II 

Calendar No. 206 

115TH CONGRESS 

1ST SESSION S. 870 

[Report No. 115–146] 

To amend title XVIII of the Social Security Act to implement Medicare 

payment policies designed to improve management of chronic disease, 

streamline care coordination, and improve quality outcomes without adding to the deficit. 

IN THE SENATE OF THE UNITED STATES 

APRIL 6 (legislative day, APRIL 4), 2017 

Mr. HATCH (for himself, Mr. WYDEN, Mr. ISAKSON, Mr. WARNER, Mr. BENNET, Mr. CARDIN, Mr. THUNE, Mr. CASEY, Mr. CORNYN, Mr. CRAPO, 

Mr. GRASSLEY, Mr. CARPER, Ms. STABENOW, Mrs. MCCASKILL, Mr. 

ROBERTS, Mr. CASSIDY, Mr. WICKER, Mr. NELSON, and Mr. SCHATZ) 

introduced the following bill; which was read twice and referred to the 

Committee on Finance 

AUGUST 3, 2017 

Reported by Mr. HATCH, with an amendment 

[Strike out all after the enacting clause and insert the part printed in italic] 

A BILL 

To amend title XVIII of the Social Security Act to implement 

Medicare payment policies designed to improve management of chronic disease, streamline care coordination, 

and improve quality outcomes without adding to the deficit. 


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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; TABLE OF CONTENTS. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘Creating High-Quality Results and Outcomes Necessary 

6 to Improve Chronic (CHRONIC) Care Act of 2017’’. 

7 (b) TABLE OF CONTENTS.—The table of contents of 

8 this Act is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—RECEIVING HIGH QUALITY CARE IN THE HOME 

Sec. 101. Extending the Independence at Home Demonstration Program. 

Sec. 102. Expanding access to home dialysis therapy. 

TITLE II—ADVANCING TEAM-BASED CARE 

Sec. 201. Providing continued access to Medicare Advantage special needs 

plans for vulnerable populations. 

TITLE III—EXPANDING INNOVATION AND TECHNOLOGY 

Sec. 301. Adapting benefits to meet the needs of chronically ill Medicare Advantage enrollees. 

Sec. 302. Expanding supplemental benefits to meet the needs of chronically ill 

Medicare Advantage enrollees. 

Sec. 303. Increasing convenience for Medicare Advantage enrollees through 

telehealth. 

Sec. 304. Providing accountable care organizations the ability to expand the use 

of telehealth. 

Sec. 305. Expanding the use of telehealth for individuals with stroke. 

TITLE IV—IDENTIFYING THE CHRONICALLY ILL POPULATION 

Sec. 401. Providing flexibility for beneficiaries to be part of an accountable care 

organization. 

TITLE V—EMPOWERING INDIVIDUALS AND CAREGIVERS IN CARE 

DELIVERY 

Sec. 501. Eliminating barriers to care coordination under accountable care organizations. 

Sec. 502. GAO study and report on longitudinal comprehensive care planning 

services under Medicare part B. 

TITLE VI—OTHER POLICIES TO IMPROVE CARE FOR THE 

CHRONICALLY ILL 

Sec. 601. GAO study and report on improving medication synchronization. 


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Sec. 602. GAO study and report on impact of obesity drugs on patient health 

and spending. 

1 TITLE I—RECEIVING HIGH 

2 QUALITY CARE IN THE HOME 

3 SEC. 101. EXTENDING THE INDEPENDENCE AT HOME DEM4 ONSTRATION PROGRAM. 

5 Section 1866E of the Social Security Act (42 U.S.C. 

6 1395cc–5) is amended— 

7 (1) in subsection (e)— 

8 (A) in paragraph (1), by striking ‘‘5-year 

9 period’’ and inserting ‘‘7-year period’’; and 

10 (B) in paragraph (5), by striking ‘‘10,000’’ 

11 and inserting ‘‘15,000’’; and 

12 (2) in subsection (i), by striking ‘‘second of 2’’ 

13 and inserting ‘‘third of 3’’. 

14 SEC. 102. EXPANDING ACCESS TO HOME DIALYSIS THER15 APY. 

16 (a) IN GENERAL.—Section 1881(b)(3) of the Social 

17 Security Act (42 U.S.C. 1395rr(b)(3)) is amended— 

18 (1) by redesignating subparagraphs (A) and 

19 (B) as clauses (i) and (ii), respectively; 

20 (2) in clause (ii), as redesignated by subpara21 graph (A), strike ‘‘on a comprehensive’’ and insert 

22 ‘‘subject to subparagraph (B), on a comprehensive’’; 

23 (3) by striking ‘‘With respect to’’ and inserting 

24 ‘‘(A) With respect to’’; and 


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1 (4) by adding at the end the following new sub2 paragraph: 

3 ‘‘(B) For purposes of subparagraph (A)(ii), an indi4 vidual determined to have end stage renal disease receiv5 ing home dialysis may choose to receive the monthly end 

6 stage renal disease-related visits furnished on or after 

7 January 1, 2019, via telehealth if the individual receives 

8 a face-to-face visit, without the use of telehealth, at least 

9 once every three consecutive months.’’. 

10 (b) ORIGINATING SITE REQUIREMENTS.— 

11 (1) IN GENERAL.—Section 1834(m) of the So12 cial Security Act (42 U.S.C. 1395m(m)) is amend13 ed— 

14 (A) in paragraph (4)(C)(ii), by adding at 

15 the end the following new subclauses: 

16 ‘‘(IX) A renal dialysis facility, 

17 but only for purposes of section 

18 1881(b)(3)(B). 

19 ‘‘(X) The home of an individual, 

20 but only for purposes of section 

21 1881(b)(3)(B).’’; and 

22 (B) by adding at the end the following new 

23 paragraph: 

24 ‘‘(5) TREATMENT OF HOME DIALYSIS MONTHLY

25 ESRD-RELATED VISIT.—The geographic requireVerDate Sep 11 2014 00:55 Aug 04, 2017 Jkt 069200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6401 E:\BILLS\S870.RS S870

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1 ments described in paragraph (4)(C)(i) shall not 

2 apply with respect to telehealth services furnished on 

3 or after January 1, 2019, for purposes of section 

4 1881(b)(3)(B), at an originating site described in 

5 subclause (VI), (IX), or (X) of paragraph 

6 (4)(C)(ii).’’. 

7 (2) NO FACILITY FEE IF ORIGINATING SITE

8 FOR HOME DIALYSIS THERAPY IS THE HOME.—Sec9 tion 1834(m)(2)(B) of the Social Security (42 

10 U.S.C. 1395m(m)(2)(B)) is amended— 

11 (A) by redesignating clauses (i) and (ii) as 

12 subclauses (I) and (II), and indenting appro13 priately; 

14 (B) in subclause (II), as redesignated by 

15 subparagraph (A), by striking ‘‘clause (i) or 

16 this clause’’ and inserting ‘‘subclause (I) or this 

17 subclause’’; 

18 (C) by striking ‘‘SITE.—With respect to’’ 

19 and inserting ‘‘SITE.— 

20 ‘‘(i) IN GENERAL.—Subject to clause 

21 (ii), with respect to’’; and 

22 (D) by adding at the end the following new 

23 clause: 

24 ‘‘(ii) NO FACILITY FEE IF ORIGI25 NATING SITE FOR HOME DIALYSIS THERVerDate Sep 11 2014 00:55 Aug 04, 2017 Jkt 069200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6401 E:\BILLS\S870.RS S870

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1 APY IS THE HOME.—No facility fee shall 

2 be paid under this subparagraph to an 

3 originating site described in paragraph 

4 (4)(C)(ii)(X).’’. 

5 (c) CONFORMING AMENDMENT.—Section 1881(b)(1) 

6 of the Social Security Act (42 U.S.C. 1395rr(b)(1)) is 

7 amended by striking ‘‘paragraph (3)(A)’’ and inserting 

8 ‘‘paragraph (3)(A)(i)’’. 

9 TITLE II—ADVANCING TEAM10 BASED CARE 

11 SEC. 201. PROVIDING CONTINUED ACCESS TO MEDICARE 

12 ADVANTAGE SPECIAL NEEDS PLANS FOR 

13 VULNERABLE POPULATIONS. 

14 (a) EXTENSION.—Section 1859(f)(1) of the Social 

15 Security Act (42 U.S.C. 1395w–28(f)(1)) is amended by 

16 striking ‘‘and for periods before January 1, 2019’’. 

17 (b) INCREASED INTEGRATION OF DUAL SNPS.— 

18 (1) IN GENERAL.—Section 1859(f) of the Social 

19 Security Act (42 U.S.C. 1395w–28(f)) is amended— 

20 (A) in paragraph (3), by adding at the end 

21 the following new subparagraph: 

22 ‘‘(F) The plan meets the requirements ap23 plicable under paragraph (8).’’; and 

24 (B) by adding at the end the following new 

25 paragraph: 


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1 ‘‘(8) INCREASED INTEGRATION OF DUAL

2 SNPS.— 

3 ‘‘(A) DESIGNATED CONTACT.—The Sec4 retary, acting through the Federal Coordinated 

5 Health Care Office established under section 

6 2602 of the Patient Protection and Affordable 

7 Care Act, shall serve as a dedicated point of 

8 contact for States to address misalignments 

9 that arise with the integration of specialized 

10 MA plans for special needs individuals de11 scribed in subsection (b)(6)(B)(ii) under this 

12 paragraph and, consistent with such role, 

13 shall— 

14 ‘‘(i) establish a uniform process for 

15 disseminating to State Medicaid agencies 

16 information under this title impacting con17 tracts between such agencies and such 

18 plans under this subsection; and 

19 ‘‘(ii) establish basic resources for 

20 States interested in exploring such plans 

21 as a platform for integration, such as a 

22 model contract or other tools to achieve 

23 those goals. 

24 ‘‘(B) UNIFIED GRIEVANCES AND APPEALS

25 PROCESS.— 


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1 ‘‘(i) IN GENERAL.—Not later than 

2 April 1, 2020, the Secretary shall establish 

3 procedures, to the extent feasible, unifying 

4 grievances and appeals procedures under 

5 sections 1852(f), 1852(g), 1902(a)(3), 

6 1902(a)(5), and 1932(b)(4) for items and 

7 services provided by specialized MA plans 

8 for special needs individuals described in 

9 subsection (b)(6)(B)(ii) under this title 

10 and title XIX. The Secretary shall solicit 

11 comment in developing such procedures 

12 from States, plans, beneficiaries and their 

13 representatives, and other relevant stake14 holders. 

15 ‘‘(ii) PROCEDURES.—The procedures 

16 established under clause (i) shall be in17 cluded in the plan contract under para18 graph (3)(D) and shall— 

19 ‘‘(I) adopt the provisions for the 

20 enrollee that are most protective for 

21 the enrollee and, to the extent feasible 

22 as determined by the Secretary, are 

23 compatible with unified timeframes 

24 and consolidated access to external re25 view under an integrated process; 


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1 ‘‘(II) take into account dif2 ferences in State plans under title 

3 XIX to the extent necessary; 

4 ‘‘(III) be easily navigable by an 

5 enrollee; and 

6 ‘‘(IV) include the elements de7 scribed in clause (iii), as applicable. 

8 ‘‘(iii) ELEMENTS DESCRIBED.—Both 

9 unified appeals and unified grievance pro10 cedures shall include, as applicable, the fol11 lowing elements described in this clause: 

12 ‘‘(I) Single written notification of 

13 all applicable grievances and appeal 

14 rights under this title and title XIX. 

15 For purposes of this subparagraph, 

16 the Secretary may waive the require17 ments under section 1852(g)(1)(B) 

18 when the specialized MA plan covers 

19 items or services under this part or 

20 under title XIX. 

21 ‘‘(II) Single pathways for resolu22 tion of any grievance or appeal related 

23 to a particular item or service pro24 vided by specialized MA plans for spe25 cial needs individuals described in 


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1 subsection (b)(6)(B)(ii) under this 

2 title and title XIX. 

3 ‘‘(III) Notices written in plain 

4 language and available in a language 

5 and format that is accessible to the 

6 enrollee, including in non-English lan7 guages that are prevalent in the serv8 ice area of the specialized MA plan. 

9 ‘‘(IV) Unified timeframes for 

10 grievances and appeals processes, 

11 such as an individual’s filing of a 

12 grievance or appeal, a plan’s acknowl13 edgment and resolution of a grievance 

14 or appeal, and notification of decisions 

15 with respect to a grievance or appeal. 

16 ‘‘(V) Requirements for how the 

17 plan must process, track, and resolve 

18 grievances and appeals, to ensure 

19 beneficiaries are notified on a timely 

20 basis of decisions that are made 

21 throughout the grievance or appeals 

22 process and are able to easily deter23 mine the status of a grievance or ap24 peal. 


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1 ‘‘(iv) CONTINUATION OF BENEFITS

2 PENDING APPEAL.—The unified procedures 

3 under clause (i) shall, with respect to all 

4 benefits under parts A and B and title 

5 XIX subject to appeal under such proce6 dures, incorporate provisions under current 

7 law and implementing regulations that pro8 vide continuation of benefits pending ap9 peal under this title and title XIX. 

10 ‘‘(C) REQUIREMENT FOR UNIFIED GRIEV11 ANCES AND APPEALS.—For 2021 and subse12 quent years, the contract of a specialized MA 

13 plan for special needs individuals described in 

14 subsection (b)(6)(B)(ii) with a State Medicaid 

15 agency under paragraph (3)(D) shall require 

16 the use of unified grievances and appeals proce17 dures as described in subparagraph (B). 

18 ‘‘(D) REQUIREMENTS FOR INTEGRA19 TION.—For 2022 and subsequent years, a spe20 cialized MA plan for special needs individuals 

21 described in subsection (b)(6)(B)(ii) shall meet 

22 one or more of the following requirements, to 

23 the extent permitted under State law, for inte24 gration of benefits under this title and title 

25 XIX: 


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1 ‘‘(i) The specialized MA plan must 

2 meet the requirements of contracting with 

3 the State Medicaid agency described in 

4 paragraph (3)(D) in addition to coordi5 nating long-term services and supports or 

6 behavioral health services, or both, by 

7 meeting an additional minimum set of re8 quirements determined by the Secretary 

9 through the Federal Coordinated Health 

10 Care Office established under section 2018 

11 of the Patient Protection and Affordable 

12 Care Act based on input from stake13 holders, such as notifying the State in a 

14 timely manner of hospitalizations, emer15 gency room visits, and hospital or nursing 

16 home discharges of enrollees, assigning one 

17 primary care provider for each enrollee, or 

18 sharing data that would benefit the coordi19 nation of items and services under this 

20 title and the State plan under title XIX. 

21 Such minimum set of requirements must 

22 be included in the contract of the special23 ized MA plan with the State Medicaid 

24 agency under such paragraph. 


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1 ‘‘(ii) The specialized MA plan must 

2 meet the requirements of a fully integrated 

3 plan described in section 

4 1853(a)(1)(B)(iv)(II) (other than the re5 quirement that the plan have similar aver6 age levels of frailty, as determined by the 

7 Secretary, as the PACE program), or enter 

8 into a capitated contract with the State 

9 Medicaid agency to provide long-term serv10 ices and supports or behavioral health 

11 services, or both. 

12 ‘‘(iii) In the case where an individual 

13 is enrolled in the specialized MA plan and 

14 a Medicaid managed care organization (as 

15 defined in section 1903(m)(1)(A)) that 

16 provides long term services and supports 

17 or behavioral health services with the same 

18 parent organization, the parent organiza19 tion offering both the specialized MA plan 

20 and the Medicaid managed care plan must 

21 assume clinical and financial responsibility 

22 for benefits provided under this title and 

23 title XIX.’’. 

24 (2) CONFORMING AMENDMENT TO RESPON25 SIBILITIES OF FEDERAL COORDINATED HEALTH


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1 CARE OFFICE.—Section 2602(d) of the Patient Pro2 tection and Affordable Care Act (42 U.S.C. 

3 1315b(d)) is amended by adding at the end the fol4 lowing new paragraphs: 

5 ‘‘(6) To act as a designated contact for States 

6 under subsection (f)(8)(A) of section 1859 of the So7 cial Security Act (42 U.S.C. 1395w–28) with respect 

8 to the integration of specialized MA plans for special 

9 needs individuals described in subsection 

10 (b)(6)(B)(ii) of such section. 

11 ‘‘(7) To be responsible for developing regula12 tions and guidance related to the implementation of 

13 a unified grievance and appeals process as described 

14 in subparagraphs (B) and (C) of section 1859(f)(8) 

15 of the Social Security Act (42 U.S.C. 1395w– 

16 28(f)(8)).’’. 

17 (c) IMPROVEMENTS TO SEVERE OR DISABLING

18 CHRONIC CONDITION SNPS.— 

19 (1) CARE MANAGEMENT REQUIREMENTS.—Sec20 tion 1859(f)(5) of the Social Security Act (42 

21 U.S.C. 1395w–28(f)(5)) is amended— 

22 (A) by striking ‘‘ALL SNPS.—The require23 ments’’ and inserting ‘‘ALL SNPS.— 

24 ‘‘(A) IN GENERAL.—Subject to subpara25 graph (B), the requirements’’; 


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1 (B) by redesignating subparagraphs (A) 

2 and (B) as clauses (i) and (ii), respectively, and 

3 indenting appropriately; 

4 (C) in clause (ii), as redesignated by sub5 paragraph (B), by redesignating clauses (i) 

6 through (iii) as subclauses (I) through (III), re7 spectively, and indenting appropriately; and 

8 (D) by adding at the end the following new 

9 subparagraph: 

10 ‘‘(B) IMPROVEMENTS TO CARE MANAGE11 MENT REQUIREMENTS FOR SEVERE OR DIS12 ABLING CHRONIC CONDITION SNPS.—For 2020 

13 and subsequent years, in the case of a special14 ized MA plan for special needs individuals de15 scribed in subsection (b)(6)(B)(iii), the require16 ments described in this paragraph include the 

17 following: 

18 ‘‘(i) The interdisciplinary team under 

19 subparagraph (A)(ii)(III) includes a team 

20 of providers with demonstrated expertise, 

21 including training in an applicable spe22 cialty, in treating individuals similar to the 

23 targeted population of the plan. 

24 ‘‘(ii) Requirements developed by the 

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1 ters with individuals enrolled in the plan 

2 not less frequently than on an annual 

3 basis. 

4 ‘‘(iii) As part of the model of care 

5 under clause (i) of subparagraph (A), the 

6 results of the initial assessment and an7 nual reassessment under clause (ii)(I) of 

8 such subparagraph of each individual en9 rolled in the plan are addressed in the indi10 vidual’s individualized care plan under 

11 clause (ii)(II) of such subparagraph. 

12 ‘‘(iv) As part of the annual evaluation 

13 and approval of such model of care, the 

14 Secretary shall take into account whether 

15 the plan fulfilled the previous year’s goals 

16 (as required under the model of care). 

17 ‘‘(v) The Secretary shall establish a 

18 minimum benchmark for each element of 

19 the model of care of a plan. The Secretary 

20 shall only approve a plan’s model of care 

21 under this paragraph if each element of 

22 the model of care meets the minimum 

23 benchmark applicable under the preceding 

24 sentence.’’. 


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1 (2) REVISIONS TO THE DEFINITION OF A SE2 VERE OR DISABLING CHRONIC CONDITIONS SPECIAL3 IZED NEEDS INDIVIDUAL.— 

4 (A) IN GENERAL.—Section 

5 1859(b)(6)(B)(iii) of the Social Security Act 

6 (42 U.S.C. 1395w–28(b)(6)(B)(iii)) is amend7 ed— 

8 (i) by striking ‘‘who have’’ and insert9 ing ‘‘who— 

10 ‘‘(I) before January 1, 2022, 

11 have’’; 

12 (ii) in subclause (I), as added by 

13 clause (i), by striking the period at the end 

14 and inserting ‘‘; and’’; and 

15 (iii) by adding at the end the fol16 lowing new subclause: 

17 ‘‘(II) on or after January 1, 

18 2022, have one or more comorbid and 

19 medically complex chronic conditions 

20 that is life threatening or significantly 

21 limits overall health or function, have 

22 a high risk of hospitalization or other 

23 adverse health outcomes, and require 

24 intensive care coordination and that is 

25 listed under subsection (f)(9)(A).’’. 


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1 (B) PANEL OF CLINICAL ADVISORS.—Sec2 tion 1859(f) of the Social Security Act (42 

3 U.S.C. 1395w–28(f)), as amended by subsection 

4 (b), is amended by adding at the end the fol5 lowing new paragraph: 

6 ‘‘(9) LIST OF CONDITIONS FOR CLARIFICATION

7 OF THE DEFINITION OF A SEVERE OR DISABLING

8 CHRONIC CONDITIONS SPECIALIZED NEEDS INDI9 VIDUAL.— 

10 ‘‘(A) IN GENERAL.—Not later than De11 cember 31, 2020, and every 5 years thereafter, 

12 the Secretary shall convene a panel of clinical 

13 advisors to establish and update a list of condi14 tions that meet each of the following criteria: 

15 ‘‘(i) Conditions that meet the defini16 tion of a severe or disabling chronic condi17 tion under subsection (b)(6)(B)(iii) on or 

18 after January 1, 2022. 

19 ‘‘(ii) Conditions that— 

20 ‘‘(I) require prescription drugs, 

21 providers, and models of care that are 

22 unique to the specific population of 

23 enrollees in a specialized MA plan for 

24 special needs individuals described in 

25 such subsection on or after such date 


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1 and would not be needed by the gen2 eral population of beneficiaries under 

3 this title; and 

4 ‘‘(II) have a low prevalence in the 

5 general population of beneficiaries 

6 under this title or a disproportionally 

7 high per-beneficiary cost under this 

8 title. 

9 ‘‘(B) REQUIREMENT.—In establishing and 

10 updating the list under subparagraph (A), the 

11 panel shall take into account the availability of 

12 varied benefits, cost-sharing, and supplemental 

13 benefits under the model described in para14 graph (2) of section 1859(h), including the ex15 pansion under paragraph (1) of such section.’’. 

16 (d) QUALITY MEASUREMENT AT THE PLAN LEVEL

17 FOR SNPS AND DETERMINATION OF FEASABILITY OF

18 QUALITY MEASUREMENT AT THE PLAN LEVEL FOR ALL

19 MA PLANS.—Section 1853(o) of the Social Security Act 

20 (42 U.S.C. 1395w–23(o)) is amended by adding at the end 

21 the following new paragraphs: 

22 ‘‘(6) QUALITY MEASUREMENT AT THE PLAN

23 LEVEL FOR SNPS.— 

24 ‘‘(A) IN GENERAL.—Subject to subpara25 graph (B), the Secretary may require reporting 


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1 of data under section 1852(e) for, and apply 

2 under this subsection, quality measures at the 

3 plan level for specialized MA plans for special 

4 needs individuals instead of at the contract 

5 level. 

6 ‘‘(B) CONSIDERATIONS.—Prior to applying 

7 quality measurement at the plan level under 

8 this paragraph, the Secretary shall— 

9 ‘‘(i) take into consideration the min10 imum number of enrollees in a specialized 

11 MA plan for special needs individuals in 

12 order to determine if a statistically signifi13 cant or valid measurement of quality at 

14 the plan level is possible under this para15 graph; 

16 ‘‘(ii) if quality measures are reported 

17 at the plan level, ensure that MA plans are 

18 not required to provide duplicative infor19 mation; and 

20 ‘‘(iii) ensure that such reporting does 

21 not interfere with the collection of encoun22 ter data submitted by MA organizations or 

23 the administration of any changes to the 

24 program under this part as a result of the 

25 collection of such data. 


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1 ‘‘(C) APPLICATION.—If the Secretary ap2 plies quality measurement at the plan level 

3 under this paragraph, such quality measure4 ment may include Medicare Health Outcomes 

5 Survey (HOS), Healthcare Effectiveness Data 

6 and Information Set (HEDIS), Consumer As7 sessment of Healthcare Providers and Systems 

8 (CAHPS) measures and quality measures under 

9 part D. 

10 ‘‘(7) DETERMINATION OF FEASIBILITY OF

11 QUALITY MEASUREMENT AT THE PLAN LEVEL FOR

12 ALL MA PLANS.— 

13 ‘‘(A) DETERMINATION OF FEASIBILITY.— 

14 The Secretary shall determine the feasibility of 

15 requiring reporting of data under section 

16 1852(e) for, and applying under this subsection, 

17 quality measures at the plan level for all MA 

18 plans under this part. 

19 ‘‘(B) CONSIDERATION OF CHANGE.—After 

20 making a determination under subparagraph 

21 (A), the Secretary shall consider requiring such 

22 reporting and applying such quality measures 

23 at the plan level as described in such subpara24 graph.’’. 


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1 (e) GAO STUDY AND REPORT ON STATE-LEVEL IN2 TEGRATION BETWEEN DUAL SNPS AND MEDICAID.— 

3 (1) STUDY.—The Comptroller General of the 

4 United States (in this paragraph referred to as the 

5 ‘‘Comptroller General’’) shall conduct a study on 

6 State-level integration between specialized MA plans 

7 for special needs individuals described in subsection 

8 (b)(6)(B)(ii) of section 1859 of the Social Security 

9 Act (42 U.S.C. 1395w–28) and the Medicaid pro10 gram under title XIX of such Act (42 U.S.C. 1396 

11 et seq.). Such study shall include an analysis of the 

12 following: 

13 (A) The characteristics of States in which 

14 the State agency responsible for administering 

15 the State plan under such title XIX has a con16 tract with such a specialized MA plan and that 

17 delivers long term services and supports under 

18 the State plan under such title XIX through a 

19 managed care program, including the require20 ments under such State plan with respect to 

21 long term services and supports. 

22 (B) The types of such specialized MA 

23 plans, which may include the following: 


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1 (i) A plan described in section 

2 1853(a)(1)(B)(iv)(II) of such Act (42 

3 U.S.C. 1395w–23(a)(1)(B)(iv)(II)). 

4 (ii) A plan that meets the require5 ments described in subsection (f)(3)(D) of 

6 such section 1859. 

7 (iii) A plan described in clause (ii) 

8 that also meets additional requirements es9 tablished by the State. 

10 (C) The characteristics of individuals en11 rolled in such specialized MA plans. 

12 (D) As practicable, the following with re13 spect to State programs for the delivery of long 

14 term services and supports under such title 

15 XIX through a managed care program: 

16 (i) Which populations of individuals 

17 are eligible to receive such services and 

18 supports. 

19 (ii) Whether all such services and sup20 ports are provided on a capitated basis or 

21 if any of such services and supports are 

22 carved out and provided through fee-for23 service. 

24 (E) How the availability and variation of 

25 integration arrangements of such specialized 


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1 MA plans offered in States affects spending, 

2 service delivery options, access to community3 based care, and utilization of care. 

4 (2) REPORT.—Not later than 2 years after the 

5 date of the enactment of this Act, the Comptroller 

6 General shall submit to Congress a report containing 

7 the results of the study conducted under paragraph 

8 (1), together with recommendations for such legisla9 tion and administrative action as the Comptroller 

10 General determines appropriate. 

11 TITLE III—EXPANDING 

12 INNOVATION AND TECHNOLOGY 

13 SEC. 301. ADAPTING BENEFITS TO MEET THE NEEDS OF 

14 CHRONICALLY ILL MEDICARE ADVANTAGE 

15 ENROLLEES. 

16 Section 1859 of the Social Security Act (42 U.S.C. 

17 1395w–28) is amended by adding at the end the following 

18 new subsection: 

19 ‘‘(h) NATIONAL TESTING OF MODEL FOR MEDICARE

20 ADVANTAGE VALUE-BASED INSURANCE DESIGN.— 

21 ‘‘(1) IN GENERAL.—In implementing the model 

22 described in paragraph (2) proposed to be tested 

23 under section 1115A(b), the Secretary shall revise 

24 the testing of the model under such section to cover, 

25 effective not later than January 1, 2020, all States. 


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1 ‘‘(2) MODEL DESCRIBED.—The model described 

2 in this paragraph is the testing of a model of Medi3 care Advantage value-based insurance design that 

4 would allow Medicare Advantage plans the option to 

5 propose and design benefit structures that vary ben6 efits, cost-sharing, and supplemental benefits offered 

7 to enrollees with specific chronic diseases proposed 

8 to be carried out in Oregon, Arizona, Texas, Iowa, 

9 Michigan, Indiana, Tennessee, Alabama, Pennsyl10 vania, and Massachusetts. 

11 ‘‘(3) TERMINATION AND MODIFICATION PROVI12 SION NOT APPLICABLE UNTIL JANUARY 1, 2022.— 

13 The provisions of section 1115A(b)(3)(B) shall apply 

14 to the model described in paragraph (2), including 

15 such model as expanded under paragraph (1), begin16 ning January 1, 2022, but shall not apply to such 

17 model, as so expanded, prior to such date. 

18 ‘‘(4) FUNDING.—The Secretary shall allocate 

19 funds made available under section 1115A(f)(1) to 

20 design, implement, and evaluate the model described 

21 in paragraph (2), as expanded under paragraph 

22 (1).’’. 


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1 SEC. 302. EXPANDING SUPPLEMENTAL BENEFITS TO MEET 

2 THE NEEDS OF CHRONICALLY ILL MEDICARE 

3 ADVANTAGE ENROLLEES. 

4 (a) IN GENERAL.—Section 1852(a)(3) of the Social 

5 Security Act (42 U.S.C. 1395w–22(a)(3)) is amended— 

6 (1) in subparagraph (A), by striking ‘‘Each’’ 

7 and inserting ‘‘Subject to subparagraph (D), each’’; 

8 and 

9 (2) by adding at the end the following new sub10 paragraph: 

11 ‘‘(D) EXPANDING SUPPLEMENTAL BENE12 FITS TO MEET THE NEEDS OF CHRONICALLY

13 ILL ENROLLEES.— 

14 ‘‘(i) IN GENERAL.—For plan year 

15 2020 and subsequent plan years, in addi16 tion to any supplemental health care bene17 fits otherwise provided under this para18 graph, an MA plan may provide supple19 mental benefits described in clause (ii) to 

20 a chronically ill enrollee (as defined in 

21 clause (iii)). 

22 ‘‘(ii) SUPPLEMENTAL BENEFITS DE23 SCRIBED.— 

24 ‘‘(I) IN GENERAL.—Supplemental 

25 benefits described in this clause are 

26 supplemental benefits that, with reVerDate Sep 11 2014 00:55 Aug 04, 2017 Jkt 069200 PO 00000 Frm 00026 Fmt 6652 Sfmt 6401 E:\BILLS\S870.RS S870

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1 spect to a chronically ill enrollee, have 

2 a reasonable expectation of improving 

3 or maintaining the health or overall 

4 function of the chronically ill enrollee 

5 and may not be limited to being pri6 marily health related benefits. 

7 ‘‘(II) AUTHORITY TO WAIVE UNI8 FORMITY REQUIREMENTS.—The Sec9 retary may, only with respect to sup10 plemental benefits provided to a 

11 chronically ill enrollee under this sub12 paragraph, waive the uniformity re13 quirement under subsection (d)(1)(A), 

14 as determined appropriate by the Sec15 retary. 

16 ‘‘(iii) CHRONICALLY ILL ENROLLEE

17 DEFINED.—In this subparagraph, the term 

18 ‘chronically ill enrollee’ means an enrollee 

19 in an MA plan that the Secretary deter20 mines— 

21 ‘‘(I) has one or more comorbid 

22 and medically complex chronic condi23 tions that is life threatening or signifi24 cantly limits the overall health or 

25 function of the enrollee; 


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1 ‘‘(II) has a high risk of hos2 pitalization or other adverse health 

3 outcomes; and 

4 ‘‘(III) requires intensive care co5 ordination.’’. 

6 (b) GAO STUDY AND REPORT.— 

7 (1) STUDY.—The Comptroller General of the 

8 United States (in this subsection referred to as the 

9 ‘‘Comptroller General’’) shall conduct a study on 

10 supplemental benefits provided to enrollees in Medi11 care Advantage plans under part C of title XVIII of 

12 the Social Security Act. Such study shall include an 

13 analysis of the following: 

14 (A) The type of supplemental benefits pro15 vided to such enrollees, the total number of en16 rollees receiving each supplemental benefit, and 

17 whether the supplemental benefit is covered by 

18 the standard benchmark cost of the benefit or 

19 with an additional premium. 

20 (B) The frequency in which supplemental 

21 benefits are utilized by such enrollees. 

22 (C) The impact supplemental benefits have 

23 on— 


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1 (i) indicators of the quality of care re2 ceived by such enrollees, including overall 

3 health and function of the enrollees; 

4 (ii) the utilization of items and serv5 ices for which benefits are available under 

6 the original Medicare fee-for-service pro7 gram option under parts A and B of such 

8 title XVIII by such enrollees; and 

9 (iii) the amount of the bids submitted 

10 by Medicare Advantage Organizations for 

11 Medicare Advantage plans under such part 

12 C. 

13 (2) REPORT.—Not later than 5 years after the 

14 date of the enactment of this Act, the Comptroller 

15 General shall submit to Congress a report containing 

16 the results of the study conducted under paragraph 

17 (1), together with recommendations for such legisla18 tion and administrative action as the Comptroller 

19 General determines appropriate. 

20 SEC. 303. INCREASING CONVENIENCE FOR MEDICARE AD21 VANTAGE ENROLLEES THROUGH TELE22 HEALTH. 

23 (a) IN GENERAL.—Section 1852 of the Social Secu24 rity Act (42 U.S.C. 1395w–22) is amended— 


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1 (1) in subsection (a)(1)(B)(i), by inserting ‘‘, 

2 subject to subsection (m),’’ after ‘‘means’’; and 

3 (2) by adding at the end the following new sub4 section: 

5 ‘‘(m) PROVISION OF ADDITIONAL TELEHEALTH

6 BENEFITS.— 

7 ‘‘(1) MA PLAN OPTION.—For plan year 2020 

8 and subsequent plan years, subject to the require9 ments of paragraph (3), an MA plan may provide 

10 additional telehealth benefits (as defined in para11 graph (2)) to individuals enrolled under this part. 

12 ‘‘(2) ADDITIONAL TELEHEALTH BENEFITS DE13 FINED.— 

14 ‘‘(A) IN GENERAL.—For purposes of this 

15 subsection and section 1854: 

16 ‘‘(i) DEFINITION.—The term ‘addi17 tional telehealth benefits’ means services— 

18 ‘‘(I) for which benefits are avail19 able under part B, including services 

20 for which payment is not made under 

21 section 1834(m) due to the conditions 

22 for payment under such section; and 

23 ‘‘(II) that are identified as clini24 cally appropriate to furnish using elec25 tronic information and telecommuniVerDate Sep 11 2014 00:55 Aug 04, 2017 Jkt 069200 PO 00000 Frm 00030 Fmt 6652 Sfmt 6401 E:\BILLS\S870.RS S870

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1 cations technology when a physician 

2 (as defined in section 1861(r)) or 

3 practitioner (described in section 

4 1842(b)(18)(C)) providing the service 

5 is not at the same location as the plan 

6 enrollee. 

7 ‘‘(ii) EXCLUSION OF CAPITAL AND IN8 FRASTRUCTURE COSTS AND INVEST9 MENTS.—The term ‘additional telehealth 

10 benefits’ does not include capital and infra11 structure costs and investments relating to 

12 such benefits. 

13 ‘‘(B) PUBLIC COMMENT.—Not later than 

14 November 30, 2018, the Secretary shall solicit 

15 comments on what types of telehealth services 

16 currently offered to enrollees under this part 

17 through supplemental health care benefits 

18 should be considered to meet the definition of 

19 additional telehealth benefits under this para20 graph. 

21 ‘‘(3) REQUIREMENTS FOR ADDITIONAL TELE22 HEALTH BENEFITS.—The Secretary shall specify re23 quirements for the provision or furnishing of addi24 tional telehealth benefits, including with respect to 

25 the following: 


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1 ‘‘(A) Physician or practitioner licensure 

2 and other requirements such as specific train3 ing. 

4 ‘‘(B) Factors necessary to ensure the co5 ordination of such benefits with items and serv6 ices furnished in-person. 

7 ‘‘(C) Such other areas as determined by 

8 the Secretary. 

9 ‘‘(4) ENROLLEE CHOICE.—If an MA plan pro10 vides a service as an additional telehealth benefit (as 

11 defined in paragraph (2)), an individual enrollee 

12 shall have discretion as to whether to receive such 

13 service as an additional telehealth benefit. 

14 ‘‘(5) CONSTRUCTION REGARDING NETWORK AC15 CESS ADEQUACY.—Provision of additional telehealth 

16 benefits under this subsection shall not be construed 

17 as making such benefits available and accessible for 

18 purposes of compliance with subsection (d). 

19 ‘‘(6) TREATMENT UNDER MA.—For purposes of 

20 this subsection and section 1854, additional tele21 health benefits shall be treated as if they were bene22 fits under the original Medicare fee-for-service pro23 gram option. 

24 ‘‘(7) CONSTRUCTION.—Nothing in this sub25 section shall be construed as affecting the requireVerDate Sep 11 2014 00:55 Aug 04, 2017 Jkt 069200 PO 00000 Frm 00032 Fmt 6652 Sfmt 6401 E:\BILLS\S870.RS S870

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1 ment under subsection (a)(1) that MA plans provide 

2 enrollees with items and services (other than hospice 

3 care) for which benefits are available under parts A 

4 and B, including benefits available under section 

5 1834(m).’’. 

6 (b) CLARIFICATION REGARDING INCLUSION IN BID

7 AMOUNT.—Section 1854(a)(6)(A)(ii)(I) of the Social Se8 curity Act (42 U.S.C. 1395w–24(a)(6)(A)(ii)(I)) is 

9 amended by inserting ‘‘, including, for plan year 2020 and 

10 subsequent plan years, the provision of additional tele11 health benefits as described in section 1852(m)’’ before 

12 the semicolon at the end. 

13 SEC. 304. PROVIDING ACCOUNTABLE CARE ORGANIZA14 TIONS THE ABILITY TO EXPAND THE USE OF 

15 TELEHEALTH. 

16 (a) IN GENERAL.—Section 1899 of the Social Secu17 rity Act (42 U.S.C. 1395jjj) is amended by adding at the 

18 end the following new subsection: 

19 ‘‘(l) PROVIDING ACOS THE ABILITY TO EXPAND

20 THE USE OF TELEHEALTH SERVICES.— 

21 ‘‘(1) IN GENERAL.—In the case of telehealth 

22 services for which payment would otherwise be made 

23 under this title furnished on or after January 1, 

24 2020, for purposes of this subsection only, the fol25 lowing shall apply with respect to such services furVerDate Sep 11 2014 00:55 Aug 04, 2017 Jkt 069200 PO 00000 Frm 00033 Fmt 6652 Sfmt 6401 E:\BILLS\S870.RS S870

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1 nished by a physician or practitioner participating in 

2 an applicable ACO (as defined in paragraph (2)) to 

3 a Medicare fee-for-service beneficiary assigned to the 

4 applicable ACO: 

5 ‘‘(A) INCLUSION OF HOME AS ORIGINATING

6 SITE.—Subject to paragraph (3), the home of a 

7 beneficiary shall be treated as an originating 

8 site described in section 1834(m)(4)(C)(ii). 

9 ‘‘(B) NO APPLICATION OF GEOGRAPHIC

10 LIMITATION.—The geographic limitation under 

11 section 1834(m)(4)(C)(i) shall not apply with 

12 respect to an originating site described in sec13 tion 1834(m)(4)(C)(ii) (including the home of a 

14 beneficiary under subparagraph (A)), subject to 

15 State licensing requirements. 

16 ‘‘(2) DEFINITIONS.—In this subsection: 

17 ‘‘(A) APPLICABLE ACO.—The term ‘appli18 cable ACO’ means an ACO participating in a 

19 model tested or expanded under section 1115A 

20 or under this section— 

21 ‘‘(i) that operates under a two-sided 

22 model— 

23 ‘‘(I) described in section 

24 425.600(a) of title 42, Code of Fed25 eral Regulations; or 


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1 ‘‘(II) tested or expanded under 

2 section 1115A; and 

3 ‘‘(ii) for which Medicare fee-for-serv4 ice beneficiaries are assigned to the ACO 

5 using a prospective assignment method, as 

6 determined appropriate by the Secretary. 

7 ‘‘(B) HOME.—The term ‘home’ means, 

8 with respect to a Medicare fee-for-service bene9 ficiary, the place of residence used as the home 

10 of the beneficiary. 

11 ‘‘(3) TELEHEALTH SERVICES RECEIVED IN THE

12 HOME.—In the case of telehealth services described 

13 in paragraph (1) where the home of a Medicare fee14 for-service beneficiary is the originating site, the fol15 lowing shall apply: 

16 ‘‘(A) NO FACILITY FEE.—There shall be 

17 no facility fee paid to the originating site under 

18 section 1834(m)(2)(B). 

19 ‘‘(B) EXCLUSION OF CERTAIN SERVICES.— 

20 No payment may be made for such services that 

21 are inappropriate to furnish in the home setting 

22 such as services that are typically furnished in 

23 inpatient settings such as a hospital.’’. 

24 (b) STUDY AND REPORT.— 

25 (1) STUDY.— 


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1 (A) IN GENERAL.—The Secretary of 

2 Health and Human Services (in this subsection 

3 referred to as the ‘‘Secretary’’) shall conduct a 

4 study on the implementation of section 1899(l) 

5 of the Social Security Act, as added by sub6 section (a). Such study shall include an analysis 

7 of the utilization of, and expenditures for, tele8 health services under such section. 

9 (B) COLLECTION OF DATA.—The Sec10 retary may collect such data as the Secretary 

11 determines necessary to carry out the study 

12 under this paragraph. 

13 (2) REPORT.—Not later than January 1, 2026, 

14 the Secretary shall submit to Congress a report con15 taining the results of the study conducted under 

16 paragraph (1), together with recommendations for 

17 such legislation and administrative action as the 

18 Secretary determines appropriate. 

19 SEC. 305. EXPANDING THE USE OF TELEHEALTH FOR INDI20 VIDUALS WITH STROKE. 

21 Section 1834(m) of the Social Security Act (42 

22 U.S.C. 1395m(m)), as amended by section 102(b)(2), is 

23 amended by adding at the end the following new para24 graph: 


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1 ‘‘(6) TREATMENT OF STROKE TELEHEALTH

2 SERVICES.— 

3 ‘‘(A) NON-APPLICATION OF ORIGINATING

4 SITE REQUIREMENTS.—The requirements de5 scribed in paragraph (4)(C) shall not apply with 

6 respect to telehealth services furnished on or 

7 after January 1, 2019, for purposes of evalua8 tion of an acute stroke, as determined by the 

9 Secretary. 

10 ‘‘(B) NO ORIGINATING SITE FACILITY

11 FEE.—The Secretary shall not pay an origi12 nating site facility fee (as described in para13 graph (2)(B)) with respect to such telehealth 

14 services.’’. 

15 TITLE IV—IDENTIFYING THE 

16 CHRONICALLY ILL POPULATION 

17 SEC. 401. PROVIDING FLEXIBILITY FOR BENEFICIARIES TO 

18 BE PART OF AN ACCOUNTABLE CARE ORGA19 NIZATION. 

20 Section 1899(c) of the Social Security Act (42 U.S.C. 

21 1395jjj(c)) is amended— 

22 (1) by redesignating paragraphs (1) and (2) as 

23 subparagraphs (A) and (B), respectively, and indent24 ing appropriately; 


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1 (2) by striking ‘‘ACOS.—The Secretary’’ and 

2 inserting ‘‘ACOS.— 

3 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

4 the Secretary’’; and 

5 (3) by adding at the end the following new 

6 paragraph: 

7 ‘‘(2) PROVIDING FLEXIBILITY.— 

8 ‘‘(A) CHOICE OF PROSPECTIVE ASSIGN9 MENT.—For each agreement period (effective 

10 for agreements entered into or renewed on or 

11 after January 1, 2020), in the case where an 

12 ACO established under the program is in a 

13 Track that provides for the retrospective assign14 ment of Medicare fee-for-service beneficiaries to 

15 the ACO, the Secretary shall permit the ACO 

16 to choose to have Medicare fee-for-service bene17 ficiaries assigned prospectively, rather than ret18 rospectively, to the ACO for an agreement pe19 riod. 

20 ‘‘(B) ASSIGNMENT BASED ON VOLUNTARY

21 IDENTIFICATION BY MEDICARE FEE-FOR-SERV22 ICE BENEFICIARIES.— 

23 ‘‘(i) IN GENERAL.—For performance 

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1 tronic designation, the Secretary shall per2 mit a Medicare fee-for-service beneficiary 

3 to voluntarily identify an ACO professional 

4 as the primary care provider of the bene5 ficiary for purposes of assigning such bene6 ficiary to an ACO, as determined by the 

7 Secretary. 

8 ‘‘(ii) NOTIFICATION PROCESS.—The 

9 Secretary shall establish a process under 

10 which a Medicare fee-for-service bene11 ficiary is— 

12 ‘‘(I) notified of their ability to 

13 make an identification described in 

14 clause (i); and 

15 ‘‘(II) informed of the process by 

16 which they may make and change 

17 such identification. 

18 ‘‘(iii) SUPERSEDING CLAIMS-BASED

19 ASSIGNMENT.—A voluntary identification 

20 by a Medicare fee-for-service beneficiary 

21 under this subparagraph shall supersede 

22 any claims-based assignment otherwise de23 termined by the Secretary.’’. 


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1 TITLE V—EMPOWERING INDI2 VIDUALS AND CAREGIVERS IN 

3 CARE DELIVERY 

4 SEC. 501. ELIMINATING BARRIERS TO CARE COORDINA5 TION UNDER ACCOUNTABLE CARE ORGANI6 ZATIONS. 

7 (a) IN GENERAL.—Section 1899 of the Social Secu8 rity Act (42 U.S.C. 1395jjj), as amended by section 

9 304(a), is amended— 

10 (1) in subsection (b)(2), by adding at the end 

11 the following new subparagraph: 

12 ‘‘(I) An ACO that seeks to operate an 

13 ACO Beneficiary Incentive Program pursuant 

14 to subsection (m) shall apply to the Secretary 

15 at such time, in such manner, and with such in16 formation as the Secretary may require.’’; 

17 (2) by adding at the end the following new sub18 section: 

19 ‘‘(m) AUTHORITY TO PROVIDE INCENTIVE PAY20 MENTS TO BENEFICIARIES WITH RESPECT TO QUALI21 FYING PRIMARY CARE SERVICES.— 

22 ‘‘(1) PROGRAM.— 

23 ‘‘(A) IN GENERAL.—In order to encourage 

24 Medicare fee-for-service beneficiaries to obtain 

25 medically necessary primary care services, an 


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1 ACO participating under this section under a 

2 payment model described in clause (i) or (ii) of 

3 paragraph (2)(B) may apply to establish an 

4 ACO Beneficiary Incentive Program to provide 

5 incentive payments to such beneficiaries who 

6 are furnished qualifying services in accordance 

7 with this subsection. The Secretary shall permit 

8 such an ACO to establish such a program at 

9 the Secretary’s discretion and subject to such 

10 requirements, including program integrity re11 quirements, as the Secretary determines nec12 essary. 

13 ‘‘(B) IMPLEMENTATION.—The Secretary 

14 shall implement this subsection on a date deter15 mined appropriate by the Secretary. Such date 

16 shall be no earlier than January 1, 2019, and 

17 no later than January 1, 2020. 

18 ‘‘(2) CONDUCT OF PROGRAM.— 

19 ‘‘(A) DURATION.—Subject to subpara20 graph (H), an ACO Beneficiary Incentive Pro21 gram established under this subsection shall be 

22 conducted for such period (of not less than 1 

23 year) as the Secretary may approve. 

24 ‘‘(B) SCOPE.—An ACO Beneficiary Incen25 tive Program established under this subsection 


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1 shall provide incentive payments to all of the 

2 following Medicare fee-for-service beneficiaries 

3 who are furnished qualifying services by the 

4 ACO: 

5 ‘‘(i) With respect to the Track 2 and 

6 Track 3 payment models described in sec7 tion 425.600(a) of title 42, Code of Fed8 eral Regulations (or in any successor regu9 lation), Medicare fee-for-service bene10 ficiaries who are preliminarily prospectively 

11 or prospectively assigned (or otherwise as12 signed, as determined by the Secretary) to 

13 the ACO. 

14 ‘‘(ii) With respect to any future pay15 ment models involving two-sided risk, 

16 Medicare fee-for-service beneficiaries who 

17 are assigned to the ACO, as determined by 

18 the Secretary. 

19 ‘‘(C) QUALIFYING SERVICE.—For purposes 

20 of this subsection, a qualifying service is a pri21 mary care service, as defined in section 425.20 

22 of title 42, Code of Federal Regulations (or in 

23 any successor regulation), with respect to which 

24 coinsurance applies under part B, furnished 

25 through an ACO by— 


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1 ‘‘(i) an ACO professional described in 

2 subsection (h)(1)(A) who has a primary 

3 care specialty designation included in the 

4 definition of primary care physician under 

5 section 425.20 of title 42, Code of Federal 

6 Regulations (or any successor regulation); 

7 ‘‘(ii) an ACO professional described in 

8 subsection (h)(1)(B); or 

9 ‘‘(iii) a Federally qualified health cen10 ter or rural health clinic (as such terms 

11 are defined in section 1861(aa)). 

12 ‘‘(D) INCENTIVE PAYMENTS.—An incentive 

13 payment made by an ACO pursuant to an ACO 

14 Beneficiary Incentive Program established 

15 under this subsection shall be— 

16 ‘‘(i) in an amount up to $20, with 

17 such maximum amount updated annually 

18 by the percentage increase in the consumer 

19 price index for all urban consumers 

20 (United States city average) for the 12- 

21 month period ending with June of the pre22 vious year; 

23 ‘‘(ii) in the same amount for each 

24 Medicare fee-for-service beneficiary de25 scribed in clause (i) or (ii) of subparagraph 


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1 (B) without regard to enrollment of such a 

2 beneficiary in a medicare supplemental pol3 icy (described in section 1882(g)(1)), in a 

4 State Medicaid plan under title XIX or a 

5 waiver of such a plan, or in any other 

6 health insurance policy or health benefit 

7 plan; 

8 ‘‘(iii) made for each qualifying service 

9 furnished to such a beneficiary described 

10 in clause (i) or (ii) of subparagraph (B) 

11 during a period specified by the Secretary; 

12 and 

13 ‘‘(iv) made no later than 30 days after 

14 a qualifying service is furnished to such a 

15 beneficiary described in clause (i) or (ii) of 

16 subparagraph (B). 

17 ‘‘(E) NO SEPARATE PAYMENTS FROM THE

18 SECRETARY.—The Secretary shall not make 

19 any separate payment to an ACO for the costs, 

20 including incentive payments, of carrying out 

21 an ACO Beneficiary Incentive Program estab22 lished under this subsection. Nothing in this 

23 subparagraph shall be construed as prohibiting 

24 an ACO from using shared savings received 


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1 under this section to carry out an ACO Bene2 ficiary Incentive Program. 

3 ‘‘(F) NO APPLICATION TO SHARED SAV4 INGS CALCULATION.—Incentive payments made 

5 by an ACO under this subsection shall be dis6 regarded for purposes of calculating bench7 marks, estimated average per capita Medicare 

8 expenditures, and shared savings under this 

9 section. 

10 ‘‘(G) REPORTING REQUIREMENTS.—An 

11 ACO conducting an ACO Beneficiary Incentive 

12 Program under this subsection shall, at such 

13 times and in such format as the Secretary may 

14 require, report to the Secretary such informa15 tion and retain such documentation as the Sec16 retary may require, including the amount and 

17 frequency of incentive payments made and the 

18 number of Medicare fee-for-service beneficiaries 

19 receiving such payments. 

20 ‘‘(H) TERMINATION.—The Secretary may 

21 terminate an ACO Beneficiary Incentive Pro22 gram established under this subsection at any 

23 time for reasons determined appropriate by the 

24 Secretary. 


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1 ‘‘(3) EXCLUSION OF INCENTIVE PAYMENTS.— 

2 Any payment made under an ACO Beneficiary In3 centive Program established under this subsection 

4 shall not be considered income or resources or other5 wise taken into account for purposes of— 

6 ‘‘(A) determining eligibility for benefits or 

7 assistance (or the amount or extent of benefits 

8 or assistance) under any Federal program or 

9 under any State or local program financed in 

10 whole or in part with Federal funds; or 

11 ‘‘(B) any Federal or State laws relating to 

12 taxation.’’; 

13 (3) in subsection (e), by inserting ‘‘, including 

14 an ACO Beneficiary Incentive Program under sub15 sections (b)(2)(I) and (m)’’ after ‘‘the program’’; 

16 and 

17 (4) in subsection (g)(6), by inserting ‘‘or of an 

18 ACO Beneficiary Incentive Program under sub19 sections (b)(2)(I) and (m)’’ after ‘‘under subsection 

20 (d)(4)’’. 

21 (b) AMENDMENT TO SECTION 1128B.—Section 

22 1128B(b)(3) of the Social Security Act (42 U.S.C. 1320a– 

23 7b(b)(3)) is amended— 

24 (1) by striking ‘‘and’’ at the end of subpara25 graph (I); 


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1 (2) by striking the period at the end of sub2 paragraph (J) and inserting ‘‘; and’’; and 

3 (3) by adding at the end the following new sub4 paragraph: 

5 ‘‘(K) an incentive payment made to a 

6 Medicare fee-for-service beneficiary by an ACO 

7 under an ACO Beneficiary Incentive Program 

8 established under subsection (m) of section 

9 1899, if the payment is made in accordance 

10 with the requirements of such subsection and 

11 meets such other conditions as the Secretary 

12 may establish.’’. 

13 (c) EVALUATION AND REPORT.— 

14 (1) EVALUATION.—The Secretary of Health 

15 and Human Services (in this subsection referred to 

16 as the ‘‘Secretary’’) shall conduct an evaluation of 

17 the ACO Beneficiary Incentive Program established 

18 under subsections (b)(2)(I) and (m) of section 1899 

19 of the Social Security Act (42 U.S.C. 1395jjj), as 

20 added by subsection (a). The evaluation shall include 

21 an analysis of the impact of the implementation of 

22 the Program on expenditures and beneficiary health 

23 outcomes under title XVIII of the Social Security 

24 Act (42 U.S.C. 1395 et seq.). 


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1 (2) REPORT.—Not later than October 1, 2023, 

2 the Secretary shall submit to Congress a report con3 taining the results of the evaluation under para4 graph (1), together with recommendations for such 

5 legislation and administrative action as the Sec6 retary determines appropriate. 

7 SEC. 502. GAO STUDY AND REPORT ON LONGITUDINAL 

8 COMPREHENSIVE CARE PLANNING SERVICES 

9 UNDER MEDICARE PART B. 

10 (a) STUDY.—The Comptroller General shall conduct 

11 a study on the establishment under part B of the Medicare 

12 program under title XVIII of the Social Security Act of 

13 a payment code for a visit for longitudinal comprehensive 

14 care planning services. Such study shall include an anal15 ysis of the following to the extent such information is 

16 available: 

17 (1) The frequency with which services similar to 

18 longitudinal comprehensive care planning services 

19 are furnished to Medicare beneficiaries, which pro20 viders of services and suppliers are furnishing those 

21 services, whether Medicare reimbursement is being 

22 received for those services, and, if so, through which 

23 codes those services are being reimbursed. 

24 (2) Whether, and the extent to which, longitu25 dinal comprehensive care planning services would 


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1 overlap, and could therefore result in duplicative 

2 payment, with services covered under the hospice 

3 benefit as well as the chronic care management code, 

4 evaluation and management codes, or other codes 

5 that already exist under part B of the Medicare pro6 gram. 

7 (3) Any barriers to hospitals, skilled nursing fa8 cilities, hospice programs, home health agencies, and 

9 other applicable providers working with a Medicare 

10 beneficiary to engage in the care planning process 

11 and complete the necessary documentation to sup12 port the treatment and care plan of the beneficiary 

13 and provide such documentation to other providers 

14 and the beneficiary or his representative. 

15 (4) Any barriers to providers, other than the 

16 provider furnishing longitudinal comprehensive care 

17 planning services, accessing the care plan and asso18 ciated documentation for use related to the care of 

19 the Medicare beneficiary. 

20 (5) Potential options for ensuring that applica21 ble providers are notified of a patient’s existing lon22 gitudinal care plan and that applicable providers 

23 consider that plan in making their treatment deci24 sions, and what the challenges might be in imple25 menting such options. 


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1 (6) Stakeholder’s views on the need for the de2 velopment of quality metrics with respect to longitu3 dinal comprehensive care planning services, such as 

4 measures related to— 

5 (A) the process of eliciting input from the 

6 Medicare beneficiary or from a legally author7 ized representative and documenting in the 

8 medical record the patient-directed care plan; 

9 (B) the effectiveness and patient10 centeredness of the care plan in organizing de11 livery of services consistent with the plan; 

12 (C) the availability of the care plan and as13 sociated documentation to other providers that 

14 care for the beneficiary; and 

15 (D) the extent to which the beneficiary re16 ceived services and support that is free from 

17 discrimination based on advanced age, disability 

18 status, or advanced illness. 

19 (7) Stakeholder’s views on how such quality 

20 metrics would provide information on— 

21 (A) the goals, values, and preferences of 

22 the beneficiary; 

23 (B) the documentation of the care plan; 

24 (C) services furnished to the beneficiary; 

25 and 


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1 (D) outcomes of treatment. 

2 (8) Stakeholder’s views on— 

3 (A) the type of training and education 

4 needed for applicable providers, individuals, and 

5 caregivers in order to facilitate longitudinal 

6 comprehensive care planning services; 

7 (B) the types of providers of services and 

8 suppliers that should be included in the inter9 disciplinary team of an applicable provider; and 

10 (C) the characteristics of Medicare bene11 ficiaries that would be most appropriate to re12 ceive longitudinal comprehensive care planning 

13 services, such as individuals with advanced dis14 ease and individuals who need assistance with 

15 multiple activities of daily living. 

16 (9) Stakeholder’s views on the frequency with 

17 which longitudinal comprehensive care planning 

18 services should be furnished. 

19 (b) REPORT.—Not later than 18 months after the 

20 date of the enactment of this Act, the Comptroller General 

21 shall submit to Congress a report containing the results 

22 of the study conducted under subsection (a), together with 

23 recommendations for such legislation and administrative 

24 action as the Comptroller General determines appropriate. 

25 (c) DEFINITIONS.—In this section: 


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1 (1) APPLICABLE PROVIDER.—The term ‘‘appli2 cable provider’’ means a hospice program (as defined 

3 in subsection (dd)(2) of section 1861 of the Social 

4 Security Act (42 U.S.C. 1395ww)) or other provider 

5 of services (as defined in subsection (u) of such sec6 tion) or supplier (as defined in subsection (d) of 

7 such section) that— 

8 (A) furnishes longitudinal comprehensive 

9 care planning services through an interdiscipli10 nary team; and 

11 (B) meets such other requirements as the 

12 Secretary may determine to be appropriate. 

13 (2) COMPTROLLER GENERAL.—The term 

14 ‘‘Comptroller General’’ means the Comptroller Gen15 eral of the United States. 

16 (3) INTERDISCIPLINARY TEAM.—The term 

17 ‘‘interdisciplinary team’’ means a group that— 

18 (A) includes the personnel described in 

19 subsection (dd)(2)(B)(i) of such section 1861; 

20 (B) may include a chaplain, minister, or 

21 other clergy; and 

22 (C) may include other direct care per23 sonnel. 

24 (4) LONGITUDINAL COMPREHENSIVE CARE

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1 prehensive care planning services’’ means a vol2 untary shared decisionmaking process that is fur3 nished by an applicable provider through an inter4 disciplinary team and includes a conversation with 

5 Medicare beneficiaries who have received a diagnosis 

6 of a serious or life-threatening illness. The purpose 

7 of such services is to discuss a longitudinal care plan 

8 that addresses the progression of the disease, treat9 ment options, the goals, values, and preferences of 

10 the beneficiary, and the availability of other re11 sources and social supports that may reduce the 

12 beneficiary’s health risks and promote self-manage13 ment and shared decisionmaking. 

14 (5) SECRETARY.—The term ‘‘Secretary’’ means 

15 the Secretary of Health and Human Services. 

16 TITLE VI—OTHER POLICIES TO 

17 IMPROVE CARE FOR THE 

18 CHRONICALLY ILL 

19 SEC. 601. GAO STUDY AND REPORT ON IMPROVING MEDI20 CATION SYNCHRONIZATION. 

21 (a) STUDY.—The Comptroller General of the United 

22 States (in this section referred to as the ‘‘Comptroller 

23 General’’) shall conduct a study on the extent to which 

24 Medicare prescription drug plans (MA–PD plans and 

25 standalone prescription drug plans) under part D of title 


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1 XVIII of the Social Security Act and private payors use 

2 programs that synchronize pharmacy dispensing so that 

3 individuals may receive multiple prescriptions on the same 

4 day to facilitate comprehensive counseling and promote 

5 medication adherence. The study shall include a review of 

6 the following: 

7 (1) The extent to which pharmacies have adopt8 ed such programs. 

9 (2) The common characteristics of such pro10 grams, including how pharmacies structure coun11 seling sessions under such programs and the types 

12 of payment and other arrangements that Medicare 

13 prescription drug plans and private payors employ 

14 under such programs to support the efforts of phar15 macies. 

16 (3) How such programs compare for Medicare 

17 prescription drug plans and private payors. 

18 (4) What is known about how such programs 

19 affect patient medication adherence and overall pa20 tient health outcomes and health outcomes, includ21 ing if adherence and outcomes vary by patient sub22 populations, such as disease state and socioeconomic 

23 status. 

24 (5) What is known about overall patient satis25 faction with such programs and satisfaction with 


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1 such programs, including within patient subpopula2 tions, such as disease state and socioeconomic sta3 tus. 

4 (6) The extent to which laws and regulations of 

5 the Medicare program support such programs. 

6 (7) Barriers to the use of medication synchroni7 zation programs by Medicare prescription drug 

8 plans. 

9 (b) REPORT.—Not later than 18 months after the 

10 date of the enactment of this Act, the Comptroller General 

11 shall submit to Congress a report containing the results 

12 of the study under subsection (a), together with rec13 ommendations for such legislation and administrative ac14 tion as the Comptroller General determines appropriate. 

15 SEC. 602. GAO STUDY AND REPORT ON IMPACT OF OBESITY 

16 DRUGS ON PATIENT HEALTH AND SPENDING. 

17 (a) STUDY.—The Comptroller General of the United 

18 States (in this section referred to as the ‘‘Comptroller 

19 General’’) shall conduct a study on the use of prescription 

20 drugs to manage the weight of obese patients and the im21 pact of coverage of such drugs on patient health and on 

22 health care spending. Such study shall examine the use 

23 and impact of these obesity drugs in the non-Medicare 

24 population and for Medicare beneficiaries who have such 

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1 tion 1860D–1(a)(3)(C) of the Social Security Act (42 

2 U.S.C. 1395w–101(a)(3)(C))) as a supplemental health 

3 care benefit. The study shall include an analysis of the 

4 following: 

5 (1) The prevalence of obesity in the Medicare 

6 and non-Medicare population. 

7 (2) The utilization of obesity drugs. 

8 (3) The distribution of Body Mass Index by in9 dividuals taking obesity drugs, to the extent prac10 ticable. 

11 (4) What is known about the use of obesity 

12 drugs in conjunction with the receipt of other items 

13 or services, such as behavioral counseling, and how 

14 these compare to items and services received by 

15 obese individuals who do not take obesity drugs. 

16 (5) Physician considerations and attitudes re17 lated to prescribing obesity drugs. 

18 (6) The extent to which coverage policies cease 

19 or limit coverage for individuals who fail to receive 

20 clinical benefit. 

21 (7) What is known about the extent to which 

22 individuals who take obesity drugs adhere to the pre23 scribed regimen. 


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1 (8) What is known about the extent to which 

2 individuals who take obesity drugs maintain weight 

3 loss over time. 

4 (9) What is known about the subsequent impact 

5 such drugs have on medical services that are directly 

6 related to obesity, including with respect to sub7 populations determined based on the extent of obe8 sity. 

9 (10) What is known about the spending associ10 ated with the care of individuals who take obesity 

11 drugs, compared to the spending associated with the 

12 care of individuals who do not take such drugs. 

13 (b) REPORT.—Not later than 18 months after the 

14 date of the enactment of this Act, the Comptroller General 

15 shall submit to Congress a report containing the results 

16 of the study under subsection (a), together with rec17 ommendations for such legislation and administrative ac18 tion as the Comptroller General determines appropriate. 

19 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

20 (a) SHORT TITLE.—This Act may be cited as the ‘‘Cre21 ating High-Quality Results and Outcomes Necessary to Im22 prove Chronic (CHRONIC) Care Act of 2017’’. 

23 (b) TABLE OF CONTENTS.—The table of contents of this 

24 Act is as follows: 

Sec. 1. Short title; table of contents. 


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TITLE I—RECEIVING HIGH QUALITY CARE IN THE HOME 

Sec. 101. Extending the Independence at Home Demonstration Program. 

Sec. 102. Expanding access to home dialysis therapy. 

TITLE II—ADVANCING TEAM-BASED CARE 

Sec. 201. Providing continued access to Medicare Advantage special needs plans 

for vulnerable populations. 

TITLE III—EXPANDING INNOVATION AND TECHNOLOGY 

Sec. 301. Adapting benefits to meet the needs of chronically ill Medicare Advantage enrollees. 

Sec. 302. Expanding supplemental benefits to meet the needs of chronically ill 

Medicare Advantage enrollees. 

Sec. 303. Increasing convenience for Medicare Advantage enrollees through telehealth. 

Sec. 304. Providing accountable care organizations the ability to expand the use 

of telehealth. 

Sec. 305. Expanding the use of telehealth for individuals with stroke. 

TITLE IV—IDENTIFYING THE CHRONICALLY ILL POPULATION 

Sec. 401. Providing flexibility for beneficiaries to be part of an accountable care 

organization. 

TITLE V—EMPOWERING INDIVIDUALS AND CAREGIVERS IN CARE 

DELIVERY 

Sec. 501. Eliminating barriers to care coordination under accountable care organizations. 

Sec. 502. GAO study and report on longitudinal comprehensive care planning 

services under Medicare part B. 

TITLE VI—OTHER POLICIES TO IMPROVE CARE FOR THE 

CHRONICALLY ILL 

Sec. 601. Providing prescription drug plans with parts A and B claims data to 

promote the appropriate use of medications and improve health 

outcomes. 

Sec. 602. GAO study and report on improving medication synchronization. 

Sec. 603. GAO study and report on impact of obesity drugs on patient health and 

spending. 

Sec. 604. HHS study and report on long-term risk factors for chronic conditions 

among Medicare beneficiaries. 

TITLE VII—OFFSETS 

Sec. 701. Medicare Improvement Fund. 

Sec. 702. Medicaid Improvement Fund 


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1 TITLE I—RECEIVING HIGH 

2 QUALITY CARE IN THE HOME 

3 SEC. 101. EXTENDING THE INDEPENDENCE AT HOME DEM4 ONSTRATION PROGRAM. 

5 Section 1866E of the Social Security Act (42 U.S.C. 

6 1395cc–5) is amended— 

7 (1) in subsection (e)— 

8 (A) in paragraph (1), by striking ‘‘5-year 

9 period’’ and inserting ‘‘7-year period’’; and 

10 (B) in paragraph (5), by striking ‘‘10,000’’ 

11 and inserting ‘‘15,000’’; 

12 (2) in subsection (g), in the first sentence, by in13 serting ‘‘, including, to the extent practicable, the use 

14 of electronic health information systems as described 

15 in subsection (b)(1)(A)(vi),’’ after ‘‘program’’; and 

16 (3) in subsection (i)(A), by striking ‘‘will not re17 ceive an incentive payment for the second of 2’’ and 

18 inserting ‘‘did not achieve savings for the third of 3’’. 

19 SEC. 102. EXPANDING ACCESS TO HOME DIALYSIS THER20 APY. 

21 (a) IN GENERAL.—Section 1881(b)(3) of the Social Se22 curity Act (42 U.S.C. 1395rr(b)(3)) is amended— 

23 (1) by redesignating subparagraphs (A) and (B) 

24 as clauses (i) and (ii), respectively; 


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1 (2) in clause (ii), as redesignated by subpara2 graph (A), strike ‘‘on a comprehensive’’ and insert 

3 ‘‘subject to subparagraph (B), on a comprehensive’’; 

4 (3) by striking ‘‘With respect to’’ and inserting 

5 ‘‘(A) With respect to’’; and 

6 (4) by adding at the end the following new sub7 paragraph: 

8 ‘‘(B) For purposes of subparagraph (A)(ii), an indi9 vidual determined to have end stage renal disease receiving 

10 home dialysis may choose to receive monthly end stage renal 

11 disease-related clinical assessments furnished on or after 

12 January 1, 2019, via telehealth if the individual receives 

13 a face-to-face clinical assessment, without the use of tele14 health, at least once every three consecutive months.’’. 

15 (b) ORIGINATING SITE REQUIREMENTS.— 

16 (1) IN GENERAL.—Section 1834(m) of the Social 

17 Security Act (42 U.S.C. 1395m(m)) is amended— 

18 (A) in paragraph (4)(C)(ii), by adding at 

19 the end the following new subclauses: 

20 ‘‘(IX) A renal dialysis facility, 

21 but only for purposes of section 

22 1881(b)(3)(B). 

23 ‘‘(X) The home of an individual, 

24 but only for purposes of section 

25 1881(b)(3)(B).’’; and 


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1 (B) by adding at the end the following new 

2 paragraph: 

3 ‘‘(5) TREATMENT OF HOME DIALYSIS MONTHLY

4 ESRD-RELATED VISIT.—The geographic requirements 

5 described in paragraph (4)(C)(i) shall not apply with 

6 respect to telehealth services furnished on or after 

7 January 1, 2019, for purposes of section 

8 1881(b)(3)(B), at an originating site described in 

9 subclause (VI), (IX), or (X) of paragraph (4)(C)(ii).’’. 

10 (2) NO FACILITY FEE IF ORIGINATING SITE FOR

11 HOME DIALYSIS THERAPY IS THE HOME.—Section 

12 1834(m)(2)(B) of the Social Security (42 U.S.C. 

13 1395m(m)(2)(B)) is amended— 

14 (A) by redesignating clauses (i) and (ii) as 

15 subclauses (I) and (II), and indenting appro16 priately; 

17 (B) in subclause (II), as redesignated by 

18 subparagraph (A), by striking ‘‘clause (i) or this 

19 clause’’ and inserting ‘‘subclause (I) or this sub20 clause’’; 

21 (C) by striking ‘‘SITE.—With respect to’’ 

22 and inserting ‘‘SITE.— 

23 ‘‘(i) IN GENERAL.—Subject to clause 

24 (ii), with respect to’’; and 


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1 (D) by adding at the end the following new 

2 clause: 

3 ‘‘(ii) NO FACILITY FEE IF ORIGINATING

4 SITE FOR HOME DIALYSIS THERAPY IS THE

5 HOME.—No facility fee shall be paid under 

6 this subparagraph to an originating site de7 scribed in paragraph (4)(C)(ii)(X).’’. 

8 (c) CONFORMING AMENDMENT.—Section 1881(b)(1) of 

9 the Social Security Act (42 U.S.C. 1395rr(b)(1)) is amend10 ed by striking ‘‘paragraph (3)(A)’’ and inserting ‘‘para11 graph (3)(A)(i)’’. 

12 TITLE II—ADVANCING TEAM13 BASED CARE 

14 SEC. 201. PROVIDING CONTINUED ACCESS TO MEDICARE 

15 ADVANTAGE SPECIAL NEEDS PLANS FOR VUL16 NERABLE POPULATIONS. 

17 (a) EXTENSION.—Section 1859(f)(1) of the Social Se18 curity Act (42 U.S.C. 1395w–28(f)(1)) is amended by strik19 ing ‘‘and for periods before January 1, 2019’’. 

20 (b) INCREASED INTEGRATION OF DUAL SNPS.— 

21 (1) IN GENERAL.—Section 1859(f) of the Social 

22 Security Act (42 U.S.C. 1395w–28(f)) is amended— 

23 (A) in paragraph (3), by adding at the end 

24 the following new subparagraph: 


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1 ‘‘(F) The plan meets the requirements ap2 plicable under paragraph (8).’’; and 

3 (B) by adding at the end the following new 

4 paragraph: 

5 ‘‘(8) INCREASED INTEGRATION OF DUAL SNPS.— 

6 ‘‘(A) DESIGNATED CONTACT.—The Sec7 retary, acting through the Federal Coordinated 

8 Health Care Office established under section 

9 2602 of the Patient Protection and Affordable 

10 Care Act, shall serve as a dedicated point of con11 tact for States to address misalignments that 

12 arise with the integration of specialized MA 

13 plans for special needs individuals described in 

14 subsection (b)(6)(B)(ii) under this paragraph 

15 and, consistent with such role, shall— 

16 ‘‘(i) establish a uniform process for dis17 seminating to State Medicaid agencies in18 formation under this title impacting con19 tracts between such agencies and such plans 

20 under this subsection; and 

21 ‘‘(ii) establish basic resources for States 

22 interested in exploring such plans as a plat23 form for integration, such as a model con24 tract or other tools to achieve those goals. 


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1 ‘‘(B) UNIFIED GRIEVANCES AND APPEALS

2 PROCESS.— 

3 ‘‘(i) IN GENERAL.—Not later than 

4 April 1, 2020, the Secretary shall establish 

5 procedures, to the extent feasible, unifying 

6 grievances and appeals procedures under 

7 sections 1852(f), 1852(g), 1902(a)(3), 

8 1902(a)(5), and 1932(b)(4) for items and 

9 services provided by specialized MA plans 

10 for special needs individuals described in 

11 subsection (b)(6)(B)(ii) under this title and 

12 title XIX. The Secretary shall solicit com13 ment in developing such procedures from 

14 States, plans, beneficiaries and their rep15 resentatives, and other relevant stakeholders. 

16 ‘‘(ii) PROCEDURES.—The procedures 

17 established under clause (i) shall be in18 cluded in the plan contract under para19 graph (3)(D) and shall— 

20 ‘‘(I) adopt the provisions for the 

21 enrollee that are most protective for the 

22 enrollee and, to the extent feasible as 

23 determined by the Secretary, are com24 patible with unified timeframes and 


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1 consolidated access to external review 

2 under an integrated process; 

3 ‘‘(II) take into account differences 

4 in State plans under title XIX to the 

5 extent necessary; 

6 ‘‘(III) be easily navigable by an 

7 enrollee; and 

8 ‘‘(IV) include the elements de9 scribed in clause (iii), as applicable. 

10 ‘‘(iii) ELEMENTS DESCRIBED.—Both 

11 unified appeals and unified grievance pro12 cedures shall include, as applicable, the fol13 lowing elements described in this clause: 

14 ‘‘(I) Single written notification of 

15 all applicable grievances and appeal 

16 rights under this title and title XIX. 

17 For purposes of this subparagraph, the 

18 Secretary may waive the requirements 

19 under section 1852(g)(1)(B) when the 

20 specialized MA plan covers items or 

21 services under this part or under title 

22 XIX. 

23 ‘‘(II) Single pathways for resolu24 tion of any grievance or appeal related 

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1 vided by specialized MA plans for spe2 cial needs individuals described in sub3 section (b)(6)(B)(ii) under this title 

4 and title XIX. 

5 ‘‘(III) Notices written in plain 

6 language and available in a language 

7 and format that is accessible to the en8 rollee, including in non-English lan9 guages that are prevalent in the service 

10 area of the specialized MA plan. 

11 ‘‘(IV) Unified timeframes for 

12 grievances and appeals processes, such 

13 as an individual’s filing of a grievance 

14 or appeal, a plan’s acknowledgment 

15 and resolution of a grievance or ap16 peal, and notification of decisions with 

17 respect to a grievance or appeal. 

18 ‘‘(V) Requirements for how the 

19 plan must process, track, and resolve 

20 grievances and appeals, to ensure bene21 ficiaries are notified on a timely basis 

22 of decisions that are made throughout 

23 the grievance or appeals process and 

24 are able to easily determine the status 

25 of a grievance or appeal. 


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1 ‘‘(iv) CONTINUATION OF BENEFITS

2 PENDING APPEAL.—The unified procedures 

3 under clause (i) shall, with respect to all 

4 benefits under parts A and B and title XIX 

5 subject to appeal under such procedures, in6 corporate provisions under current law and 

7 implementing regulations that provide con8 tinuation of benefits pending appeal under 

9 this title and title XIX. 

10 ‘‘(C) REQUIREMENT FOR UNIFIED GRIEV11 ANCES AND APPEALS.—For 2021 and subsequent 

12 years, the contract of a specialized MA plan for 

13 special needs individuals described in subsection 

14 (b)(6)(B)(ii) with a State Medicaid agency 

15 under paragraph (3)(D) shall require the use of 

16 unified grievances and appeals procedures as de17 scribed in subparagraph (B). 

18 ‘‘(D) REQUIREMENTS FOR INTEGRATION.— 

19 For 2021 and subsequent years, a specialized MA 

20 plan for special needs individuals described in 

21 subsection (b)(6)(B)(ii) shall meet one or more of 

22 the following requirements, to the extent per23 mitted under State law, for integration of bene24 fits under this title and title XIX: 


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1 ‘‘(i) The specialized MA plan must 

2 meet the requirements of contracting with 

3 the State Medicaid agency described in 

4 paragraph (3)(D) in addition to coordi5 nating long-term services and supports or 

6 behavioral health services, or both, by meet7 ing an additional minimum set of require8 ments determined by the Secretary through 

9 the Federal Coordinated Health Care Office 

10 established under section 2602 of the Pa11 tient Protection and Affordable Care Act 

12 based on input from stakeholders, such as 

13 notifying the State in a timely manner of 

14 hospitalizations, emergency room visits, and 

15 hospital or nursing home discharges of en16 rollees, assigning one primary care provider 

17 for each enrollee, or sharing data that 

18 would benefit the coordination of items and 

19 services under this title and the State plan 

20 under title XIX. Such minimum set of re21 quirements must be included in the contract 

22 of the specialized MA plan with the State 

23 Medicaid agency under such paragraph. 

24 ‘‘(ii) The specialized MA plan must 

25 meet the requirements of a fully integrated 


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1 plan described in section 

2 1853(a)(1)(B)(iv)(II) (other than the re3 quirement that the plan have similar aver4 age levels of frailty, as determined by the 

5 Secretary, as the PACE program), or enter 

6 into a capitated contract with the State 

7 Medicaid agency to provide long-term serv8 ices and supports or behavioral health serv9 ices, or both. 

10 ‘‘(iii) In the case where an individual 

11 is enrolled in both the specialized MA plan 

12 and a Medicaid managed care organization 

13 (as defined in section 1903(m)(1)(A)) pro14 viding long term services and supports or 

15 behavioral health services that have the 

16 same parent organization, the parent orga17 nization offering both the specialized MA 

18 plan and the Medicaid managed care plan 

19 must assume clinical and financial respon20 sibility for benefits provided under this title 

21 and title XIX.’’. 

22 (2) CONFORMING AMENDMENT TO RESPONSIBIL23 ITIES OF FEDERAL COORDINATED HEALTH CARE OF24 FICE.—Section 2602(d) of the Patient Protection and 


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1 Affordable Care Act (42 U.S.C. 1315b(d)) is amended 

2 by adding at the end the following new paragraphs: 

3 ‘‘(6) To act as a designated contact for States 

4 under subsection (f)(8)(A) of section 1859 of the So5 cial Security Act (42 U.S.C. 1395w–28) with respect 

6 to the integration of specialized MA plans for special 

7 needs individuals described in subsection (b)(6)(B)(ii) 

8 of such section. 

9 ‘‘(7) To be responsible for developing regulations 

10 and guidance related to the implementation of a uni11 fied grievance and appeals process as described in 

12 subparagraphs (B) and (C) of section 1859(f)(8) of 

13 the Social Security Act (42 U.S.C. 1395w–28(f)(8)).’’. 

14 (c) IMPROVEMENTS TO SEVERE OR DISABLING CHRON15 IC CONDITION SNPS.— 

16 (1) CARE MANAGEMENT REQUIREMENTS.—Sec17 tion 1859(f)(5) of the Social Security Act (42 U.S.C. 

18 1395w–28(f)(5)) is amended— 

19 (A) by striking ‘‘ALL SNPS.—The require20 ments’’ and inserting ‘‘ALL SNPS.— 

21 ‘‘(A) IN GENERAL.—Subject to subpara22 graph (B), the requirements’’; 

23 (B) by redesignating subparagraphs (A) 

24 and (B) as clauses (i) and (ii), respectively, and 

25 indenting appropriately; 


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1 (C) in clause (ii), as redesignated by sub2 paragraph (B), by redesignating clauses (i) 

3 through (iii) as subclauses (I) through (III), re4 spectively, and indenting appropriately; and 

5 (D) by adding at the end the following new 

6 subparagraph: 

7 ‘‘(B) IMPROVEMENTS TO CARE MANAGE8 MENT REQUIREMENTS FOR SEVERE OR DIS9 ABLING CHRONIC CONDITION SNPS.—For 2020 

10 and subsequent years, in the case of a specialized 

11 MA plan for special needs individuals described 

12 in subsection (b)(6)(B)(iii), the requirements de13 scribed in this paragraph include the following: 

14 ‘‘(i) The interdisciplinary team under 

15 subparagraph (A)(ii)(III) includes a team 

16 of providers with demonstrated expertise, 

17 including training in an applicable spe18 cialty, in treating individuals similar to the 

19 targeted population of the plan. 

20 ‘‘(ii) Requirements developed by the 

21 Secretary to provide face-to-face encounters 

22 with individuals enrolled in the plan not 

23 less frequently than on an annual basis. 

24 ‘‘(iii) As part of the model of care 

25 under clause (i) of subparagraph (A), the 


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1 results of the initial assessment and annual 

2 reassessment under clause (ii)(I) of such 

3 subparagraph of each individual enrolled in 

4 the plan are addressed in the individual’s 

5 individualized care plan under clause 

6 (ii)(II) of such subparagraph. 

7 ‘‘(iv) As part of the annual evaluation 

8 and approval of such model of care, the Sec9 retary shall take into account whether the 

10 plan fulfilled the previous year’s goals (as 

11 required under the model of care). 

12 ‘‘(v) The Secretary shall establish a 

13 minimum benchmark for each element of the 

14 model of care of a plan. The Secretary shall 

15 only approve a plan’s model of care under 

16 this paragraph if each element of the model 

17 of care meets the minimum benchmark ap18 plicable under the preceding sentence.’’. 

19 (2) REVISIONS TO THE DEFINITION OF A SEVERE

20 OR DISABLING CHRONIC CONDITIONS SPECIALIZED

21 NEEDS INDIVIDUAL.— 

22 (A) IN GENERAL.—Section 

23 1859(b)(6)(B)(iii) of the Social Security Act (42 

24 U.S.C. 1395w–28(b)(6)(B)(iii)) is amended— 


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1 (i) by striking ‘‘who have’’ and insert2 ing ‘‘who— 

3 ‘‘(I) before January 1, 2022, 

4 have’’; 

5 (ii) in subclause (I), as added by 

6 clause (i), by striking the period at the end 

7 and inserting ‘‘; and’’; and 

8 (iii) by adding at the end the following 

9 new subclause: 

10 ‘‘(II) on or after January 1, 2022, 

11 have one or more comorbid and medi12 cally complex chronic conditions that 

13 is life threatening or significantly lim14 its overall health or function, have a 

15 high risk of hospitalization or other 

16 adverse health outcomes, and require 

17 intensive care coordination and that is 

18 listed under subsection (f)(9)(A).’’. 

19 (B) PANEL OF CLINICAL ADVISORS.—Sec20 tion 1859(f) of the Social Security Act (42 

21 U.S.C. 1395w–28(f)), as amended by subsection 

22 (b), is amended by adding at the end the fol23 lowing new paragraph: 


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1 ‘‘(9) LIST OF CONDITIONS FOR CLARIFICATION OF

2 THE DEFINITION OF A SEVERE OR DISABLING CHRON3 IC CONDITIONS SPECIALIZED NEEDS INDIVIDUAL.— 

4 ‘‘(A) IN GENERAL.—Not later than Decem5 ber 31, 2020, and every 5 years thereafter, the 

6 Secretary shall convene a panel of clinical advi7 sors to establish and update a list of conditions 

8 that meet each of the following criteria: 

9 ‘‘(i) Conditions that meet the defini10 tion of a severe or disabling chronic condi11 tion under subsection (b)(6)(B)(iii) on or 

12 after January 1, 2022. 

13 ‘‘(ii) Conditions that require prescrip14 tion drugs, providers, and models of care 

15 that are unique to the specific population of 

16 enrollees in a specialized MA plan for spe17 cial needs individuals described in such sub18 section on or after such date and— 

19 ‘‘(I) as a result of access to, and 

20 enrollment in, such a specialized MA 

21 plan for special needs individuals, in22 dividuals with such condition would 

23 have a reasonable expectation of slow24 ing or halting the progression of the 

25 disease, improving health outcomes and 


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1 decreasing overall costs for individuals 

2 diagnosed with such condition com3 pared to available options of care other 

4 than through such a specialized MA 

5 plan for special needs individuals; or 

6 ‘‘(II) have a low prevalence in the 

7 general population of beneficiaries 

8 under this title or a disproportionally 

9 high per-beneficiary cost under this 

10 title. 

11 ‘‘(B) REQUIREMENT.—In establishing and 

12 updating the list under subparagraph (A), the 

13 panel shall take into account the availability of 

14 varied benefits, cost-sharing, and supplemental 

15 benefits under the model described in paragraph 

16 (2) of section 1859(h), including the expansion 

17 under paragraph (1) of such section.’’. 

18 (d) QUALITY MEASUREMENT AT THE PLAN LEVEL FOR

19 SNPS AND DETERMINATION OF FEASABILITY OF QUALITY

20 MEASUREMENT AT THE PLAN LEVEL FOR ALL MA 

21 PLANS.—Section 1853(o) of the Social Security Act (42 

22 U.S.C. 1395w–23(o)) is amended by adding at the end the 

23 following new paragraphs: 

24 ‘‘(6) QUALITY MEASUREMENT AT THE PLAN

25 LEVEL FOR SNPS.— 


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1 ‘‘(A) IN GENERAL.—Subject to subpara2 graph (B), the Secretary may require reporting 

3 of data under section 1852(e) for, and apply 

4 under this subsection, quality measures at the 

5 plan level for specialized MA plans for special 

6 needs individuals instead of at the contract level. 

7 ‘‘(B) CONSIDERATIONS.—Prior to applying 

8 quality measurement at the plan level under this 

9 paragraph, the Secretary shall— 

10 ‘‘(i) take into consideration the min11 imum number of enrollees in a specialized 

12 MA plan for special needs individuals in 

13 order to determine if a statistically signifi14 cant or valid measurement of quality at the 

15 plan level is possible under this paragraph; 

16 ‘‘(ii) take into consideration the im17 pact of such application on plans that serve 

18 a disproportionate number of individuals 

19 dually eligible for benefits under this title 

20 and under title XIX; 

21 ‘‘(iii) if quality measures are reported 

22 at the plan level, ensure that MA plans are 

23 not required to provide duplicative informa24 tion; 


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1 ‘‘(iv) ensure that such reporting does 

2 not interfere with the collection of encounter 

3 data submitted by MA organizations or the 

4 administration of any changes to the pro5 gram under this part as a result of the col6 lection of such data. 

7 ‘‘(C) APPLICATION.—If the Secretary ap8 plies quality measurement at the plan level 

9 under this paragraph, such quality measurement 

10 may include Medicare Health Outcomes Survey 

11 (HOS), Healthcare Effectiveness Data and Infor12 mation Set (HEDIS), Consumer Assessment of 

13 Healthcare Providers and Systems (CAHPS) 

14 measures and quality measures under part D. 

15 ‘‘(7) DETERMINATION OF FEASIBILITY OF QUAL16 ITY MEASUREMENT AT THE PLAN LEVEL FOR ALL MA

17 PLANS.— 

18 ‘‘(A) DETERMINATION OF FEASIBILITY.— 

19 The Secretary shall determine the feasibility of 

20 requiring reporting of data under section 1852(e) 

21 for, and applying under this subsection, quality 

22 measures at the plan level for all MA plans 

23 under this part. 

24 ‘‘(B) CONSIDERATION OF CHANGE.—After 

25 making a determination under subparagraph 


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1 (A), the Secretary shall consider requiring such 

2 reporting and applying such quality measures at 

3 the plan level as described in such subpara4 graph.’’. 

5 (e) GAO STUDY AND REPORT ON STATE-LEVEL INTE6 GRATION BETWEEN DUAL SNPS AND MEDICAID.— 

7 (1) STUDY.—The Comptroller General of the 

8 United States (in this paragraph referred to as the 

9 ‘‘Comptroller General’’) shall conduct a study on 

10 State-level integration between specialized MA plans 

11 for special needs individuals described in subsection 

12 (b)(6)(B)(ii) of section 1859 of the Social Security 

13 Act (42 U.S.C. 1395w–28) and the Medicaid program 

14 under title XIX of such Act (42 U.S.C. 1396 et seq.). 

15 Such study shall include an analysis of the following: 

16 (A) The characteristics of States in which 

17 the State agency responsible for administering 

18 the State plan under such title XIX has a con19 tract with such a specialized MA plan and that 

20 delivers long term services and supports under 

21 the State plan under such title XIX through a 

22 managed care program, including the require23 ments under such State plan with respect to long 

24 term services and supports. 


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1 (B) The types of such specialized MA plans, 

2 which may include the following: 

3 (i) A plan described in section 

4 1853(a)(1)(B)(iv)(II) of such Act (42 U.S.C. 

5 1395w–23(a)(1)(B)(iv)(II)). 

6 (ii) A plan that meets the requirements 

7 described in subsection (f)(3)(D) of such sec8 tion 1859. 

9 (iii) A plan described in clause (ii) 

10 that also meets additional requirements es11 tablished by the State. 

12 (C) The characteristics of individuals en13 rolled in such specialized MA plans. 

14 (D) As practicable, the following with re15 spect to State programs for the delivery of long 

16 term services and supports under such title XIX 

17 through a managed care program: 

18 (i) Which populations of individuals 

19 are eligible to receive such services and sup20 ports. 

21 (ii) Whether all such services and sup22 ports are provided on a capitated basis or 

23 if any of such services and supports are 

24 carved out and provided through fee-for25 service. 


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1 (E) How the availability and variation of 

2 integration arrangements of such specialized MA 

3 plans offered in States affects spending, service 

4 delivery options, access to community-based care, 

5 and utilization of care. 

6 (F) The efforts of State Medicaid programs 

7 to transition dually-eligible beneficiaries receiv8 ing long term services and supports (LTSS) 

9 from institutional settings to home and commu10 nity-based settings and related financial impacts 

11 of such transitions 

12 (2) REPORT.—Not later than 2 years after the 

13 date of the enactment of this Act, the Comptroller 

14 General shall submit to Congress a report containing 

15 the results of the study conducted under paragraph 

16 (1), together with recommendations for such legisla17 tion and administrative action as the Comptroller 

18 General determines appropriate. 


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1 TITLE III—EXPANDING 

2 INNOVATION AND TECHNOLOGY 

3 SEC. 301. ADAPTING BENEFITS TO MEET THE NEEDS OF 

4 CHRONICALLY ILL MEDICARE ADVANTAGE 

5 ENROLLEES. 

6 Section 1859 of the Social Security Act (42 U.S.C. 

7 1395w–28) is amended by adding at the end the following 

8 new subsection: 

9 ‘‘(h) NATIONAL TESTING OF MODEL FOR MEDICARE

10 ADVANTAGE VALUE-BASED INSURANCE DESIGN.— 

11 ‘‘(1) IN GENERAL.—In implementing the model 

12 described in paragraph (2) proposed to be tested 

13 under section 1115A(b), the Secretary shall revise the 

14 testing of the model under such section to cover, effec15 tive not later than January 1, 2020, all States. 

16 ‘‘(2) MODEL DESCRIBED.—The model described 

17 in this paragraph is the testing of a model of Medi18 care Advantage value-based insurance design that 

19 would allow Medicare Advantage plans the option to 

20 propose and design benefit structures that vary bene21 fits, cost-sharing, and supplemental benefits offered to 

22 enrollees with specific chronic diseases proposed to be 

23 carried out in Oregon, Arizona, Texas, Iowa, Michi24 gan, Indiana, Tennessee, Alabama, Pennsylvania, 

25 and Massachusetts. 


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1 ‘‘(3) TERMINATION AND MODIFICATION PROVI2 SION NOT APPLICABLE UNTIL JANUARY 1, 2022.—The 

3 provisions of section 1115A(b)(3)(B) shall apply to 

4 the model described in paragraph (2), including such 

5 model as expanded under paragraph (1), beginning 

6 January 1, 2022, but shall not apply to such model, 

7 as so expanded, prior to such date. 

8 ‘‘(4) FUNDING.—The Secretary shall allocate 

9 funds made available under section 1115A(f)(1) to de10 sign, implement, and evaluate the model described in 

11 paragraph (2), as expanded under paragraph (1).’’. 

12 SEC. 302. EXPANDING SUPPLEMENTAL BENEFITS TO MEET 

13 THE NEEDS OF CHRONICALLY ILL MEDICARE 

14 ADVANTAGE ENROLLEES. 

15 (a) IN GENERAL.—Section 1852(a)(3) of the Social Se16 curity Act (42 U.S.C. 1395w–22(a)(3)) is amended— 

17 (1) in subparagraph (A), by striking ‘‘Each’’ 

18 and inserting ‘‘Subject to subparagraph (D), each’’; 

19 and 

20 (2) by adding at the end the following new sub21 paragraph: 

22 ‘‘(D) EXPANDING SUPPLEMENTAL BENEFITS

23 TO MEET THE NEEDS OF CHRONICALLY ILL EN24 ROLLEES.— 


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1 ‘‘(i) IN GENERAL.—For plan year 2020 

2 and subsequent plan years, in addition to 

3 any supplemental health care benefits other4 wise provided under this paragraph, an MA 

5 plan may provide supplemental benefits de6 scribed in clause (ii) to a chronically ill en7 rollee (as defined in clause (iii)). 

8 ‘‘(ii) SUPPLEMENTAL BENEFITS DE9 SCRIBED.— 

10 ‘‘(I) IN GENERAL.—Supplemental 

11 benefits described in this clause are 

12 supplemental benefits that, with respect 

13 to a chronically ill enrollee, have a rea14 sonable expectation of improving or 

15 maintaining the health or overall func16 tion of the chronically ill enrollee and 

17 may not be limited to being primarily 

18 health related benefits. 

19 ‘‘(II) AUTHORITY TO WAIVE UNI20 FORMITY REQUIREMENTS.—The Sec21 retary may, only with respect to sup22 plemental benefits provided to a chron23 ically ill enrollee under this subpara24 graph, waive the uniformity requireVerDate Sep 11 2014 00:55 Aug 04, 2017 Jkt 069200 PO 00000 Frm 00083 Fmt 6652 Sfmt 6203 E:\BILLS\S870.RS S870

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1 ment under subsection (d)(1)(A), as de2 termined appropriate by the Secretary. 

3 ‘‘(iii) CHRONICALLY ILL ENROLLEE

4 DEFINED.—In this subparagraph, the term 

5 ‘chronically ill enrollee’ means an enrollee 

6 in an MA plan that the Secretary deter7 mines— 

8 ‘‘(I) has one or more comorbid 

9 and medically complex chronic condi10 tions that is life threatening or signifi11 cantly limits the overall health or func12 tion of the enrollee; 

13 ‘‘(II) has a high risk of hos14 pitalization or other adverse health 

15 outcomes; and 

16 ‘‘(III) requires intensive care co17 ordination.’’. 

18 (b) GAO STUDY AND REPORT.— 

19 (1) STUDY.—The Comptroller General of the 

20 United States (in this subsection referred to as the 

21 ‘‘Comptroller General’’) shall conduct a study on sup22 plemental benefits provided to enrollees in Medicare 

23 Advantage plans under part C of title XVIII of the 

24 Social Security Act. To the extend data are available, 

25 such study shall include an analysis of the following: 


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1 (A) The type of supplemental benefits pro2 vided to such enrollees, the total number of en3 rollees receiving each supplemental benefit, and 

4 whether the supplemental benefit is covered by 

5 the standard benchmark cost of the benefit or 

6 with an additional premium. 

7 (B) The frequency in which supplemental 

8 benefits are utilized by such enrollees. 

9 (C) The impact supplemental benefits have 

10 on— 

11 (i) indicators of the quality of care re12 ceived by such enrollees, including overall 

13 health and function of the enrollees; 

14 (ii) the utilization of items and serv15 ices for which benefits are available under 

16 the original Medicare fee-for-service pro17 gram option under parts A and B of such 

18 title XVIII by such enrollees; and 

19 (iii) the amount of the bids submitted 

20 by Medicare Advantage Organizations for 

21 Medicare Advantage plans under such part 

22 C. 

23 (2) REPORT.—Not later than 5 years after the 

24 date of the enactment of this Act, the Comptroller 

25 General shall submit to Congress a report containing 


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1 the results of the study conducted under paragraph 

2 (1), together with recommendations for such legisla3 tion and administrative action as the Comptroller 

4 General determines appropriate. 

5 SEC. 303. INCREASING CONVENIENCE FOR MEDICARE AD6 VANTAGE ENROLLEES THROUGH TELE7 HEALTH. 

8 (a) IN GENERAL.—Section 1852 of the Social Security 

9 Act (42 U.S.C. 1395w–22) is amended— 

10 (1) in subsection (a)(1)(B)(i), by inserting ‘‘, 

11 subject to subsection (m),’’ after ‘‘means’’; and 

12 (2) by adding at the end the following new sub13 section: 

14 ‘‘(m) PROVISION OF ADDITIONAL TELEHEALTH BENE15 FITS.— 

16 ‘‘(1) MA PLAN OPTION.—For plan year 2020 

17 and subsequent plan years, subject to the requirements 

18 of paragraph (3), an MA plan may provide addi19 tional telehealth benefits (as defined in paragraph 

20 (2)) to individuals enrolled under this part. 

21 ‘‘(2) ADDITIONAL TELEHEALTH BENEFITS DE22 FINED.— 

23 ‘‘(A) IN GENERAL.—For purposes of this 

24 subsection and section 1854: 


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1 ‘‘(i) DEFINITION.—The term ‘addi2 tional telehealth benefits’ means services— 

3 ‘‘(I) for which benefits are avail4 able under part B, including services 

5 for which payment is not made under 

6 section 1834(m) due to the conditions 

7 for payment under such section; and 

8 ‘‘(II) that are identified as clini9 cally appropriate to furnish using elec10 tronic information and telecommuni11 cations technology when a physician 

12 (as defined in section 1861(r)) or prac13 titioner (described in section 

14 1842(b)(18)(C)) providing the service 

15 is not at the same location as the plan 

16 enrollee. 

17 ‘‘(ii) EXCLUSION OF CAPITAL AND IN18 FRASTRUCTURE COSTS AND INVEST19 MENTS.—The term ‘additional telehealth 

20 benefits’ does not include capital and infra21 structure costs and investments relating to 

22 such benefits. 

23 ‘‘(B) PUBLIC COMMENT.—Not later than 

24 November 30, 2018, the Secretary shall solicit 

25 comments on— 


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1 ‘‘(i) what types of items and services 

2 (including those provided through supple3 mental health care benefits) should be con4 sidered to be additional telehealth benefits; 

5 and 

6 ‘‘(ii) the requirements for the provision 

7 or furnishing of such benefits (such as licen8 sure, training, and coordination require9 ments). 

10 ‘‘(3) REQUIREMENTS FOR ADDITIONAL TELE11 HEALTH BENEFITS.—The Secretary shall specify re12 quirements for the provision or furnishing of addi13 tional telehealth benefits, including with respect to the 

14 following: 

15 ‘‘(A) Physician or practitioner licensure 

16 and other requirements such as specific training. 

17 ‘‘(B) Factors necessary to ensure the coordi18 nation of such benefits with items and services 

19 furnished in-person. 

20 ‘‘(C) Such other areas as determined by the 

21 Secretary. 

22 ‘‘(4) ENROLLEE CHOICE.—If an MA plan pro23 vides a service as an additional telehealth benefit (as 

24 defined in paragraph (2))— 


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1 ‘‘(A) the MA plan shall also provide access 

2 to such benefit through an in-person visit (and 

3 not only as an additional telehealth benefit); and 

4 ‘‘(B) an individual enrollee shall have dis5 cretion as to whether to receive such service 

6 through the in-person visit or as an additional 

7 telehealth benefit. 

8 ‘‘(5) TREATMENT UNDER MA.—For purposes of 

9 this subsection and section 1854, additional telehealth 

10 benefits shall be treated as if they were benefits under 

11 the original Medicare fee-for-service program option. 

12 ‘‘(6) CONSTRUCTION.—Nothing in this subsection 

13 shall be construed as affecting the requirement under 

14 subsection (a)(1) that MA plans provide enrollees 

15 with items and services (other than hospice care) for 

16 which benefits are available under parts A and B, in17 cluding benefits available under section 1834(m).’’. 

18 (b) CLARIFICATION REGARDING INCLUSION IN BID

19 AMOUNT.—Section 1854(a)(6)(A)(ii)(I) of the Social Secu20 rity Act (42 U.S.C. 1395w–24(a)(6)(A)(ii)(I)) is amended 

21 by inserting ‘‘, including, for plan year 2020 and subse22 quent plan years, the provision of additional telehealth ben23 efits as described in section 1852(m)’’ before the semicolon 

24 at the end. 


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1 SEC. 304. PROVIDING ACCOUNTABLE CARE ORGANIZATIONS 

2 THE ABILITY TO EXPAND THE USE OF TELE3 HEALTH. 

4 (a) IN GENERAL.—Section 1899 of the Social Security 

5 Act (42 U.S.C. 1395jjj) is amended by adding at the end 

6 the following new subsection: 

7 ‘‘(l) PROVIDING ACOS THE ABILITY TO EXPAND THE

8 USE OF TELEHEALTH SERVICES.— 

9 ‘‘(1) IN GENERAL.—In the case of telehealth serv10 ices for which payment would otherwise be made 

11 under this title furnished on or after January 1, 

12 2020, for purposes of this subsection only, the fol13 lowing shall apply with respect to such services fur14 nished by a physician or practitioner participating 

15 in an applicable ACO (as defined in paragraph (2)) 

16 to a Medicare fee-for-service beneficiary assigned to 

17 the applicable ACO: 

18 ‘‘(A) INCLUSION OF HOME AS ORIGINATING

19 SITE.—Subject to paragraph (3), the home of a 

20 beneficiary shall be treated as an originating site 

21 described in section 1834(m)(4)(C)(ii). 

22 ‘‘(B) NO APPLICATION OF GEOGRAPHIC LIM23 ITATION.—The geographic limitation under sec24 tion 1834(m)(4)(C)(i) shall not apply with re25 spect to an originating site described in section 

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1 ficiary under subparagraph (A)), subject to State 

2 licensing requirements. 

3 ‘‘(2) DEFINITIONS.—In this subsection: 

4 ‘‘(A) APPLICABLE ACO.—The term ‘applica5 ble ACO’ means an ACO participating in a 

6 model tested or expanded under section 1115A or 

7 under this section— 

8 ‘‘(i) that operates under a two-sided 

9 model— 

10 ‘‘(I) described in section 

11 425.600(a) of title 42, Code of Federal 

12 Regulations; or 

13 ‘‘(II) tested or expanded under 

14 section 1115A; and 

15 ‘‘(ii) for which Medicare fee-for-service 

16 beneficiaries are assigned to the ACO using 

17 a prospective assignment method, as deter18 mined appropriate by the Secretary. 

19 ‘‘(B) HOME.—The term ‘home’ means, with 

20 respect to a Medicare fee-for-service beneficiary, 

21 the place of residence used as the home of the 

22 beneficiary. 

23 ‘‘(3) TELEHEALTH SERVICES RECEIVED IN THE

24 HOME.—In the case of telehealth services described in 

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1 service beneficiary is the originating site, the fol2 lowing shall apply: 

3 ‘‘(A) NO FACILITY FEE.—There shall be no 

4 facility fee paid to the originating site under sec5 tion 1834(m)(2)(B). 

6 ‘‘(B) EXCLUSION OF CERTAIN SERVICES.— 

7 No payment may be made for such services that 

8 are inappropriate to furnish in the home setting 

9 such as services that are typically furnished in 

10 inpatient settings such as a hospital.’’. 

11 (b) STUDY AND REPORT.— 

12 (1) STUDY.— 

13 (A) IN GENERAL.—The Secretary of Health 

14 and Human Services (in this subsection referred 

15 to as the ‘‘Secretary’’) shall conduct a study on 

16 the implementation of section 1899(l) of the So17 cial Security Act, as added by subsection (a). 

18 Such study shall include an analysis of the utili19 zation of, and expenditures for, telehealth serv20 ices under such section. 

21 (B) COLLECTION OF DATA.—The Secretary 

22 may collect such data as the Secretary deter23 mines necessary to carry out the study under 

24 this paragraph. 


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1 (2) REPORT.—Not later than January 1, 2026, 

2 the Secretary shall submit to Congress a report con3 taining the results of the study conducted under para4 graph (1), together with recommendations for such 

5 legislation and administrative action as the Secretary 

6 determines appropriate. 

7 SEC. 305. EXPANDING THE USE OF TELEHEALTH FOR INDI8 VIDUALS WITH STROKE. 

9 Section 1834(m) of the Social Security Act (42 U.S.C. 

10 1395m(m)), as amended by section 102(b)(2), is amended 

11 by adding at the end the following new paragraph: 

12 ‘‘(6) TREATMENT OF STROKE TELEHEALTH

13 SERVICES.— 

14 ‘‘(A) NON-APPLICATION OF ORIGINATING

15 SITE REQUIREMENTS.—The requirements de16 scribed in paragraph (4)(C) shall not apply with 

17 respect to telehealth services furnished on or after 

18 January 1, 2021, for purposes of evaluation of 

19 an acute stroke, as determined by the Secretary. 

20 ‘‘(B) NO ORIGINATING SITE FACILITY

21 FEE.—In the case of an originating site that 

22 does not meet the requirements described in 

23 paragraph (4)(C), he Secretary shall not pay an 

24 originating site facility fee (as described in 


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1 paragraph (2)(B)) to the originating site with 

2 respect to such telehealth services.’’. 

3 TITLE IV—IDENTIFYING THE 

4 CHRONICALLY ILL POPULATION 

5 SEC. 401. PROVIDING FLEXIBILITY FOR BENEFICIARIES TO 

6 BE PART OF AN ACCOUNTABLE CARE ORGANI7 ZATION. 

8 Section 1899(c) of the Social Security Act (42 U.S.C. 

9 1395jjj(c)) is amended— 

10 (1) by redesignating paragraphs (1) and (2) as 

11 subparagraphs (A) and (B), respectively, and indent12 ing appropriately; 

13 (2) by striking ‘‘ACOS.—The Secretary’’ and in14 serting ‘‘ACOS.— 

15 ‘‘(1) IN GENERAL.—Subject to paragraph (2), the 

16 Secretary’’; and 

17 (3) by adding at the end the following new para18 graph: 

19 ‘‘(2) PROVIDING FLEXIBILITY.— 

20 ‘‘(A) CHOICE OF PROSPECTIVE ASSIGN21 MENT.—For each agreement period (effective for 

22 agreements entered into or renewed on or after 

23 January 1, 2020), in the case where an ACO es24 tablished under the program is in a Track that 

25 provides for the retrospective assignment of 


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1 Medicare fee-for-service beneficiaries to the ACO, 

2 the Secretary shall permit the ACO to choose to 

3 have Medicare fee-for-service beneficiaries as4 signed prospectively, rather than retrospectively, 

5 to the ACO for an agreement period. 

6 ‘‘(B) ASSIGNMENT BASED ON VOLUNTARY

7 IDENTIFICATION BY MEDICARE FEE-FOR-SERVICE

8 BENEFICIARIES.— 

9 ‘‘(i) IN GENERAL.—For performance 

10 year 2018 and each subsequent performance 

11 year, if a system is available for electronic 

12 designation, the Secretary shall permit a 

13 Medicare fee-for-service beneficiary to volun14 tarily identify an ACO professional as the 

15 primary care provider of the beneficiary for 

16 purposes of assigning such beneficiary to an 

17 ACO, as determined by the Secretary. 

18 ‘‘(ii) NOTIFICATION PROCESS.—The 

19 Secretary shall establish a process under 

20 which a Medicare fee-for-service beneficiary 

21 is— 

22 ‘‘(I) notified of their ability to 

23 make an identification described in 

24 clause (i); and 


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1 ‘‘(II) informed of the process by 

2 which they may make and change such 

3 identification. 

4 ‘‘(iii) SUPERSEDING CLAIMS-BASED AS5 SIGNMENT.—A voluntary identification by 

6 a Medicare fee-for-service beneficiary under 

7 this subparagraph shall supersede any 

8 claims-based assignment otherwise deter9 mined by the Secretary.’’. 

10 TITLE V—EMPOWERING INDIVID11 UALS AND CAREGIVERS IN 

12 CARE DELIVERY 

13 SEC. 501. ELIMINATING BARRIERS TO CARE COORDINATION 

14 UNDER ACCOUNTABLE CARE ORGANIZA15 TIONS. 

16 (a) IN GENERAL.—Section 1899 of the Social Security 

17 Act (42 U.S.C. 1395jjj), as amended by section 304(a), is 

18 amended— 

19 (1) in subsection (b)(2), by adding at the end the 

20 following new subparagraph: 

21 ‘‘(I) An ACO that seeks to operate an ACO 

22 Beneficiary Incentive Program pursuant to sub23 section (m) shall apply to the Secretary at such 

24 time, in such manner, and with such informa25 tion as the Secretary may require.’’; 


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1 (2) by adding at the end the following new sub2 section: 

3 ‘‘(m) AUTHORITY TO PROVIDE INCENTIVE PAYMENTS

4 TO BENEFICIARIES WITH RESPECT TO QUALIFYING PRI5 MARY CARE SERVICES.— 

6 ‘‘(1) PROGRAM.— 

7 ‘‘(A) IN GENERAL.—In order to encourage 

8 Medicare fee-for-service beneficiaries to obtain 

9 medically necessary primary care services, an 

10 ACO participating under this section under a 

11 payment model described in clause (i) or (ii) of 

12 paragraph (2)(B) may apply to establish an 

13 ACO Beneficiary Incentive Program to provide 

14 incentive payments to such beneficiaries who are 

15 furnished qualifying services in accordance with 

16 this subsection. The Secretary shall permit such 

17 an ACO to establish such a program at the Sec18 retary’s discretion and subject to such require19 ments, including program integrity require20 ments, as the Secretary determines necessary. 

21 ‘‘(B) IMPLEMENTATION.—The Secretary 

22 shall implement this subsection on a date deter23 mined appropriate by the Secretary. Such date 

24 shall be no earlier than January 1, 2019, and no 

25 later than January 1, 2020. 


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1 ‘‘(2) CONDUCT OF PROGRAM.— 

2 ‘‘(A) DURATION.—Subject to subparagraph 

3 (H), an ACO Beneficiary Incentive Program es4 tablished under this subsection shall be conducted 

5 for such period (of not less than 1 year) as the 

6 Secretary may approve. 

7 ‘‘(B) SCOPE.—An ACO Beneficiary Incen8 tive Program established under this subsection 

9 shall provide incentive payments to all of the fol10 lowing Medicare fee-for-service beneficiaries who 

11 are furnished qualifying services by the ACO: 

12 ‘‘(i) With respect to the Track 2 and 

13 Track 3 payment models described in sec14 tion 425.600(a) of title 42, Code of Federal 

15 Regulations (or in any successor regula16 tion), Medicare fee-for-service beneficiaries 

17 who are preliminarily prospectively or pro18 spectively assigned (or otherwise assigned, 

19 as determined by the Secretary) to the ACO. 

20 ‘‘(ii) With respect to any future pay21 ment models involving two-sided risk, Medi22 care fee-for-service beneficiaries who are as23 signed to the ACO, as determined by the 

24 Secretary. 


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1 ‘‘(C) QUALIFYING SERVICE.—For purposes 

2 of this subsection, a qualifying service is a pri3 mary care service, as defined in section 425.20 

4 of title 42, Code of Federal Regulations (or in 

5 any successor regulation), with respect to which 

6 coinsurance applies under part B, furnished 

7 through an ACO by— 

8 ‘‘(i) an ACO professional described in 

9 subsection (h)(1)(A) who has a primary 

10 care specialty designation included in the 

11 definition of primary care physician under 

12 section 425.20 of title 42, Code of Federal 

13 Regulations (or any successor regulation); 

14 ‘‘(ii) an ACO professional described in 

15 subsection (h)(1)(B); or 

16 ‘‘(iii) a Federally qualified health cen17 ter or rural health clinic (as such terms are 

18 defined in section 1861(aa)). 

19 ‘‘(D) INCENTIVE PAYMENTS.—An incentive 

20 payment made by an ACO pursuant to an ACO 

21 Beneficiary Incentive Program established under 

22 this subsection shall be— 

23 ‘‘(i) in an amount up to $20, with 

24 such maximum amount updated annually 

25 by the percentage increase in the consumer 


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1 price index for all urban consumers (United 

2 States city average) for the 12-month period 

3 ending with June of the previous year; 

4 ‘‘(ii) in the same amount for each 

5 Medicare fee-for-service beneficiary described 

6 in clause (i) or (ii) of subparagraph (B) 

7 without regard to enrollment of such a bene8 ficiary in a medicare supplemental policy 

9 (described in section 1882(g)(1)), in a State 

10 Medicaid plan under title XIX or a waiver 

11 of such a plan, or in any other health in12 surance policy or health benefit plan; 

13 ‘‘(iii) made for each qualifying service 

14 furnished to such a beneficiary described in 

15 clause (i) or (ii) of subparagraph (B) dur16 ing a period specified by the Secretary; and 

17 ‘‘(iv) made no later than 30 days after 

18 a qualifying service is furnished to such a 

19 beneficiary described in clause (i) or (ii) of 

20 subparagraph (B). 

21 ‘‘(E) NO SEPARATE PAYMENTS FROM THE

22 SECRETARY.—The Secretary shall not make any 

23 separate payment to an ACO for the costs, in24 cluding incentive payments, of carrying out an 

25 ACO Beneficiary Incentive Program established 


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1 under this subsection. Nothing in this subpara2 graph shall be construed as prohibiting an ACO 

3 from using shared savings received under this 

4 section to carry out an ACO Beneficiary Incen5 tive Program. 

6 ‘‘(F) NO APPLICATION TO SHARED SAVINGS

7 CALCULATION.—Incentive payments made by an 

8 ACO under this subsection shall be disregarded 

9 for purposes of calculating benchmarks, esti10 mated average per capita Medicare expenditures, 

11 and shared savings under this section. 

12 ‘‘(G) REPORTING REQUIREMENTS.—An 

13 ACO conducting an ACO Beneficiary Incentive 

14 Program under this subsection shall, at such 

15 times and in such format as the Secretary may 

16 require, report to the Secretary such information 

17 and retain such documentation as the Secretary 

18 may require, including the amount and fre19 quency of incentive payments made and the 

20 number of Medicare fee-for-service beneficiaries 

21 receiving such payments. 

22 ‘‘(H) TERMINATION.—The Secretary may 

23 terminate an ACO Beneficiary Incentive Pro24 gram established under this subsection at any 


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1 time for reasons determined appropriate by the 

2 Secretary. 

3 ‘‘(3) EXCLUSION OF INCENTIVE PAYMENTS.—Any 

4 payment made under an ACO Beneficiary Incentive 

5 Program established under this subsection shall not be 

6 considered income or resources or otherwise taken into 

7 account for purposes of— 

8 ‘‘(A) determining eligibility for benefits or 

9 assistance (or the amount or extent of benefits or 

10 assistance) under any Federal program or under 

11 any State or local program financed in whole or 

12 in part with Federal funds; or 

13 ‘‘(B) any Federal or State laws relating to 

14 taxation.’’; 

15 (3) in subsection (e), by inserting ‘‘, including 

16 an ACO Beneficiary Incentive Program under sub17 sections (b)(2)(I) and (m)’’ after ‘‘the program’’; and 

18 (4) in subsection (g)(6), by inserting ‘‘or of an 

19 ACO Beneficiary Incentive Program under sub20 sections (b)(2)(I) and (m)’’ after ‘‘under subsection 

21 (d)(4)’’. 

22 (b) AMENDMENT TO SECTION 1128B.—Section 

23 1128B(b)(3) of the Social Security Act (42 U.S.C. 1320a– 

24 7b(b)(3)) is amended— 


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1 (1) by striking ‘‘and’’ at the end of subpara2 graph (I); 

3 (2) by striking the period at the end of subpara4 graph (J) and inserting ‘‘; and’’; and 

5 (3) by adding at the end the following new sub6 paragraph: 

7 ‘‘(K) an incentive payment made to a Medi8 care fee-for-service beneficiary by an ACO under 

9 an ACO Beneficiary Incentive Program estab10 lished under subsection (m) of section 1899, if 

11 the payment is made in accordance with the re12 quirements of such subsection and meets such 

13 other conditions as the Secretary may estab14 lish.’’. 

15 (c) EVALUATION AND REPORT.— 

16 (1) EVALUATION.—The Secretary of Health and 

17 Human Services (in this subsection referred to as the 

18 ‘‘Secretary’’) shall conduct an evaluation of the ACO 

19 Beneficiary Incentive Program established under sub20 sections (b)(2)(I) and (m) of section 1899 of the So21 cial Security Act (42 U.S.C. 1395jjj), as added by 

22 subsection (a). The evaluation shall include an anal23 ysis of the impact of the implementation of the Pro24 gram on expenditures and beneficiary health outcomes 


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1 under title XVIII of the Social Security Act (42 

2 U.S.C. 1395 et seq.). 

3 (2) REPORT.—Not later than October 1, 2023, 

4 the Secretary shall submit to Congress a report con5 taining the results of the evaluation under paragraph 

6 (1), together with recommendations for such legisla7 tion and administrative action as the Secretary deter8 mines appropriate. 

9 SEC. 502. GAO STUDY AND REPORT ON LONGITUDINAL 

10 COMPREHENSIVE CARE PLANNING SERVICES 

11 UNDER MEDICARE PART B. 

12 (a) STUDY.—The Comptroller General shall conduct a 

13 study on the establishment under part B of the Medicare 

14 program under title XVIII of the Social Security Act of 

15 a payment code for a visit for longitudinal comprehensive 

16 care planning services. Such study shall include an anal17 ysis of the following to the extent such information is avail18 able: 

19 (1) The frequency with which services similar to 

20 longitudinal comprehensive care planning services are 

21 furnished to Medicare beneficiaries, which providers 

22 of services and suppliers are furnishing those services, 

23 whether Medicare reimbursement is being received for 

24 those services, and, if so, through which codes those 

25 services are being reimbursed. 


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1 (2) Whether, and the extent to which, longitu2 dinal comprehensive care planning services would 

3 overlap, and could therefore result in duplicative pay4 ment, with services covered under the hospice benefit 

5 as well as the chronic care management code, evalua6 tion and management codes, or other codes that al7 ready exist under part B of the Medicare program. 

8 (3) Any barriers to hospitals, skilled nursing fa9 cilities, hospice programs, home health agencies, and 

10 other applicable providers working with a Medicare 

11 beneficiary to engage in the care planning process 

12 and complete the necessary documentation to support 

13 the treatment and care plan of the beneficiary and 

14 provide such documentation to other providers and 

15 the beneficiary or the beneficiary’s representative. 

16 (4) Any barriers to providers, other than the pro17 vider furnishing longitudinal comprehensive care 

18 planning services, accessing the care plan and associ19 ated documentation for use related to the care of the 

20 Medicare beneficiary. 

21 (5) Potential options for ensuring that applica22 ble providers are notified of a patient’s existing longi23 tudinal care plan and that applicable providers con24 sider that plan in making their treatment decisions, 


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1 and what the challenges might be in implementing 

2 such options. 

3 (6) Stakeholder’s views on the need for the devel4 opment of quality metrics with respect to longitudinal 

5 comprehensive care planning services, such as meas6 ures related to— 

7 (A) the process of eliciting input from the 

8 Medicare beneficiary or from a legally author9 ized representative and documenting in the med10 ical record the patient-directed care plan; 

11 (B) the effectiveness and patient12 centeredness of the care plan in organizing deliv13 ery of services consistent with the plan; 

14 (C) the availability of the care plan and as15 sociated documentation to other providers that 

16 care for the beneficiary; and 

17 (D) the extent to which the beneficiary re18 ceived services and support that is free from dis19 crimination based on advanced age, disability 

20 status, or advanced illness. 

21 (7) Stakeholder’s views on how such quality 

22 metrics would provide information on— 

23 (A) the goals, values, and preferences of the 

24 beneficiary; 

25 (B) the documentation of the care plan; 


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1 (C) services furnished to the beneficiary; 

2 and 

3 (D) outcomes of treatment. 

4 (8) Stakeholder’s views on— 

5 (A) the type of training and education 

6 needed for applicable providers, individuals, and 

7 caregivers in order to facilitate longitudinal 

8 comprehensive care planning services; 

9 (B) the types of providers of services and 

10 suppliers that should be included in the inter11 disciplinary team of an applicable provider; and 

12 (C) the characteristics of Medicare bene13 ficiaries that would be most appropriate to re14 ceive longitudinal comprehensive care planning 

15 services, such as individuals with advanced dis16 ease and individuals who need assistance with 

17 multiple activities of daily living. 

18 (9) Stakeholder’s views on the frequency with 

19 which longitudinal comprehensive care planning serv20 ices should be furnished. 

21 (b) REPORT.—Not later than 18 months after the date 

22 of the enactment of this Act, the Comptroller General shall 

23 submit to Congress a report containing the results of the 

24 study conducted under subsection (a), together with recVerDate Sep 11 2014 00:55 Aug 04, 2017 Jkt 069200 PO 00000 Frm 00107 Fmt 6652 Sfmt 6203 E:\BILLS\S870.RS S870

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1 ommendations for such legislation and administrative ac2 tion as the Comptroller General determines appropriate. 

3 (c) DEFINITIONS.—In this section: 

4 (1) APPLICABLE PROVIDER.—The term ‘‘applica5 ble provider’’ means a hospice program (as defined in 

6 subsection (dd)(2) of section 1861 of the Social Secu7 rity Act (42 U.S.C. 1395ww)) or other provider of 

8 services (as defined in subsection (u) of such section) 

9 or supplier (as defined in subsection (d) of such sec10 tion) that— 

11 (A) furnishes longitudinal comprehensive 

12 care planning services through an interdiscipli13 nary team; and 

14 (B) meets such other requirements as the 

15 Secretary may determine to be appropriate. 

16 (2) COMPTROLLER GENERAL.—The term ‘‘Comp17 troller General’’ means the Comptroller General of the 

18 United States. 

19 (3) INTERDISCIPLINARY TEAM.—The term 

20 ‘‘interdisciplinary team’’ means a group that— 

21 (A) includes the personnel described in sub22 section (dd)(2)(B)(i) of such section 1861; 

23 (B) may include a chaplain, minister, or 

24 other clergy; and 

25 (C) may include other direct care personnel. 


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1 (4) LONGITUDINAL COMPREHENSIVE CARE PLAN2 NING SERVICES.—The term ‘‘longitudinal comprehen3 sive care planning services’’ means a voluntary 

4 shared decisionmaking process that is furnished by an 

5 applicable provider through an interdisciplinary 

6 team and includes a conversation with Medicare bene7 ficiaries who have received a diagnosis of a serious or 

8 life-threatening illness. The purpose of such services is 

9 to discuss a longitudinal care plan that addresses the 

10 progression of the disease, treatment options, the 

11 goals, values, and preferences of the beneficiary, and 

12 the availability of other resources and social supports 

13 that may reduce the beneficiary’s health risks and 

14 promote self-management and shared decisionmaking. 

15 (5) SECRETARY.—The term ‘‘Secretary’’ means 

16 the Secretary of Health and Human Services. 


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1 TITLE VI—OTHER POLICIES TO 

2 IMPROVE CARE FOR THE 

3 CHRONICALLY ILL 

4 SEC. 601. PROVIDING PRESCRIPTION DRUG PLANS WITH 

5 PARTS A AND B CLAIMS DATA TO PROMOTE 

6 THE APPROPRIATE USE OF MEDICATIONS 

7 AND IMPROVE HEALTH OUTCOMES. 

8 Section 1860D–4(c) of the Social Security Act (42 

9 U.S.C. 1395w–104(c)) is amended by adding at the end the 

10 following new paragraph: 

11 ‘‘(6) PROVIDING PRESCRIPTION DRUG PLANS

12 WITH PARTS A AND B CLAIMS DATA TO PROMOTE THE

13 APPROPRIATE USE OF MEDICATIONS AND IMPROVE

14 HEALTH OUTCOMES.— 

15 ‘‘(A) PROCESS.—Subject to subparagraph 

16 (B), the Secretary shall establish a process under 

17 which a PDP sponsor of a prescription drug 

18 plan may submit a request for the Secretary to 

19 provide the sponsor, on a periodic basis and in 

20 an electronic format, beginning in plan year 

21 2020, data described in subparagraph (D) with 

22 respect to enrollees in such plan. Such data shall 

23 be provided without regard to whether such en24 rollees are described in clause (ii) of paragraph 

25 (2)(A). 


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1 ‘‘(B) PURPOSES.—A PDP sponsor may use 

2 the data provided to the sponsor pursuant to 

3 subparagraph (A) for any of the following pur4 poses: 

5 ‘‘(i) To optimize therapeutic outcomes 

6 through improved medication use, as such 

7 phrase is used in clause (i) of paragraph 

8 (2)(A). 

9 ‘‘(ii) To improving care coordination 

10 so as to prevent adverse health outcomes, 

11 such as preventable emergency department 

12 visits and hospital readmissions. 

13 ‘‘(iii) For any other purpose deter14 mined appropriate by the Secretary. 

15 ‘‘(C) LIMITATIONS ON DATA USE.—A PDP 

16 sponsor shall not use data provided to the spon17 sor pursuant to subparagraph (A) for any of the 

18 following purposes: 

19 ‘‘(i) To inform coverage determinations 

20 under this part. 

21 ‘‘(ii) To conduct retroactive reviews of 

22 medically accepted indications determina23 tions. 

24 ‘‘(iii) To facilitate enrollment changes 

25 to a different prescription drug plan or an 


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1 MA-PD plan offered by the same parent or2 ganization. 

3 ‘‘(iv) To inform marketing of benefits. 

4 ‘‘(v) For any other purpose that the 

5 Secretary determines is necessary to include 

6 in order to protect the identity of individ7 uals entitled to, or enrolled for, benefits 

8 under this title and to protect the security 

9 of personal health information 

10 ‘‘(D) DATA DESCRIBED.—The data de11 scribed in this clause are standardized extracts 

12 (as determined by the Secretary) of claims data 

13 under parts A and B for items and services fur14 nished under such parts for time periods speci15 fied by the Secretary. Such data shall include 

16 data as current as practicable.’’. 

17 SEC. 602. GAO STUDY AND REPORT ON IMPROVING MEDICA18 TION SYNCHRONIZATION. 

19 (a) STUDY.—The Comptroller General of the United 

20 States (in this section referred to as the ‘‘Comptroller Gen21 eral’’) shall conduct a study on the extent to which Medicare 

22 prescription drug plans (MA–PD plans and standalone 

23 prescription drug plans) under part D of title XVIII of the 

24 Social Security Act and private payors use programs that 

25 synchronize pharmacy dispensing so that individuals may 


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1 receive multiple prescriptions on the same day to facilitate 

2 comprehensive counseling and promote medication adher3 ence. The study shall include a analysis of the following: 

4 (1) The extent to which pharmacies have adopted 

5 such programs. 

6 (2) The common characteristics of such pro7 grams, including how pharmacies structure coun8 seling sessions under such programs and the types of 

9 payment and other arrangements that Medicare pre10 scription drug plans and private payors employ 

11 under such programs to support the efforts of phar12 macies. 

13 (3) How such programs compare for Medicare 

14 prescription drug plans and private payors. 

15 (4) What is known about how such programs af16 fect patient medication adherence and overall patient 

17 health outcomes, including if adherence and outcomes 

18 vary by patient subpopulations, such as disease state 

19 and socioeconomic status. 

20 (5) What is known about overall patient satisfac21 tion with such programs and satisfaction with such 

22 programs, including within patient subpopulations, 

23 such as disease state and socioeconomic status. 

24 (6) The extent to which laws and regulations of 

25 the Medicare program support such programs. 


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1 (7) Barriers to the use of medication synchroni2 zation programs by Medicare prescription drug plans. 

3 (b) REPORT.—Not later than 18 months after the date 

4 of the enactment of this Act, the Comptroller General shall 

5 submit to Congress a report containing the results of the 

6 study under subsection (a), together with recommendations 

7 for such legislation and administrative action as the Comp8 troller General determines appropriate. 

9 SEC. 603. GAO STUDY AND REPORT ON IMPACT OF OBESITY 

10 DRUGS ON PATIENT HEALTH AND SPENDING. 

11 (a) STUDY.—The Comptroller General of the United 

12 States (in this section referred to as the ‘‘Comptroller Gen13 eral’’) shall, to the extent data are available, conduct a 

14 study on the use of prescription drugs to manage the weight 

15 of obese patients and the impact of coverage of such drugs 

16 on patient health and on health care spending. Such study 

17 shall examine the use and impact of these obesity drugs in 

18 the non-Medicare population and for Medicare beneficiaries 

19 who have such drugs covered through an MA–PD plan (as 

20 defined in section 1860D–1(a)(3)(C) of the Social Security 

21 Act (42 U.S.C. 1395w–101(a)(3)(C))) as a supplemental 

22 health care benefit. The study shall include an analysis of 

23 the following: 

24 (1) The prevalence of obesity in the Medicare 

25 and non-Medicare population. 


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1 (2) The utilization of obesity drugs. 

2 (3) The distribution of Body Mass Index by in3 dividuals taking obesity drugs, to the extent prac4 ticable. 

5 (4) What is known about the use of obesity drugs 

6 in conjunction with the receipt of other items or serv7 ices, such as behavioral counseling, and how these 

8 compare to items and services received by obese indi9 viduals who do not take obesity drugs. 

10 (5) Physician considerations and attitudes re11 lated to prescribing obesity drugs. 

12 (6) The extent to which coverage policies cease or 

13 limit coverage for individuals who fail to receive clin14 ical benefit. 

15 (7) What is known about the extent to which in16 dividuals who take obesity drugs adhere to the pre17 scribed regimen. 

18 (8) What is known about the extent to which in19 dividuals who take obesity drugs maintain weight loss 

20 over time. 

21 (9) What is known about the subsequent impact 

22 such drugs have on medical services that are directly 

23 related to obesity, including with respect to sub24 populations determined based on the extent of obesity. 


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1 (10) What is known about the spending associ2 ated with the care of individuals who take obesity 

3 drugs, compared to the spending associated with the 

4 care of individuals who do not take such drugs. 

5 (b) REPORT.—Not later than 18 months after the date 

6 of the enactment of this Act, the Comptroller General shall 

7 submit to Congress a report containing the results of the 

8 study under subsection (a), together with recommendations 

9 for such legislation and administrative action as the Comp10 troller General determines appropriate. 

11 SEC. 604. HHS STUDY AND REPORT ON LONG-TERM RISK 

12 FACTORS FOR CHRONIC CONDITIONS AMONG 

13 MEDICARE BENEFICIARIES. 

14 (a) STUDY.—The Secretary of Health and Human 

15 Services (in this section referred to as the ‘‘Secretary’’) shall 

16 conduct a study on long-term cost drivers to the Medicare 

17 program, including obesity, tobacco use, mental health con18 ditions, and other factors that may contribute to the deterio19 ration of health conditions among individuals with chronic 

20 conditions in the Medicare population. The study shall in21 clude an analysis of any barriers to collecting and ana22 lyzing such information and how to remove any such bar23 riers (including through legislation and administrative ac24 tions). 


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1 (b) REPORT.—Not later than 18 months after the date 

2 of the enactment of this Act, the Secretary shall submit to 

3 Congress a report containing the results of the study under 

4 subsection (a), together with recommendations for such leg5 islation and administrative action as the Secretary deter6 mines appropriate. The Secretary shall also post such re7 port on the Internet website of the Department of Health 

8 and Human Services. 

9 TITLE VII—OFFSETS 

10 SEC. 701. MEDICARE IMPROVEMENT FUND. 

11 Section 1898(b)(1) of the Social Security Act (42 

12 U.S.C. 1395iii(b)(1)) is amended by striking 

13 ‘‘$270,000,000’’ and inserting ‘‘$0’’. 

14 SEC. 702. MEDICAID IMPROVEMENT FUND. 

15 Section 1941(b)(1) of the Social Security Act (42 

16 U.S.C. 1396w–1(b)(1)) is amended by striking 

17 ‘‘$5,000,000’’ and inserting ‘‘$0’’. 


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Calendar No. 206 

115TH CONGRESS 

1ST SESSION S. 870 

[Report No. 115–146] 

A BILL 

To amend title XVIII of the Social Security Act to 

comes without adding to the deficit. line care coordination, and improve quality outimprove management of chronic disease, streamimplement Medicare payment policies designed to 

AUGUST 3, 2017 

Reported with an amendment 


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