I 

113TH CONGRESS 

1ST SESSION H. R. 3567 

To amend title XVIII of the Social Security Act to provide for additional 

coverage options for beneficiaries under the original Medicare fee-forservice program through a Medicare Link program. 

IN THE HOUSE OF REPRESENTATIVES 

NOVEMBER 20, 2013 

Mr. SCHRADER (for himself and Mr. RIBBLE) 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 provide 

for additional coverage options for beneficiaries under 

the original Medicare fee-for-service program through a 

Medicare Link program. 

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. 

4 This Act may be cited as the ‘‘Medicare Link Act 

5 of 2013’’. 


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1 SEC. 2. ESTABLISHMENT OF MEDICARE LINK PROGRAM. 

2 (a) IN GENERAL.—Title XVIII of the Social Security 

3 Act is amended by adding after section 1899A (42 U.S.C. 

4 1395kkk) the following new section: 

5 ‘‘MEDICARE LINK PROGRAM OPTION

6 ‘‘SEC. 1899B. (a) IN GENERAL.—The Secretary shall 

7 establish under this section a program (to be known as 

8 the ‘Medicare Link Program’ and in this section referred 

9 to as the ‘Program’) through which individuals who are 

10 entitled to enroll in a Medicare Advantage plan under part 

11 C but who are not enrolled in such a plan under such part 

12 are eligible to enroll with a Medicare Link contractor 

13 under this section. 

14 ‘‘(b) ENROLLMENT; DISENROLLMENT.—The Sec15 retary shall establish a process for the enrollment (and 

16 disenrollment) of eligible individuals with Medicare Link 

17 contractors under the Program which process shall be, to 

18 the maximum extent practicable, the same as (and coordi19 nated with) the process for enrollment (and disenrollment) 

20 of individuals in Medicare Advantage plans under part C. 

21 ‘‘(c) QUALIFICATION OF CONTRACTORS; AWARDING

22 OF CONTRACTS.— 

23 ‘‘(1) IN GENERAL.—In this section, the term 

24 ‘Medicare Link contractor’ means a nongovern25 mental entity, that may be a Medicare Advantage 

26 organization, health plan, health insurance issuer, 


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1 medicare administrative contractor, or other quali2 fied third-party entity, that has entered into a con3 tract with the Secretary with respect to one or more 

4 Medicare Link regions (as specified by the Secretary 

5 under paragraph (3)) for the offering of Medicare 

6 Link services (described in subsection (d)) to indi7 viduals residing in the region who enroll with the 

8 contractor under the Program. 

9 ‘‘(2) LIMITATION; REQUIREMENTS.—For each 

10 such Medicare Link region, the Secretary shall select 

11 (and contract with) at least 1, and not more than 

12 3, Medicare Link contractors for the offering of 

13 plans (in this section referred to as ‘Medicare Link 

14 plans’) under this section. The Secretary shall seek 

15 to contract with at least 2 Medicare Link contrac16 tors within each Medicare Link region. A contract 

17 with a Medicare Link contractor may cover a multi18 year period. 

19 ‘‘(3) SPECIFICATION OF MEDICARE LINK RE20 GIONS.—The Secretary shall define and specify 

21 Medicare Link regions (each in this section referred 

22 to as a ‘Medicare Link region’) that, across all such 

23 regions, encompass all 50 States, the District of Co24 lumbia, and the territories. 


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1 ‘‘(4) QUALIFICATION OF CONTRACTORS.—The 

2 Secretary shall establish uniform qualifications for 

3 Medicare Link contractors based on their experience 

4 and qualifications to offer Medicare Link plans 

5 under this section and to provide additional services 

6 to individuals enrolled under such plans under this 

7 section and to provide for reduced expenditures 

8 under parts A and B. Contracts with Medicare Link 

9 contractors under this section shall be for periods 

10 similar to the contracts with MA organizations 

11 under part C and shall contain such terms and con12 ditions as the Secretary shall specify. 

13 ‘‘(5) CONTRACTING AUTHORITY.—Nothing in 

14 this section shall be construed as preventing a Medi15 care Link contractor from contracting with other en16 tities in carrying out activities under this section, in17 cluding the offering of Medicare Link plans under 

18 this section. 

19 ‘‘(6) BIDDING PROCESS.—In selecting Medicare 

20 Link contractors, the Secretary shall establish a bid21 ding process similar to the process of bidding by 

22 medicare administrative contractors under section 

23 1874A. 

24 ‘‘(7) CONTRACTOR PAYMENTS.—Medicare Link 

25 contractors with contracts under this section shall be 


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1 paid, on a monthly basis, a per enrollee monthly 

2 service fee for the provision of services under the 

3 contract consistent with the provisions of paragraph 

4 (8). A portion of such fee (not to exceed 5 percent) 

5 may be subject to adjustment based on a contrac6 tor’s performance on financial and quality bench7 marks based upon pre-established measures specified 

8 by the Secretary. 

9 ‘‘(8) REQUIREMENT FOR FEDERAL SAVINGS

10 UNDER CONTRACT.— 

11 ‘‘(A) IN GENERAL.—Before entering into 

12 or renewing a contract with a Medicare Link 

13 contractor, the Secretary must determine (and 

14 the Chief Actuary of the Centers for Medicare 

15 & Medicaid Services must certify) that the 

16 terms of the contract are expected to yield aver17 age, net savings to the Medicare program under 

18 this title of not less than 5 percent per program 

19 enrollee in the Medicare Link region covered 

20 under the contract. 

21 ‘‘(B) COMPUTATION.—Such savings shall 

22 be computed taking into account all effects on 

23 spending under this title, including any reduc24 tions in premiums and cost sharing or other in25 centives for enrollees under subsection (d), payVerDate Mar 15 2010 04:40 Nov 23, 2013 Jkt 039200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H3567.IH H3567

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1 ments to Medicare Link contractors under the 

2 contract, and reductions in payments to medi3 care administrative contractors that would oth4 erwise have been made under section 1874A. 

5 ‘‘(C) PAYMENTS BASED ON SHARED SAV6 INGS, ADJUSTED FOR QUALITY.—The contract 

7 shall be structured in a manner so that— 

8 ‘‘(i) subject to clause (ii), the pay9 ments to the contractor under paragraph 

10 (7) are computed to represent a proportion 

11 (as specified in the contract) of the net 

12 savings in excess of the minimum savings 

13 required under subparagraph (A); and 

14 ‘‘(ii) such proportion may be increased 

15 under the contract based on a contractor’s 

16 performance on quality benchmarks, based 

17 upon pre-established measures specified by 

18 the Secretary. 

19 ‘‘(D) GUARANTEED FEDERAL SAVINGS.—If 

20 the Secretary determines that a Medicare Link 

21 contractor, after a period of three consecutive 

22 years, does not maintain an average net savings 

23 to the Medicare program of at least 5 percent 

24 per program enrollee as required under sub25 paragraph (A), the Medicare Link contractor 


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1 shall remit to the Secretary a sum specified by 

2 the Secretary and related to the amount of the 

3 shortfall. 

4 ‘‘(9) SAVINGS VALIDATION AUDIT.—The Sec5 retary shall provide for the annual auditing of the fi6 nancial records (including data relating to Medicare 

7 utilization and costs) of organizations offering Medi8 care Link plans under this section 

9 ‘‘(10) GAO AUDIT.—Every 3 years the Comp10 troller General of the United States shall conduct an 

11 audit of the Medicare Link program costs and pro12 gram savings. Such report shall be submitted to the 

13 committees of the House of Representatives and of 

14 the Senate with jurisdiction over Medicare. 

15 ‘‘(d) SERVICES UNDER A MEDICARE LINK PLAN.— 

16 ‘‘(1) IN GENERAL.—Each Medicare Link plan 

17 offered under this section— 

18 ‘‘(A) shall provide for care management 

19 services (described in paragraph (2)) and pre20 dictive modeling and risk prioritization (de21 scribed in paragraph (3)) for individuals en22 rolled under the plan consistent with this sub23 section; 


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1 ‘‘(B) shall carry out the functions of medi2 care administrative contractors described in 

3 paragraph 1874A(a)(4); 

4 ‘‘(C) shall provide a reduction or rebate in 

5 the premium otherwise applicable under part B 

6 (as determined without regard to section 

7 1839(i)) to individuals so enrolled; and 

8 ‘‘(D) may provide for a reduction in cost9 sharing otherwise applicable to such individuals 

10 who use providers within a plan network. 

11 ‘‘(2) CARE MANAGEMENT SERVICES.— 

12 ‘‘(A) REQUIRED.—The required care man13 agement services shall include clinical interven14 tions to help coordinate care. 

15 ‘‘(B) OPTIONAL.—Optional care manage16 ment services may include interventions such as 

17 the following: 

18 ‘‘(i) Prevention and wellness. 

19 ‘‘(ii) Transitional and case manage20 ment and other clinical programs. 

21 ‘‘(iii) Chronic disease management. 

22 ‘‘(iv) Advanced illness care initiatives. 

23 ‘‘(v) Diabetes prevention programs. 


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1 ‘‘(vi) Transitional case management, 

2 for individuals discharged from a hospital 

3 or other health care institution. 

4 ‘‘(vii) Nurse practitioner-led interven5 tions (consistent with restrictions under 

6 applicable State law). 

7 ‘‘(viii) Post-acute transition programs. 

8 ‘‘(ix) High-risk case management. 

9 ‘‘(x) Home-based primary care. 

10 ‘‘(xi) Advanced illness transitional 

11 care. 

12 ‘‘(xii) Operation of clinical manage13 ment programs. 

14 ‘‘(xiii) Management and development 

15 of provider networks. 

16 ‘‘(xiv) Consumer engagement with de17 cision support. 

18 ‘‘(3) PREDICTIVE MODELING AND RISK

19 PRIORITIZATION.—The predictive modeling and risk 

20 prioritization services described in this paragraph 

21 shall include the following: 

22 ‘‘(A) PREDICTIVE MODELING AND HIGH

23 RISK IDENTIFICATION.—The use of claims data 

24 and trend data to predict which enrollees could 

25 benefit from the application of a clinical interVerDate Mar 15 2010 03:01 Nov 23, 2013 Jkt 039200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H3567.IH H3567

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1 vention or which might be high risk and in need 

2 of a care plan. 

3 ‘‘(B) PRIORITIZATION OF INTERVEN4 TIONS.—Programs to identify, prioritize, and 

5 personalize care opportunities through a com6 prehensive profile of each enrollee. 

7 ‘‘(4) OPTIONAL INCENTIVES AND ENROLLEE

8 EMPOWERMENT.— 

9 ‘‘(A) IN GENERAL.—A Medicare Link con10 tractor may use appropriate incentives to man11 age overall care for enrollees. The Secretary 

12 shall establish terms and conditions under 

13 which a Medicare Link contractor may elect to 

14 use optional incentives for its members. 

15 ‘‘(B) TYPES OF INCENTIVES.—The types 

16 of incentives that may be used include the fol17 lowing: 

18 ‘‘(i) HEALTHY REWARDS.—Premium 

19 rebates and other incentives approved by 

20 the Secretary for enrollees to make 

21 healthier choices and actively engage in 

22 their health care. 

23 ‘‘(ii) MEMBER INCENTIVES TO USE

24 QUALITY NETWORK PROVIDERS.—Reduc25 tions in beneficiary cost-sharing (and other 


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1 incentives approved by the Secretary) for 

2 enrollees who use providers (which may be 

3 accountable care organizations) within a 

4 plan network in order to reward quality, 

5 efficient care. 

6 ‘‘(iii) COST ESTIMATOR TOOLS.—Pro7 viding beneficiaries with tools designed to 

8 help them simplify the evaluation of health 

9 care costs through cost estimates for dif10 ferent treatment options. 

11 ‘‘(5) APPLICATION OF MA GRIEVANCE AND AP12 PEALS PROCEDURES.—In accordance with regula13 tions, the provisions of part C insofar as they apply 

14 to grievances and appeals, shall apply to Medicare 

15 Link plans and enrollees under this section in a 

16 manner similar to how such provisions apply to MA 

17 plans under such part. 

18 ‘‘(e) MAINTENANCE OF CURRENT BENEFITS; CON19 TRACTOR NOT AT FINANCIAL RISK FOR ORIGINAL FEE20 FOR-SERVICE BENEFITS.— 

21 ‘‘(1) NO CHANGE IN MEDICARE COVERED ITEMS

22 AND SERVICES OR LIMITATION ON SUPPLEMENTAL

23 PLANS.—Medicare Link plans shall provide for cov24 erage of the same items and services that are cov25 ered under parts A and B. Nothing in this section 


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1 shall be construed as preventing an individual en2 rolled under a Medicare Link plan from purchasing 

3 a medicare supplemental policy (described in section 

4 1881) or other supplemental coverage outside of a 

5 Medicare Link plan. 

6 ‘‘(2) NO CHANGE IN PAYMENTS TO PRO7 VIDERS.— 

8 ‘‘(A) IN GENERAL.—Subject to subpara9 graph (B), nothing in this section shall be con10 strued as authorizing a payment level to a pro11 vider of services or supplier for Medicare cov12 ered services that is other than the payment 

13 level otherwise applicable under part A or B for 

14 such services. 

15 ‘‘(B) NEGOTIATION OF RATES PER16 MITTED.—A Medicare Link contractor may ne17 gotiate with providers of services and suppliers 

18 payment rates that are less or greater than the 

19 payment rates referred to in subparagraph (A). 

20 ‘‘(3) CONTRACTOR NOT AT FINANCIAL RISK.— 

21 A Medicare Link contractor shall not be at financial 

22 risk with respect to the coverage or payment for 

23 Medicare services covered under parts A and B. But 

24 the Secretary may provide financial incentives for 

25 contractors that are able to reduce Medicare expendVerDate Mar 15 2010 04:40 Nov 23, 2013 Jkt 039200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\H3567.IH H3567

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1 itures for such services below benchmark levels 

2 (specified by the Secretary) that reasonably rep3 resent the levels of payments that would be made 

4 (with respect to individuals enrolled under a Medi5 care Link plan) if such individuals were not so en6 rolled.’’. 

Æ 


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