I 

113TH CONGRESS 

1ST SESSION H. R. 2376 

To implement a demonstration project under titles XVIII and XIX of the 

Social Security Act to examine the costs and benefits of providing payments for comprehensive coordinated health care services provided by 

purpose-built, continuing care retirement communities to Medicare beneficiaries. 

IN THE HOUSE OF REPRESENTATIVES 

JUNE 14, 2013 

Mr. FITZPATRICK introduced the following bill; which was referred to the 

Committee on Energy and Commerce, and in addition to the Committee 

on Ways and Means, for a period to be subsequently determined by the 

Speaker, in each case for consideration of such provisions as fall within 

the jurisdiction of the committee concerned 

A BILL 

To implement a demonstration project under titles XVIII 

and XIX of the Social Security Act to examine the 

costs and benefits of providing payments for comprehensive coordinated health care services provided by purposebuilt, continuing care retirement communities to Medicare beneficiaries. 

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


tjames on DSK6SPTVN1PROD with BILLS
2 

•HR 2376 IH

1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Medicare Residential 

3 Care Coordination Act of 2013’’. 

4 SEC. 2. MEDICARE AND MEDICAID RESIDENTIAL CARE CO5 ORDINATION DEMONSTRATION PROJECT. 

6 (a) ESTABLISHMENT AND IMPLEMENTATION.— 

7 (1) IN GENERAL.—The Secretary of Health and 

8 Human Services (in this section referred to as the 

9 ‘‘Secretary’’) shall establish and implement a dem10 onstration project (in this section referred to as the 

11 ‘‘demonstration project’’) under titles XVIII and 

12 XIX of the Social Security Act to evaluate the use 

13 of capitated payments made to eligible continuing 

14 care retirement communities for residential care co15 ordination programs. 

16 (2) TIMETABLE FOR IMPLEMENTATION.—In 

17 carrying out this section— 

18 (A) not later than 1 year after the date of 

19 the enactment of this Act the Secretary shall 

20 complete the design for the demonstration 

21 project and enter into one or more agreements 

22 with eligible CCRCs for the implementation of 

23 the project with respect to such CCRCs; and 

24 (B) not later than 4 years after the date 

25 of entering into such agreements, first provide 


tjames on DSK6SPTVN1PROD with BILLS
3 

•HR 2376 IH

1 for implementation of the project through such 

2 CCRCs. 

3 (b) BUDGET NEUTRALITY.—With respect to the pe4 riod of the demonstration project under this section, the 

5 aggregate expenditures under titles XVIII and XIX of the 

6 Social Security Act for such period shall not exceed the 

7 aggregate expenditures that would have been expended 

8 under such titles if the demonstration project had not been 

9 implemented. 

10 (c) STATE ELECTION REQUIRED.— 

11 (1) IN GENERAL.—The Secretary may only im12 plement the demonstration project in a State that 

13 elects to participate in the demonstration project. 

14 (2) BENEFITS AND PAYMENTS.—A State that 

15 elects to participate in the demonstration project 

16 shall provide medical assistance through title XIX of 

17 the Social Security Act for each eligible CCRC resi18 dent who is eligible for medical assistance under the 

19 State plan under such title (including such residents 

20 who are made eligible under subsection 

21 (d)(3)(B)(iii)) and who is enrolled in a residential 

22 care coordination program in a manner that is con23 sistent with the requirements of this section, includ24 ing making the payments under subsection (e). 


tjames on DSK6SPTVN1PROD with BILLS
4 

•HR 2376 IH

1 (3) LIMITATION.—A State may establish a nu2 merical limit on— 

3 (A) the number of eligible CCRC residents 

4 who may be enrolled in residential care coordi5 nation programs in the State; and 

6 (B) the number of eligible CCRCs that 

7 may operate residential care coordination pro8 grams in the State. 

9 (d) RESIDENTIAL CARE COORDINATION PROGRAM

10 (RCCP); ELIGIBLE CONTINUE CARE RETIREMENT COM11 MUNITY (CCRC); ELIGIBLE CCRC RESIDENTS; COM12 PREHENSIVE COORDINATED HEALTH CARE SERVICES

13 DEFINED.— 

14 (1) RESIDENTIAL CARE COORDINATION PRO15 GRAM; RCCP.—For purposes of this section, the 

16 terms ‘‘residential care coordination program’’ and 

17 ‘‘RCCP’’ mean a program that— 

18 (A) is operated within one or more eligible 

19 continuing care retirement communities (as de20 fined in paragraph (2)); 

21 (B) is designed with a capacity of serving 

22 at least 1,000, but not more than 1,500, eligible 

23 CCRC residents (as defined in paragraph (3)) 

24 at any one time; and 


tjames on DSK6SPTVN1PROD with BILLS
5 

•HR 2376 IH

1 (C) provides comprehensive coordinated 

2 health care services (as defined in paragraph 

3 (4)) to participating CCRC residents enrolled in 

4 the program in accordance with the program 

5 agreement under subsection (f) and the require6 ments of this section. 

7 (2) ELIGIBLE CONTINUING CARE RETIREMENT

8 COMMUNITY; ELIGIBLE CCRC.—In this section, the 

9 terms ‘‘eligible continuing care retirement commu10 nity’’ and ‘‘eligible CCRC’’ mean an entity that is a 

11 continuing care retirement community (as defined in 

12 section 1852(l)(4)(B) of the Social Security Act (42 

13 U.S.C. 1395w–22(l)(4)(B))) that— 

14 (A) is built for the purposes of partici15 pating in the demonstration project; 

16 (B) provides onsite— 

17 (i) housing accommodations for eligi18 ble CCRC residents, including apartments 

19 for independent living; and 

20 (ii) additional services to facilitate 

21 aging in place for such residents, including 

22 assisted living and skilled nursing facilities 

23 or alternatives; and 

24 (C) has entered into a program agreement 

25 with the Secretary and the State with respect 


tjames on DSK6SPTVN1PROD with BILLS
6 

•HR 2376 IH

1 to its operation of the residential care coordina2 tion program and such agreement is consistent 

3 with the requirements of this section. 

4 (3) ELIGIBLE CCRC RESIDENT; PARTICIPATING

5 CCRC RESIDENT.— 

6 (A) IN GENERAL.—For purposes of this 

7 section: 

8 (i) ELIGIBLE CCRC RESIDENT.—The 

9 term ‘‘eligible CCRC resident’’ means an 

10 individual who— 

11 (I) is entitled to, or enrolled for, 

12 benefits under part A of title XVIII of 

13 the Social Security Act, and enrolled 

14 for benefits under part B of such title; 

15 and 

16 (II) resides in an eligible CCRC. 

17 (ii) PARTICIPATING CCRC RESI18 DENT.—The term ‘‘participating CCRC 

19 resident’’ means, with respect to a resident 

20 care coordination program, an eligible 

21 CCRC resident who is enrolled in that pro22 gram. 

23 (B) PARTICIPATION BY DUAL-ELIGIBLE IN24 DIVIDUALS; EXPANDED ELIGIBILITY.— 


tjames on DSK6SPTVN1PROD with BILLS
7 

•HR 2376 IH

1 (i) IN GENERAL.—An eligible CCRC 

2 resident may be, but is not required to be, 

3 a dual-eligible individual. 

4 (ii) DUAL-ELIGIBLE INDIVIDUAL DE5 FINED.—In this section, the term ‘‘dual-el6 igible individual’’ means any individual 

7 who is— 

8 (I) a full-benefit dual eligible in9 dividual (as defined in section 

10 1935(c)(6) of the Social Security 

11 Act); or 

12 (II) is described in clause (iii). 

13 (iii) QUALIFICATION OF PARTICI14 PATING CCRC RESIDENTS FOR MEDICAID

15 BENEFITS.—An individual who is a partici16 pating CCRC resident, regardless of the 

17 level of care, who meets income and re18 source eligibility criteria established under 

19 the State Medicaid plan for an individual 

20 to obtain coverage for nursing facility serv21 ices on the basis of the individual’s re22 quirement for the level of care for such 

23 services, shall be treated as a dual-eligible 

24 individual under this section and under 

25 title XIX of the Social Security Act so long 


tjames on DSK6SPTVN1PROD with BILLS
8 

•HR 2376 IH

1 as the individual remains a participating 

2 CCRC resident. 

3 (C) ENROLLMENT AND DISENROLLMENT

4 RULES.— 

5 (i) DEEMED ENROLLMENT AT TIME

6 OF INITIAL RESIDENCY.—An individual 

7 who is described in subclause (I) of sub8 paragraph (A)(i) is deemed, at the time of 

9 becoming a resident in an eligible CCRC, 

10 to have voluntarily consented to enroll in 

11 the RCCP operated by that CCRC for pur12 poses of subparagraph (A)(ii). 

13 (ii) DISENROLLMENT PROCESS.—The 

14 demonstration project shall provide a 

15 method for the disenrollment from the 

16 project of participating CCRC residents, 

17 which method shall take into account the 

18 unique circumstances of residents who are 

19 required to leave the CCRC and shall per20 mit disenrollment at least in the same cir21 cumstances as would permit an individual 

22 to disenroll from a Medicare Advantage 

23 plan under part C of title XVIII of the So24 cial Security Act for cause. 


tjames on DSK6SPTVN1PROD with BILLS
9 

•HR 2376 IH

1 (D) RELATION TO MEDICARE ADVANTAGE

2 AND PRESCRIPTION DRUG PROGRAM.— 

3 (i) SUPERCEDES ENROLLMENT.—A 

4 participating CCRC resident is not eligible 

5 to enroll in an MA plan under part C of 

6 title XVIII of the Social Security Act or 

7 under a prescription drug plan under part 

8 D of such title. 

9 (ii) COORDINATION IN CASE OF

10 DISENROLLMENT.—In the case of a par11 ticipating CCRC resident who disenrolls 

12 from the demonstration project, the 

13 disenrollment shall be treated, for purposes 

14 of parts C and D of such title, as if the in15 dividual had been previously enrolled in, 

16 and disenrolled from, an MA–PD plan 

17 under part C of such title. 

18 (E) PREMIUM PAYMENTS.—During the pe19 riod in which an individual is a participating 

20 CCRC resident— 

21 (i) for purposes of payment of pre22 miums under parts B, C, and D of title 

23 XVIII of the Social Security Act, the indi24 vidual shall be treated as if the individual 

25 were enrolled under an MA–PD plan with 


tjames on DSK6SPTVN1PROD with BILLS
10 

•HR 2376 IH

1 a premium equal to an amount specified in 

2 the program agreement; and 

3 (ii) the individual shall be eligible for 

4 assistance with respect to such premiums 

5 under part D and Medicare cost-sharing in 

6 the same manner and in the equivalent 

7 amounts as if the individual had not been 

8 enrolled as a participating CCRC resident. 

9 (4) COMPREHENSIVE COORDINATED HEALTH

10 CARE SERVICES DEFINED.—For purposes of this 

11 section, the term ‘‘comprehensive coordinated health 

12 care services’’, with respect to an eligible CCRC resi13 dent— 

14 (A) means all items and services that are 

15 otherwise payable under title XVIII of the So16 cial Security Act, including the minimum pre17 scription drug coverage required under a pre18 scription drug plan under part D of such title; 

19 (B) includes in the case of a dual eligible 

20 individual all items and services that are other21 wise payable under the State plan under title 

22 XIX of such Act of the State in which the resi23 dent resides; and 

24 (C) also includes— 


tjames on DSK6SPTVN1PROD with BILLS
11 

•HR 2376 IH

1 (i) care management services that co2 ordinate acute and specialty services (in3 cluding inpatient hospital services, services 

4 provided by specialty physicians, and other 

5 necessary services) provided to eligible 

6 CCRC residents; 

7 (ii) wellness services, including assist8 ance and instruction in healthy living (in9 cluding diet and exercise); and 

10 (iii) other health care items and serv11 ices to manage chronic conditions, treat 

12 subacute conditions, and provide preventive 

13 care. 

14 (e) PAYMENT UNDER MEDICARE AND MEDICAID.— 

15 (1) IN GENERAL.—In the case of an individual 

16 who is a participating CCRC resident who is en17 rolled in a residential care coordination program op18 erated by an eligible CCRC— 

19 (A) the individual shall receive benefits 

20 under title XVIII of the Social Security Act, 

21 and, if such individual is a dual-eligible indi22 vidual (as defined in subsection (d)(3)(B)(ii)), 

23 under the State Medicaid plan or waiver under 

24 title XIX of such Act, solely through the resi25 dential care coordination program, which shall 


tjames on DSK6SPTVN1PROD with BILLS
12 

•HR 2376 IH

1 provide such individual with comprehensive co2 ordinated health care services; and 

3 (B) the eligible CCRC shall receive 

4 capitated payments for the provision of such 

5 services (from the Secretary for benefits under 

6 title XVIII and from the State for benefits 

7 under such State plan or waiver), in accordance 

8 with this section. 

9 (2) PAYMENT METHODOLOGY.— 

10 (A) PAYMENT UNDER MEDICARE.— 

11 (i) PAYMENT ON MONTHLY BASIS.— 

12 With respect to each eligible CCRC, the 

13 Secretary shall make prospective monthly 

14 payments of a capitated amount, based on 

15 the rate established under clause (ii), for 

16 each participating CCRC resident enrolled 

17 in the residential care coordination pro18 gram operated by such CCRC in the same 

19 manner and from the same sources as pay20 ments are made to a Medicare Advantage 

21 organization under section 1853 of the So22 cial Security Act. Such payments shall be 

23 subject to adjustment in the manner de24 scribed in paragraphs (2) and (3) of sec25 tion 1853(a). 


tjames on DSK6SPTVN1PROD with BILLS
13 

•HR 2376 IH

1 (ii) ESTABLISHMENT OF PAYMENT

2 RATE.— 

3 (I) IN GENERAL.—The Secretary 

4 shall establish a risk-adjusted 

5 capitated payment rate under title 

6 XVIII of the Social Security Act for 

7 comprehensive coordinated health care 

8 services provided to eligible CCRC 

9 residents through a residential care 

10 coordination program operated by an 

11 eligible CCRC. The payment rate shall 

12 be 90 percent of the adjusted average 

13 per capita cost described in section 

14 1853(c)(1)(D)(i) of such Act (42 

15 U.S.C. 1395w–23(c)(1)(D)(i)), plus 

16 an amount equivalent to 90 percent of 

17 the amount that would have been paid 

18 to a prescription drug plan the stand19 ardized bid amount of which (as de20 fined in 1860D–13(a)(5) of such Act) 

21 was equal to the adjusted national av22 erage monthly bid amount (as defined 

23 in section 1860D–13(a)(1)(B)(iii) of 

24 such Act) and taking into account 


tjames on DSK6SPTVN1PROD with BILLS
14 

•HR 2376 IH

1 low-income subsidies paid under sec2 tion 1860D–14. 

3 (II) PROGRAM AGREEMENT.— 

4 The mechanism for establishing the 

5 capitated amount under this subpara6 graph for a specific eligible CCRC 

7 shall be specified in the program 

8 agreement. 

9 (B) PAYMENT UNDER MEDICAID.— 

10 (i) PAYMENT ON A MONTHLY BASIS.— 

11 With respect to an eligible CCRC oper12 ating an RCCP, the State shall make pro13 spective monthly payments of the capitated 

14 amount determined under and specified in 

15 the program agreement for each eligible 

16 CCRC resident of such community who is 

17 a dual-eligible individual. 

18 (ii) RELATIONSHIP TO MEDICARE PAY19 MENTS.—The payment made under this 

20 subparagraph shall be in addition to any 

21 payment made under subparagraph (A) to 

22 an eligible CCRC for eligible CCRC resi23 dents who are dual-eligible individuals. 

24 (iii) PROGRAM AGREEMENT.—The 

25 capitated amount under this subparagraph 


tjames on DSK6SPTVN1PROD with BILLS
15 

•HR 2376 IH

1 for a specific eligible CCRC shall be speci2 fied in the program agreement. 

3 (iv) PAYMENTS TO THE STATE.—The 

4 Secretary shall treat the payments made 

5 under clause (i) as medical assistance 

6 under title XIX of the Social Security Act 

7 for purposes of making payments to the 

8 State under section 1903 of such Act (42 

9 U.S.C. 1396b). 

10 (v) PAYMENTS TO REFLECT SPEND

11 DOWN AMOUNTS AND PERSONAL NEEDS

12 ALLOWANCES.—The payments under this 

13 subparagraph shall be made in a manner 

14 that takes into account the financial con15 tributions required of dual-eligible individ16 uals and the personal needs allowance es17 tablished under the State plan. Such per18 sonal needs allowances may vary depending 

19 upon the level of care required by such an 

20 individual. 

21 (3) TREATMENT OF SERVICES FURNISHED BY

22 NONCONTRACT PHYSICIANS AND OTHER ENTITIES.— 

23 (A) APPLICATION OF MEDICARE ADVAN24 TAGE REQUIREMENTS.—Section 1852(k)(1) of 

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


tjames on DSK6SPTVN1PROD with BILLS
16 

•HR 2376 IH

1 22(k)(1)) (relating to limitations on balance 

2 billing against Medicare Advantage organiza3 tions for noncontract physicians and other enti4 ties with respect to services covered under title 

5 XVIII of such Act) shall apply to eligible 

6 CCRCs, eligible CCRC residents enrolled in a 

7 residential care coordination program, and phy8 sicians and other entities that do not have a 

9 contract or other agreement establishing pay10 ment amounts for services furnished to such a 

11 resident in the same manner as such section ap12 plies to Medicare Advantage organizations, indi13 viduals enrolled with such organizations, and 

14 physicians and other entities referred to in such 

15 section. 

16 (B) APPLICATION OF BALANCED BILLING

17 LIMITATIONS.—Section 1866(a)(1)(O) shall 

18 apply to services that are covered under title 

19 XVIII of the Social Security Act and are fur20 nished to any eligible CCRC residents enrolled 

21 in a residential care coordination program in 

22 the same manner that such section applies to 

23 services furnished to an individual enrolled with 

24 a PACE provider under section 1894 or 1934 

25 of such Act. 


tjames on DSK6SPTVN1PROD with BILLS
17 

•HR 2376 IH

1 (f) PROGRAM AGREEMENT.— 

2 (1) REQUIREMENT.—The Secretary, in close co3 operation with the single State agency that admin4 isters or supervises the administration of the State 

5 plan under title XIX of the Social Security Act (42 

6 U.S.C. 1396 et seq.) (in this section referred to as 

7 the ‘‘State Medicaid agency’’), shall establish proce8 dures for entering into, extending, and terminating 

9 program agreements (each in this section referred to 

10 as a ‘‘program agreement’’) for the operation of resi11 dential care coordination programs by eligible 

12 CCRCs. 

13 (2) AGREEMENT REQUIRED FOR PAYMENT.—In 

14 order to receive payment under subsection (e), each 

15 eligible CCRC operating a residential care coordina16 tion program shall enter into a program agreement 

17 with the Secretary and the State, which shall con18 tain such terms and conditions as the parties may 

19 agree to, so long as such terms and conditions are 

20 consistent with this section. 

21 (3) DURATION.— 

22 (A) IN GENERAL.—A program agreement 

23 under this section shall be effective for a con24 tract year, beginning consistent with subsection 

25 (a)(2)(B) not later than the fourth calendar 


tjames on DSK6SPTVN1PROD with BILLS
18 

•HR 2376 IH

1 year to begin after the establishment of the 

2 demonstration project, and shall be extended 

3 for additional contract years in the absence of 

4 notice by a party to terminate. 

5 (B) TERMINATION.— 

6 (i) END OF DEMONSTRATION

7 PROJECT.—The Secretary and the State 

8 Medicaid agency shall terminate the pro9 gram agreement at the termination of the 

10 demonstration project under subsection (i). 

11 (ii) NOTICE OF PROVIDER TERMI12 NATION.—The eligible CCRC may termi13 nate the agreement after appropriate no14 tice to the Secretary, the State Medicaid 

15 agency, and eligible CCRC residents. 

16 (iii) TERMINATION FOR CAUSE.—The 

17 Secretary and the State Medicaid agency 

18 may terminate the program agreement at 

19 any time for cause (as provided under the 

20 agreement). Reasons for terminating an 

21 agreement under this clause include that 

22 the Secretary or State administering agen23 cy determines that— 

24 (I) there are significant defi25 ciencies in the quality of care provided 


tjames on DSK6SPTVN1PROD with BILLS
19 

•HR 2376 IH

1 to eligible CCRC residents enrolled in 

2 the program or the eligible CCRC has 

3 failed to comply substantially with the 

4 requirements of this section; and 

5 (II) the entity has failed to de6 velop and successfully initiate, within 

7 30 days of the date of the receipt of 

8 written notice of such a determina9 tion, a plan to correct the deficiencies, 

10 or has failed to continue implementa11 tion of such a plan. 

12 (iv) RIGHT TO REMAIN.—Nothing in 

13 this paragraph shall be construed, in the 

14 case that a program agreement is termi15 nated— 

16 (I) for a previously participating 

17 CCRC resident continuing, as affect18 ing the individual’s right to continue 

19 to reside in the CCRC and to receive 

20 traditional CCRC care and services in 

21 accordance with the contract between 

22 the CCRC resident and the CCRC; 

23 and 

24 (II) as relieving the State from 

25 continuing to provide medical assistVerDate Mar 15 2010 02:47 Jun 21, 2013 Jkt 029200 PO 00000 Frm 00019 Fmt 6652 Sfmt 6201 E:\BILLS\H2376.IH H2376

tjames on DSK6SPTVN1PROD with BILLS
20 

•HR 2376 IH

1 ance with respect to such services for 

2 individuals who would qualify as dual3 eligible individuals if the agreement 

4 had not been terminated. 

5 (4) SCOPE OF BENEFITS.— 

6 (A) IN GENERAL.—Under the agreement 

7 under paragraph (2), the eligible CCRC shall— 

8 (i) provide to participating CCRC 

9 residents of such community, regardless of 

10 source of payment, directly or under con11 tracts with other entities, at a minimum, 

12 all comprehensive coordinated health care 

13 services, without regard to any limitation 

14 or condition as to amount, duration, or 

15 scope under title XVIII or title XIX of the 

16 Social Security Act; 

17 (ii) provide such residents with access 

18 to necessary covered items and services 24 

19 hours a day, every day of the year; 

20 (iii) provide services to such residents 

21 onsite at the eligible CCRC through a mul22 tidisciplinary team that is led by a primary 

23 care physician and includes care coordina24 tors, case managers, and nurses; 


tjames on DSK6SPTVN1PROD with BILLS
21 

•HR 2376 IH

1 (iv) has a ratio of accessible physi2 cians to eligible CCRC residents that the 

3 Secretary determines is adequate; and 

4 (v) specify the covered items and serv5 ices that will not be provided directly by 

6 the eligible CCRC and— 

7 (I) provide for delivery of those 

8 items and services through contracts 

9 to ensure compliance with the require10 ments of this section; and 

11 (II) provides, on an as needed 

12 basis for those residents who cannot 

13 transport themselves, for necessary 

14 transportation services to the pro15 viders of such items and services, if 

16 such items and services are provided 

17 outside of the eligible CCRC. 

18 (B) APPLICATION OF REGULAR COST19 SHARING RULES.—Under such agreement the 

20 eligible CCRC may apply deductibles, copay21 ments, coinsurance, or other cost sharing that 

22 would otherwise apply under titles XVIII and 

23 XIX of the Social Security Act in the case of 

24 a MA–PD plan under part C of title XVIII of 

25 such Act. 


tjames on DSK6SPTVN1PROD with BILLS
22 

•HR 2376 IH

1 (5) QUALITY CONTROL.— 

2 (A) IN GENERAL.—Under the program 

3 agreement, the eligible CCRC shall— 

4 (i) collect data; 

5 (ii) maintain, and afford the Secretary 

6 and the State Medicaid agency access to, 

7 the records relating to the program, in8 cluding pertinent financial, medical, and 

9 personnel records; and 

10 (iii) submit to the Secretary and the 

11 State Medicaid agency such reports as the 

12 Secretary finds (in consultation with State 

13 Medicaid agencies) necessary to monitor 

14 the operation, cost, and effectiveness of the 

15 demonstration project, including data rel16 evant to the measurements established by 

17 the Secretary under subparagraph (B), to 

18 permit the Secretary and the State to 

19 evaluate such demonstration project. 

20 (B) QUALITY AND OUTCOME MEASURES.— 

21 The Secretary shall establish clinical and other 

22 outcome measurements to assess the efficacy of 

23 the demonstration project in— 

24 (i) improving— 


tjames on DSK6SPTVN1PROD with BILLS
23 

•HR 2376 IH

1 (I) the health status and out2 comes of participating CCRC resi3 dents enrolled in residential care co4 ordination programs under this dem5 onstration project, compared to Medi6 care beneficiaries (including tradi7 tional dual-eligible individuals de8 scribed in subsection (d)(3)(B)(ii)(I)) 

9 who are not enrolled in such pro10 grams; and 

11 (II) the quality of health care 

12 provided to such participating CCRC 

13 residents; and 

14 (ii) controlling the overall cost of pro15 viding health care items and services to 

16 such participating CCRC residents, com17 pared to the cost of providing such items 

18 and services to other Medicare bene19 ficiaries. 

20 (6) PATIENT SAFEGUARDS.—The agreement 

21 under paragraph (2) shall provide for written safe22 guards of the rights of participating CCRC residents 

23 enrolled in a residential care coordination program 

24 (including a patient bill of rights and procedures for 

25 grievances and appeals). Such safeguards shall be 


tjames on DSK6SPTVN1PROD with BILLS
24 

•HR 2376 IH

1 similar to the safeguards required under the section 

2 1894(b)(2)(B) of the Social Security Act (42 U.S.C. 

3 1395eee(b)(2)(B)) with respect to the PACE pro4 gram. 

5 (7) TRANSITION.—If a participating CCRC 

6 resident who is enrolled in a residential care coordi7 nation program is disenrolled from such program, 

8 the eligible CCRC shall provide assistance to the in9 dividual in obtaining necessary care through appro10 priate referrals and making the individual’s medical 

11 records available to new providers. 

12 (8) RULE OF CONSTRUCTION.—Nothing is this 

13 subsection shall be construed as preventing the eligi14 ble CCRC from assessing typical and appropriate 

15 fees to eligible CCRC residents. 

16 (g) SECRETARY’S OVERSIGHT; ENFORCEMENT AU17 THORITY.— 

18 (1) OVERSIGHT.— 

19 (A) IN GENERAL.—During the duration of 

20 the demonstration project, with respect to an el21 igible CCRC operating a residential care coordi22 nation program under a program agreement 

23 under subsection (f), the Secretary (acting in 

24 cooperation with the State Medicaid agency) 

25 shall conduct a comprehensive annual review of 


tjames on DSK6SPTVN1PROD with BILLS
25 

•HR 2376 IH

1 the operation of the eligible CCRC in order to 

2 ensure compliance with the requirements of this 

3 section. Such review shall include— 

4 (i) an onsite visit to the eligible 

5 CCRC; 

6 (ii) a comprehensive assessment of the 

7 community’s fiscal soundness; 

8 (iii) a comprehensive assessment of 

9 the eligible CCRC’s capacity to provide all 

10 comprehensive coordinated health care 

11 services to participating CCRC residents; 

12 (iv) detailed analysis of the commu13 nity’s substantial compliance with the re14 quirements of this section; and 

15 (v) any other elements that the Sec16 retary or the State Medicaid agency con17 siders necessary or appropriate. 

18 (B) DISCLOSURE.—The results of reviews 

19 under this paragraph shall be reported prompt20 ly to the eligible CCRC, along with any rec21 ommendations for changes to the community’s 

22 program, and shall be made available to the 

23 public through a public Web site of the Depart24 ment of Health and Human Services. 

25 (2) SANCTIONS.— 


tjames on DSK6SPTVN1PROD with BILLS
26 

•HR 2376 IH

1 (A) IN GENERAL.—If the Secretary deter2 mines (after consultation with the State Med3 icaid agency) that an eligible CCRC operating 

4 a residential care coordination program under a 

5 program agreement under subsection (f) is fail6 ing substantially to comply with the require7 ments of this section, the Secretary (and the 

8 State Medicaid agency) may take any or all of 

9 the following actions: 

10 (i) Condition the continuation of the 

11 program agreement upon timely execution 

12 of a corrective action plan. 

13 (ii) Withhold some or all further pay14 ments under the program agreement under 

15 this section with respect to services fur16 nished by such community until the defi17 ciencies have been corrected. 

18 (iii) Terminate such agreement under 

19 subsection (f)(3)(B). 

20 (B) APPLICATION OF INTERMEDIATE

21 SANCTIONS.—The Secretary may, by regulation, 

22 provide for the application against an eligible 

23 CCRC operating a residential care coordination 

24 program under a program agreement under this 

25 section of remedies described in section 


tjames on DSK6SPTVN1PROD with BILLS
27 

•HR 2376 IH

1 1857(g)(2) of the Social Security Act (42 

2 U.S.C. 1395w–27(g)(2)) or section 

3 1903(m)(5)(B) of such Act (42 U.S.C. 

4 1396b(m)(5)(B)) in the case of violations by 

5 the community of the type described in section 

6 1857(g)(1) or 1903(m)(5)(A) of such Act, re7 spectively (in relation to agreements, enrollees, 

8 and requirements under this section). 

9 (C) PROCEDURES FOR TERMINATION OR

10 IMPOSITION OF SANCTIONS.—The provisions of 

11 section 1857(h) of the Social Security Act (42 

12 U.S.C. 1395w–27(h)) shall apply, by regulation, 

13 to termination and sanctions respecting a pro14 gram agreement and an eligible CCRC oper15 ating a residential care coordination program 

16 under a program agreement under this sub17 section in the same manner as they apply to a 

18 termination and sanctions with respect to a 

19 contract and a Medicare Advantage organiza20 tion under part C of title XVIII of such Act. 

21 (h) WAIVER.—Notwithstanding section 1115(a) of 

22 the Social Security Act (42 U.S.C. 1315(a)), the Secretary 

23 may waive such provisions of titles XI, XVIII, and XIX 

24 of that Act as may be necessary to— 


tjames on DSK6SPTVN1PROD with BILLS
28 

•HR 2376 IH

1 (1) accomplish the goals of the demonstration 

2 project under this section; and 

3 (2) maximize the quality of life of eligible 

4 CCRC beneficiaries, as determined using the meas5 ures established under subsection (f)(5)(B). 

6 (i) DURATION OF 10 YEARS.— 

7 (1) IN GENERAL.—Subject to paragraph (2) 

8 and subsection (f)(3)(B), the demonstration project 

9 shall terminate 10 years after the date on which the 

10 demonstration project is first implemented under 

11 subsection (a)(2)(B). 

12 (2) EXTENSION.—The Secretary, acting 

13 through the Center for Medicare and Medicaid Inno14 vation, may extend the use of capitated payments 

15 for eligible CCRCs for residential care coordination 

16 programs under this section if, by the termination 

17 date that would otherwise apply under paragraph 

18 (1), the Secretary has demonstrated that the dem19 onstration project has improved the coordination, 

20 quality, and efficiency of health care services fur21 nished to Medicare beneficiaries. 

22 (j) STUDY AND REPORT TO CONGRESS.— 

23 (1) INTERIM EVALUATION AND REPORT.—Not 

24 later than 3 years after the date on which the dem25 onstration project is first implemented under subVerDate Mar 15 2010 02:47 Jun 21, 2013 Jkt 029200 PO 00000 Frm 00028 Fmt 6652 Sfmt 6201 E:\BILLS\H2376.IH H2376

tjames on DSK6SPTVN1PROD with BILLS
29 

•HR 2376 IH

1 section (a)(2)(B), the Secretary shall submit to Con2 gress a report that contains the following: 

3 (A) An interim evaluation of the costs and 

4 benefits of providing comprehensive coordinated 

5 health care services to Medicare beneficiaries 

6 (including dual-eligible individuals) through res7 idential care coordination programs, including 

8 the costs and benefits of using payments under 

9 title XIX of the Social Security Act to provide 

10 continuity of care by permitting certain individ11 uals to continue to participate in such programs 

12 after qualifying for enrollment in the Medicaid 

13 program under this section due to reduced in14 come and assets. 

15 (B) An analysis of the appropriateness of 

16 implementing a new payment methodology 

17 under titles XVIII and XIX of the Social Secu18 rity Act for such services in the future. 

19 (2) FINAL EVALUATION AND REPORT.—Not 

20 later than 10 years after the date on which the dem21 onstration project is first so implemented, the Sec22 retary shall submit to Congress a report that con23 tains a final evaluation of the impact of the dem24 onstration project. 

Æ 


tjames on DSK6SPTVN1PROD with BILLS