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[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[S. 1932 Introduced in Senate (IS)]

113th CONGRESS
  2d Session
                                S. 1932

To amend title XVIII of the Social Security Act to establish a Medicare 
      Better Care Program to provide integrated care for Medicare 
     beneficiaries with chronic conditions, and for other purposes.

_______________________________________________________________________

                   IN THE SENATE OF THE UNITED STATES

                            January 15, 2014

Mr. Wyden (for himself and Mr. Isakson) introduced the following bill; 
     which was read twice and referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL

 
To amend title XVIII of the Social Security Act to establish a Medicare 
      Better Care Program to provide integrated care for Medicare 
     beneficiaries with chronic conditions, and for other purposes.

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Better Care, Lower 
Cost Act''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Findings.
Sec. 3. Medicare Better Care Program.
Sec. 4. Chronic special needs plans.
Sec. 5. Improvements to welcome to Medicare visit and annual wellness 
                            visits.
Sec. 6. Chronic care innovation centers.
Sec. 7. Curricula requirements for direct and indirect graduate medical 
                            education payments.

SEC. 2. FINDINGS.

    Congress makes the following findings:
            (1) The field of medicine is ever-evolving and we need a 
        highly skilled, team-oriented workforce that can meet the 
        health care needs of today as well as the health care 
        challenges of tomorrow.
            (2) The Medicare program should recognize the growing uses 
        and benefits of health technology in delivering quality and 
        cost-efficient care by encouraging the use of telemedicine and 
        remote patient monitoring.

SEC. 3. MEDICARE BETTER CARE PROGRAM.

    (a) In General.--Title XVIII of the Social Security Act (42 U.S.C. 
1395 et seq.) is amended by adding at the end the following new 
section:

                     ``medicare better care program

    ``Sec. 1899B.  (a) Establishment.--
            ``(1) In general.--Not later than January 1, 2017, the 
        Secretary shall establish an integrated chronic care delivery 
        program (in this section referred to as the `program') that 
        promotes accountability and better care management for 
        chronically ill patient populations and coordinates items and 
        services under parts A, B, and D, while encouraging investment 
        in infrastructure and redesigned care processes that result in 
        high quality and efficient service delivery for the most 
        vulnerable and costly populations. The program shall--
                    ``(A) focus on long-term cost containment and 
                better overall health of the Medicare population by 
                implementing through qualified BCPs (as described in 
                paragraph (2)(A)) strategies that prevent, delay, or 
                minimize the progression of illness or disability 
                associated with chronic conditions; and
                    ``(B) include the program elements described in 
                paragraph (2).
            ``(2) Program elements.--The following program elements are 
        described in this paragraph:
                    ``(A) A health plan or group of providers of 
                services and suppliers, or a health plan working with 
                such a group, that the Secretary certifies in 
                accordance with subsection (e) as meeting criteria 
                developed by the Secretary to recognize the challenges 
                of managing a chronically ill population, including 
                patient satisfaction and engagement, quality 
                measurement developed specifically for a chronically 
                ill population, and effective use of resources and 
                providers, may manage and coordinate care for BCP 
                eligible individuals through an integrated care 
                network, or Better Care Program (referred to in this 
                section as a `qualified BCP'). A group of providers of 
                services and suppliers described in the preceding 
                sentence may also be participating in another 
                alternative payment model (as defined in subsection 
                (k)).
                    ``(B) Payments to a qualified BCP shall be made in 
                accordance with subsection (g).
                    ``(C) Implementation of the program shall focus on 
                physical, behavioral, and psychosocial needs of BCP 
                eligible individuals.
                    ``(D) Quality and cost containment are considered 
                interdependent goals of the program.
                    ``(E) The calculation of long-term cost savings is 
                dependent on qualified BCPs delivering the full 
                continuum of covered primary, post-acute care, and 
                social services using capitated financing.
            ``(3) Targeted participation.--
                    ``(A) In general.--In certifying qualified BCPs 
                throughout the country, the Secretary shall give 
                priority to areas--
                            ``(i) that do not have a concentration of 
                        accountable care organizations under section 
                        1899; and
                            ``(ii) with a high burden of chronic 
                        conditions.
                    ``(B) Initial requirement.--In the first 5 years of 
                the program, at least 50 percent of all new qualified 
                BCPs certified nationwide by the Secretary shall be 
                from counties or regions, as determined by the 
                Secretary, where the prevalence of the most costly 
                chronic conditions is at or greater than 125 percent of 
                the national average.
                    ``(C) Restricting the number of participating 
                bcps.--
                            ``(i) In general.--The Secretary shall take 
                        into account geography, urban and rural 
                        designations, and the population case mix that 
                        will be served, when selecting BCPs for 
                        participation.
                            ``(ii) Limitation during the first four 
                        program years.--During the first four years of 
                        the program, the total number of qualified BCPs 
                        certified by the Secretary shall not exceed 
                        250.
                            ``(iii) No limitation during fifth and 
                        subsequent program years.--During the fifth 
                        year and any subsequent year of the program, 
                        the Secretary may certify any BCP that meets 
                        the requirements to be certified as a qualified 
                        BCP.
            ``(4) Alignment with approved state plan waivers.--In 
        certifying qualified BCPs, the Secretary shall ensure alignment 
        with other approved waivers of State plans under title XIX.
    ``(b) Definition of BCP Eligible Individuals.--
            ``(1) Definition.--For purposes of this section, the term 
        `BCP eligible individual' means an individual who--
                    ``(A) is entitled to benefits under part A and 
                enrolled under parts B and D, including an individual 
                who is enrolled in a Medicare Advantage plan under part 
                C, an eligible organization under section 1876, or a 
                PACE program under section 1894; and
                    ``(B) is medically complex given the prevalence of 
                chronic disease that actively and persistently affects 
                their health status, and absent appropriate care 
                interventions, causes them to be at enhanced risk for 
                hospitalization, limitations on activities of daily 
                living, or other significant health outcomes.
            ``(2) Dual eligible individuals.--An individual who is 
        dually eligible for Medicare and Medicaid shall not be excluded 
        from enrolling in a qualified BCP. Dually eligible 
        beneficiaries enrolled in a qualified BCP will see the full 
        scope of their benefits under this title and title XIX (other 
        than long-term care) managed by the qualified BCP.
    ``(c) Notification and Enrollment.--
            ``(1) Notification.--Not later than October 1 of each year, 
        the Secretary shall use all available tools, including the 
        notice mailed annually under section 1804(a) and State health 
        insurance assistance programs, to notify BCP eligible 
        individuals of qualified BCPs in their area for the upcoming 
        plan year. Such information shall also be easily accessible on 
        the Internet website of the Centers for Medicare & Medicaid 
        Services.
            ``(2) Enrollment.--The Secretary shall establish procedures 
        under which BCP eligible individuals may voluntarily enroll in 
        a qualified BCP at the following times:
                    ``(A) During the annual, coordinated election 
                period under section 1851(e)(3)(B).
                    ``(B) During or following (for a length of time 
                determined by the Secretary)--
                            ``(i) an initial preventive physical 
                        examination (as defined in section 1861(ww)); 
                        or
                            ``(ii) any subsequent visit where a chronic 
                        condition is identified or a previous condition 
                        is identified as having escalated to the level 
                        of a chronic condition.
    ``(d) Patient Assessment.--
            ``(1) Standardized functional and health risk assessment.--
                    ``(A) Minimum guidelines.--Not later than January 
                1, 2016, the Secretary shall publish minimum guidelines 
                for qualified BCPs to furnish to enrollees a health 
                information technology-compatible, standardized, and 
                multidimensional risk assessment that--
                            ``(i) assesses and quantifies the medical, 
                        psychosocial, and functional status of an 
                        enrollee; and
                            ``(ii) includes a mechanism to determine 
                        the level of patient activation and ability to 
                        engage in self-care of an enrollee.
                    ``(B) Updating.--Not less frequently than once 
                every 3 years, the Secretary shall, through rulemaking, 
                update such minimum guidelines to reflect new clinical 
                standards and practices, as appropriate.
            ``(2) Individual patient-centered chronic care plan.--
                    ``(A) Model plan.--Not later than January 1, 2016, 
                the Secretary shall publish minimum guidelines for 
                qualified BCPs to develop individual patient-centered 
                chronic care plans for enrollees. Such a plan shall--
                            ``(i) allow health professionals to 
                        incorporate the medical, psychosocial, and 
                        functional components identified in the risk 
                        assessment described in paragraph (1)(A)(i);
                            ``(ii) provide a framework that can be 
                        easily integrated into electronic health 
                        records, allowing clinicians to make timely, 
                        accurate, evidence-based decisions at the point 
                        of care; and
                            ``(iii) allow for the provider to describe 
                        how services will be provided to the enrollee.
                    ``(B) Use of technology for patient self care.--
                            ``(i) In general.--Whenever appropriate, 
                        the individual patient-centered chronic care 
                        plan of an enrollee shall include the use of 
                        technologies that enhance communication between 
                        patients, providers, and communities of care, 
                        such as telehealth, remote patient monitoring, 
                        Smartphone applications, and other such 
                        enabling technologies, that promote patient 
                        engagement and self care while maintaining 
                        patient safety.
                            ``(ii) Coordination and development of 
                        streamlined pathway.--The Secretary shall work 
                        with the Office of the National Coordinator for 
                        Health Information Technology and the 
                        Department of Health and Human Services Chief 
                        Technology Officer to develop a streamlined 
                        pathway for the use of mobile applications and 
                        communications devices that effectively enhance 
                        the experience of the patient while maintaining 
                        patient safety and cost-effectiveness. Such 
                        pathway shall not duplicate existing efforts.
    ``(e) Qualified BCP Providers.--
            ``(1) Criteria.--
                    ``(A) In general.--Any health plan, provider of 
                services, or group of providers of services and 
                suppliers, who agrees to meet the requirements 
                described in paragraph (2) and is specified in 
                subparagraph (C) may form a multidisciplinary team of 
                health professionals to be certified as a qualified 
                BCP. Those providers may also choose to partner with a 
                qualified insurer to become a qualified BCP.
                    ``(B) No preemption of state licensure laws.--
                Nothing in this section shall preempt State licensure 
                laws.
                    ``(C) Groups of providers and suppliers 
                specified.--
                            ``(i) In general.--As determined 
                        appropriate by the Secretary, the following 
                        health plans, providers of services, or groups 
                        of providers of services and suppliers, that 
                        meet the criteria described in clause (ii) may 
                        be certified as qualified BCPs under the 
                        program:
                                    ``(I) Health professionals acting 
                                as part of a multidisciplinary team.
                                    ``(II) Networks of individual 
                                practices of health professionals that 
                                may include community health centers, 
                                Federally qualified health centers, 
                                rural health clinics, and partnerships 
                                or affiliations with hospitals.
                                    ``(III) Health plans that meet 
                                appropriate network adequacy standards, 
                                as determined by the Secretary, and 
                                that include providers with experience 
                                and interest in managing a population 
                                with chronic conditions.
                                    ``(IV) Independent health 
                                professionals partnering with an 
                                independent risk manager.
                                    ``(V) Such other groups of 
                                providers of services or suppliers as 
                                the Secretary determines appropriate.
                            ``(ii) Criteria described.--The following 
                        criteria are described in this clause:
                                    ``(I) Demonstrated capacity to 
                                manage the full continuum of care 
                                (other than long-term care) for the 
                                specialized population of BCP eligible 
                                individuals.
                                    ``(II) Having a high rate of 
                                Medicare customer satisfaction, when 
                                applicable, or partnering with 
                                providers of services or suppliers with 
                                such a demonstrated high satisfaction 
                                rate.
            ``(2) Requirements.--A qualified BCP shall meet the 
        following requirements:
                    ``(A) The qualified BCP shall be accountable for 
                the quality, cost, and overall care of enrolled BCP 
                eligible individuals and agree to be at financial risk 
                for that enrolled population. A qualified BCP shall be 
                established with the objective of serving BCP eligible 
                individuals.
                    ``(B) The qualified BCP shall be responsible for 
                the full continuum of care (other than long-term care) 
                for enrollees. This continuum shall include medical 
                care, skilled nursing and home health services, 
                behavioral health care, and social services. The 
                qualified BCP may not actively restrict an enrollee's 
                access to providers based on a practitioner's license 
                or medical specialty based on cost alone.
                    ``(C) The qualified BCP shall primarily consist of 
                a care team tasked with responding to, treating, and 
                actively supporting the needs of BCP eligible 
                individuals. The care team shall also develop a care 
                plan for each eligible BCP enrollee and use it as a 
                tool to execute effective care management and 
                transitions.
                    ``(D) The qualified BCP shall include physicians, 
                nurse practitioners, registered nurses, social workers, 
                pharmacists, and behavioral health providers who commit 
                to caring for BCP eligible individuals.
                    ``(E) The qualified BCP shall enter into an 
                agreement with the Secretary to participate in the 
                program under this section for not less than a 3-year 
                period.
                    ``(F) The qualified BCP shall include adequate 
                numbers of primary care and other relevant 
                professionals that can effectively care for the number 
                of BCP eligible individuals enrolled in the qualified 
                BCP.
                    ``(G) The qualified BCP shall provide the Secretary 
                with such information regarding qualified BCP 
                professionals participating in the qualified BCP 
                necessary to support the enrollment of BCP eligible 
                individuals in a qualified BCP, including evidence 
                relating to high patient satisfaction when available, 
                the implementation of quality reporting and other 
                reporting requirements, and evidence to support a 
                determination of capitated payments in accordance with 
                subsection (g).
                    ``(H) The qualified BCP shall have in place a 
                structure that includes clinical and administrative 
                systems, including health information technology, that 
                supports the integration of services and providers 
                across sites of care.
                    ``(I) The qualified BCP may develop a collaborative 
                partnership that supports the mission of the BCP with 
                each of the following:
                            ``(i) A regional or national Chronic Care 
                        Innovation Center under section 6 of the Better 
                        Care, Lower Cost Act.
                            ``(ii) A regional or national Center of 
                        Innovation (COIN) of the Department of Veterans 
                        Affairs Health Services Research and 
                        Development Service to identify and implement 
                        best practices--
                                    ``(I) to increase access to, and 
                                implementation of, prevention and 
                                wellness tools;
                                    ``(II) to integrate physical and 
                                behavior health care with social 
                                services;
                                    ``(III) to promote evidence-based 
                                medicine and patient engagement;
                                    ``(IV) to coordinate care across 
                                providers and care settings;
                                    ``(V) to allow more patients to be 
                                cared for in their homes and 
                                communities;
                                    ``(VI) to reduce hospital 
                                readmissions;
                                    ``(VII) to improve health outcomes 
                                for patients with chronic conditions; 
                                and
                                    ``(VIII) to report on quality 
                                improvement and cost measures.
                            ``(iii) A regional or national Telehealth 
                        Resource Center of the Health Resources and 
                        Services Administration (HRSA) Office for the 
                        Advancement of Telehealth to create an 
                        interactive, online resource for qualified BCP 
                        professionals who may need additional training 
                        or assistance in managing the needs of a 
                        complex patient population, including--
                                    ``(I) continuing training and 
                                education and mentoring for qualified 
                                BCP professionals at any level of 
                                licensure;
                                    ``(II) clinician support for 
                                complex patients by an expert panel;
                                    ``(III) remote access to regional, 
                                national, and international experts in 
                                the field;
                                    ``(IV) forums for best practices to 
                                be discussed among qualified BCP 
                                professionals;
                                    ``(V) inter-professional education 
                                supporting optimal communication 
                                between members of a chronic care team; 
                                and
                                    ``(VI) continuing training on the 
                                use of telehealth, remote patient 
                                monitoring, and other such enabling 
                                technologies.
                    ``(J) The qualified BCP shall demonstrate to the 
                Secretary that it meets person-centeredness criteria 
                specified by the Secretary in collaboration with 
                accreditation organizations, including the use of 
                patient and caregiver assessments and the use of 
                individual patient-centered chronic care plans for each 
                enrollee (as described in subsection (d)(2)).
                    ``(K) The qualified BCP may identify and respond to 
                unique cultural, social, and economic needs of a 
                community that impact access to, and quality of, 
                healthcare.
                    ``(L) The qualified BCP shall provide care across 
                settings, including in the home as needed.
                    ``(M) The qualified BCP shall demonstrate financial 
                solvency (as determined by the Secretary).
                    ``(N) The qualified BCP shall demonstrate the 
                ability to partner with providers of social and 
                behavioral health services within the community.
                    ``(O) The qualified BCP shall engage in continuing 
                education on chronic care, on an ongoing basis (as 
                determined necessary by the Chronic Care Innovation 
                Center under the partnership under subparagraph 
                (J)(i)), in collaboration with the Agency for 
                Healthcare Research and Quality, the Health Resources 
                and Services Administration, and the Department of 
                Veterans Affairs.
    ``(f) Implementing Value-Based Insurance Design.--
            ``(1) In general.--
                    ``(A) Election.--A qualified BCP may elect to 
                provide value-based Medicare coverage in accordance 
                with this subsection.
                    ``(B) Inclusion of original medicare fee-for-
                service program benefits.--Subject to subparagraph (C), 
                enrollees in a qualified BCP that elects to provide 
                value-based Medicare coverage under this subsection 
                shall receive such coverage that includes items and 
                services for which benefits are available under parts A 
                and B to individuals entitled to benefits under part A 
                and enrolled under part B, with cost-sharing for those 
                items and services as described in subparagraph (C).
                    ``(C) Cost-sharing.--Cost-sharing described in this 
                subparagraph, with respect to an enrollee in a 
                qualified BCP that makes such an election, is varied 
                cost-sharing approved by the Secretary to incentivize 
                the use of high-value, high-quality services that have 
                been clinically proven to benefit BCP eligible 
                individuals.
                    ``(D) Changes in coverage.--The Secretary, in 
                consultation with experts in the field, shall establish 
                a process for qualified BCPs to submit value-based 
                Medicare coverage changes that encourage and 
                incentivize the use of evidence-based practices that 
                will drive better outcomes while ensuring patient 
                protections and access are maintained.
                    ``(E) No requirement for coverage of long-term care 
                services.--In no case shall a qualified BCP be required 
                to provide to enrollees coverage for long-term care 
                services.
            ``(2) Qualified bcp participation.--
                    ``(A) Continued access.--Subject to subparagraph 
                (B), enrollees in a qualified BCP shall continue to 
                have access to all providers of services and suppliers 
                under this title.
                    ``(B) No application of varied cost-sharing for 
                nonparticipating providers of services and suppliers.--
                            ``(i) In general.--The varied cost-sharing 
                        under paragraph (1)(B) shall only apply to 
                        items and services furnished by qualified BCP 
                        professionals of a qualified BCP that makes an 
                        election under paragraph (1). In the case where 
                        items and services are furnished by a provider 
                        of services or supplier who is not such a 
                        qualified BCP professional, the cost-sharing 
                        applicable for those items and services will be 
                        the cost-sharing as required under parts A and 
                        B, or an actuarially equivalent level of cost-
                        sharing as determined by the Secretary.
                            ``(ii) Notification.--A BCP eligible 
                        individual shall be notified and counseled 
                        prior to the time of enrollment on potential 
                        changes in out-of-pocket costs that may occur 
                        if care is provided by a provider of services 
                        or supplier that is not a qualified BCP 
                        professional.
            ``(3) Limitations on out-of-pocket expenses outside a 
        qualified bcp.--
                    ``(A) In general.--Out-of-pocket costs, including 
                individual beneficiary copayments, with respect to 
                items and services furnished by a provider of services 
                or supplier who is not a qualified BCP professional 
                shall not exceed what would otherwise have been paid 
                with respect to the item or service under the original 
                Medicare fee-for-service program under parts A and B 
                for the same services or an actuarially equivalent 
                level of cost-sharing as determined by the Secretary, 
                or, in the case of a dual eligible individual, under 
                the Medicaid program under title XIX.
                    ``(B) Prohibition on coverage of cost-sharing for 
                certain items and services furnished to an enrollee 
                outside of a qualified bcp under medigap policies.--For 
                provisions relating to prohibition on coverage of cost-
                sharing for items and services (other than emergent 
                services, as defined by the Secretary) furnished to an 
                enrollee outside of a qualified BCP under Medigap 
                policies, see section 1882(z).
            ``(4) Prescription drug coverage.--
                    ``(A) Drug plan option.--
                            ``(i) In general.--A health plan certified 
                        as a qualified BCP may provide enrollees with a 
                        drug plan option specifically designed to 
                        reflect the medication needs of enrollees.
                            ``(ii) Application of part d provisions.--
                                    ``(I) In general.--Except as 
                                otherwise provided in this section, the 
                                provisions of part D shall apply to a 
                                drug plan option offered by a qualified 
                                BCP under clause (i) in the same manner 
                                as such provisions apply to a 
                                prescription drug plan offered by a PDP 
                                sponsor under such part.
                                    ``(II) Limitation of enrollment.--A 
                                qualified BCP offering such a drug plan 
                                option may limit enrollment in the drug 
                                plan option to enrollees in the 
                                qualified BCP.
                                    ``(III) Waiver.--The Secretary may 
                                waive such provisions of part D as are 
                                necessary to carry out this section.
                    ``(B) Agreement with prescription drug plans.--A 
                qualified BCP managed by a group of providers of 
                services may enter into an agreement with a PDP sponsor 
                of a prescription drug plan under part D to establish 
                and encourage individuals enrolled in the qualified BCP 
                to enroll in a prescription drug plan under such part 
                that is better suited to the needs of chronically ill 
                individuals.
                    ``(C) Limitation.--A drug plan option offered by a 
                qualified BCP under subparagraph (A)(i) shall not have 
                the authority to increase out-of-pocket limits 
                otherwise applicable under part D.
    ``(g) Payments and Treatment of Savings.--
            ``(1) Payments to qualified bcps on a capitated basis.--
                    ``(A) In general.--In the case of a qualified BCP 
                under this section, the Secretary shall make 
                prospective monthly payments of a capitation amount for 
                each BCP eligible individual enrolled in the qualified 
                BCP in the same manner and from the same sources as 
                payments are made to a Medicare Advantage organization 
                under section 1853. Such payments shall be subject to 
                adjustment in the manner described in section 
                1853(a)(2) or section 1876(a)(1)(E), as the case may 
                be.
                    ``(B) Capitation amount.--The capitation amount to 
                be applied under this paragraph for a qualified BCP for 
                each enrollee for a year shall be \1/12\ of the 
                benchmark rate under subparagraph (C)(ii) for the year 
                (or the relevant rate under subparagraph (C)(i) for the 
                first year of the program under this section) (referred 
                to in this paragraph as the `per member per month 
                payment'), as adjusted under clause (iii).
                    ``(C) Determining the rate using risk relevant 
                control group.--
                            ``(i) Relevant rate.--
                                    ``(I) Identification of beneficiary 
                                grouping.--Using claims data, the 
                                Secretary shall identify a group of 
                                beneficiaries who have similar health 
                                risk characteristics, and have sought 
                                care in the same county, multi-county, 
                                or State level (as determined 
                                appropriate by the Secretary to 
                                establish a payment area) to the 
                                population the qualified BCP is tasked 
                                with serving. To the extent feasible 
                                for a statistically valid control 
                                group, the health risk of such group 
                                shall reflect social characteristics, 
                                such as income, as well as medical 
                                risk.
                                    ``(II) Determination of relevant 
                                rate.--The per capita spending amounts 
                                under this title and, as appropriate, 
                                title XIX, of the group of 
                                beneficiaries identified under 
                                subclause (I) shall determine the 
                                `relevant rate' that will serve as the 
                                basis of the benchmark for 
                                participating qualified BCPs.
                            ``(ii) Benchmark rate.--The Secretary shall 
                        establish the benchmark rate for a qualified 
                        BCP service area for each year of the program 
                        by updating the relevant rate determined under 
                        clause (i) with the projected change in per 
                        capita spending for the group of beneficiaries 
                        identified under clause (i)(I) for the payment 
                        area described in such clause, as determined by 
                        the Chief Actuary of the Centers for Medicare & 
                        Medicaid Services.
                            ``(iii) Adjustment for health status.--
                                    ``(I) Comparison of health 
                                status.--The Secretary shall establish 
                                a risk score mechanism to compare the 
                                health status of an enrollee in a 
                                qualified BCP to the average health 
                                risk of group of beneficiaries 
                                identified under clause (i)(I).
                                    ``(II) Inclusion of number of 
                                conditions.--The Secretary shall 
                                provide that a risk score under the 
                                mechanism under this clause, with 
                                respect to an individual, includes an 
                                indicator for the number of chronic 
                                conditions with which the individual 
                                has been diagnosed.
                                    ``(III) Use of 2 years of diagnosis 
                                data.--The Secretary shall ensure that 
                                such risk score, with respect to an 
                                individual reflects not less than 2 
                                years of diagnosis data, to the extent 
                                available.
                                    ``(IV) Adjustment for health 
                                status.--The per member per month 
                                payment to the qualified BCP for each 
                                enrollee shall be adjusted depending on 
                                how the individual risk profile of the 
                                enrollee compares to the average health 
                                status of such group of beneficiaries. 
                                If an enrollee has a risk profile that 
                                is not as severe as the average health 
                                status of such group of beneficiaries, 
                                then the per member per month shall be 
                                decreased to reflect the `healthier' 
                                status of the enrollee. If an enrollee 
                                has a risk profile that is more severe, 
                                then the per member per month payment 
                                to the qualified BCP shall be increased 
                                to reflect the more acutely ill status 
                                of the enrollee.
                    ``(D) Shared risk payments for certain qualified 
                bcps during first 3 years of the program.--
                            ``(i) In general.--This subparagraph shall 
                        only apply to qualified BCPs offered by a group 
                        of providers of services and suppliers during 
                        the first 3 years of the program under this 
                        section.
                            ``(ii) Sharing of risk to alleviate 
                        outliers.--The Secretary shall determine shared 
                        risk payments and recoupments under this 
                        subparagraph for a qualified BCP described in 
                        clause (i) as follows:
                                    ``(I) Determination of gain or 
                                loss.--The Secretary shall, for each of 
                                the first 3 years of the program under 
                                this section, determine the percentage 
                                of gain or loss for the qualified BCP 
                                in providing benefits to enrollees 
                                under this section.
                                    ``(II) Gain or loss greater than 5 
                                percent.--If the Secretary determines 
                                the qualified BCP has a gain or loss 
                                for the year of greater than 5 percent, 
                                the qualified BCP shall bear 100 
                                percent of the risk or reward of such 
                                loss or gain.
                                    ``(III) Gain or loss of not less 
                                than 2 and not greater than 5 
                                percent.--If the Secretary determines 
                                the qualified BCP has a gain or loss 
                                for the year of not less than 2 percent 
                                but not greater than 5 percent--
                                            ``(aa) the qualified BCP 
                                        shall bear 80 percent of the 
                                        risk or reward, as applicable, 
                                        of such loss or gain; and
                                            ``(bb) the Secretary shall 
                                        bear 20 percent of the risk or 
                                        reward, as applicable, of such 
                                        loss or gain.
                                    ``(IV) Gain or loss between 0 and 2 
                                percent.--If the Secretary determines 
                                the qualified BCP has a gain or loss 
                                for the year of greater than 0 percent 
                                but less than 2 percent--
                                            ``(aa) the qualified BCP 
                                        shall bear 50 percent of the 
                                        risk or reward, as applicable, 
                                        of such loss or gain; and
                                            ``(bb) the Secretary shall 
                                        bear 50 percent of the risk or 
                                        reward, as applicable, of such 
                                        loss or gain.
                            ``(iii) Provision of information.--A 
                        qualified BCP shall provide to the Secretary 
                        such information as the Secretary determines is 
                        necessary to carry out this subparagraph.
                    ``(E) Bid submission.--Beginning with the fourth 
                year of the program, a qualified BCP shall submit a bid 
                for participation in the program for the year that 
                reflects the experience of the qualified BCP--
                            ``(i) in managing the care of the enrolled 
                        population; and
                            ``(ii) in managing such care given the 
                        relevant rate determined under subparagraph 
                        (C).
                    ``(F) Quality bonus system.--
                            ``(i) In general.--The Secretary shall 
                        establish a quality bonus system whereby the 
                        Secretary distributes bonus payments to 
                        qualified BCPs that meet the requirements 
                        described in clause (iii) and other standards 
                        specified by the Secretary, which may include a 
                        focus on quality measurement and improvement, 
                        delivering patient-centered care, and 
                        practicing in integrated health systems, 
                        including training in community-based settings. 
                        In developing such standards, the Secretary 
                        shall collaborate with relevant stakeholders, 
                        including program accrediting bodies, 
                        certifying boards, training programs, health 
                        care organizations, health care purchasers, and 
                        patient and consumer groups.
                            ``(ii) Determination of quality bonuses.--
                        Quality bonuses to the BCP shall be based on a 
                        comparison of the quality of care provided by 
                        the qualified BCP to enrollees to the quality 
                        of care provided to beneficiaries not enrolled 
                        in a qualified BCP or a Medicare Advantage plan 
                        under part C in the same region. For not less 
                        than the first 5 years of the program under 
                        this section, quality measures for the 
                        geographic region shall be based on local 
                        standards of care, and not on a national 
                        standard. For subsequent years, appropriate 
                        national standards shall be considered for 
                        inclusion in the comparison of the quality of 
                        care under this subparagraph.
                            ``(iii) Requirements.--A qualified BCP is 
                        eligible for quality bonuses under this 
                        subparagraph if--
                                    ``(I) the qualified BCP meets 
                                quality performance standards under 
                                subsection (h)(3); and
                                    ``(II) the qualified BCP meets the 
                                requirements under subsection (e)(2).
    ``(h) Quality and Other Reporting Requirements.--
            ``(1) In general.--The Secretary shall develop and 
        implement, with assistance and input of relevant experts in the 
        field and the National Strategy for Quality Improvement in 
        Health Care, appropriate measures for BCP eligible individuals. 
        The Secretary shall determine appropriate measures under this 
        title and title XIX to assess the quality of care furnished by 
        a qualified BCP, as well as those measures that are no longer 
        appropriate and shall be removed from use. Such measures shall 
        include measures--
                    ``(A) of clinical processes and outcomes;
                    ``(B) of patient and, where practicable, caregiver 
                experience of care, including measurement that enhances 
                patient activation and engagement;
                    ``(C) of utilization (such as rates of hospital 
                admissions for ambulatory care sensitive conditions);
                    ``(D) of care coordination, management, and 
                transitions; and
                    ``(E) that appropriately align with the National 
                Strategy for Quality Improvement in Health Care.
        The Secretary may use existing measures under this title, title 
        XIX, or any other health care program, as appropriate, under 
        this paragraph.
            ``(2) Reporting requirements.--A qualified BCP shall submit 
        data in a form and manner specified by the Secretary which is 
        not overly burdensome to the qualified BCP, on measures the 
        Secretary determines necessary for the qualified BCP to report 
        in order to evaluate the quality of care furnished by the 
        qualified BCP. Such data reporting shall emphasize `patient-
        centered measurement' and may include the functional status of 
        patients, case management and care transitions across health 
        care settings, including hospital discharge planning and post-
        hospital discharge follow-up by qualified BCP professionals, as 
        the Secretary determines appropriate.
            ``(3) Quality performance standards.--The Secretary shall 
        establish quality performance standards to assess the quality 
        of care furnished by qualified BCPs. The Secretary shall seek 
        to improve the quality of care furnished by qualified BCPs over 
        time by specifying higher standards, new measures, or both for 
        purposes of assessing such quality of care. The Secretary shall 
        also include a process for retiring measures that are no longer 
        adequately contributing to improving standards of care at the 
        greatest possible value.
            ``(4) Other reporting requirements and call for 
        alignment.--The Secretary shall, as the Secretary determines 
        appropriate, incorporate and align reporting requirements and 
        incentive payments related to the physician quality reporting 
        system under section 1848, including those related to reporting 
        on quality measures under subsection (m) of that section, 
        reporting requirements under subsection (o) of that section 
        relating to meaningful use of electronic health records, the 
        establishment of a value-based payment modifier under 
        subsection (p) of that section, and other similar initiatives 
        under that section, and may use alternative criteria than would 
        otherwise apply under section 1848 for determining whether to 
        make such payments to qualified BCP professionals. The 
        incentive payments described in the preceding sentence shall 
        not be taken into consideration when calculating any payments 
        otherwise made under subsection (g).
    ``(i) Beneficiary Protections.--The Secretary shall ensure that, to 
the extent consistent with this section, a qualified BCP offers 
beneficiary protections applicable to beneficiaries under this title 
and, as applicable, title XIX.
    ``(j) Payment of Medicare Cost-Sharing for Dual Eligible 
Individuals.--In the case of a dual eligible individual enrolled in a 
qualified BCP, the Secretary may provide for the payment of medicare 
cost-sharing (as defined in section 1905(p)(3)) that would otherwise be 
available under the State plan under title XIX if the individual was 
not enrolled in the qualified BCP.
    ``(k) Definitions.--In this section:
            ``(1) Alternative payment model (apm).--The term 
        `alternative payment model' means any of the following:
                    ``(A) A model under section 1115A (other than a 
                health care innovation award).
                    ``(B) An accountable care organization under 
                section 1899.
                    ``(C) A demonstration under section 1866C.
                    ``(D) A demonstration required by Federal law.
                    ``(E) A qualified BCP.
            ``(2) Hospital.--The term `hospital' means a subsection (d) 
        hospital (as defined in section 1886(d)(1)(B)).
            ``(3) Qualified bcp professional.--The term `qualified BCP 
        professional' means a certified and licensed professional of 
        medical or behavioral health services that is participating in 
        a qualified BCP.''.
    (b) Federal Assumption of Medicaid Costs for Full Benefit Dual 
Eligible Individuals Enrolled in a Qualified BCP.--Title XIX of the 
Social Security Act is amended by inserting after section 1943 the 
following new section:

   ``federal assumption of medicaid costs for full benefit eligible 
                individuals enrolled in a qualified bcp

    ``Sec. 1944.  (a) State Contribution.--
            ``(1) In general.--The State shall provide for payment to 
        the Secretary for each month in an amount determined under 
        paragraph (2)(A) for each applicable dual eligible BCP enrollee 
        for such State.
            ``(2) State contribution amount.--
                    ``(A) In general.--Subject to subparagraph (C), the 
                amount determined under this paragraph for a State for 
                a month in a year is equal to the product described in 
                subparagraph (A) of section 1935(c)(1) for the State 
                for the month, except that the reference in such 
                subparagraph to the total number of full-benefit dual 
                eligible individuals shall be deemed a reference to the 
                total number of applicable dual eligible BCP enrollees.
                    ``(B) Form and manner of payment.--The provisions 
                of subparagraphs (B) through (D) of section 1935(c)(1) 
                shall apply to payment by a State to the Secretary 
                under this paragraph in the same manner as such 
                subparagraphs apply to payment under section 
                1935(c)(1)(A).
                    ``(C) Application of different factors.--In 
                applying subparagraph (A), the following shall be 
                substituted under paragraphs (2) and (3) of section 
                1935(c):
                            ``(i) The base year State Medicaid per 
                        capita expenditures for covered part D drugs 
                        described in subparagraph (A)(i)(I) of such 
                        paragraph (2) shall be deemed to be the per 
                        capita expenditures for health care items and 
                        services that would apply (including any 
                        medicare cost-sharing), with respect to an 
                        applicable dual eligible BCP enrollee, if such 
                        an individual received benefits only under 
                        title XVIII (and not the State plan under this 
                        title).
                            ``(ii) Any reference to expenditures for 
                        covered part D drugs or for prescription drug 
                        benefits shall be deemed a reference to the 
                        expenditures for health care items and services 
                        described in clause (i).
                            ``(iii) Any reference to 2003 or 2004 shall 
                        be deemed a reference to 2017 or 2018, 
                        respectively.
                            ``(iv) Any reference to a full-benefit-
                        dual-eligible individual shall be deemed a 
                        reference to an applicable dual eligible BCP 
                        enrollee.
                            ``(v) The applicable growth factor under 
                        section 1935(c)(4) for a year, with respect to 
                        a State, shall be the average annual percentage 
                        change (to that year from the previous year) of 
                        the expenditures of the State under the State 
                        plan under title XIX.
                            ``(vi) The factor described in section 
                        1935(c)(5) is deemed to be 90 percent.
            ``(3) Applicable dual eligible bcp enrollee.--For purposes 
        of this section, the term `applicable dual eligible BCP 
        enrollee' means, with respect to a State, an individual 
        described in subparagraph (A)(ii) of section 1935(c)(6) (taking 
        into account the application of subparagraph (B) of such 
        section) for such State who is enrolled in a qualified BCP 
        under section 1899B. Such term includes, in the case of medical 
        assistance for medicare cost-sharing under a State plan under 
        this title, an individual who is a qualified medicare 
        beneficiary (as defined in section 1905(p)(1)), a qualified 
        disabled and working individual (described in section 1905(s)), 
        an individual described in section 1902(a)(10)(E)(iii), or 
        otherwise entitled to such medicare cost-sharing and who is 
        enrolled in such a qualified BCP.
    ``(b) Coordination of Benefits.--
            ``(1) Medicare as primary payor.--In the case of an 
        applicable dual eligible BCP enrollee, notwithstanding any 
        other provision of this title, medical assistance is not 
        available under this title for health care items or services 
        (or for any cost-sharing respecting such health care items and 
        services), and the rules under this title relating to the 
        provision of medical assistance for such health care items and 
        services shall not apply. The provision of benefits with 
        respect to such health care items and services shall not be 
        considered as the provision of care or services under the plan 
        under this title. No payment may be made under section 1903(a) 
        for health care items and services for which medical assistance 
        is not available pursuant to this paragraph.
            ``(2) Coverage of long-term care services.--In the case of 
        medical assistance under this title with respect to coverage of 
        long-term care services furnished to an applicable dual 
        eligible BCP enrollee, the State may elect to provide such 
        medical assistance in the manner otherwise provided in the case 
        of individuals who are not full-benefit dual eligible 
        individuals or through an arrangement with such qualified BCP. 
        In no case shall a qualified BCP be required to provide to 
        enrollees coverage of long-term care services.''.
    (c) State Marketing Materials for Dually Eligible Individuals.--
            (1) State plan requirement.--Section 1902(a) of the Social 
        Security Act (42 U.S.C. 1396a(a)) is amended--
                    (A) in paragraph (80), by striking ``and'' at the 
                end;
                    (B) in paragraph (81), by striking the period at 
                the end and inserting ``; and''; and
                    (C) by inserting after paragraph (81) the 
                following:
            ``(82) provide that any marketing materials distributed by 
        the State that are directed at dual eligible individuals (as 
        defined in section 1915(h)(2)(B)) include information on 
        qualified BCPs offered under section 1899B.''.
            (2) Effective date.--The amendments made by this section 
        shall apply to calendar quarters beginning on or after January 
        1, 2017, without regard to whether or not final regulations to 
        carry out such amendments have been promulgated by such date.
    (d) Prohibition on Coverage of Cost-Sharing for Certain Items and 
Services Furnished to an Enrollee Outside of a Qualified BCP Under 
Medigap Policies.--Section 1882 of the Social Security Act (42 U.S.C. 
1395ss) is amended by adding at the end the following new subsection:
    ``(z) Prohibition on Coverage of Cost-Sharing for Certain Items and 
Services Furnished to an Enrollee Outside of a Qualified BCP and 
Development of New Standards for Medicare Supplemental Policies.--
            ``(1) Development.--The Secretary shall request the 
        National Association of Insurance Commissioners to review and 
        revise the standards for benefit packages under subsection 
        (p)(1), taking into account the changes in benefits resulting 
        from the enactment of the Better Care, Lower Cost Act and to 
        otherwise update standards to include the requirements for 
        cost-sharing described in paragraph (2). Such revisions shall 
        be made consistent with the rules applicable under subsection 
        (p)(1)(E) with the reference to the `1991 NAIC Model 
        Regulation' deemed a reference to the NAIC Model Regulation as 
        published in the Federal Register on December 4, 1998, and as 
        subsequently updated by the National Association of Insurance 
        Commissioners to reflect previous changes in law and the 
        reference to `date of enactment of this subsection' deemed a 
        reference to the date of enactment of the Better Care, Lower 
        Cost Act. To the extent practicable, such revision shall 
        provide for the implementation of revised standards for benefit 
        packages as of January 1, 2017.
            ``(2) Cost-sharing requirements.--The cost-sharing 
        requirements described in this paragraph are that, 
        notwithstanding any other provision of law, no medicare 
        supplemental policy may provide for coverage of cost-sharing 
        with respect to items and services (other than emergent 
        services, as defined by the Secretary) furnished to an 
        individual enrolled in a qualified BCP under section 1899B by a 
        provider of services or supplier that is not a qualified BCP 
        professional (as defined in section 1899B(k)).
            ``(3) Renewability.--The renewability requirement under 
        subsection (q)(1) shall be satisfied with the renewal of the 
        revised package under paragraph (1) that most closely matches 
        the policy in which the individual was enrolled prior to such 
        revision.''.

SEC. 4. CHRONIC SPECIAL NEEDS PLANS.

    Section 1859 of the Social Security Act (42 U.S.C. 1395w-28) is 
amended--
            (1) in subsection (f)(4)--
                    (A) by striking ``In the case of'' and inserting 
                ``Subject to subsection (h), in the case of''; and
                    (B) by adding at the end the following flush text:
        ``Notwithstanding any other provision of this section, on or 
        after January 1, 2014, the Secretary shall establish procedures 
        for the transition of those individuals to a Medicare Advantage 
        plan qualified BCP in accordance with subsection (h).''; and
            (2) by adding at the end the following new subsection:
    ``(h) Medicare Advantage Plan Qualified BCPs.--
            ``(1) In general.--A Medicare Advantage plan that is 
        certified as a qualified BCP (referred to in this subsection as 
        a `Medicare Advantage plan qualified BCP')--
                    ``(A) is deemed to be a specialized MA plan for 
                special needs individuals described in subsection 
                (b)(6)(B)(iii); and
                    ``(B) may enroll such special needs individuals.
            ``(2) Specialized benefit packages.--A Medicare Advantage 
        plan qualified BCP shall have the flexibility to offer 
        specialized benefit packages to enrollees described in 
        subsection (b)(6)(B)(iii), consistent with the value-based 
        insurance requirements under section 1899B(f).
            ``(3) Application of bcp requirements.--A Medicare 
        Advantage plan qualified BCP shall be subject to all 
        requirements applicable to a qualified BCP under section 1899B, 
        including enrollment periods under subsection (c) of that 
        section, applicable criteria relating to network adequacy, 
        requirements with respect to individual patient-centered 
        chronic care plans under subsection (d)(2) of that section, 
        applicable criteria with respect to care management processes, 
        and quality reporting under subsection (h) of that section.
            ``(4) Application of part c requirements.--The provisions 
        of this part, including the provisions relating to specialized 
        MA plans for special needs individuals described in subsection 
        (b)(6)(B)(iii), shall apply to a Medicare Advantage plan 
        qualified BCP to the extent they are consistent with the 
        provisions of section 1899B.''.

SEC. 5. IMPROVEMENTS TO WELCOME TO MEDICARE VISIT AND ANNUAL WELLNESS 
              VISITS.

    (a) Welcome to Medicare Visit.--Section 1861(ww)(1) of the Social 
Security Act (42 U.S.C. 1395x(ww)(1)) is amended by adding at the end 
the following new sentence: ``In the case of a BCP eligible individual 
(as defined in section 1899B(b)), such term includes a standardized 
functional and health risk assessment (as described in section 
1899B(d)(1)) furnished by a qualified BCP professional (as defined in 
section 1899B(k)).''.
    (b) Annual Wellness Visit.--Section 1861(hhh)(1) of the Social 
Security Act (42 U.S.C. 1395x(h)(1)) is amended--
            (1) in subparagraph (A), by striking ``and'' at the end;
            (2) in subparagraph (B), by striking the period at the end 
        and inserting ``; and''; and
            (3) by adding at the end the following new subparagraph:
                    ``(C) in the case of a BCP eligible individual (as 
                defined in section 1899B(b)), that includes a 
                standardized functional and health risk assessment (as 
                described in section 1899B(d)(1)) furnished by a 
                qualified BCP professional (as defined in section 
                1899B(k)).''.
    (c) Effective Date.--The amendments made by this section shall 
apply to services furnished on or after the date that is one year after 
the date of enactment of this Act.

SEC. 6. CHRONIC CARE INNOVATION CENTERS.

    (a) Designation.--Not later than October 1, 2016, the Secretary, 
acting through the Agency for Healthcare Research and Quality, shall 
designate and provide core funding for not less than three Chronic Care 
Innovation Centers. The Secretary shall develop a process for entities 
seeking to become a Chronic Care Innovation Center, and shall ensure 
sufficient geographic representation among those entities selected. The 
main objectives of such Centers shall include the following:
            (1) Improving the understanding of how to measure, monitor, 
        and understand quality and efficiency for a patient population 
        with substantial disease burden.
            (2) Rigorously examining alternative and innovative systems 
        and strategies for efficiently improving quality and outcomes 
        for common, serious, and chronic illnesses.
            (3) Developing and applying improved methodologies for 
        informing policymakers regarding heterogeneity in the 
        effectiveness and safety of proposed interventions, and 
        assessing barriers to the implementation of high-priority care.
            (4) Studying organization and management practices that 
        result in higher quality of care.
            (5) Defining and improving quality of care for patients 
        with the chronic diseases prevalent in primary care settings.
            (6) Understanding the influence of race, ethnicity, and 
        cultural factors on access, quality, and outcomes (such as 
        clinical, patient-centered, health care utilization, and 
        costs).
            (7) Evaluating new technology to enhance access to, and 
        quality of care (such as telemedicine).
            (8) Assessing the use of patient self-management and 
        behavioral interventions as a means of improving outcomes for 
        Medicare beneficiaries with complex chronic conditions.
            (9) Understanding how management of care is affected when 
        patients have multiple chronic conditions in which evidence or 
        recommended guidelines are lacking, conflict with, or 
        complicate overall care management.
            (10) Characterizing coordination of care within and across 
        healthcare systems, including the Department of Veterans 
        Affairs, the Medicare program under title XVIII of the Social 
        Security Act (42 U.S.C. 1395 et seq.), the Medicaid program 
        under title XIX of such Act, and private sector programs for 
        veterans with complex chronic conditions.
    (b) Requirements.--In order to be designated a Chronic Care 
Innovation Center under this section, each eligible entity must meet 
the following requirements:
            (1) Develop and implement a sustained research agenda in 
        the field of chronic care.
            (2) Collaborate with local schools of public health and 
        universities to carry out its mission.
            (3) Actively engage in the development of new, best 
        practices for the delivery of care to the chronically ill.
            (4) Actively engage in the development and routine updating 
        of quality measures for the chronically ill.
            (5) Have the ability to convene experts practiced in the 
        needs of a chronically ill patient, including pharmacologists, 
        psychiatrists, cardiologists, pulmonologists, rheumatologists, 
        nutritionists and dieticians, social workers, and physical 
        therapists.
            (6) Partner with the Secretary of Health and Human Services 
        and the Secretary of Veterans Affairs (including the Center for 
        Health Services Research in Primary Care of the Department of 
        Veterans Affairs Health Services Research and Development 
        Service), the medical community, medical schools, and public 
        health departments through the Agency for Healthcare Research 
        and Quality, the Health Resources and Services Administration, 
        and the Association of American Medical Colleges to routinely 
        develop new, forward thinking, and evidence-based curricula 
        that addresses the tremendous need for team-based care and 
        chronic care management. Such curricula shall include 
        palliative medicine, chronic care management, leadership and 
        team-based skills and planning, and leveraging technology as a 
        care tool.
    (c) Oversight and Evaluation.--
            (1) In general.--The Agency for Healthcare Research and 
        Quality shall be responsible for oversight and evaluation of 
        all Chronic Care Innovation Centers under this section.
            (2) Reports.--Not less frequently than every 3 years, the 
        Agency for Healthcare Research and Quality shall submit to the 
        Secretary of Health and Human Services and to Congress a report 
        containing the findings of oversight and evaluations conducted 
        under paragraph (1).
    (d) Contract Authority.--In order to carry out this section, the 
Secretary may contract with existing Centers of Innovation (COINs) of 
the Department of Veterans Affairs Health Services Research and 
Development Service that meet the requirements described in subsection 
(c).
    (e) Authorization.--There are authorized to be appropriated such 
sums as are necessary to carry out this section.

SEC. 7. CURRICULA REQUIREMENTS FOR DIRECT AND INDIRECT GRADUATE MEDICAL 
              EDUCATION PAYMENTS.

    (a) Direct Graduate Medical Education Payments.--Section 1886(h) of 
the Social Security Act (42 U.S.C. 1395ww(h)) is amended by adding at 
the end the following new paragraph:
            ``(9) New curricula requirements.--
                    ``(A) Development.--The Secretary shall engage with 
                the medical community and medical schools in developing 
                curricula that meets the following requirements:
                            ``(i) The curricula is new, forward 
                        thinking, and evidence-based.
                            ``(ii) The curricula addresses the need for 
                        team-based care and chronic care management.
                            ``(iii) The curricula includes palliative 
                        medicine, chronic care management, leadership 
                        and team-based skills and planning, and 
                        leveraging technology as a care tool.
                    ``(B) Rural areas.--The curricula developed under 
                subparagraph (A) shall include appropriate focus on 
                care practices required for rural and underserved 
                areas.
                    ``(C) Limitation.--Notwithstanding the preceding 
                provisions of this subsection, for cost reporting 
                periods beginning on or after the date that is 5 years 
                after the date of enactment of the Better Care, Lower 
                Cost Act, if a hospital has not begun to implement 
                curricula that meets the requirements described in 
                subparagraph (A), payments otherwise made to a hospital 
                under this subsection may be reduced by a percentage 
                determined appropriate by the Secretary. For purposes 
                of the preceding sentence, successful development and 
                implementation of such curricula shall be determined by 
                program accrediting bodies.''.
    (b) Indirect Graduate Medical Education Payments.--Section 
1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is 
amended--
            (1) by redesignating clause (x), as added by section 
        5505(b) of the Patient Protection and Affordable Care Act 
        (Public Law 111-148), as clause (xi) and moving such clause 6 
        ems to the left; and
            (2) by adding at the end the following new clause:
    ``(xii) Notwithstanding the preceding provisions of this 
subparagraph, effective for discharges occurring on or after the date 
that is 5 years after the date of enactment of the Better Care, Lower 
Cost Act, if a hospital has not begun to implement curricula that meets 
the requirements described in subsection (h)(9)(A), as determined in 
accordance with subsection (h)(9)(C), payments otherwise made to a 
hospital under this subparagraph may be reduced by a percentage 
determined appropriate by the Secretary.''.
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