeals.--Section 603(c) of the Social Security Amendments of 
1983, section 9220 of the Consolidated Omnibus Budget Reconciliation 
Act of 1985, and section 9412(b) of the Omnibus Budget Reconciliation 
Act of 1986 are repealed.
    (b) Effective Date.--
            (1) In general.--Except as provided in paragraph (2), the 
        provisions of subsection (a) shall be effective on the date of 
        the enactment of this Act.
            (2) Application to existing waivers.--
                    (A) In general.--To the extent that any 
                organization is operating on the date of the enactment 
                of this Act under the On Lok waiver (referred to in 
                section 603(c) of the Social Security Amendments of 
                1983 and extended by section 9220 of the Consolidated 
                Omnibus Budget Reconciliation Act of 1985), or a waiver 
                granted under section 9412(b) of the Omnibus Budget 
                Reconciliation Act of 1986, the provisions of such 
                sections (as in effect before the date of the enactment 
                of this Act) shall continue to apply with respect to 
                such waiver until--
                            (i) the organization is eligible to be a 
                        provider under this Act;
                            (ii) the Secretary issues and implements 
                        the regulations referred to in section 2(c)(1); 
                        and
                            (iii) the organization has had a reasonable 
                        opportunity to apply to be recognized as a 
                        provider, such application has been formally 
                        considered by the Secretary, and a final 
                        determination on the application has been made.
                    (B) Continuation of waiver until effective date.--
                The waiver authority of any organization applying for 
                recognition under subparagraph (A) shall continue 
                until--
                            (i) the date that the Secretary determines 
                        that such organization is eligible to be and 
                        can actually serve as a provider under this 
                        Act; or
                            (ii) if the Secretary determines that the 
                        organization is not eligible to be a provider 
                        under this Act, the expiration of the waiver.
                    (C) Consideration of periods of operation prior to 
                this act.--In determining whether an organization is 
                eligible to be a provider under subparagraph (A), the 
                Secretary--
                            (i) in determining whether the organization 
                        has successfully completed a trial period under 
                        this Act, shall consider any period before the 
                        date of the enactment of this Act during which 
                        an organization was operating under a waiver 
                        described in subparagraph (A); and
                            (ii) shall treat the organization as 
                        eligible to be a provider under this Act for 
                        periods after the date of the enactment of this 
                        Act and before such determination if the 
                        organization meets the requirements of the 
                        regulations issued under section 2(c)(1) during 
                        such periods.