I 

115TH CONGRESS 

1ST SESSION H. R. 4579 

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

payment policies designed to improve management of chronic disease, 

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

IN THE HOUSE OF REPRESENTATIVES 

DECEMBER 6, 2017 

Mr. WELCH (for himself and Mr. SCHRADER) introduced the following bill; 

which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of 

such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To amend title XVIII of the Social Security Act to implement 

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

and improve quality outcomes without adding to the deficit. 

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

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

5 ‘‘Creating High-Quality Results and Outcomes Necessary 

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


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

2 this Act is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—RECEIVING HIGH-QUALITY CARE IN THE HOME 

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

Sec. 102. Expanding access to home dialysis therapy. 

TITLE II—ADVANCING TEAM-BASED CARE 

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

plans for vulnerable populations. 

TITLE III—EXPANDING INNOVATION AND TECHNOLOGY 

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

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

Medicare Advantage enrollees. 

Sec. 303. Increasing convenience for Medicare Advantage enrollees through 

telehealth. 

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

of telehealth. 

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

TITLE IV—IDENTIFYING THE CHRONICALLY ILL POPULATION 

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

organization. 

TITLE V—EMPOWERING INDIVIDUALS AND CAREGIVERS IN CARE 

DELIVERY 

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

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

services under Medicare part B. 

TITLE VI—OTHER POLICIES TO IMPROVE CARE FOR THE 

CHRONICALLY ILL 

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

promote the appropriate use of medications and improve health 

outcomes. 

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

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

and spending. 

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

TITLE VII—OFFSETS 

Sec. 701. Medicare Improvement Fund. 

Sec. 702. Medicaid Improvement Fund. 


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1 TITLE I—RECEIVING HIGH2 QUALITY CARE IN THE HOME 

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

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

6 1395cc–5) is amended— 

7 (1) in subsection (e)— 

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

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

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

11 and inserting ‘‘15,000’’; 

12 (2) in subsection (g), in the first sentence, by 

13 inserting ‘‘, including, to the extent practicable, the 

14 use of electronic health information systems as de15 scribed in subsection (b)(1)(A)(vi),’’ after ‘‘pro16 gram’’; and 

17 (3) in subsection (i)(A), by striking ‘‘will not re18 ceive an incentive payment for the second of 2’’ and 

19 inserting ‘‘did not achieve savings for the third of 

20 3’’. 

21 SEC. 102. EXPANDING ACCESS TO HOME DIALYSIS THER22 APY. 

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

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


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1 (1) by redesignating subparagraphs (A) and 

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

3 (2) in clause (ii), as redesignated by subpara4 graph (A), strike ‘‘on a comprehensive’’ and insert 

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

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

7 ‘‘(A) With respect to’’; and 

8 (4) by adding at the end the following new sub9 paragraph: 

10 ‘‘(B) For purposes of subparagraph (A)(ii), an indi11 vidual determined to have end stage renal disease receiv12 ing home dialysis may choose to receive monthly end stage 

13 renal disease-related clinical assessments furnished on or 

14 after January 1, 2019, via telehealth if the individual re15 ceives a face-to-face clinical assessment, without the use 

16 of telehealth, at least once every three consecutive 

17 months.’’. 

18 (b) ORIGINATING SITE REQUIREMENTS.— 

19 (1) IN GENERAL.—Section 1834(m) of the So20 cial Security Act (42 U.S.C. 1395m(m)) is amend21 ed— 

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

23 the end the following new subclauses: 


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1 ‘‘(IX) A renal dialysis facility, 

2 but only for purposes of section 

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

4 ‘‘(X) The home of an individual, 

5 but only for purposes of section 

6 1881(b)(3)(B).’’; and 

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

8 paragraph: 

9 ‘‘(5) TREATMENT OF HOME DIALYSIS MONTHLY

10 ESRD-RELATED VISIT.—The geographic require11 ments described in paragraph (4)(C)(i) shall not 

12 apply with respect to telehealth services furnished on 

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

14 1881(b)(3)(B), at an originating site described in 

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

16 (4)(C)(ii).’’. 

17 (2) NO FACILITY FEE IF ORIGINATING SITE

18 FOR HOME DIALYSIS THERAPY IS THE HOME.—Sec19 tion 1834(m)(2)(B) of the Social Security Act (42 

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

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

22 subclauses (I) and (II), and indenting appro23 priately; 

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

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


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

2 subclause’’; 

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

4 and inserting ‘‘SITE.— 

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

6 (ii), with respect to’’; and 

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

8 clause: 

9 ‘‘(ii) NO FACILITY FEE IF ORIGI10 NATING SITE FOR HOME DIALYSIS THER11 APY IS THE HOME.—No facility fee shall 

12 be paid under this subparagraph to an 

13 originating site described in paragraph 

14 (4)(C)(ii)(X).’’. 

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

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

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

18 ‘‘paragraph (3)(A)(i)’’. 


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1 TITLE II—ADVANCING TEAM2 BASED CARE 

3 SEC. 201. PROVIDING CONTINUED ACCESS TO MEDICARE 

4 ADVANTAGE SPECIAL NEEDS PLANS FOR 

5 VULNERABLE POPULATIONS. 

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

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

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

9 (b) INCREASED INTEGRATION OF DUAL SNPS.— 

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

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

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

13 the following new subparagraph: 

14 ‘‘(F) The plan meets the requirements ap15 plicable under paragraph (8).’’; and 

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

17 paragraph: 

18 ‘‘(8) INCREASED INTEGRATION OF DUAL

19 SNPS.— 

20 ‘‘(A) DESIGNATED CONTACT.—The Sec21 retary, acting through the Federal Coordinated 

22 Health Care Office established under section 

23 2602 of the Patient Protection and Affordable 

24 Care Act, shall serve as a dedicated point of 

25 contact for States to address misalignments 


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1 that arise with the integration of specialized 

2 MA plans for special needs individuals de3 scribed in subsection (b)(6)(B)(ii) under this 

4 paragraph and, consistent with such role, 

5 shall— 

6 ‘‘(i) establish a uniform process for 

7 disseminating to State Medicaid agencies 

8 information under this title impacting con9 tracts between such agencies and such 

10 plans under this subsection; and 

11 ‘‘(ii) establish basic resources for 

12 States interested in exploring such plans 

13 as a platform for integration, such as a 

14 model contract or other tools to achieve 

15 those goals. 

16 ‘‘(B) UNIFIED GRIEVANCES AND APPEALS

17 PROCESS.— 

18 ‘‘(i) IN GENERAL.—Not later than 

19 April 1, 2020, the Secretary shall establish 

20 procedures, to the extent feasible, unifying 

21 grievances and appeals procedures under 

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

23 1902(a)(5), and 1932(b)(4) for items and 

24 services provided by specialized MA plans 

25 for special needs individuals described in 


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

2 and title XIX. The Secretary shall solicit 

3 comment in developing such procedures 

4 from States, plans, beneficiaries and their 

5 representatives, and other relevant stake6 holders. 

7 ‘‘(ii) PROCEDURES.—The procedures 

8 established under clause (i) shall be in9 cluded in the plan contract under para10 graph (3)(D) and shall— 

11 ‘‘(I) adopt the provisions for the 

12 enrollee that are most protective for 

13 the enrollee and, to the extent feasible 

14 as determined by the Secretary, are 

15 compatible with unified timeframes 

16 and consolidated access to external re17 view under an integrated process; 

18 ‘‘(II) take into account dif19 ferences in State plans under title 

20 XIX to the extent necessary; 

21 ‘‘(III) be easily navigable by an 

22 enrollee; and 

23 ‘‘(IV) include the elements de24 scribed in clause (iii), as applicable. 


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1 ‘‘(iii) ELEMENTS DESCRIBED.—Both 

2 unified appeals and unified grievance pro3 cedures shall include, as applicable, the fol4 lowing elements described in this clause: 

5 ‘‘(I) Single written notification of 

6 all applicable grievances and appeal 

7 rights under this title and title XIX. 

8 For purposes of this subparagraph, 

9 the Secretary may waive the require10 ments under section 1852(g)(1)(B) 

11 when the specialized MA plan covers 

12 items or services under this part or 

13 under title XIX. 

14 ‘‘(II) Single pathways for resolu15 tion of any grievance or appeal related 

16 to a particular item or service pro17 vided by specialized MA plans for spe18 cial needs individuals described in 

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

20 title and title XIX. 

21 ‘‘(III) Notices written in plain 

22 language and available in a language 

23 and format that is accessible to the 

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1 guages that are prevalent in the serv2 ice area of the specialized MA plan. 

3 ‘‘(IV) Unified timeframes for 

4 grievances and appeals processes, 

5 such as an individual’s filing of a 

6 grievance or appeal, a plan’s acknowl7 edgment and resolution of a grievance 

8 or appeal, and notification of decisions 

9 with respect to a grievance or appeal. 

10 ‘‘(V) Requirements for how the 

11 plan must process, track, and resolve 

12 grievances and appeals, to ensure 

13 beneficiaries are notified on a timely 

14 basis of decisions that are made 

15 throughout the grievance or appeals 

16 process and are able to easily deter17 mine the status of a grievance or ap18 peal. 

19 ‘‘(iv) CONTINUATION OF BENEFITS

20 PENDING APPEAL.—The unified procedures 

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

22 benefits under parts A and B and title 

23 XIX subject to appeal under such proce24 dures, incorporate provisions under current 

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1 vide continuation of benefits pending ap2 peal under this title and title XIX. 

3 ‘‘(C) REQUIREMENT FOR UNIFIED GRIEV4 ANCES AND APPEALS.—For 2021 and subse5 quent years, the contract of a specialized MA 

6 plan for special needs individuals described in 

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

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

9 the use of unified grievances and appeals proce10 dures as described in subparagraph (B). 

11 ‘‘(D) REQUIREMENTS FOR INTEGRA12 TION.—For 2021 and subsequent years, a spe13 cialized MA plan for special needs individuals 

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

15 one or more of the following requirements, to 

16 the extent permitted under State law, for inte17 gration of benefits under this title and title 

18 XIX: 

19 ‘‘(i) The specialized MA plan must 

20 meet the requirements of contracting with 

21 the State Medicaid agency described in 

22 paragraph (3)(D) in addition to coordi23 nating long-term services and supports or 

24 behavioral health services, or both, by 

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1 quirements determined by the Secretary 

2 through the Federal Coordinated Health 

3 Care Office established under section 2602 

4 of the Patient Protection and Affordable 

5 Care Act based on input from stake6 holders, such as notifying the State in a 

7 timely manner of hospitalizations, emer8 gency room visits, and hospital or nursing 

9 home discharges of enrollees, assigning one 

10 primary care provider for each enrollee, or 

11 sharing data that would benefit the coordi12 nation of items and services under this 

13 title and the State plan under title XIX. 

14 Such minimum set of requirements must 

15 be included in the contract of the special16 ized MA plan with the State Medicaid 

17 agency under such paragraph. 

18 ‘‘(ii) The specialized MA plan must 

19 meet the requirements of a fully integrated 

20 plan described in section 

21 1853(a)(1)(B)(iv)(II) (other than the re22 quirement that the plan have similar aver23 age levels of frailty, as determined by the 

24 Secretary, as the PACE program), or enter 

25 into a capitated contract with the State 


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1 Medicaid agency to provide long-term serv2 ices and supports or behavioral health 

3 services, or both. 

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

5 is enrolled in both the specialized MA plan 

6 and a Medicaid managed care organization 

7 (as defined in section 1903(m)(1)(A)) pro8 viding long-term services and supports or 

9 behavioral health services that have the 

10 same parent organization, the parent orga11 nization offering both the specialized MA 

12 plan and the Medicaid managed care plan 

13 must assume clinical and financial respon14 sibility for benefits provided under this 

15 title and title XIX.’’. 

16 (2) CONFORMING AMENDMENT TO RESPON17 SIBILITIES OF FEDERAL COORDINATED HEALTH

18 CARE OFFICE.—Section 2602(d) of the Patient Pro19 tection and Affordable Care Act (42 U.S.C. 

20 1315b(d)) is amended by adding at the end the fol21 lowing new paragraphs: 

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

23 under subsection (f)(8)(A) of section 1859 of the So24 cial Security Act (42 U.S.C. 1395w–28) with respect 

25 to the integration of specialized MA plans for special 


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1 needs individuals described in subsection 

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

3 ‘‘(7) To be responsible for developing regula4 tions and guidance related to the implementation of 

5 a unified grievance and appeals process as described 

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

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

8 28(f)(8)).’’. 

9 (c) IMPROVEMENTS TO SEVERE OR DISABLING

10 CHRONIC CONDITION SNPS.— 

11 (1) CARE MANAGEMENT REQUIREMENTS.—Sec12 tion 1859(f)(5) of the Social Security Act (42 

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

14 (A) by striking ‘‘ALL SNPS.—The require15 ments’’ and inserting ‘‘ALL SNPS.— 

16 ‘‘(A) IN GENERAL.—Subject to subpara17 graph (B), the requirements’’; 

18 (B) by redesignating subparagraphs (A) 

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

20 indenting appropriately; 

21 (C) in clause (ii), as redesignated by sub22 paragraph (B), by redesignating clauses (i) 

23 through (iii) as subclauses (I) through (III), re24 spectively, and indenting appropriately; and 


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

2 subparagraph: 

3 ‘‘(B) IMPROVEMENTS TO CARE MANAGE4 MENT REQUIREMENTS FOR SEVERE OR DIS5 ABLING CHRONIC CONDITION SNPS.—For 2020 

6 and subsequent years, in the case of a special7 ized MA plan for special needs individuals de8 scribed in subsection (b)(6)(B)(iii), the require9 ments described in this paragraph include the 

10 following: 

11 ‘‘(i) The interdisciplinary team under 

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

13 of providers with demonstrated expertise, 

14 including training in an applicable spe15 cialty, in treating individuals similar to the 

16 targeted population of the plan. 

17 ‘‘(ii) Requirements developed by the 

18 Secretary to provide face-to-face encoun19 ters with individuals enrolled in the plan 

20 not less frequently than on an annual 

21 basis. 

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

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

24 results of the initial assessment and an25 nual reassessment under clause (ii)(I) of 


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1 such subparagraph of each individual en2 rolled in the plan are addressed in the indi3 vidual’s individualized care plan under 

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

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

6 and approval of such model of care, the 

7 Secretary shall take into account whether 

8 the plan fulfilled the previous year’s goals 

9 (as required under the model of care). 

10 ‘‘(v) The Secretary shall establish a 

11 minimum benchmark for each element of 

12 the model of care of a plan. The Secretary 

13 shall only approve a plan’s model of care 

14 under this paragraph if each element of 

15 the model of care meets the minimum 

16 benchmark applicable under the preceding 

17 sentence.’’. 

18 (2) REVISIONS TO THE DEFINITION OF A SE19 VERE OR DISABLING CHRONIC CONDITIONS SPECIAL20 IZED NEEDS INDIVIDUAL.— 

21 (A) IN GENERAL.—Section 

22 1859(b)(6)(B)(iii) of the Social Security Act 

23 (42 U.S.C. 1395w–28(b)(6)(B)(iii)) is amend24 ed— 


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

3 ‘‘(I) before January 1, 2022, 

4 have’’; 

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

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

7 and inserting ‘‘; and’’; and 

8 (iii) by adding at the end the fol9 lowing new subclause: 

10 ‘‘(II) on or after January 1, 

11 2022, have one or more comorbid and 

12 medically complex chronic conditions 

13 that is life threatening or significantly 

14 limits overall health or function, have 

15 a high risk of hospitalization or other 

16 adverse health outcomes, and require 

17 intensive care coordination and that is 

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

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

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

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

24 ‘‘(9) LIST OF CONDITIONS FOR CLARIFICATION

25 OF THE DEFINITION OF A SEVERE OR DISABLING


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1 CHRONIC CONDITIONS SPECIALIZED NEEDS INDI2 VIDUAL.— 

3 ‘‘(A) IN GENERAL.—Not later than De4 cember 31, 2020, and every 5 years thereafter, 

5 the Secretary shall convene a panel of clinical 

6 advisors to establish and update a list of condi7 tions that meet each of the following criteria: 

8 ‘‘(i) Conditions that meet the defini9 tion of a severe or disabling chronic condi10 tion under subsection (b)(6)(B)(iii) on or 

11 after January 1, 2022. 

12 ‘‘(ii) Conditions that require prescrip13 tion drugs, providers, and models of care 

14 that are unique to the specific population 

15 of enrollees in a specialized MA plan for 

16 special needs individuals described in such 

17 subsection on or after such date and— 

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

19 enrollment in, such a specialized MA 

20 plan for special needs individuals, in21 dividuals with such condition would 

22 have a reasonable expectation of slow23 ing or halting the progression of the 

24 disease, improving health outcomes 

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1 viduals diagnosed with such condition 

2 compared to available options of care 

3 other than through such a specialized 

4 MA plan for special needs individuals; 

5 or 

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

7 general population of beneficiaries 

8 under this title or a disproportionally 

9 high per-beneficiary cost under this 

10 title. 

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

12 updating the list under subparagraph (A), the 

13 panel shall take into account the availability of 

14 varied benefits, cost-sharing, and supplemental 

15 benefits under the model described in para16 graph (2) of section 1859(h), including the ex17 pansion under paragraph (1) of such section.’’. 

18 (d) QUALITY MEASUREMENT AT THE PLAN LEVEL

19 FOR SNPS AND DETERMINATION OF FEASIBILITY OF

20 QUALITY MEASUREMENT AT THE PLAN LEVEL FOR ALL

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

22 (42 U.S.C. 1395w–23(o)) is amended by adding at the end 

23 the following new paragraphs: 

24 ‘‘(6) QUALITY MEASUREMENT AT THE PLAN

25 LEVEL FOR SNPS.— 


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

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

4 under this subsection, quality measures at the 

5 plan level for specialized MA plans for special 

6 needs individuals instead of at the contract 

7 level. 

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

9 quality measurement at the plan level under 

10 this paragraph, the Secretary shall— 

11 ‘‘(i) take into consideration the min12 imum number of enrollees in a specialized 

13 MA plan for special needs individuals in 

14 order to determine if a statistically signifi15 cant or valid measurement of quality at 

16 the plan level is possible under this para17 graph; 

18 ‘‘(ii) take into consideration the im19 pact of such application on plans that 

20 serve a disproportionate number of individ21 uals dually eligible for benefits under this 

22 title and under title XIX; 

23 ‘‘(iii) if quality measures are reported 

24 at the plan level, ensure that MA plans are 


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1 not required to provide duplicative infor2 mation; and 

3 ‘‘(iv) ensure that such reporting does 

4 not interfere with the collection of encoun5 ter data submitted by MA organizations or 

6 the administration of any changes to the 

7 program under this part as a result of the 

8 collection of such data. 

9 ‘‘(C) APPLICATION.—If the Secretary ap10 plies quality measurement at the plan level 

11 under this paragraph, such quality measure12 ment may include Medicare Health Outcomes 

13 Survey (HOS), Healthcare Effectiveness Data 

14 and Information Set (HEDIS), Consumer As15 sessment of Healthcare Providers and Systems 

16 (CAHPS) measures and quality measures under 

17 part D. 

18 ‘‘(7) DETERMINATION OF FEASIBILITY OF

19 QUALITY MEASUREMENT AT THE PLAN LEVEL FOR

20 ALL MA PLANS.— 

21 ‘‘(A) DETERMINATION OF FEASIBILITY.— 

22 The Secretary shall determine the feasibility of 

23 requiring reporting of data under section 

24 1852(e) for, and applying under this subsection, 


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1 quality measures at the plan level for all MA 

2 plans under this part. 

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

4 making a determination under subparagraph 

5 (A), the Secretary shall consider requiring such 

6 reporting and applying such quality measures 

7 at the plan level as described in such subpara8 graph.’’. 

9 (e) GAO STUDY AND REPORT ON STATE-LEVEL IN10 TEGRATION BETWEEN DUAL SNPS AND MEDICAID.— 

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

12 United States (in this paragraph referred to as the 

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

14 State-level integration between specialized MA plans 

15 for special needs individuals described in subsection 

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

17 Act (42 U.S.C. 1395w–28) and the Medicaid pro18 gram under title XIX of such Act (42 U.S.C. 1396 

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

20 following: 

21 (A) The characteristics of States in which 

22 the State agency responsible for administering 

23 the State plan under such title XIX has a con24 tract with such a specialized MA plan and that 

25 delivers long-term services and supports under 


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1 the State plan under such title XIX through a 

2 managed care program, including the require3 ments under such State plan with respect to 

4 long-term services and supports. 

5 (B) The types of such specialized MA 

6 plans, which may include the following: 

7 (i) A plan described in section 

8 1853(a)(1)(B)(iv)(II) of such Act (42 

9 U.S.C. 1395w–23(a)(1)(B)(iv)(II)). 

10 (ii) A plan that meets the require11 ments described in subsection (f)(3)(D) of 

12 such section 1859. 

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

14 that also meets additional requirements es15 tablished by the State. 

16 (C) The characteristics of individuals en17 rolled in such specialized MA plans. 

18 (D) As practicable, the following with re19 spect to State programs for the delivery of long20 term services and supports under such title 

21 XIX through a managed care program: 

22 (i) Which populations of individuals 

23 are eligible to receive such services and 

24 supports. 


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1 (ii) Whether all such services and sup2 ports are provided on a capitated basis or 

3 if any of such services and supports are 

4 carved out and provided through fee-for5 service. 

6 (E) How the availability and variation of 

7 integration arrangements of such specialized 

8 MA plans offered in States affects spending, 

9 service delivery options, access to community10 based care, and utilization of care. 

11 (F) The efforts of State Medicaid pro12 grams to transition dually eligible beneficiaries 

13 receiving long-term services and supports 

14 (LTSS) from institutional settings to home and 

15 community-based settings and related financial 

16 impacts of such transitions. 

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

18 date of the enactment of this Act, the Comptroller 

19 General shall submit to Congress a report containing 

20 the results of the study conducted under paragraph 

21 (1), together with recommendations for such legisla22 tion and administrative action as the Comptroller 

23 General determines appropriate. 


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1 TITLE III—EXPANDING 

2 INNOVATION AND TECHNOLOGY 

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

4 CHRONICALLY ILL MEDICARE ADVANTAGE 

5 ENROLLEES. 

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

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

8 new subsection: 

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

10 ADVANTAGE VALUE-BASED INSURANCE DESIGN.— 

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

12 described in paragraph (2) proposed to be tested 

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

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

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

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

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

19 would allow Medicare Advantage plans the option to 

20 propose and design benefit structures that vary ben21 efits, cost-sharing, and supplemental benefits offered 

22 to enrollees with specific chronic diseases proposed 

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

24 Michigan, Indiana, Tennessee, Alabama, Pennsyl25 vania, and Massachusetts. 


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

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

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

5 such model as expanded under paragraph (1), begin6 ning January 1, 2022, but shall not apply to such 

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

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

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

10 design, implement, and evaluate the model described 

11 in paragraph (2), as expanded under paragraph 

12 (1).’’. 

13 SEC. 302. EXPANDING SUPPLEMENTAL BENEFITS TO MEET 

14 THE NEEDS OF CHRONICALLY ILL MEDICARE 

15 ADVANTAGE ENROLLEES. 

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

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

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

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

20 and 

21 (2) by adding at the end the following new sub22 paragraph: 

23 ‘‘(D) EXPANDING SUPPLEMENTAL BENE24 FITS TO MEET THE NEEDS OF CHRONICALLY

25 ILL ENROLLEES.— 


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1 ‘‘(i) IN GENERAL.—For plan year 

2 2020 and subsequent plan years, in addi3 tion to any supplemental health care bene4 fits otherwise provided under this para5 graph, an MA plan may provide supple6 mental benefits described in clause (ii) to 

7 a chronically ill enrollee (as defined in 

8 clause (iii)). 

9 ‘‘(ii) SUPPLEMENTAL BENEFITS DE10 SCRIBED.— 

11 ‘‘(I) IN GENERAL.—Supplemental 

12 benefits described in this clause are 

13 supplemental benefits that, with re14 spect to a chronically ill enrollee, have 

15 a reasonable expectation of improving 

16 or maintaining the health or overall 

17 function of the chronically ill enrollee 

18 and may not be limited to being pri19 marily health related benefits. 

20 ‘‘(II) AUTHORITY TO WAIVE UNI21 FORMITY REQUIREMENTS.—The Sec22 retary may, only with respect to sup23 plemental benefits provided to a 

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1 quirement under subsection (d)(1)(A), 

2 as determined appropriate by the Sec3 retary. 

4 ‘‘(iii) CHRONICALLY ILL ENROLLEE

5 DEFINED.—In this subparagraph, the term 

6 ‘chronically ill enrollee’ means an enrollee 

7 in an MA plan that the Secretary deter8 mines— 

9 ‘‘(I) has one or more comorbid 

10 and medically complex chronic condi11 tions that is life threatening or signifi12 cantly limits the overall health or 

13 function of the enrollee; 

14 ‘‘(II) has a high risk of hos15 pitalization or other adverse health 

16 outcomes; and 

17 ‘‘(III) requires intensive care co18 ordination.’’. 

19 (b) GAO STUDY AND REPORT.— 

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

21 United States (in this subsection referred to as the 

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

23 supplemental benefits provided to enrollees in Medi24 care Advantage plans under part C of title XVIII of 

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1 able, such study shall include an analysis of the fol2 lowing: 

3 (A) The type of supplemental benefits pro4 vided to such enrollees, the total number of en5 rollees receiving each supplemental benefit, and 

6 whether the supplemental benefit is covered by 

7 the standard benchmark cost of the benefit or 

8 with an additional premium. 

9 (B) The frequency in which supplemental 

10 benefits are utilized by such enrollees. 

11 (C) The impact supplemental benefits have 

12 on— 

13 (i) indicators of the quality of care re14 ceived by such enrollees, including overall 

15 health and function of the enrollees; 

16 (ii) the utilization of items and serv17 ices for which benefits are available under 

18 the original Medicare fee-for-service pro19 gram option under parts A and B of such 

20 title XVIII by such enrollees; and 

21 (iii) the amount of the bids submitted 

22 by Medicare Advantage Organizations for 

23 Medicare Advantage plans under such part 

24 C. 


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

2 date of the enactment of this Act, the Comptroller 

3 General shall submit to Congress a report containing 

4 the results of the study conducted under paragraph 

5 (1), together with recommendations for such legisla6 tion and administrative action as the Comptroller 

7 General determines appropriate. 

8 SEC. 303. INCREASING CONVENIENCE FOR MEDICARE AD9 VANTAGE ENROLLEES THROUGH TELE10 HEALTH. 

11 (a) IN GENERAL.—Section 1852 of the Social Secu12 rity Act (42 U.S.C. 1395w–22) is amended— 

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

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

15 (2) by adding at the end the following new sub16 section: 

17 ‘‘(m) PROVISION OF ADDITIONAL TELEHEALTH

18 BENEFITS.— 

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

20 and subsequent plan years, subject to the require21 ments of paragraph (3), an MA plan may provide 

22 additional telehealth benefits (as defined in para23 graph (2)) to individuals enrolled under this part. 

24 ‘‘(2) ADDITIONAL TELEHEALTH BENEFITS DE25 FINED.— 


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

2 subsection and section 1854— 

3 ‘‘(i) DEFINITION.—The term ‘addi4 tional telehealth benefits’ means services— 

5 ‘‘(I) for which benefits are avail6 able under part B, including services 

7 for which payment is not made under 

8 section 1834(m) due to the conditions 

9 for payment under such section; and 

10 ‘‘(II) that are identified as clini11 cally appropriate to furnish using elec12 tronic information and telecommuni13 cations technology when a physician 

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

15 practitioner (described in section 

16 1842(b)(18)(C)) providing the service 

17 is not at the same location as the plan 

18 enrollee. 

19 ‘‘(ii) EXCLUSION OF CAPITAL AND IN20 FRASTRUCTURE COSTS AND INVEST21 MENTS.—The term ‘additional telehealth 

22 benefits’ does not include capital and infra23 structure costs and investments relating to 

24 such benefits. 


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

2 November 30, 2018, the Secretary shall solicit 

3 comments on— 

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

5 (including those provided through supple6 mental health care benefits) should be con7 sidered to be additional telehealth benefits; 

8 and 

9 ‘‘(ii) the requirements for the provi10 sion or furnishing of such benefits (such as 

11 licensure, training, and coordination re12 quirements). 

13 ‘‘(3) REQUIREMENTS FOR ADDITIONAL TELE14 HEALTH BENEFITS.—The Secretary shall specify re15 quirements for the provision or furnishing of addi16 tional telehealth benefits, including with respect to 

17 the following: 

18 ‘‘(A) Physician or practitioner licensure 

19 and other requirements such as specific train20 ing. 

21 ‘‘(B) Factors necessary to ensure the co22 ordination of such benefits with items and serv23 ices furnished in-person. 

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

25 the Secretary. 


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1 ‘‘(4) ENROLLEE CHOICE.—If an MA plan pro2 vides a service as an additional telehealth benefit (as 

3 defined in paragraph (2))— 

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

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

6 not only as an additional telehealth benefit); 

7 and 

8 ‘‘(B) an individual enrollee shall have dis9 cretion as to whether to receive such service 

10 through the in-person visit or as an additional 

11 telehealth benefit. 

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

13 this subsection and section 1854, additional tele14 health benefits shall be treated as if they were bene15 fits under the original Medicare fee-for-service pro16 gram option. 

17 ‘‘(6) CONSTRUCTION.—Nothing in this sub18 section shall be construed as affecting the require19 ment under subsection (a)(1) that MA plans provide 

20 enrollees with items and services (other than hospice 

21 care) for which benefits are available under parts A 

22 and B, including benefits available under section 

23 1834(m).’’. 

24 (b) CLARIFICATION REGARDING INCLUSION IN BID

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1 curity Act (42 U.S.C. 1395w–24(a)(6)(A)(ii)(I)) is 

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

3 subsequent plan years, the provision of additional tele4 health benefits as described in section 1852(m)’’ before 

5 the semicolon at the end. 

6 SEC. 304. PROVIDING ACCOUNTABLE CARE ORGANIZA7 TIONS THE ABILITY TO EXPAND THE USE OF 

8 TELEHEALTH. 

9 (a) IN GENERAL.—Section 1899 of the Social Secu10 rity Act (42 U.S.C. 1395jjj) is amended by adding at the 

11 end the following new subsection: 

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

13 THE USE OF TELEHEALTH SERVICES.— 

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

15 services for which payment would otherwise be made 

16 under this title furnished on or after January 1, 

17 2020, for purposes of this subsection only, the fol18 lowing shall apply with respect to such services fur19 nished by a physician or practitioner participating in 

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

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

22 applicable ACO: 

23 ‘‘(A) INCLUSION OF HOME AS ORIGINATING

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


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1 beneficiary shall be treated as an originating 

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

3 ‘‘(B) NO APPLICATION OF GEOGRAPHIC

4 LIMITATION.—The geographic limitation under 

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

6 respect to an originating site described in sec7 tion 1834(m)(4)(C)(ii) (including the home of a 

8 beneficiary under subparagraph (A)), subject to 

9 State licensing requirements. 

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

11 ‘‘(A) APPLICABLE ACO.—The term ‘appli12 cable ACO’ means an ACO participating in a 

13 model tested or expanded under section 1115A 

14 or under this section— 

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

16 model— 

17 ‘‘(I) described in section 

18 425.600(a) of title 42, Code of Fed19 eral Regulations; or 

20 ‘‘(II) tested or expanded under 

21 section 1115A; and 

22 ‘‘(ii) for which Medicare fee-for-serv23 ice beneficiaries are assigned to the ACO 

24 using a prospective assignment method, as 

25 determined appropriate by the Secretary. 


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1 ‘‘(B) HOME.—The term ‘home’ means, 

2 with respect to a Medicare fee-for-service bene3 ficiary, the place of residence used as the home 

4 of the beneficiary. 

5 ‘‘(3) TELEHEALTH SERVICES RECEIVED IN THE

6 HOME.—In the case of telehealth services described 

7 in paragraph (1) where the home of a Medicare fee8 for-service beneficiary is the originating site, the fol9 lowing shall apply: 

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

11 no facility fee paid to the originating site under 

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

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

14 No payment may be made for such services that 

15 are inappropriate to furnish in the home setting 

16 such as services that are typically furnished in 

17 inpatient settings such as a hospital.’’. 

18 (b) STUDY AND REPORT.— 

19 (1) STUDY.— 

20 (A) IN GENERAL.—The Secretary of 

21 Health and Human Services (in this subsection 

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

23 study on the implementation of section 1899(l) 

24 of the Social Security Act, as added by sub25 section (a). Such study shall include an analysis 


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1 of the utilization of, and expenditures for, tele2 health services under such section. 

3 (B) COLLECTION OF DATA.—The Sec4 retary may collect such data as the Secretary 

5 determines necessary to carry out the study 

6 under this paragraph. 

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

8 the Secretary shall submit to Congress a report con9 taining the results of the study conducted under 

10 paragraph (1), together with recommendations for 

11 such legislation and administrative action as the 

12 Secretary determines appropriate. 

13 SEC. 305. EXPANDING THE USE OF TELEHEALTH FOR INDI14 VIDUALS WITH STROKE. 

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

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

17 amended by adding at the end the following new para18 graph: 

19 ‘‘(6) TREATMENT OF STROKE TELEHEALTH

20 SERVICES.— 

21 ‘‘(A) NON-APPLICATION OF ORIGINATING

22 SITE REQUIREMENTS.—The requirements de23 scribed in paragraph (4)(C) shall not apply with 

24 respect to telehealth services furnished on or 

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1 tion of an acute stroke, as determined by the 

2 Secretary. 

3 ‘‘(B) NO ORIGINATING SITE FACILITY

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

5 does not meet the requirements described in 

6 paragraph (4)(C), the Secretary shall not pay 

7 an originating site facility fee (as described in 

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

9 respect to such telehealth services.’’. 

10 TITLE IV—IDENTIFYING THE 

11 CHRONICALLY ILL POPULATION 

12 SEC. 401. PROVIDING FLEXIBILITY FOR BENEFICIARIES TO 

13 BE PART OF AN ACCOUNTABLE CARE ORGA14 NIZATION. 

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

16 1395jjj(c)) is amended— 

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

18 subparagraphs (A) and (B), respectively, and indent19 ing appropriately; 

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

21 inserting ‘‘ACOS.— 

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

23 the Secretary’’; and 

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

25 paragraph: 


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1 ‘‘(2) PROVIDING FLEXIBILITY.— 

2 ‘‘(A) CHOICE OF PROSPECTIVE ASSIGN3 MENT.—For each agreement period (effective 

4 for agreements entered into or renewed on or 

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

6 ACO established under the program is in a 

7 Track that provides for the retrospective assign8 ment of Medicare fee-for-service beneficiaries to 

9 the ACO, the Secretary shall permit the ACO 

10 to choose to have Medicare fee-for-service bene11 ficiaries assigned prospectively, rather than ret12 rospectively, to the ACO for an agreement pe13 riod. 

14 ‘‘(B) ASSIGNMENT BASED ON VOLUNTARY

15 IDENTIFICATION BY MEDICARE FEE-FOR-SERV16 ICE BENEFICIARIES.— 

17 ‘‘(i) IN GENERAL.—For performance 

18 year 2018 and each subsequent perform19 ance year, if a system is available for elec20 tronic designation, the Secretary shall per21 mit a Medicare fee-for-service beneficiary 

22 to voluntarily identify an ACO professional 

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1 ficiary to an ACO, as determined by the 

2 Secretary. 

3 ‘‘(ii) NOTIFICATION PROCESS.—The 

4 Secretary shall establish a process under 

5 which a Medicare fee-for-service bene6 ficiary is— 

7 ‘‘(I) notified of their ability to 

8 make an identification described in 

9 clause (i); and 

10 ‘‘(II) informed of the process by 

11 which they may make and change 

12 such identification. 

13 ‘‘(iii) SUPERSEDING CLAIMS-BASED

14 ASSIGNMENT.—A voluntary identification 

15 by a Medicare fee-for-service beneficiary 

16 under this subparagraph shall supersede 

17 any claims-based assignment otherwise de18 termined by the Secretary.’’. 


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1 TITLE V—EMPOWERING INDI2 VIDUALS AND CAREGIVERS IN 

3 CARE DELIVERY 

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

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

9 304(a), is amended— 

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

11 the following new subparagraph: 

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

13 ACO Beneficiary Incentive Program pursuant 

14 to subsection (m) shall apply to the Secretary 

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

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

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

22 ‘‘(1) PROGRAM.— 

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

24 Medicare fee-for-service beneficiaries to obtain 

25 medically necessary primary care services, an 


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1 ACO participating under this section under a 

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

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

4 ACO Beneficiary Incentive Program to provide 

5 incentive payments to such beneficiaries who 

6 are furnished qualifying services in accordance 

7 with this subsection. The Secretary shall permit 

8 such an ACO to establish such a program at 

9 the Secretary’s discretion and subject to such 

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

13 ‘‘(B) IMPLEMENTATION.—The Secretary 

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

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

17 no later than January 1, 2020. 

18 ‘‘(2) CONDUCT OF PROGRAM.— 

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

22 conducted for such period (of not less than 1 

23 year) as the Secretary may approve. 

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


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1 shall provide incentive payments to all of the 

2 following Medicare fee-for-service beneficiaries 

3 who are furnished qualifying services by the 

4 ACO: 

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

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

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

13 the ACO. 

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

16 Medicare fee-for-service beneficiaries who 

17 are assigned to the ACO, as determined by 

18 the Secretary. 

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

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

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

23 any successor regulation), with respect to which 

24 coinsurance applies under part B, furnished 

25 through an ACO by— 


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1 ‘‘(i) an ACO professional described in 

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

3 care specialty designation included in the 

4 definition of primary care physician under 

5 section 425.20 of title 42, Code of Federal 

6 Regulations (or any successor regulation); 

7 ‘‘(ii) an ACO professional described in 

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

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

11 are defined in section 1861(aa)). 

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

13 payment made by an ACO pursuant to an ACO 

14 Beneficiary Incentive Program established 

15 under this subsection shall be— 

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

17 such maximum amount updated annually 

18 by the percentage increase in the consumer 

19 price index for all urban consumers 

20 (United States city average) for the 12- 

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

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

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


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1 (B) without regard to enrollment of such a 

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

4 State Medicaid plan under title XIX or a 

5 waiver of such a plan, or in any other 

6 health insurance policy or health benefit 

7 plan; 

8 ‘‘(iii) made for each qualifying service 

9 furnished to such a beneficiary described 

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

11 during a period specified by the Secretary; 

12 and 

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

14 a qualifying service is furnished to such a 

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

16 subparagraph (B). 

17 ‘‘(E) NO SEPARATE PAYMENTS FROM THE

18 SECRETARY.—The Secretary shall not make 

19 any separate payment to an ACO for the costs, 

20 including incentive payments, of carrying out 

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

23 subparagraph shall be construed as prohibiting 

24 an ACO from using shared savings received 


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

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

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

8 expenditures, and shared savings under this 

9 section. 

10 ‘‘(G) REPORTING REQUIREMENTS.—An 

11 ACO conducting an ACO Beneficiary Incentive 

12 Program under this subsection shall, at such 

13 times and in such format as the Secretary may 

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

17 frequency of incentive payments made and the 

18 number of Medicare fee-for-service beneficiaries 

19 receiving such payments. 

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

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

23 time for reasons determined appropriate by the 

24 Secretary. 


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

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

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

6 ‘‘(A) determining eligibility for benefits or 

7 assistance (or the amount or extent of benefits 

8 or assistance) under any Federal program or 

9 under any State or local program financed in 

10 whole or in part with Federal funds; or 

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

12 taxation.’’; 

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

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

16 and 

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

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

20 (d)(4)’’. 

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

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

23 7b(b)(3)) is amended— 

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


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

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

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

6 Medicare fee-for-service beneficiary by an ACO 

7 under an ACO Beneficiary Incentive Program 

8 established under subsection (m) of section 

9 1899, if the payment is made in accordance 

10 with the requirements of such subsection and 

11 meets such other conditions as the Secretary 

12 may establish.’’. 

13 (c) EVALUATION AND REPORT.— 

14 (1) EVALUATION.—The Secretary of Health 

15 and Human Services (in this subsection referred to 

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

17 the ACO Beneficiary Incentive Program established 

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

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

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

21 an analysis of the impact of the implementation of 

22 the Program on expenditures and beneficiary health 

23 outcomes under title XVIII of the Social Security 

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


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

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

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

7 SEC. 502. GAO STUDY AND REPORT ON LONGITUDINAL 

8 COMPREHENSIVE CARE PLANNING SERVICES 

9 UNDER MEDICARE PART B. 

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

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

12 program under title XVIII of the Social Security Act of 

13 a payment code for a visit for longitudinal comprehensive 

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

16 available: 

17 (1) The frequency with which services similar to 

18 longitudinal comprehensive care planning services 

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

21 services, whether Medicare reimbursement is being 

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

23 codes those services are being reimbursed. 

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


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1 overlap, and could therefore result in duplicative 

2 payment, with services covered under the hospice 

3 benefit as well as the chronic care management code, 

4 evaluation and management codes, or other codes 

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

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

9 other applicable providers working with a Medicare 

10 beneficiary to engage in the care planning process 

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

13 and provide such documentation to other providers 

14 and the beneficiary or the beneficiary’s representa15 tive. 

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

17 provider furnishing longitudinal comprehensive care 

18 planning services, accessing the care plan and asso19 ciated documentation for use related to the care of 

20 the Medicare beneficiary. 

21 (5) Potential options for ensuring that applica22 ble providers are notified of a patient’s existing lon23 gitudinal care plan and that applicable providers 

24 consider that plan in making their treatment deciVerDate Sep 11 2014 03:58 Dec 12, 2017 Jkt 079200 PO 00000 Frm 00051 Fmt 6652 Sfmt 6201 E:\BILLS\H4579.IH H4579

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1 sions, and what the challenges might be in imple2 menting such options. 

3 (6) Stakeholder’s views on the need for the de4 velopment of quality metrics with respect to longitu5 dinal comprehensive care planning services, such as 

6 measures related to— 

7 (A) the process of eliciting input from the 

8 Medicare beneficiary or from a legally author9 ized representative and documenting in the 

10 medical record the patient-directed care plan; 

11 (B) the effectiveness and patient12 centeredness of the care plan in organizing de13 livery of services consistent with the plan; 

14 (C) the availability of the care plan and as15 sociated documentation to other providers that 

16 care for the beneficiary; and 

17 (D) the extent to which the beneficiary re18 ceived services and support that is free from 

19 discrimination based on advanced age, disability 

20 status, or advanced illness. 

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

22 metrics would provide information on— 

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

24 the beneficiary; 

25 (B) the documentation of the care plan; 


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1 (C) services furnished to the beneficiary; 

2 and 

3 (D) outcomes of treatment. 

4 (8) Stakeholder’s views on— 

5 (A) the type of training and education 

6 needed for applicable providers, individuals, and 

7 caregivers in order to facilitate longitudinal 

8 comprehensive care planning services; 

9 (B) the types of providers of services and 

10 suppliers that should be included in the inter11 disciplinary team of an applicable provider; and 

12 (C) the characteristics of Medicare bene13 ficiaries that would be most appropriate to re14 ceive longitudinal comprehensive care planning 

15 services, such as individuals with advanced dis16 ease and individuals who need assistance with 

17 multiple activities of daily living. 

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

19 which longitudinal comprehensive care planning 

20 services should be furnished. 

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

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

23 shall submit to Congress a report containing the results 

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


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1 recommendations for such legislation and administrative 

2 action as the Comptroller General determines appropriate. 

3 (c) DEFINITIONS.—In this section: 

4 (1) APPLICABLE PROVIDER.—The term ‘‘appli5 cable provider’’ means a hospice program (as defined 

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

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

8 of services (as defined in subsection (u) of such sec9 tion) or supplier (as defined in subsection (d) of 

10 such section) that— 

11 (A) furnishes longitudinal comprehensive 

12 care planning services through an interdiscipli13 nary team; and 

14 (B) meets such other requirements as the 

15 Secretary may determine to be appropriate. 

16 (2) COMPTROLLER GENERAL.—The term 

17 ‘‘Comptroller General’’ means the Comptroller Gen18 eral of the United States. 

19 (3) INTERDISCIPLINARY TEAM.—The term 

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

21 (A) includes the personnel described in 

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

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

24 other clergy; and 


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1 (C) may include other direct care per2 sonnel. 

3 (4) LONGITUDINAL COMPREHENSIVE CARE

4 PLANNING SERVICES.—The term ‘‘longitudinal com5 prehensive care planning services’’ means a vol6 untary shared decisionmaking process that is fur7 nished by an applicable provider through an inter8 disciplinary team and includes a conversation with 

9 Medicare beneficiaries who have received a diagnosis 

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

11 of such services is to discuss a longitudinal care plan 

12 that addresses the progression of the disease, treat13 ment options, the goals, values, and preferences of 

14 the beneficiary, and the availability of other re15 sources and social supports that may reduce the 

16 beneficiary’s health risks and promote self-manage17 ment and shared decisionmaking. 

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

19 the Secretary of Health and Human Services. 


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1 TITLE VI—OTHER POLICIES TO 

2 IMPROVE CARE FOR THE 

3 CHRONICALLY ILL 

4 SEC. 601. PROVIDING PRESCRIPTION DRUG PLANS WITH 

5 PARTS A AND B CLAIMS DATA TO PROMOTE 

6 THE APPROPRIATE USE OF MEDICATIONS 

7 AND IMPROVE HEALTH OUTCOMES. 

8 Section 1860D–4(c) of the Social Security Act (42 

9 U.S.C. 1395w–104(c)) is amended by adding at the end 

10 the following new paragraph: 

11 ‘‘(6) PROVIDING PRESCRIPTION DRUG PLANS

12 WITH PARTS A AND B CLAIMS DATA TO PROMOTE

13 THE APPROPRIATE USE OF MEDICATIONS AND IM14 PROVE HEALTH OUTCOMES.— 

15 ‘‘(A) PROCESS.—Subject to subparagraph 

16 (B), the Secretary shall establish a process 

17 under which a PDP sponsor of a prescription 

18 drug plan may submit a request for the Sec19 retary to provide the sponsor, on a periodic 

20 basis and in an electronic format, beginning in 

21 plan year 2020, data described in subparagraph 

22 (D) with respect to enrollees in such plan. Such 

23 data shall be provided without regard to wheth24 er such enrollees are described in clause (ii) of 

25 paragraph (2)(A). 


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1 ‘‘(B) PURPOSES.—A PDP sponsor may 

2 use the data provided to the sponsor pursuant 

3 to subparagraph (A) for any of the following 

4 purposes: 

5 ‘‘(i) To optimize therapeutic outcomes 

6 through improved medication use, as such 

7 phrase is used in clause (i) of paragraph 

8 (2)(A). 

9 ‘‘(ii) To improving care coordination 

10 so as to prevent adverse health outcomes, 

11 such as preventable emergency department 

12 visits and hospital readmissions. 

13 ‘‘(iii) For any other purpose deter14 mined appropriate by the Secretary. 

15 ‘‘(C) LIMITATIONS ON DATA USE.—A PDP 

16 sponsor shall not use data provided to the spon17 sor pursuant to subparagraph (A) for any of 

18 the following purposes: 

19 ‘‘(i) To inform coverage determina20 tions under this part. 

21 ‘‘(ii) To conduct retroactive reviews of 

22 medically accepted indications determina23 tions. 

24 ‘‘(iii) To facilitate enrollment changes 

25 to a different prescription drug plan or an 


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1 MA–PD plan offered by the same parent 

2 organization. 

3 ‘‘(iv) To inform marketing of benefits. 

4 ‘‘(v) For any other purpose that the 

5 Secretary determines is necessary to in6 clude in order to protect the identity of in7 dividuals entitled to, or enrolled for, bene8 fits under this title and to protect the se9 curity of personal health information. 

10 ‘‘(D) DATA DESCRIBED.—The data de11 scribed in this clause are standardized extracts 

12 (as determined by the Secretary) of claims data 

13 under parts A and B for items and services fur14 nished under such parts for time periods speci15 fied by the Secretary. Such data shall include 

16 data as current as practicable.’’. 

17 SEC. 602. GAO STUDY AND REPORT ON IMPROVING MEDI18 CATION SYNCHRONIZATION. 

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

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

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

22 Medicare prescription drug plans (MA–PD plans and 

23 standalone prescription drug plans) under part D of title 

24 XVIII of the Social Security Act and private payors use 

25 programs that synchronize pharmacy dispensing so that 


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1 individuals may receive multiple prescriptions on the same 

2 day to facilitate comprehensive counseling and promote 

3 medication adherence. The study shall include a analysis 

4 of the following: 

5 (1) The extent to which pharmacies have adopt6 ed such programs. 

7 (2) The common characteristics of such pro8 grams, including how pharmacies structure coun9 seling sessions under such programs and the types 

10 of payment and other arrangements that Medicare 

11 prescription drug plans and private payors employ 

12 under such programs to support the efforts of phar13 macies. 

14 (3) How such programs compare for Medicare 

15 prescription drug plans and private payors. 

16 (4) What is known about how such programs 

17 affect patient medication adherence and overall pa18 tient health outcomes, including if adherence and 

19 outcomes vary by patient subpopulations, such as 

20 disease state and socioeconomic status. 

21 (5) What is known about overall patient satis22 faction with such programs and satisfaction with 

23 such programs, including within patient subpopula24 tions, such as disease state and socioeconomic sta25 tus. 


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

2 the Medicare program support such programs. 

3 (7) Barriers to the use of medication synchroni4 zation programs by Medicare prescription drug 

5 plans. 

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

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

8 shall submit to Congress a report containing the results 

9 of the study under subsection (a), together with rec10 ommendations for such legislation and administrative ac11 tion as the Comptroller General determines appropriate. 

12 SEC. 603. GAO STUDY AND REPORT ON IMPACT OF OBESITY 

13 DRUGS ON PATIENT HEALTH AND SPENDING. 

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

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

16 General’’) shall, to the extent data are available, conduct 

17 a study on the use of prescription drugs to manage the 

18 weight of obese patients and the impact of coverage of 

19 such drugs on patient health and on health care spending. 

20 Such study shall examine the use and impact of these obe21 sity drugs in the non-Medicare population and for Medi22 care beneficiaries who have such drugs covered through 

23 an MA–PD plan (as defined in section 1860D–1(a)(3)(C) 

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


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1 101(a)(3)(C))) as a supplemental health care benefit. The 

2 study shall include an analysis of the following: 

3 (1) The prevalence of obesity in the Medicare 

4 and non-Medicare population. 

5 (2) The utilization of obesity drugs. 

6 (3) The distribution of Body Mass Index by in7 dividuals taking obesity drugs, to the extent prac8 ticable. 

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

10 drugs in conjunction with the receipt of other items 

11 or services, such as behavioral counseling, and how 

12 these compare to items and services received by 

13 obese individuals who do not take obesity drugs. 

14 (5) Physician considerations and attitudes re15 lated to prescribing obesity drugs. 

16 (6) The extent to which coverage policies cease 

17 or limit coverage for individuals who fail to receive 

18 clinical benefit. 

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

20 individuals who take obesity drugs adhere to the pre21 scribed regimen. 

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

23 individuals who take obesity drugs maintain weight 

24 loss over time. 


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1 (9) What is known about the subsequent impact 

2 such drugs have on medical services that are directly 

3 related to obesity, including with respect to sub4 populations determined based on the extent of obe5 sity. 

6 (10) What is known about the spending associ7 ated with the care of individuals who take obesity 

8 drugs, compared to the spending associated with the 

9 care of individuals who do not take such drugs. 

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

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

12 shall submit to Congress a report containing the results 

13 of the study under subsection (a), together with rec14 ommendations for such legislation and administrative ac15 tion as the Comptroller General determines appropriate. 

16 SEC. 604. HHS STUDY AND REPORT ON LONG-TERM RISK 

17 FACTORS FOR CHRONIC CONDITIONS AMONG 

18 MEDICARE BENEFICIARIES. 

19 (a) STUDY.—The Secretary of Health and Human 

20 Services (in this section referred to as the ‘‘Secretary’’) 

21 shall conduct a study on long-term cost drivers to the 

22 Medicare program, including obesity, tobacco use, mental 

23 health conditions, and other factors that may contribute 

24 to the deterioration of health conditions among individuals 

25 with chronic conditions in the Medicare population. The 


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1 study shall include an analysis of any barriers to collecting 

2 and analyzing such information and how to remove any 

3 such barriers (including through legislation and adminis4 trative actions). 

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

6 date of the enactment of this Act, the Secretary shall sub7 mit to Congress a report containing the results of the 

8 study under subsection (a), together with recommenda9 tions for such legislation and administrative action as the 

10 Secretary determines appropriate. The Secretary shall also 

11 post such report on the Internet website of the Depart12 ment of Health and Human Services. 

13 TITLE VII—OFFSETS 

14 SEC. 701. MEDICARE IMPROVEMENT FUND. 

15 Section 1898(b)(1) of the Social Security Act (42 

16 U.S.C. 1395iii(b)(1)) is amended by striking 

17 ‘‘$270,000,000’’ and inserting ‘‘$0’’. 

18 SEC. 702. MEDICAID IMPROVEMENT FUND. 

19 Section 1941(b)(1) of the Social Security Act (42 

20 U.S.C. 1396w–1(b)(1)) is amended by striking 

21 ‘‘$5,000,000’’ and inserting ‘‘$0’’. 

Æ 


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