I 

114TH CONGRESS 

1ST SESSION H. R. 4212 

To establish a Community-Based Institutional Special Needs Plan demonstration program to target home and community-based care to eligible Medicare beneficiaries, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

DECEMBER 10, 2015 

Ms. LINDA T. SA ́NCHEZ of California (for herself, Mr. MEEHAN, Mr. SCHRADER, and Mr. LANCE) introduced the following bill; which was referred 

to the Committee on Ways and Means, and in addition to the Committee 

on Energy and Commerce, for a period to be subsequently determined by 

the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To establish a Community-Based Institutional Special Needs 

Plan demonstration program to target home and community-based care to eligible Medicare beneficiaries, and 

for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Community-Based 

5 Independence for Seniors Act of 2015’’. 


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1 SEC. 2. FINDINGS. 

2 Congress makes the following findings: 

3 (1) Community-based services play an essential 

4 role in keeping individuals healthy. 

5 (2) Without community-based long-term serv6 ices and supports, which are not typically covered by 

7 Medicare, seniors frequently experience negative 

8 health outcomes and lose their ability to live inde9 pendently. 

10 (3) Seniors who deplete their resources often 

11 have no option but to turn to Medicaid for coverage 

12 of long-term care expenses. 

13 (4) Targeting community-based services and 

14 supports to at-risk seniors can help these individuals 

15 avoid depleting their assets and becoming Medicaid 

16 dependent. 

17 SEC. 3. COMMUNITY-BASED INSTITUTIONAL SPECIAL 

18 NEEDS PLAN DEMONSTRATION. 

19 Part C of title XVIII of the Social Security Act is 

20 amended by inserting after section 1859 (42 U.S.C. 

21 1395w–28) the following new section: 

22 ‘‘SEC. 1859A. COMMUNITY-BASED INSTITUTIONAL SPECIAL 

23 NEEDS PLAN DEMONSTRATION. 

24 ‘‘(a) ESTABLISHMENT.— 

25 ‘‘(1) IN GENERAL.—The Secretary shall estab26 lish a Community-Based Institutional Special Needs 


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1 Plan demonstration program (in this section referred 

2 to as the ‘CBI–SNP demonstration program’) to 

3 provide home and community-based care to eligible 

4 Medicare beneficiaries. 

5 ‘‘(2) AGREEMENTS.—The Secretary shall enter 

6 into agreements with eligible MA organizations 

7 under which such organizations shall offer eligible 

8 MA plans under the CBI–SNP demonstration pro9 gram to eligible Medicare beneficiaries. 

10 ‘‘(3) LIMITATION ON NUMBER OF PLANS.—The 

11 CBI–SNP demonstration program shall be carried 

12 out with respect to not greater than five MA plans. 

13 ‘‘(4) ELIGIBLE MA PLANS DEFINED.—For pur14 poses of this section, the term ‘eligible MA plan’ 

15 means a plan that, in addition to items and services 

16 for which coverage is otherwise provided under this 

17 part (including benefits under section 1852(a)(3) 

18 and notwithstanding any waivers under section 

19 1915(c)), provides for coverage of long-term care 

20 services and supports that the Secretary determines 

21 appropriate for the purposes of the CBI–SNP dem22 onstration program, such as— 

23 ‘‘(A) homemaker services; 

24 ‘‘(B) home delivered meals; 

25 ‘‘(C) transportation services; 


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1 ‘‘(D) respite care; 

2 ‘‘(E) adult day care services; and 

3 ‘‘(F) safety and other equipment not other4 wise covered under this title. 

5 ‘‘(b) ELIGIBLE MA ORGANIZATIONS.—For purposes 

6 of this section, the term ‘eligible MA organization’ means 

7 an MA organization that— 

8 ‘‘(1) has experience in offering specialized MA 

9 plans for special needs individuals, as defined in sec10 tion 1859(b)(6)(A), to individuals who live in the 

11 community in which the eligible MA plan is offered; 

12 ‘‘(2) has experience working with low-income 

13 seniors groups; 

14 ‘‘(3) is located in a State that the Secretary has 

15 determined is able to participate in the CBI–SNP 

16 demonstration program by agreeing to make avail17 able data necessary for purposes of conducting the 

18 independent evaluation required under subsection 

19 (h); and 

20 ‘‘(4) meets such other criteria as the Secretary 

21 may require. 

22 ‘‘(c) ELIGIBLE MEDICARE BENEFICIARY DE23 FINED.—In this section, the term ‘eligible Medicare bene24 ficiary’ means a Medicare beneficiary who— 


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1 ‘‘(1) is eligible to enroll in an eligible MA plan 

2 under the CBI–SNP demonstration program; 

3 ‘‘(2) is a subsidy eligible individual (as defined 

4 in section 1860D–14(a)(3)(A)); 

5 ‘‘(3) is not eligible to receive benefits under title 

6 XIX; 

7 ‘‘(4) is unable to perform 2 or more activities 

8 of daily living (as defined in section 7702B(c)(2)(B) 

9 of the Internal Revenue Code of 1986); and 

10 ‘‘(5) is age 65 or older. 

11 ‘‘(d) PAYMENTS.—The Secretary shall establish pay12 ment rates for eligible MA organizations offering eligible 

13 MA plans under the CBI–SNP demonstration program for 

14 benefits covered under such program (and not otherwise 

15 covered under part C) and provided to eligible Medicare 

16 beneficiaries under such plans. Such payment rates 

17 shall— 

18 ‘‘(1) be based upon payment rates established 

19 for purposes of payment under section 1853; 

20 ‘‘(2) be in addition to payments otherwise made 

21 to such organization with respect to such plans 

22 under part C; 

23 ‘‘(3) be adjusted to reflect the costs of treating 

24 eligible Medicare beneficiaries under this section; 

25 and 


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1 ‘‘(4) not, with respect to a month in which an 

2 eligible MA organization provides home and commu3 nity-based care to eligible Medicare beneficiaries 

4 under such demonstration program, exceed an 

5 amount for such month that is equal to the amount 

6 that would be awarded to such organization if the 

7 organization were to receive $400 with respect to 

8 each such beneficiary that the organization provides 

9 with such care during such month. 

10 ‘‘(e) SPECIAL ELECTION PERIOD.—Notwithstanding 

11 sections 1852(e)(2)(C) and 1860D–1(b)(1)(B)(iii), an eli12 gible Medicare beneficiary may, other than during the an13 nual, coordinated election periods under such sections— 

14 ‘‘(1) discontinue enrollment in an MA plan not 

15 participating in the CBI–SNP demonstration pro16 gram and enroll in an MA plan participating in such 

17 program; and 

18 ‘‘(2) discontinue enrollment under the original 

19 medicare fee-for-service program under parts A and 

20 B and the enrollment in a prescription drug plan 

21 under part D and enroll in an MA plan participating 

22 in the CBI–SNP demonstration program. 

23 ‘‘(f) BENEFICIARY EDUCATION.—The Secretary shall 

24 help to educate, through State Health Insurance Assist25 ance Programs and other organizations that assist seniors 


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1 with respect to benefits and enrollment under this title, 

2 eligible Medicare beneficiaries on the availability of the 

3 CBI–SNP demonstration program. 

4 ‘‘(g) IMPLEMENTATION.— 

5 ‘‘(1) DEADLINE.—The CBI–SNP demonstra6 tion program shall be implemented not later than 

7 January 1 of the second year beginning after the 

8 date of the enactment of this section. 

9 ‘‘(2) DURATION.—Subject to paragraph (3), the 

10 CBI–SNP demonstration program shall be con11 ducted for a period of five years. 

12 ‘‘(3) EXTENSION OR EXPANSION.—Taking into 

13 account the report under subsection (h)(2), the Sec14 retary may, through rulemaking, expand (including 

15 implementation on a nationwide or permanent basis) 

16 the duration or the scope CBI–SNP demonstration 

17 program to the extent determined appropriate by the 

18 Secretary, unless the Secretary determines that such 

19 expansion is expected to— 

20 ‘‘(A) increase aggregate expenditures 

21 under this title and title XIX with respect to el22 igible Medicare beneficiaries participating in the 

23 CBI–SNP demonstration program; or 

24 ‘‘(B) decrease the quality of health care 

25 services furnished to eligible Medicare beneVerDate Sep 11 2014 06:04 Dec 11, 2015 Jkt 059200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H4212.IH H4212

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1 ficiaries participating in the CBI–SNP dem2 onstration program. 

3 ‘‘(h) INDEPENDENT EVALUATION AND REPORTS.— 

4 ‘‘(1) INDEPENDENT EVALUATION.— 

5 ‘‘(A) IN GENERAL.—The Secretary shall 

6 provide for the evaluation of the CBI–SNP 

7 demonstration program by an independent third 

8 party. 

9 ‘‘(B) EVALUATION OBJECTIVES.—Such 

10 evaluation shall determine the extent to which 

11 the CBI–SNP demonstration program has re12 sulted in— 

13 ‘‘(i) improved patient care; 

14 ‘‘(ii) reduced hospitalizations or rehos15 pitalizations; 

16 ‘‘(iii) reduced or delayed nursing facil17 ity admissions and lengths of stay under 

18 title XIX; 

19 ‘‘(iv) reduced spend down of income 

20 and assets for purposes of becoming eligi21 ble for medical assistance under a State 

22 plan under title XIX; 

23 ‘‘(v) improved quality of life for the 

24 eligible Medicare beneficiaries enrolled in 


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1 an eligible MA plan participating in the 

2 CBI–SNP demonstration program; and 

3 ‘‘(vi) improved caregiver satisfaction. 

4 ‘‘(C) EVALUATION PROCESS.—Such eval5 uation shall be completed in accordance with 

6 the following process: 

7 ‘‘(i) The Secretary shall, prior to the 

8 implementation of such program, establish 

9 goals for such program with respect to the 

10 evaluation objectives described in subpara11 graph (B) and criteria for measuring the 

12 extent to which an eligible MA plan par13 ticipating in the CBI–SNP demonstration 

14 program meets such goals. 

15 ‘‘(ii) The Secretary shall implement 

16 clear data collection and reporting require17 ments for such eligible MA plans in order 

18 to carry out such evaluation. 

19 In carrying out such process, the Secretary 

20 shall recognize that definitions, benefits, and 

21 program requirements for long-term care serv22 ices and supports vary across States. 

23 ‘‘(2) REPORTS.—Not later than four years after 

24 the implementation of the CBI–SNP demonstration 

25 program, the Secretary shall submit to Congress a 


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1 report containing the results of the evaluation con2 ducted under paragraph (1), together with such rec3 ommendations for legislative or administrative action 

4 as the Secretary determines appropriate. In pre5 paring such report, the Secretary shall use at least 

6 three years worth of data under the demonstration 

7 program. 

8 ‘‘(i) BUDGET NEUTRALITY.—For any year after the 

9 third year of the CBI–SNP demonstration program, the 

10 Secretary shall ensure that the aggregate payments made 

11 under this title and title XIX, including under the dem12 onstration program, do not exceed the amount which the 

13 Secretary estimates would have been expended under such 

14 titles during such year if the CBI–SNP demonstration 

15 program had not been implemented. 

16 ‘‘(j) PAPERWORK REDUCTION ACT.—Chapter 35 of 

17 title 44, United States Code, shall not apply to the testing 

18 and evaluation of the CBI–SNP demonstration program.’’. 

Æ 


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