II 

115TH CONGRESS 

1ST SESSION S. 2065 

To establish a demonstration program to provide integrated care for Medicare 

beneficiaries with end-stage renal disease, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

NOVEMBER 2, 2017 

Mr. YOUNG (for himself, Mr. NELSON, Mr. HELLER, and Mr. BENNET) introduced the following bill; which was read twice and referred to the Committee on Finance 

A BILL 

To establish a demonstration program to provide integrated 

care for Medicare beneficiaries with end-stage renal disease, and for other purposes. 

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 ‘‘Dialysis Patient Access 

5 To Integrated-care, Empowerment, Nephrologists, Treat6 ment, and Services Demonstration Act of 2017’’ or the 

7 ‘‘Dialysis PATIENTS Demonstration Act of 2017’’. 


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1 SEC. 2. DEMONSTRATION PROGRAM TO PROVIDE INTE2 GRATED CARE FOR MEDICARE BENE3 FICIARIES WITH END-STAGE RENAL DISEASE. 

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

5 Act is amended by inserting after section 1866E the fol6 lowing new section: 

7 ‘‘DEMONSTRATION PROGRAM TO PROVIDE INTEGRATED

8 CARE FOR MEDICARE BENEFICIARIES WITH END9 STAGE RENAL DISEASE

10 ‘‘SEC. 1866F. (a) ESTABLISHMENT.— 

11 ‘‘(1) IN GENERAL.—The Secretary shall con12 duct under this section the ESRD Integrated Care 

13 Demonstration Program (in this section referred to 

14 as the ‘Program’) which is voluntary for patients 

15 and providers to assess the effects of alternative care 

16 delivery models and payment methodologies on pa17 tient care improvements under this title for Pro18 gram-eligible beneficiaries (as defined in paragraph 

19 (2)). Under the Program— 

20 ‘‘(A) Program-eligible beneficiaries shall be 

21 considered enrolled under the original Medicare 

22 fee-for-service program under parts A and B; 

23 ‘‘(B) eligible participating providers (as de24 fined in such paragraph) may form an ESRD 

25 Integrated Care Organization (in this section 

26 referred to as an ‘Organization’); and 


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1 ‘‘(C) an Organization shall integrate care 

2 and serve as the medical home under the origi3 nal Medicare fee-for-service program under 

4 parts A and B for Program-eligible bene5 ficiaries. 

6 ‘‘(2) DEFINITIONS.—In this section: 

7 ‘‘(A) ELIGIBLE PARTICIPATING PRO8 VIDER.—The term ‘eligible participating pro9 vider’ means the following: 

10 ‘‘(i) A facility certified as a renal di11 alysis facility under this title. 

12 ‘‘(ii) A dialysis organization that owns 

13 one or more of such facilities described in 

14 clause (i). 

15 ‘‘(iii) A nephrologist or nephrology 

16 practice. 

17 ‘‘(iv) Any other physician group prac18 tice or a group of affiliated physicians or 

19 providers. 

20 ‘‘(B) ELIGIBLE PARTICIPATING PART21 NER.—The term ‘eligible participating partner’ 

22 means, with respect to an Organization, the fol23 lowing: 

24 ‘‘(i) A Medicare Advantage plan de25 scribed in section 1851(a)(2) or a MediVerDate Sep 11 2014 03:08 Nov 04, 2017 Jkt 079200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S2065.IS S2065

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1 care Advantage organization offering such 

2 a plan. 

3 ‘‘(ii) A prescription drug plan (as de4 fined in section 1860D–41(a)(14)). 

5 ‘‘(iii) A Medicaid managed care orga6 nization (as defined in section 1903(m)). 

7 ‘‘(iv) An entity that is able to bear 

8 risk as deemed by a State, including public 

9 medical educational institutions experi10 enced in the care of patients receiving di11 alysis, and that chooses to bear risk as a 

12 condition of partnership in such organiza13 tion. 

14 ‘‘(v) A third-party administrator orga15 nization. 

16 ‘‘(C) PROGRAM-ELIGIBLE BENEFICIARY.— 

17 The term ‘Program-eligible beneficiary’ means, 

18 with respect to an Organization offering an 

19 ESRD Integrated Care Model, an individual en20 titled to benefits under part A and enrolled 

21 under part B who— 

22 ‘‘(i) is identified by the Secretary or 

23 the Organization as receiving renal dialysis 

24 services under the original Medicare fee25 for-service program under parts A and B; 


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1 ‘‘(ii) resides in the service area of 

2 such Organization; 

3 ‘‘(iii) receives renal dialysis services 

4 primarily from a facility that participates 

5 in such Organization; and 

6 ‘‘(iv) has not received a successful 

7 kidney transplant or has experienced a 

8 failed kidney transplant. 

9 ‘‘(b) ESRD INTEGRATED CARE ORGANIZATION ELI10 GIBILITY REQUIREMENTS.— 

11 ‘‘(1) ORGANIZATIONS.— 

12 ‘‘(A) IN GENERAL.—One or more eligible 

13 participating providers may establish an Orga14 nization or may enter into, subject to subpara15 graph (B), one or more partnership, ownership, 

16 or co-ownership agreements with one or more 

17 eligible participating partners to establish an 

18 Organization. 

19 ‘‘(B) LIMITATION ON NUMBER OF AGREE20 MENTS.—The Secretary may specify a limita21 tion on the number of Organizations in which 

22 an eligible participating partner may participate 

23 under agreements described in subparagraph 

24 (A). 

25 ‘‘(2) ESRD INTEGRATED CARE MODEL.— 


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1 ‘‘(A) BENEFITS REQUIREMENTS.— 

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

3 (iii), an Organization shall offer at least 

4 one ESRD Integrated Care Model that is 

5 an open network model (as described in 

6 subparagraph (B)(i)) in each of its service 

7 areas and may offer one or more ESRD 

8 Integrated Care Models that is a preferred 

9 network model (as described in subpara10 graph (B)(ii)) in each of its service areas. 

11 For purposes of this section an ESRD In12 tegrated Care Model (in this section re13 ferred to as the ‘Model’), subject to sub14 section (f)(3)(B)— 

15 ‘‘(I) shall cover all benefits under 

16 parts A and B (other than hospice 

17 care) and include benefits for transi18 tion (particularly including education) 

19 into transplantation, palliative care, or 

20 hospice; and 

21 ‘‘(II) may, through a partnership 

22 or other agreement with an MA–PD 

23 plan under part C or prescription 

24 drug plan under part D, cover all preVerDate Sep 11 2014 03:08 Nov 04, 2017 Jkt 079200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S2065.IS S2065

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1 scription drug benefits under such 

2 part D. 

3 ‘‘(ii) TREATMENT OF SAVINGS.— 

4 ‘‘(I) IN GENERAL.—Any Organi5 zation offering an ESRD Integrated 

6 Care Model shall provide for the re7 turn under subclause (IV) to a Pro8 gram-eligible beneficiary enrolled in 

9 the Organization of the amount, if 

10 any, by which the payment amount 

11 described in subclause (III) with re12 spect to the Program-eligible bene13 ficiary for a year exceeds the revenue 

14 amount described in subclause (II) 

15 with respect to the Program-eligible 

16 beneficiary for the year. 

17 ‘‘(II) REVENUE AMOUNT DE18 SCRIBED.—The revenue amount de19 scribed in this subclause, with respect 

20 to an Organization offering an ESRD 

21 Integrated Care Model and a Pro22 gram-eligible beneficiary enrolled in 

23 such Organization, is the Organiza24 tion’s estimated average revenue re25 quirements, including administrative 


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1 costs and return on investment, for 

2 the Organization to provide the bene3 fits described in clause (i) under the 

4 Model for the Program-eligible bene5 ficiary for the year. 

6 ‘‘(III) PAYMENT AMOUNT DE7 SCRIBED.—The payment amount de8 scribed in this subclause, with respect 

9 to an Organization offering an ESRD 

10 Integrated Care Model and a Pro11 gram-eligible beneficiary enrolled in 

12 such Organization, is the payment 

13 amount to the Organization under 

14 subsection (f)(1) made with respect to 

15 the Program-eligible beneficiary for 

16 the year. 

17 ‘‘(IV) MEANS OF RETURNING

18 SAVINGS TO PROGRAM-ELIGIBLE

19 BENEFICIARIES ENROLLED IN ORGA20 NIZATIONS.—An Organization shall 

21 return the amount under subclause (I) 

22 to a Program-eligible beneficiary en23 rolled in the Organization in a man24 ner specified by the Organization, 

25 which may include, as applicable, costVerDate Sep 11 2014 03:08 Nov 04, 2017 Jkt 079200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S2065.IS S2065

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1 sharing lower than otherwise applica2 ble, benefits not covered under the 

3 original Medicare fee-for-service pro4 gram (including preventive services re5 lated to chronic kidney disease and 

6 education surrounding the importance 

7 of transplantation), or financial incen8 tives (such as reduced cost sharing) 

9 for Program-eligible beneficiaries en10 rolled in the Organization to promote 

11 the delivery of high-value and efficient 

12 care and services. 

13 ‘‘(iii) BENEFIT REQUIREMENTS FOR

14 DUAL ELIGIBLES.—In the case of a Pro15 gram-eligible beneficiary who is eligible for 

16 benefits under this title and title XIX, an 

17 Organization, in accordance with an agree18 ment entered into under subsection 

19 (f)(4)— 

20 ‘‘(I) may be responsible for pro21 viding, or arranging for the provision 

22 of, all benefits (other than long-term 

23 services and supports) for which the 

24 Program-eligible beneficiary is eligible 

25 for under the State Medicaid program 


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1 under title XIX in which the Pro2 gram-eligible beneficiary is enrolled; 

3 and 

4 ‘‘(II) may elect to provide, or ar5 range for the provision of, long-term 

6 services and supports available to the 

7 Program-eligible beneficiary under the 

8 State Medicaid program, including 

9 services related to the transition into 

10 palliative care or hospice. 

11 ‘‘(B) REQUIREMENTS FOR OPEN NETWORK

12 AND PREFERRED NETWORK MODELS.— 

13 ‘‘(i) OPEN NETWORK MODEL.—Under 

14 an ESRD Integrated Care Model offered 

15 by an Organization that is an open net16 work model, the Organization shall— 

17 ‘‘(I) allow Program-eligible bene18 ficiaries to receive such covered bene19 fits from any provider of services or 

20 supplier regardless of whether such 

21 provider is within the network assem22 bled under clause (ii)(I); 

23 ‘‘(II) pay any Medicare-certified 

24 provider or supplier that is not within 

25 the network assembled under subVerDate Sep 11 2014 03:08 Nov 04, 2017 Jkt 079200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\S2065.IS S2065

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1 clause (I) for such covered benefits an 

2 amount equal to the amount the pro3 vider or supplier would otherwise re4 ceive under this title; and 

5 ‘‘(III) not apply any additional 

6 premium or cost sharing requirements 

7 for such covered benefits in addition 

8 to premium or cost sharing require9 ments, respectively, that would be ap10 plicable under part A or part B for 

11 such benefits. 

12 ‘‘(ii) PREFERRED NETWORK

13 MODEL.—Under an ESRD Integrated 

14 Care Model offered by an Organization 

15 that is a preferred network model, the Or16 ganization— 

17 ‘‘(I) shall assemble a network of 

18 providers of services and suppliers 

19 identified by the Organization and 

20 confirmed by the Secretary as includ21 ing providers of services and suppliers 

22 with significant expertise in caring for 

23 individuals with end-stage renal dis24 ease through which Program-eligible 

25 beneficiaries shall receive covered benVerDate Sep 11 2014 03:08 Nov 04, 2017 Jkt 079200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S2065.IS S2065

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1 efits as described in subparagraph (A) 

2 that are required to be covered under 

3 the Model; 

4 ‘‘(II) shall provide for payment 

5 for items and services furnished by 

6 providers of services and suppliers 

7 within such network to Program-eligi8 ble beneficiaries enrolled in such Or9 ganization in accordance with pay10 ment rates determined pursuant to an 

11 agreement entered into between the 

12 Organization and such providers of 

13 services and suppliers and shall pro14 vide for payment for items and serv15 ices furnished by providers of services 

16 and suppliers not within such network 

17 to such beneficiaries so enrolled in ac18 cordance that would be determined 

19 under section 1853(a)(1)(H); 

20 ‘‘(III) may apply premium and 

21 cost-sharing requirements, in addition 

22 to premium or cost-sharing require23 ments, respectively, that would be ap24 plicable under part B, for benefits in 


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1 addition to those required to be cov2 ered under the Model; and 

3 ‘‘(IV) shall apply network stand4 ards as defined by the Secretary. 

5 ‘‘(iii) PROMOTING ACCESS TO HIGH6 QUALITY PROVIDERS.—An Organization 

7 offering an ESRD Integrated Care Model 

8 may develop and implement performance9 based incentives for providers of services 

10 and suppliers to promote delivery of high 

11 quality and efficient care. Such incentives 

12 shall be based on clinical measures and 

13 non-clinical measures, such as with respect 

14 to notification of patient discharge from a 

15 hospital, patient education (such as with 

16 respect to treatment options, including 

17 chronic kidney disease maintenance, and 

18 nutrition), and the interoperability of elec19 tronic health records developed by an Or20 ganization according to requirements and 

21 standards specified by the Secretary pursu22 ant to subparagraph (C). 

23 ‘‘(iv) APPLICATION OF MEDICARE AD24 VANTAGE REQUIREMENT WITH RESPECT

25 TO MEDICARE SERVICES FURNISHED BY


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1 OUT-OF-NETWORK PROVIDERS AND SUP2 PLIERS.— 

3 ‘‘(I) IN GENERAL.—Section 

4 1852(k)(1) (relating to limitations on 

5 balance billing against MA organiza6 tions for noncontract physicians and 

7 other entities with respect to services 

8 covered under this title) shall apply to 

9 Organizations, Program-eligible bene10 ficiaries enrolled in such Organiza11 tions, and physicians and other enti12 ties that do not have a contract or 

13 other agreement with the Organiza14 tion establishing payment amounts for 

15 services furnished to such a bene16 ficiary in the same manner as such 

17 section applies to MA organizations, 

18 individuals enrolled with such organi19 zations, and physicians and other en20 tities referred to in such section. 

21 ‘‘(II) REFERENCE FOR ADDI22 TIONAL PROVISION.—For the provi23 sion relating to limitations on balance 

24 billing against Organizations for serv25 ices covered under this title furnished 


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1 by noncontract providers of services 

2 and suppliers, see section 

3 1866(a)(1)(O). 

4 ‘‘(C) QUALITY AND REPORTING REQUIRE5 MENTS.— 

6 ‘‘(i) CLINICAL MEASURES.—Under the 

7 Program, the Secretary shall— 

8 ‘‘(I) require each participating 

9 Organization to submit to the Sec10 retary data on clinical measures con11 sistent with those measures submitted 

12 by organizations participating in the 

13 Comprehensive ESRD Care Initiative 

14 operated by the Center for Medicare 

15 and Medicaid Innovation as of Octo16 ber 1, 2016, to assess the quality of 

17 care provided; 

18 ‘‘(II) establish requirements for 

19 participating Organizations to report 

20 to the Secretary, in a form and man21 ner specified by the Secretary, infor22 mation on such measures; and 

23 ‘‘(III) establish quality perform24 ance standards on such measures to 

25 assess the quality of care. 


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1 ‘‘(ii) REQUIREMENT FOR STAKE2 HOLDER INPUT.—In developing require3 ments and standards under subclauses (II) 

4 and (III) of clause (i), the Secretary shall 

5 request and consider input from a stake6 holder board, at least one nephrologist, 

7 other suppliers and providers of services, 

8 renal dialysis facilities, and beneficiary ad9 vocates. 

10 ‘‘(iii) ADDITIONAL ASSESSMENTS AND

11 REPORTING REQUIREMENTS.—The Sec12 retary shall assess the extent to which an 

13 Organization delivers integrated and pa14 tient-centered care through analysis of in15 formation obtained from Program-eligible 

16 beneficiaries enrolled in the Organization 

17 through surveys, such as the In-Center 

18 Hemodialysis Consumer Assessment of 

19 Healthcare Providers and Systems. 

20 ‘‘(D) REQUIREMENTS FOR ESRD INTE21 GRATED CARE STRATEGY.— 

22 ‘‘(i) IN GENERAL.—An Organization 

23 seeking a contract under this section to 

24 offer one or more ESRD Integrated Care 

25 Models must develop and submit for the 


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1 Secretary’s approval, subject to clauses (ii) 

2 and (iii), an ESRD Integrated Care Strat3 egy. 

4 ‘‘(ii) ESRD INTEGRATED CARE

5 STRATEGY.—In assessing an ESRD Inte6 grated Care Strategy under clause (i), the 

7 Secretary shall consider the extent to 

8 which the Strategy includes elements, such 

9 as the following: 

10 ‘‘(I) Interdisciplinary care teams 

11 led by at least one nephrologist, and 

12 comprised of registered nurses, social 

13 workers, renal dialysis facility man14 agers, and other representatives from 

15 alternative settings described in sub16 clause (VIII). 

17 ‘‘(II) A decision process for care 

18 plans and care management that in19 cludes the nephrologist and other 

20 practitioners responsible for direct de21 livery of care to Program-eligible 

22 beneficiaries enrolled in the Organiza23 tion involved. 

24 ‘‘(III) Health risk and other as25 sessments to determine the physical, 


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1 psychosocial, nutrition, language, cul2 tural, and other needs of Program-eli3 gible beneficiaries enrolled in the Or4 ganization involved. 

5 ‘‘(IV) Development and at least 

6 annual updating of individualized care 

7 plans that incorporate at least the 

8 medical, social, and functional needs, 

9 preferences, and care goals of Pro10 gram-eligible beneficiaries enrolled in 

11 the Organization. 

12 ‘‘(V) Coordination and delivery of 

13 non-clinical services, such as transpor14 tation, aimed at improving the adher15 ence of Program-eligible beneficiaries 

16 enrolled in the Organization with care 

17 recommendations. 

18 ‘‘(VI) Services, such as trans19 plant evaluation, palliative care, eval20 uation for hospice eligibility, and vas21 cular access care. 

22 ‘‘(VII) In the case of an indi23 vidual who, while enrolled in the Or24 ganization, receives confirmation that 

25 a kidney transplant is imminent, the 


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1 provision by an interdisciplinary care 

2 team described in subclause (I) of 

3 counseling services to such individual 

4 on preparation for and potential chal5 lenges surrounding such transplant. 

6 ‘‘(VIII) Delivery of benefits and 

7 services in alternative settings, such 

8 as the home of the Program-eligible 

9 beneficiary enrolled in the Organiza10 tion, in coordination with the provider 

11 or other appropriate stakeholder in12 volved in such delivery serving on an 

13 interdisciplinary care team described 

14 in subclause (I). 

15 ‘‘(IX) Use of patient reminder 

16 systems. 

17 ‘‘(X) Education programs for pa18 tients, families, and caregivers. 

19 ‘‘(XI) Use of health care advice 

20 resources, such as nurse advice lines. 

21 ‘‘(XII) Use of team-based health 

22 care delivery models that provide com23 prehensive and continuous medical 

24 care, such as medical homes. 


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1 ‘‘(XIII) Co-location of providers 

2 and services. 

3 ‘‘(XIV) Use of a demonstrated 

4 capacity to share electronic health 

5 record information across sites of 

6 care. 

7 ‘‘(XV) Use of programs to pro8 mote better adherence to rec9 ommended treatment regimens by in10 dividuals, including by addressing bar11 riers to access to care by such individ12 uals. 

13 ‘‘(XVI) Defined protocols to fa14 cilitate the transition of pediatric pa15 tients into adult end stage renal dis16 ease care, developed in conjunction 

17 with the pediatric nephrology commu18 nity. 

19 ‘‘(XVII) Other services, strate20 gies, and approaches identified by the 

21 Organization to improve care coordi22 nation and delivery. 

23 ‘‘(iii) REQUIREMENTS.—The Sec24 retary may not approve an ESRD Inte25 grated Care Strategy of an Organization 


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1 unless under such Strategy the Organiza2 tion— 

3 ‘‘(I) provides services to Pro4 gram-eligible beneficiaries enrolled in 

5 the Organization through a com6 prehensive, multidisciplinary health 

7 and social services delivery system 

8 which integrates acute and long-term 

9 care services pursuant to regulations; 

10 ‘‘(II) specifies the covered items 

11 and services that will not be provided 

12 directly by the Organization, and to 

13 arrange for delivery of those items 

14 and services through contracts meet15 ing the requirements of regulations; 

16 and 

17 ‘‘(III) establishes a governing 

18 body that— 

19 ‘‘(aa) consists of representa20 tion from each eligible partici21 pating provider of such Organiza22 tion; 

23 ‘‘(bb) includes at least one 

24 nephrologist who may be affili25 ated with a participating provider 


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1 in the preferred network, at least 

2 one nephrologist in the open net3 work, and at least one beneficiary 

4 advocate; and 

5 ‘‘(cc) has responsibility for 

6 the oversight of the activities of 

7 the Organization. 

8 ‘‘(3) REQUIREMENT FOR CAPITAL RESERVES.— 

9 ‘‘(A) IN GENERAL.—The Secretary shall 

10 enter into contracts under this section only with 

11 Organizations that demonstrate sufficient cap12 ital reserves, measured as a percentage of 

13 capitated payments and consistent with require14 ments established by the State in which the Or15 ganization operates. 

16 ‘‘(B) ALTERNATIVE MECHANISM TO DEM17 ONSTRATE CAPACITY TO BEAR RISK.—An Orga18 nization shall be considered to meet the require19 ment in subparagraph (A) if the Organization 

20 includes at least one eligible participating pro21 vider or eligible participating partner that— 

22 ‘‘(i) is licensed as a risk-bearing entity 

23 or deemed by a State as able to bear risk; 

24 and 


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1 ‘‘(ii) chooses to bear risk as a condi2 tion of partnership in such Organization. 

3 ‘‘(4) BENEFICIARY PROTECTIONS.— 

4 ‘‘(A) SEAMLESS ACCESS TO CARE.—The 

5 Secretary shall establish processes and take 

6 steps as necessary, including educating Medi7 care-certified providers and suppliers about the 

8 Program, to ensure that Program-eligible bene9 ficiaries assigned into an open network model 

10 or who elect into a preferred network model of11 fered by an Organization experience no disrup12 tion of access to Medicare-certified providers or 

13 suppliers furnishing items or services to such 

14 beneficiary immediately before such assignment 

15 or election and for purposes of receipt of such 

16 items or services. Assignment into an open net17 work model or election into a preferred network 

18 model under the Program shall in no way be 

19 construed as affecting a Program-eligible bene20 ficiary’s ability to receive covered benefits from 

21 any Medicare-certified provider or supplier as 

22 described in subsection (b)(2)(A). 

23 ‘‘(B) CONTINUITY OF CARE.—To provide 

24 for continuity of care, each contract entered 

25 into with an Organization under this section 


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1 shall provide for a transition period during 

2 which a Program-eligible beneficiary who is 

3 first enrolled in the Organization or who elects 

4 to opt out of the Program or otherwise disenroll 

5 from the Organization maintains access to eligi6 ble participating providers furnishing items or 

7 services to such beneficiary immediately before 

8 such enrollment or election for purposes of re9 ceipt of such items or services. Payment for 

10 such items or services covered under this title 

11 furnished to such Program-eligible beneficiary 

12 during such transition period shall be made in 

13 accordance with this title and in such amounts 

14 as would otherwise be determined for such 

15 items and services provided to such a bene16 ficiary not enrolled under the Program. 

17 ‘‘(C) ANTIDISCRIMINATION.—Each con18 tract entered into with an Organization under 

19 this section shall provide that each eligible par20 ticipating provider of such Organization may 

21 not deny, limit, or condition the furnishing of 

22 services, or affect the quality of services fur23 nished, under this title to Program-eligible 

24 beneficiaries on whether or not such a bene25 ficiary is enrolled with the Organization. 


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1 ‘‘(D) QUALITY ASSURANCE; PATIENT

2 SAFEGUARDS.—Each contract entered into with 

3 an Organization under this section shall require 

4 that such Organization have in effect at a min5 imum— 

6 ‘‘(i) a written plan of quality assur7 ance and improvement, and procedures im8 plementing such plan, in accordance with 

9 regulations; and 

10 ‘‘(ii) written safeguards of the rights 

11 of Program-eligible beneficiaries enrolled in 

12 the Organization (including a patient bill 

13 of rights and procedures for grievances 

14 and appeals) in accordance with regula15 tions and with other requirements of this 

16 title and Federal and State law that are 

17 designed for the protection of patients. 

18 ‘‘(E) OVERSIGHT.—The Secretary shall 

19 oversee the marketing and assignment practices 

20 of each Organization entering into a contract 

21 under this section as part of the approval and 

22 renewal processes of Organizations under this 

23 section. 

24 ‘‘(5) NON-APPLICATION OF CERTAIN PROVI25 SIONS OF LAW.—For purposes of sections 162(m)(6) 


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1 and 414(m) of the Internal Revenue Code of 1986 

2 and section 9010 of the Patient Protection and Af3 fordable Care Act (26 U.S.C. 4001 note prec.), in 

4 the case of an eligible participating provider that es5 tablishes an Organization or that enters into a part6 nership, ownership, or co-ownership agreement to es7 tablish an Organization, or an Organization with a 

8 contract under this section, risk-based payments in 

9 exchange for providing medical care shall not be con10 sidered premiums for health insurance coverage. 

11 ‘‘(6) TREATMENT AS MEDICARE ADVANCED AL12 TERNATIVE PAYMENT MODEL.—Alternative care de13 livery models under the Program shall be treated 

14 under this title as an advanced alternative payment 

15 model. 

16 ‘‘(c) PROGRAM OPERATION AND SCOPE.— 

17 ‘‘(1) IN GENERAL.—Not later than one year 

18 after the date of enactment of this section, the Sec19 retary shall establish a process through which an 

20 Organization can apply to offer one or more ESRD 

21 Integrated Care Models. Such application shall in22 clude information on at least the following: 

23 ‘‘(A) The estimated average revenue 

24 amount described in subsection (b)(2)(A)(ii)(II) 


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1 for the Organization to deliver benefits de2 scribed in subsection (b)(2)(A). 

3 ‘‘(B) Any benefits offered by the Organiza4 tion beyond those described in such subsection. 

5 ‘‘(C) A listing of network providers of serv6 ices and supplier. 

7 ‘‘(D) Information on the expertise of net8 work providers of services and suppliers in serv9 ing ESRD patients. 

10 ‘‘(E) A description of the ESRD Inte11 grated Care Strategy of the Organization de12 scribed in subsection (b)(2)(D). 

13 ‘‘(2) PROGRAM INITIATION.—The Secretary 

14 shall initiate the Program such that Organizations 

15 begin serving Program-eligible beneficiaries not later 

16 than January 1, 2019. 

17 ‘‘(3) CONTRACT AWARD AND PERIOD.—The 

18 Secretary shall enter into contracts for an initial pe19 riod of not less than 5 years with all Organizations 

20 that meet Program requirements. 

21 ‘‘(4) ALLOWANCE FOR LARGER SERVICE AREAS

22 AND EXPANSION OF SERVICE AREAS.—Organizations 

23 shall demonstrate in their application that the pro24 posed service area has the capacity to serve Pro25 gram-eligible beneficiaries through an adequate proVerDate Sep 11 2014 03:08 Nov 04, 2017 Jkt 079200 PO 00000 Frm 00027 Fmt 6652 Sfmt 6201 E:\BILLS\S2065.IS S2065

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1 vider network and is reflective of the communities in 

2 which beneficiaries live, work, and obtain health care 

3 services. 

4 ‘‘(5) CONTRACT TERMINATION AND SUSPEN5 SION.— 

6 ‘‘(A) IN GENERAL.—The Secretary may 

7 terminate a contract with an Organization 

8 under this section if the Secretary determines 

9 that an Organization has failed to meet quality 

10 requirements described in subsection (b) or 

11 (e)(2)(C)(iii) or violates other terms of the con12 tract. 

13 ‘‘(B) INSUFFICIENT BENEFICIARY PARTICI14 PATION.—The Secretary shall, in the case of an 

15 Organization with a contract under this section 

16 with respect to which, for any period of at least 

17 30 consecutive days during a year for which 

18 such contract applies, fewer than 50 percent of 

19 the total number of Program-eligible bene20 ficiaries served by the Organization receive ben21 efits through the Organization under this sec22 tion— 

23 ‘‘(i) suspend such contract for the re24 mainder of such year; and 


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1 ‘‘(ii) provide for the Organization to 

2 return any prospective payments made to 

3 the Organization under this section for 

4 items and services not provided pursuant 

5 to clause (i). 

6 ‘‘(C) REMEDY AND APPEALS PROCESS.— 

7 Prior to the Secretary terminating or sus8 pending a contract with an Organization under 

9 this section, the Secretary shall afford such Or10 ganization sufficient opportunity to remedy any 

11 contract violations and appeal a contract termi12 nation. 

13 ‘‘(D) PROGRAM-ELIGIBLE BENEFICIARY

14 NOTICE AT TIME OF CONTRACT TERMI15 NATION.—Each contract under this section with 

16 an Organization shall require the Organization 

17 to provide (and pay for) written notice in ad18 vance of the contract’s termination or suspen19 sion, as well as a description of alternatives for 

20 obtaining benefits under this title, to each Pro21 gram-eligible beneficiary assigned to or who 

22 elected to receive benefits through the Organi23 zation under this section. 

24 ‘‘(6) PROGRAM EXPANSION.—The Secretary 

25 may, through rulemaking, expand the duration and 


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1 scope of the Program under this section, to the ex2 tent determined appropriate by the Secretary, if— 

3 ‘‘(A) the Secretary determines that such 

4 expansion is expected to— 

5 ‘‘(i) reduce spending under this title 

6 without reducing the quality of patient 

7 care; or 

8 ‘‘(ii) improve the quality of patient 

9 care without increasing spending under 

10 this title; 

11 ‘‘(B) the Chief Actuary of the Centers for 

12 Medicare & Medicaid Services certifies that 

13 such expansion would reduce (or would not re14 sult in any increase in) net program spending 

15 under this title; and 

16 ‘‘(C) the Secretary determines that such 

17 expansion would not deny or limit the coverage 

18 or provision of benefits under this title for ap19 plicable individuals. 

20 ‘‘(7) STUDY.—The Secretary shall conduct a 

21 study on an appropriate payment adjustor under the 

22 Program to ensure there are not disincentives in 

23 under the payment method under the Program from 

24 providing proper transplant evaluations. 


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1 ‘‘(d) IDENTIFICATION OF PROGRAM-ELIGIBLE BENE2 FICIARIES.—The Secretary shall establish a process for 

3 the initial and ongoing identification of Program-eligible 

4 beneficiaries. 

5 ‘‘(e) PROGRAM-ELIGIBLE BENEFICIARIES ASSIGNED

6 INTO AN ESRD INTEGRATED CARE ORGANIZATION OPEN

7 NETWORK MODEL.— 

8 ‘‘(1) ASSIGNMENT.— 

9 ‘‘(A) IN GENERAL.—Under the Program, 

10 subject to the succeeding provisions of this 

11 paragraph, the Secretary shall, upon the Sec12 retary identifying a beneficiary as a Program13 eligible beneficiary, assign all such Program-eli14 gible beneficiary to an open network model of15 fered by an Organization that includes the di16 alysis facility at which the Program-eligible ben17 eficiary primarily receives renal dialysis serv18 ices. 

19 ‘‘(B) PROGRAM-ELIGIBLE BENEFICIARY

20 NOTIFICATION OF ASSIGNMENT.— 

21 ‘‘(i) IN GENERAL.—Upon assignment 

22 of a Program-eligible beneficiary to an Or23 ganization, the Secretary shall provide to 

24 the Organization written notification of 

25 such assignment of such Program-eligible 


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1 beneficiary and not later than 15 business 

2 days after the date of receipt of such noti3 fication, the Organization shall provide 

4 written notice to the Program-eligible ben5 eficiary— 

6 ‘‘(I) of such assignment; and 

7 ‘‘(II) including education regard8 ing the importance of transplantation 

9 as the best health outcome, as well as 

10 the minimum health requirements for 

11 transplant eligibility before and dur12 ing dialysis treatment. 

13 ‘‘(ii) OPT–OUT PERIOD AND CHANGES

14 UPON INITIAL ASSIGNMENT.—The Sec15 retary shall provide for a 75-day period be16 ginning on the date on which the assign17 ment of a Program-eligible beneficiary into 

18 an open network model offered by an Or19 ganization becomes effective during which 

20 a Program-eligible beneficiary may— 

21 ‘‘(I) opt out of the Program; 

22 ‘‘(II) make a one-time change of 

23 assignment into an open network 

24 model offered by a different Organiza25 tion; or 


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1 ‘‘(III) elect a preferred network 

2 model offered by the same or different 

3 Organization. 

4 ‘‘(C) ADDITIONAL OPT-IN POPULATION IN

5 CASE OF BENEFICIARY RELOCATION OR

6 CHOICE.—An individual who, without applica7 tion of clause (iv) of subsection (a)(2)(C), 

8 would be treated as a Program-eligible bene9 ficiary, may elect to enroll in an Organization 

10 under the Program under this section if such 

11 individual agrees to receive renal dialysis serv12 ices primarily from a facility that participates 

13 in such Organization. For purposes of this sec14 tion (other than subparagraphs (A) and (B) of 

15 this paragraph, paragraph (2), and subsection 

16 (d), an individual making an election pursuant 

17 to the previous sentence shall be treated as a 

18 Program-eligible beneficiary. 

19 ‘‘(D) DEEMED RE-ENROLLMENT.—A Pro20 gram-eligible beneficiary assigned under this 

21 paragraph to an ESRD Integrated Care Model 

22 offered by an Organization with respect to a 

23 year is deemed, unless the individual elects oth24 erwise under this paragraph, to have elected to 


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1 continue such assignment with respect to the 

2 subsequent year. 

3 ‘‘(E) ADDITIONAL OPPORTUNITY TO OPT

4 OUT OR ELECT DIFFERENT MODEL OR ORGANI5 ZATION.—On the date that is one year after the 

6 effective date of the initial assignment of a Pro7 gram-eligible beneficiary to an open network 

8 model offered by an Organization (and annually 

9 thereafter), a Program-eligible beneficiary shall 

10 be given the opportunity to— 

11 ‘‘(i) opt out of the Program; 

12 ‘‘(ii) make a one-time change of as13 signment into an open network model of14 fered by a different Organization; or 

15 ‘‘(iii) elect a preferred network model 

16 offered by the same or different Organiza17 tion. 

18 ‘‘(F) CHANGE IN PRINCIPAL DIAGNOSIS

19 OPT OUT.—In addition to any other period dur20 ing which a Program-eligible beneficiary may, 

21 pursuant to this paragraph, opt out of the Pro22 gram, in the case of a Program-eligible bene23 ficiary who, after assignment under this para24 graph, is diagnosed with a principal diagnosis 

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1 stage renal disease, such individual shall be 

2 given the opportunity to opt out of the Program 

3 during such period as specified by the Sec4 retary. 

5 ‘‘(G) SPECIAL ELECTION PERIODS.—The 

6 Secretary shall offer Program-eligible bene7 ficiaries special election periods consistent with 

8 those described in section 1851(e)(4). 

9 ‘‘(2) PROGRAM-ELIGIBLE BENEFICIARY NOTIFI10 CATION.— 

11 ‘‘(A) IN GENERAL.—The Secretary shall 

12 notify Program-eligible beneficiaries about the 

13 Program under this section and provide them 

14 with information about receiving benefits under 

15 this title through an Organization. 

16 ‘‘(B) REQUIREMENTS.—Notwithstanding 

17 any other provision of law, subject to subpara18 graph (C), such notification shall allow for eligi19 ble participating providers that are part of an 

20 Organization to— 

21 ‘‘(i) inform Program-eligible bene22 ficiaries about the Program; 

23 ‘‘(ii) distribute Program materials to 

24 Program-eligible beneficiaries; and 


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1 ‘‘(iii) assist Program-eligible bene2 ficiaries in assessing the options of such 

3 beneficiaries under the Program. 

4 ‘‘(C) LIMITATION ON UNSOLICITED MAR5 KETING.— 

6 ‘‘(i) IN GENERAL.—Under the Pro7 gram, an eligible participating provider 

8 may not provide marketing information or 

9 materials, including information, materials, 

10 and assistance described in subparagraph 

11 (B), to a Program-eligible beneficiary un12 less the Program-eligible beneficiary re13 quests such marketing information or ma14 terials. 

15 ‘‘(ii) EXCEPTION FOR PROVIDERS

16 TREATING BENEFICIARIES.—An eligible 

17 participating provider that is part of an 

18 Organization may provide information, ma19 terials, and assistance described in sub20 paragraph (B) to a Program-eligible bene21 ficiary, without prior request of such bene22 ficiary, if such beneficiary is receiving 

23 renal dialysis services from such provider. 

24 ‘‘(iii) PARITY IN MARKETING.—In any 

25 case that an Organization participates in 


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1 any form of marketing, such form of mar2 keting shall be the same for all Program3 eligible beneficiaries to which, pursuant to 

4 (ii), the Organization may provide informa5 tion, materials, and assistance described in 

6 such clause. 

7 ‘‘(3) PROGRAM-ELIGIBLE BENEFICIARY APPEAL

8 RIGHTS.—Program-eligible beneficiaries enrolled in 

9 an Organization shall have the same right to appeal 

10 any denial of benefits under this title as such a Pro11 gram-eligible beneficiary would have under this title 

12 if such Program-eligible beneficiary were not so en13 rolled. 

14 ‘‘(f) PAYMENT.— 

15 ‘‘(1) IN GENERAL.—For each Program-eligible 

16 beneficiary receiving care through an Organization, 

17 the Secretary shall make a monthly capitated pay18 ment in accordance with payment rates that would 

19 be determined under section 1853(a)(1)(H), as ad20 justed pursuant to paragraph (2). 

21 ‘‘(2) APPLICATION OF HEALTH STATUS RISK

22 ADJUSTMENT METHODOLOGY.—The Secretary shall 

23 adjust the payment amount to an Organization 

24 under this subsection in the same manner in which 


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1 the payment amount to a Medicare Advantage plan 

2 is adjusted under section 1853(a)(1)(C). 

3 ‘‘(3) TREATMENT OF KIDNEY ACQUISITION

4 COSTS.— 

5 ‘‘(A) EXCLUDING COSTS FOR KIDNEY AC6 QUISITIONS FROM MA BENCHMARK.—The Sec7 retary shall adjust the payment amount to an 

8 Organization to exclude from such payment 

9 amount the Secretary’s estimate of the stand10 ardized costs for payments for organ acquisi11 tions for kidney transplants in the area involved 

12 for the year. 

13 ‘‘(B) FFS COVERAGE OF KIDNEY ACQUISI14 TIONS.—An Organization shall provide all bene15 fits described in subclause (I) of subsection 

16 (b)(2)(A)(i), except for kidney acquisition costs. 

17 Payment for kidney acquisition costs covered 

18 under this title furnished to a Program-eligible 

19 beneficiary shall be made in accordance with 

20 this title and in such amounts as would other21 wise be made and determined for such items 

22 and services provided to such a beneficiary not 

23 enrolled under the Program. 

24 ‘‘(4) PAYMENT FOR PART D BENEFITS.—In the 

25 case where an Organization elects to offer part D 


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1 prescription drug coverage under the Program under 

2 this section, payments to the Organization for such 

3 benefits provided to Program-eligible beneficiaries by 

4 the Organization shall be made in the same manner 

5 and amounts as those payments would be made in 

6 the case of an organization with a contract under 

7 such part. 

8 ‘‘(5) AGREEMENT WITH STATE MEDICAID

9 AGENCY.—In the event of an Organization that 

10 elects to cover benefits under title XIX for Program11 eligible beneficiaries eligible for benefits under this 

12 title and title XIX such Organization shall enter into 

13 an agreement with the State Medicaid agency to 

14 provide benefits, or arrange for benefits to be pro15 vided, for which such beneficiaries are entitled to re16 ceive medical assistance under title XIX and to re17 ceive payment from the State for providing or ar18 ranging for the provision of such benefits. 

19 ‘‘(6) AFFIRMATION OF STATE OBLIGATIONS TO

20 PAY PREMIUM AND COST-SHARING AMOUNTS.— 

21 ‘‘(A) IN GENERAL.—A State shall continue 

22 to make medical assistance under the State 

23 plan under title XIX available in the amount 

24 described in subparagraph (B) for the duration 

25 of the Program for cost-sharing (as defined in 


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1 section 1905(p)(3)) under this title for qualified 

2 Medicare beneficiaries described in section 

3 1905(p)(1) and other individuals who are Pro4 gram-eligible beneficiaries enrolled in an Orga5 nization and entitled to medical assistance for 

6 premiums and such cost-sharing under the 

7 State plan under title XIX. 

8 ‘‘(B) AMOUNTS MADE AVAILABLE FOR

9 COST-SHARING.—For purposes of subparagraph 

10 (A): 

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

12 (ii), the amount of medical assistance de13 scribed in this clause to be made available 

14 for cost-sharing pursuant to subparagraph 

15 (A) for an individual described in such 

16 subparagraph entitled to medical assist17 ance for such cost-sharing under a State 

18 plan under title XIX shall be equal to the 

19 amount of medical assistance that would 

20 be made available under such State plan as 

21 in effect as of January 1, 2016. 

22 ‘‘(ii) AMOUNTS IN THE CASE OF A

23 STATE THAT INCREASES PAYMENTS FOR

24 COST-SHARING.—If a State increases the 

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1 able under the State plan under title XIX 

2 for cost-sharing described in subparagraph 

3 (A) after such date, such increased 

4 amounts shall be made available under 

5 subparagraph (A) for the remaining dura6 tion of the Program. 

7 ‘‘(g) WAIVER AUTHORITY.— 

8 ‘‘(1) IN GENERAL.—In order to carry out the 

9 Program under this section, the Secretary shall 

10 waive those requirements waived under section 1899 

11 and may waive such additional requirements con12 sistent with those waived under programs adminis13 tered through the Center for Medicare and Medicaid 

14 Innovation as may be necessary. 

15 ‘‘(2) NOTICE OF WAIVERS.—Not later than 3 

16 months after the date of enactment of this section, 

17 the Secretary shall publish a notice of waivers that 

18 will apply in connection with the Program. The no19 tice shall include the specific conditions that an Or20 ganization must meet to qualify for each waiver, and 

21 commentary explaining the waiver requirements. 

22 ‘‘(h) REPORT.—Not later than December 31, 2024, 

23 the Medicare Payment Advisory Commission shall submit 

24 to Congress an interim report on the Program.’’. 


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1 (b) CONFORMING AMENDMENT RELATING TO BAL2 ANCED BILLING.—Section 1866(a)(1)(O) of the Social Se3 curity Act (42 U.S.C. 1395cc(a)(1)(O)) is amended— 

4 (1) by inserting ‘‘with an ESRD Integrated 

5 Care Organization under section 1866F,’’ after 

6 ‘‘with a PACE provider under section 1894 or 

7 1934,’’; 

8 (2) by inserting ‘‘or ESRD Integrated Care Or9 ganization’’ after ‘‘in the case of a PACE provider’’; 

10 (3) by striking ‘‘or PACE program eligible indi11 viduals enrolled with the PACE provider’’ and in12 serting ‘‘, Program-eligible beneficiaries enrolled in 

13 the ESRD Integrated Care Organization, or PACE 

14 program eligible individuals enrolled with the PACE 

15 provider’’; and 

16 (4) by inserting ‘‘(or in the case of a Program17 eligible beneficiary enrolled in the ESRD Integrated 

18 Care Organization, the amounts that would be made 

19 in accordance with payment rates that would be de20 termined under section 1853(a)(1)(H))’’ after ‘‘the 

21 amounts that would be made’’. 

22 (c) EXTENSION OF GUARANTEED ISSUE RIGHTS

23 UNDER MEDIGAP.— 

24 (1) IN GENERAL.—Section 1882(s)(3)(B) of the 

25 Social Security Act (42 U.S.C. 1395ss(s)(3)(B)) is 


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1 amended by adding at the end the following new 

2 clause: 

3 ‘‘(vii) The individual is participating 

4 in the demonstration program established 

5 under section 1866F, regardless of the du6 ration of the individual’s participation in 

7 the program and regardless of any pre8 vious enrollment in, or disenrollment from, 

9 a Medicare supplemental policy under this 

10 section.’’. 

11 (2) NOTIFICATION.—The Secretary of Health 

12 and Human Services shall develop a process to no13 tify (and shall notify) individuals described in clause 

14 (vii) of section 1882(s)(3)(B) of the Social Security 

15 Act (42 U.S.C. 1395ss(s)(3)(B)), as added by para16 graph (1), of their guaranteed issue rights under 

17 such section. 

Æ 


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