I 

114TH CONGRESS 

1ST SESSION H. R. 837 

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 

FEBRUARY 10, 2015 

Mr. FITZPATRICK (for himself, Mr. KELLY of Pennsylvania, Mr. CARTWRIGHT, Mr. ROTHFUS, Mr. BRENDAN F. BOYLE of Pennsylvania, Mr. 

MICHAEL F. DOYLE of Pennsylvania, Mr. BARTON, Mr. BRADY of Pennsylvania, Mr. FATTAH, Mr. BUCHANAN, and Ms. JENKINS of Kansas) 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, 


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1 SECTION 1. SHORT TITLE. 

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

3 Care Coordination Act of 2015’’. 

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 


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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). 


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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 CONTINUING CARE RETIREMENT

11 COMMUNITY (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 


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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 


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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.— 


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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 


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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. 


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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 


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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— 


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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 


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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 (42 U.S.C. 1395w–23). 

23 Such payments shall be subject to adjust24 ment in the manner described in paraVerDate Sep 11 2014 00:49 Feb 18, 2015 Jkt 049200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\H837.IH H837

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1 graphs (2) and (3) of subsection (a) of 

2 such section 1853. 

3 (ii) ESTABLISHMENT OF PAYMENT

4 RATE.— 

5 (I) IN GENERAL.—The Secretary 

6 shall establish a risk-adjusted 

7 capitated payment rate under title 

8 XVIII of the Social Security Act for 

9 comprehensive coordinated health care 

10 services provided to eligible CCRC 

11 residents through a residential care 

12 coordination program operated by an 

13 eligible CCRC. The payment rate shall 

14 be 90 percent of the adjusted average 

15 per capita cost described in section 

16 1853(c)(1)(D)(i) of such Act (42 

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

18 an amount equivalent to 90 percent of 

19 the amount that would have been paid 

20 to a prescription drug plan the stand21 ardized bid amount of which (as de22 fined in section 1860D–13(a)(5) of 

23 such Act (42 U.S.C. 1395w– 

24 113(a)(5))) was equal to the adjusted 

25 national average monthly bid amount 


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1 (as defined in section 1860D– 

2 13(a)(1)(B)(iii) of such Act (42 

3 U.S.C. 1395w–113(a)(1)(B)(iii))) and 

4 taking into account low-income sub5 sidies paid under section 1860D–14 

6 (42 U.S.C. 1395w–114). 

7 (II) PROGRAM AGREEMENT.— 

8 The mechanism for establishing the 

9 capitated amount under this subpara10 graph for a specific eligible CCRC 

11 shall be specified in the program 

12 agreement. 

13 (B) PAYMENT UNDER MEDICAID.— 

14 (i) PAYMENT ON A MONTHLY BASIS.— 

15 With respect to an eligible CCRC oper16 ating an RCCP, the State shall make pro17 spective monthly payments of the capitated 

18 amount determined under and specified in 

19 the program agreement for each eligible 

20 CCRC resident of such community who is 

21 a dual-eligible individual. 

22 (ii) RELATIONSHIP TO MEDICARE PAY23 MENTS.—The payment made under this 

24 subparagraph shall be in addition to any 

25 payment made under subparagraph (A) to 


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1 an eligible CCRC for eligible CCRC resi2 dents who are dual-eligible individuals. 

3 (iii) PROGRAM AGREEMENT.—The 

4 capitated amount under this subparagraph 

5 for a specific eligible CCRC shall be speci6 fied in the program agreement. 

7 (iv) PAYMENTS TO THE STATE.—The 

8 Secretary shall treat the payments made 

9 under clause (i) as medical assistance 

10 under title XIX of the Social Security Act 

11 for purposes of making payments to the 

12 State under section 1903 of such Act (42 

13 U.S.C. 1396b). 

14 (v) PAYMENTS TO REFLECT SPEND

15 DOWN AMOUNTS AND PERSONAL NEEDS

16 ALLOWANCES.—The payments under this 

17 subparagraph shall be made in a manner 

18 that takes into account the financial con19 tributions required of dual-eligible individ20 uals and the personal needs allowance es21 tablished under the State plan. Such per22 sonal needs allowances may vary depending 

23 upon the level of care required by such an 

24 individual. 


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1 (3) TREATMENT OF SERVICES FURNISHED BY

2 NONCONTRACT PHYSICIANS AND OTHER ENTITIES.— 

3 (A) APPLICATION OF MEDICARE ADVAN4 TAGE REQUIREMENTS.—Section 1852(k)(1) of 

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

6 22(k)(1)) (relating to limitations on balance 

7 billing against Medicare Advantage organiza8 tions for noncontract physicians and other enti9 ties with respect to services covered under title 

10 XVIII of such Act) shall apply to eligible 

11 CCRCs, eligible CCRC residents enrolled in a 

12 residential care coordination program, and phy13 sicians and other entities that do not have a 

14 contract or other agreement establishing pay15 ment amounts for services furnished to such a 

16 resident in the same manner as such section ap17 plies to Medicare Advantage organizations, indi18 viduals enrolled with such organizations, and 

19 physicians and other entities referred to in such 

20 section. 

21 (B) APPLICATION OF BALANCED BILLING

22 LIMITATIONS.—Section 1866(a)(1)(O) of the 

23 Social Security Act (42 U.S.C. 

24 1395cc(a)(1)(O)) shall apply to services that 

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1 curity Act and are furnished to any eligible 

2 CCRC residents enrolled in a residential care 

3 coordination program in the same manner that 

4 such section applies to services furnished to an 

5 individual enrolled with a PACE provider under 

6 section 1894 or 1934 of such Act (42 U.S.C. 

7 1395eee). 

8 (f) PROGRAM AGREEMENT.— 

9 (1) REQUIREMENT.—The Secretary, in close co10 operation with the single State agency that admin11 isters or supervises the administration of the State 

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

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

14 the ‘‘State Medicaid agency’’), shall establish proce15 dures for entering into, extending, and terminating 

16 program agreements (each in this section referred to 

17 as a ‘‘program agreement’’) for the operation of resi18 dential care coordination programs by eligible 

19 CCRCs. 

20 (2) AGREEMENT REQUIRED FOR PAYMENT.—In 

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

22 eligible CCRC operating a residential care coordina23 tion program shall enter into a program agreement 

24 with the Secretary and the State, which shall con25 tain such terms and conditions as the parties may 


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

2 consistent with this section. 

3 (3) DURATION.— 

4 (A) IN GENERAL.—A program agreement 

5 under this section shall be effective for a con6 tract year, beginning consistent with subsection 

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

8 year to begin after the establishment of the 

9 demonstration project, and shall be extended 

10 for additional contract years in the absence of 

11 notice by a party to terminate. 

12 (B) TERMINATION.— 

13 (i) END OF DEMONSTRATION

14 PROJECT.—The Secretary and the State 

15 Medicaid agency shall terminate the pro16 gram agreement at the termination of the 

17 demonstration project under subsection (i). 

18 (ii) NOTICE OF PROVIDER TERMI19 NATION.—The eligible CCRC may termi20 nate the agreement after appropriate no21 tice to the Secretary, the State Medicaid 

22 agency, and eligible CCRC residents. 

23 (iii) TERMINATION FOR CAUSE.—The 

24 Secretary and the State Medicaid agency 

25 may terminate the program agreement at 


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1 any time for cause (as provided under the 

2 agreement). Reasons for terminating an 

3 agreement under this clause include that 

4 the Secretary or State administering agen5 cy determines that— 

6 (I) there are significant defi7 ciencies in the quality of care provided 

8 to eligible CCRC residents enrolled in 

9 the program or the eligible CCRC has 

10 failed to comply substantially with the 

11 requirements of this section; and 

12 (II) the entity has failed to de13 velop and successfully initiate, within 

14 30 days of the date of the receipt of 

15 written notice of such a determina16 tion, a plan to correct the deficiencies, 

17 or has failed to continue implementa18 tion of such a plan. 

19 (iv) RIGHT TO REMAIN.—Nothing in 

20 this paragraph shall be construed, in the 

21 case that a program agreement is termi22 nated— 

23 (I) for a previously participating 

24 CCRC resident continuing, as affect25 ing the individual’s right to continue 


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1 to reside in the CCRC and to receive 

2 traditional CCRC care and services in 

3 accordance with the contract between 

4 the CCRC resident and the CCRC; 

5 and 

6 (II) as relieving the State from 

7 continuing to provide medical assist8 ance with respect to such services for 

9 individuals who would qualify as dual10 eligible individuals if the agreement 

11 had not been terminated. 

12 (4) SCOPE OF BENEFITS.— 

13 (A) IN GENERAL.—Under the agreement 

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

15 (i) provide to participating CCRC 

16 residents of such community, regardless of 

17 source of payment, directly or under con18 tracts with other entities, at a minimum, 

19 all comprehensive coordinated health care 

20 services, without regard to any limitation 

21 or condition as to amount, duration, or 

22 scope under title XVIII or title XIX of the 

23 Social Security Act; 


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1 (ii) provide such residents with access 

2 to necessary covered items and services 24 

3 hours a day, every day of the year; 

4 (iii) provide services to such residents 

5 onsite at the eligible CCRC through a mul6 tidisciplinary team that is led by a primary 

7 care physician and includes care coordina8 tors, case managers, and nurses; 

9 (iv) has a ratio of accessible physi10 cians to eligible CCRC residents that the 

11 Secretary determines is adequate; and 

12 (v) specify the covered items and serv13 ices that will not be provided directly by 

14 the eligible CCRC and— 

15 (I) provide for delivery of those 

16 items and services through contracts 

17 to ensure compliance with the require18 ments of this section; and 

19 (II) provides, on an as needed 

20 basis for those residents who cannot 

21 transport themselves, for necessary 

22 transportation services to the pro23 viders of such items and services, if 

24 such items and services are provided 

25 outside of the eligible CCRC. 


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1 (B) APPLICATION OF REGULAR COST2 SHARING RULES.—Under such agreement the 

3 eligible CCRC may apply deductibles, copay4 ments, coinsurance, or other cost sharing that 

5 would otherwise apply under titles XVIII and 

6 XIX of the Social Security Act in the case of 

7 an MA–PD plan under part C of title XVIII of 

8 such Act. 

9 (5) QUALITY CONTROL.— 

10 (A) IN GENERAL.—Under the program 

11 agreement, the eligible CCRC shall— 

12 (i) collect data; 

13 (ii) maintain, and afford the Secretary 

14 and the State Medicaid agency access to, 

15 the records relating to the program, in16 cluding pertinent financial, medical, and 

17 personnel records; and 

18 (iii) submit to the Secretary and the 

19 State Medicaid agency such reports as the 

20 Secretary finds (in consultation with State 

21 Medicaid agencies) necessary to monitor 

22 the operation, cost, and effectiveness of the 

23 demonstration project, including data rel24 evant to the measurements established by 

25 the Secretary under subparagraph (B), to 


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1 permit the Secretary and the State to 

2 evaluate such demonstration project. 

3 (B) QUALITY AND OUTCOME MEASURES.— 

4 The Secretary shall establish clinical and other 

5 outcome measurements to assess the efficacy of 

6 the demonstration project in— 

7 (i) improving— 

8 (I) the health status and out9 comes of participating CCRC resi10 dents enrolled in residential care co11 ordination programs under this dem12 onstration project, compared to Medi13 care beneficiaries (including tradi14 tional dual-eligible individuals de15 scribed in subsection (d)(3)(B)(ii)(I)) 

16 who are not enrolled in such pro17 grams; and 

18 (II) the quality of health care 

19 provided to such participating CCRC 

20 residents; and 

21 (ii) controlling the overall cost of pro22 viding health care items and services to 

23 such participating CCRC residents, com24 pared to the cost of providing such items 


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1 and services to other Medicare bene2 ficiaries. 

3 (6) PATIENT SAFEGUARDS.—The agreement 

4 under paragraph (2) shall provide for written safe5 guards of the rights of participating CCRC residents 

6 enrolled in a residential care coordination program 

7 (including a patient bill of rights and procedures for 

8 grievances and appeals). Such safeguards shall be 

9 similar to the safeguards required under the section 

10 1894(b)(2)(B) of the Social Security Act (42 U.S.C. 

11 1395eee(b)(2)(B)) with respect to the PACE pro12 gram. 

13 (7) TRANSITION.—If a participating CCRC 

14 resident who is enrolled in a residential care coordi15 nation program is disenrolled from such program, 

16 the eligible CCRC shall provide assistance to the in17 dividual in obtaining necessary care through appro18 priate referrals and making the individual’s medical 

19 records available to new providers. 

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

21 subsection shall be construed as preventing the eligi22 ble CCRC from assessing typical and appropriate 

23 fees to eligible CCRC residents. 

24 (g) SECRETARY’S OVERSIGHT; ENFORCEMENT AU25 THORITY.— 


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1 (1) OVERSIGHT.— 

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

3 the demonstration project, with respect to an el4 igible CCRC operating a residential care coordi5 nation program under a program agreement 

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

7 cooperation with the State Medicaid agency) 

8 shall conduct a comprehensive annual review of 

9 the operation of the eligible CCRC in order to 

10 ensure compliance with the requirements of this 

11 section. Such review shall include— 

12 (i) an onsite visit to the eligible 

13 CCRC; 

14 (ii) a comprehensive assessment of the 

15 community’s fiscal soundness; 

16 (iii) a comprehensive assessment of 

17 the eligible CCRC’s capacity to provide all 

18 comprehensive coordinated health care 

19 services to participating CCRC residents; 

20 (iv) detailed analysis of the commu21 nity’s substantial compliance with the re22 quirements of this section; and 

23 (v) any other elements that the Sec24 retary or the State Medicaid agency con25 siders necessary or appropriate. 


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1 (B) DISCLOSURE.—The results of reviews 

2 under this paragraph shall be reported prompt3 ly to the eligible CCRC, along with any rec4 ommendations for changes to the community’s 

5 program, and shall be made available to the 

6 public through a public Web site of the Depart7 ment of Health and Human Services. 

8 (2) SANCTIONS.— 

9 (A) IN GENERAL.—If the Secretary deter10 mines (after consultation with the State Med11 icaid agency) that an eligible CCRC operating 

12 a residential care coordination program under a 

13 program agreement under subsection (f) is fail14 ing substantially to comply with the require15 ments of this section, the Secretary (and the 

16 State Medicaid agency) may take any or all of 

17 the following actions: 

18 (i) Condition the continuation of the 

19 program agreement upon timely execution 

20 of a corrective action plan. 

21 (ii) Withhold some or all further pay22 ments under the program agreement under 

23 this section with respect to services fur24 nished by such community until the defi25 ciencies have been corrected. 


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1 (iii) Terminate such agreement under 

2 subsection (f)(3)(B). 

3 (B) APPLICATION OF INTERMEDIATE

4 SANCTIONS.—The Secretary may, by regulation, 

5 provide for the application against an eligible 

6 CCRC operating a residential care coordination 

7 program under a program agreement under this 

8 section of remedies described in section 

9 1857(g)(2) of the Social Security Act (42 

10 U.S.C. 1395w–27(g)(2)) or section 

11 1903(m)(5)(B) of such Act (42 U.S.C. 

12 1396b(m)(5)(B)) in the case of violations by 

13 the community of the type described in section 

14 1857(g)(1) or 1903(m)(5)(A) of such Act, re15 spectively (in relation to agreements, enrollees, 

16 and requirements under this section). 

17 (C) PROCEDURES FOR TERMINATION OR

18 IMPOSITION OF SANCTIONS.—The provisions of 

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

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

21 to termination and sanctions respecting a pro22 gram agreement and an eligible CCRC oper23 ating a residential care coordination program 

24 under a program agreement under this sub25 section in the same manner as they apply to a 


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1 termination and sanctions with respect to a 

2 contract and a Medicare Advantage organiza3 tion under part C of title XVIII of such Act. 

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

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

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

7 of that Act as may be necessary to— 

8 (1) accomplish the goals of the demonstration 

9 project under this section; and 

10 (2) maximize the quality of life of eligible 

11 CCRC beneficiaries, as determined using the meas12 ures established under subsection (f)(5)(B). 

13 (i) DURATION OF 10 YEARS.— 

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

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

16 shall terminate 10 years after the date on which the 

17 demonstration project is first implemented under 

18 subsection (a)(2)(B). 

19 (2) EXTENSION.—The Secretary, acting 

20 through the Center for Medicare and Medicaid Inno21 vation, may extend the use of capitated payments 

22 for eligible CCRCs for residential care coordination 

23 programs under this section if, by the termination 

24 date that would otherwise apply under paragraph 

25 (1), the Secretary has demonstrated that the demVerDate Sep 11 2014 00:49 Feb 18, 2015 Jkt 049200 PO 00000 Frm 00028 Fmt 6652 Sfmt 6201 E:\BILLS\H837.IH H837

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1 onstration project has improved the coordination, 

2 quality, and efficiency of health care services fur3 nished to Medicare beneficiaries. 

4 (j) STUDY AND REPORT TO CONGRESS.— 

5 (1) INTERIM EVALUATION AND REPORT.—Not 

6 later than 3 years after the date on which the dem7 onstration project is first implemented under sub8 section (a)(2)(B), the Secretary shall submit to Con9 gress a report that contains the following: 

10 (A) An interim evaluation of the costs and 

11 benefits of providing comprehensive coordinated 

12 health care services to Medicare beneficiaries 

13 (including dual-eligible individuals) through res14 idential care coordination programs, including 

15 the costs and benefits of using payments under 

16 title XIX of the Social Security Act to provide 

17 continuity of care by permitting certain individ18 uals to continue to participate in such programs 

19 after qualifying for enrollment in the Medicaid 

20 program under this section due to reduced in21 come and assets. 

22 (B) An analysis of the appropriateness of 

23 implementing a new payment methodology 

24 under titles XVIII and XIX of the Social Secu25 rity Act for such services in the future. 


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1 (2) FINAL EVALUATION AND REPORT.—Not 

2 later than 10 years after the date on which the dem3 onstration project is first so implemented, the Sec4 retary shall submit to Congress a report that con5 tains a final evaluation of the impact of the dem6 onstration project. 

Æ 


smartinez on DSK4TPTVN1PROD with BILLS