I 

114TH CONGRESS 

1ST SESSION H. R. 3244 

To amend title XVIII of the Social Security Act to establish a pilot program 

to improve care for the most costly Medicare fee-for-service beneficiaries 

through the use of comprehensive and effective care management while 

reducing costs to the Federal Government for these beneficiaries, and 

for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

JULY 28, 2015 

Mrs. MCMORRIS RODGERS (for herself, Mr. LARSON of Connecticut, Mr. 

REED, 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 establish 

a pilot program to improve care for the most costly 

Medicare fee-for-service beneficiaries through the use of 

comprehensive and effective care management while reducing costs to the Federal Government for these beneficiaries, 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, 


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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Providing Innovative 

3 Care for Complex Cases Demonstration Act of 2015’’. 

4 SEC. 2. PROGRAM TO IMPROVE CARE FOR HIGHEST COST 

5 MEDICARE FEE-FOR-SERVICE BENE6 FICIARIES. 

7 Title XVIII of the Social Security Act is amended by 

8 inserting after section 1866E (42 U.S.C. 1395cc–5) the 

9 following new section: 

10 ‘‘PROGRAM TO IMPROVE CARE FOR HIGHEST COST

11 MEDICARE FEE-FOR-SERVICE BENEFICIARIES

12 ‘‘SEC. 1866F. (a) ESTABLISHMENT.—The Secretary 

13 shall conduct under this section a pilot program (in this 

14 section referred to as the ‘program’) to demonstrate im15 provements in patient care and cost savings for the high16 est cost Medicare fee-for-service beneficiaries through en17 rollment of such beneficiaries with participating organiza18 tions. Under the program, the Secretary shall, through a 

19 competitive process, enter into a contract with one or two 

20 selected organizations to offer benefits for items and serv21 ices in service areas identified under subsection (b)(1)(A) 

22 to the highest cost Medicare fee-for-service beneficiaries 

23 (identified under subsection (c)(1)) in the service area in24 volved. The program shall be designed in a manner to pro25 vide comprehensive and integrated care management and 


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1 services through a network of health care providers to 

2 meet the specialized needs of such identified beneficiaries. 

3 ‘‘(b) CONDUCT OF PROGRAM.— 

4 ‘‘(1) PERIOD OF OPERATION AND SCOPE.— 

5 ‘‘(A) INITIAL CONDUCT.—The program 

6 shall initially be conducted over a 3-year period, 

7 beginning not later than 1 year after the date 

8 of the enactment of this section, in at least 4 

9 service areas, each identified by the Secretary 

10 and each including at least 3 contiguous coun11 ties. 

12 ‘‘(B) EXPANSION AND EXTENSION.—The 

13 Secretary may expand the program to addi14 tional service areas and extend its duration if 

15 the Secretary determines, in consultation with 

16 the Chief Actuary of the Centers for Medicare 

17 & Medicaid Services, that such expansion and 

18 extension will result in additional savings to the 

19 Medicare program and will meet the quality 

20 performance standards established under sub21 section (d)(3)(A)(iii). 

22 ‘‘(C) RELATION TO PART D.— 

23 ‘‘(i) IN GENERAL.—The Secretary 

24 shall design and implement the program in 

25 such manner as to preserve the operation 


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1 of part D, including payment, noninter2 ference, and beneficiary protections under 

3 such part. 

4 ‘‘(ii) COORDINATION MECHANISMS.— 

5 The Secretary shall identify mechanisms 

6 that may be used, in the case of a highest 

7 cost Medicare fee-for-service beneficiary 

8 who is enrolled with a participating organi9 zation under the program and in a pre10 scription drug plan offered by a PDP 

11 sponsor under part D or a qualified retiree 

12 prescription drug plan offered by a sponsor 

13 under section 1860D–22, in order to en14 hance coordination of the individual’s care 

15 between the organization and the respec16 tive sponsor. 

17 ‘‘(2) NUMBER OF PARTICIPATING ORGANIZA18 TIONS PER SERVICE AREA.—Under the program the 

19 Secretary shall enter into a contract with at least 

20 one selected organization (and no more than 2 se21 lected organizations) in each service area identified 

22 and covered under the program. 

23 ‘‘(c) IDENTIFICATION AND ENROLLMENT OF HIGH24 EST COST MEDICARE FEE-FOR-SERVICE BENE25 FICIARIES.— 


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1 ‘‘(1) IDENTIFICATION.— 

2 ‘‘(A) IN GENERAL.—For purposes of the 

3 program, the Secretary shall develop criteria to 

4 identify, subject to subparagraph (B), Medicare 

5 fee-for-service beneficiaries with projected total 

6 costs under parts A and B in the highest 10th 

7 percentile of all Medicare fee-for-service bene8 ficiaries on an ongoing basis. Such criteria shall 

9 be developed in a manner so as to identify such 

10 beneficiaries using the most recent national 

11 data available for a 2-year period. 

12 ‘‘(B) REFINEMENT OF ELIGIBILITY CRI13 TERIA.—In identifying highest cost Medicare 

14 fee-for-service beneficiaries under this para15 graph, the Secretary shall develop such criteria 

16 in a manner that eliminates, to the extent prac17 ticable, the identification of individuals who oth18 erwise appear to meet such criteria only be19 cause of a single, isolated high-cost incident, 

20 item, or service. 

21 ‘‘(2) ELIGIBLE BENEFICIARY INITIAL OUT22 REACH.—The Secretary shall inform the highest cost 

23 Medicare fee-for-service beneficiaries residing in an 

24 area covered by the program of the program and 

25 provide them with information about the program 


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1 and the process for enrollment and disenrollment 

2 from participation organizations in such area. Such 

3 information shall include information about such or4 ganizations, about rights and protections under the 

5 program, a contact telephone number where bene6 ficiaries can obtain additional information about the 

7 program, and the use of an advance directive (as de8 fined in section 1866(f)(3)) in connection with par9 ticipation in the program. 

10 ‘‘(3) AUTO-ENROLLMENT AND DISENROLLMENT

11 PROCEDURES.— 

12 ‘‘(A) IN GENERAL.—Under the program, 

13 the highest cost Medicare fee-for-service bene14 ficiaries residing in a service area covered under 

15 the program— 

16 ‘‘(i) shall be enrolled, in a form and 

17 manner specified by the Secretary, with a 

18 participating organization offered under 

19 the program to such a resident in such 

20 area; and 

21 ‘‘(ii) may change or terminate such 

22 enrollment in a form and manner so speci23 fied. 

24 In specifying such form and manner, the Sec25 retary shall take into account the form and 


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1 manner in which individuals may change or ter2 minate an enrollment under a Medicare Advan3 tage plan under part C, including permitting 

4 special disenrollment periods described in sec5 tion 1851(e)(4). 

6 ‘‘(B) DEFAULT ORGANIZATION SELEC7 TION.—In carrying out subparagraph (A), if 

8 there are two participating organizations in a 

9 service area, the Secretary shall identify, to the 

10 extent possible, and enroll the beneficiary in the 

11 participating organization which has providers 

12 in its network from whom the beneficiary has 

13 received services under the Medicare fee-for14 service program in the previous year. 

15 ‘‘(C) TIMEFRAMES.—In carrying out sub16 paragraph (A), there shall be an initial enroll17 ment period of 12 months, during which a high18 est cost Medicare fee-for-service beneficiary may 

19 also opt out of participation in the program. 

20 ‘‘(4) EXTENSION OF CERTAIN GUARANTEED

21 ISSUANCE RIGHTS TO MEDIGAP COVERAGE IN CASE

22 OF DISENROLLMENT.—Subparagraph (A) of section 

23 1882(s)(3) shall apply to a Medicare beneficiary en24 rolled with a participating organization under this 

25 section who had previous coverage under a medicare 


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1 supplemental insurance policy and who terminates 

2 enrollment with the participating organization in the 

3 same manner as such section applies to an individual 

4 described in subparagraph (B)(v) of such section 

5 with respect to enrollment with a health plan, re6 gardless of the time period of participation in the 

7 program and without regard to subparagraph (E)(ii) 

8 of such section. 

9 ‘‘(5) TREATMENT OF MEDICARE FEE-FOR-SERV10 ICE BENEFITS TO ENROLLEES THROUGH PRO11 GRAM.—The provisions of section 1851(i) shall apply 

12 to individuals enrolled with a participating organiza13 tion under the program in the same manner as they 

14 apply to an individual enrolled in a Medicare Advan15 tage plan under part C. 

16 ‘‘(6) RELATION TO PART D, EMPLOYER-BASED

17 PRESCRIPTION DRUG COVERAGE, AND MEDICARE

18 SUPPLEMENTAL COVERAGE.—Except as specifically 

19 provided, nothing in this section shall be construed 

20 as intending to impact on benefits or coverage fur21 nished under a prescription drug plan under part D, 

22 under a group health plan (including under a quali23 fied retiree prescription drug plan as defined in sec24 tion 1860D–22(a)(2)), or under a medicare supple25 mental policy. 


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1 ‘‘(d) PARTICIPATING ORGANIZATION REQUIRE2 MENTS.— 

3 ‘‘(1) IN GENERAL.—For purposes of partici4 pating in the program, except as provided in this 

5 subsection, a participating organization must meet 

6 the same requirements that apply to a Medicare Ad7 vantage organization and an MA plan that is not an 

8 MA–PD plan under part C, including requirements 

9 relating to— 

10 ‘‘(A) coverage of items and services under 

11 parts A and B; and 

12 ‘‘(B) beneficiary protections under part C. 

13 ‘‘(2) WAIVER AUTHORITY.—Under the pro14 gram, the Secretary may waive the requirements of 

15 this title and title XI but only to the extent nec16 essary to permit participating organizations— 

17 ‘‘(A) to provide care management, custo18 dial care, transportation, in-home assistance, 

19 and other services that are not otherwise cov20 ered under this title; 

21 ‘‘(B) to structure patient incentives, such 

22 as a reduction or elimination of cost-sharing, 

23 for services and benefits under parts A and B 

24 and the use of in-home technology, to improve 

25 beneficiary adherence to treatment protocols 


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1 and the effectiveness of treatment for enrolled 

2 beneficiaries with chronic clinical conditions; 

3 and 

4 ‘‘(C) to maintain provider and pharmacy 

5 networks that do not otherwise meet network 

6 adequacy standards. 

7 ‘‘(3) QUALITY AND REPORTING REQUIRE8 MENTS.— 

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

10 the Secretary shall— 

11 ‘‘(i) determine appropriate measures 

12 (including, to the extent feasible, outcome 

13 measures) to assess the quality of care 

14 being provided under the program; 

15 ‘‘(ii) establish requirements for par16 ticipating organizations to report, in a 

17 form and manner specified by the Sec18 retary, information on such measures; 

19 ‘‘(iii) establish quality performance 

20 standards on such measures to assess the 

21 quality of care being provided by such or22 ganizations under the program; and 

23 ‘‘(iv) seek the input of stakeholders 

24 (in a manner similar to that provided for 


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1 under section 1848(r)) in determining such 

2 measures, requirements, and standards. 

3 ‘‘(B) TERMINATION OF PARTICIPATION

4 FOR FAILURE TO MEET QUALITY PERFORMANCE

5 STANDARDS.—The Secretary may terminate 

6 participation of an organization under the pro7 gram for failure to meet the quality perform8 ance standards established under subparagraph 

9 (A)(iii). 

10 ‘‘(C) QUALITY PERFORMANCE STAND11 ARDS.—In establishing quality performance 

12 standards under subparagraph (A)(iii) in the 

13 case of— 

14 ‘‘(i) a provider-based organization 

15 (such as an accountable care organization), 

16 the Secretary may apply the quality meas17 urement system used under the Medicare 

18 shared savings program under section 

19 1899(b)(3); and 

20 ‘‘(ii) an MA organization, the Sec21 retary may require that only an organiza22 tion with a rating (under the star quality 

23 rating system under section 1853(o)(4)) of 

24 4 stars or higher be permitted to partici25 pate in the program. 


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1 ‘‘(4) USE OF INTEGRATED MODEL OF CARE.— 

2 The Secretary shall develop care management re3 quirements for participating organizations that pro4 vides an integrated care model and that includes the 

5 following elements: 

6 ‘‘(A) Provision of person-centered, com7 prehensive, and integrated care management 

8 and services. 

9 ‘‘(B) Provision of services through— 

10 ‘‘(i) the use of a network of providers 

11 characterized as best-in-class, such as cen12 ters of excellence; and 

13 ‘‘(ii) the use of an interdisciplinary 

14 management team that includes a nurse 

15 coordinator (or other appropriate health 

16 care professional) assigned to each enrolled 

17 beneficiary and that shares a common 

18 health information technology platform. 

19 ‘‘(C) An evidence-based model of care with 

20 appropriate networks of providers and special21 ists. 

22 ‘‘(D) For each beneficiary enrolled with 

23 the organization under the program, the organi24 zation— 


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1 ‘‘(i) conducts an initial assessment 

2 and an annual reassessment of the bene3 ficiary’s physical, psychosocial, and func4 tional needs, including an evaluation and 

5 plan with respect to the beneficiary’s 

6 chronic conditions; 

7 ‘‘(ii) provides for regular in-person 

8 visits to the beneficiary by a care provider 

9 and provides the beneficiary with access to 

10 a specialized team, including a hospitalist 

11 physician; and 

12 ‘‘(iii) develops a plan, in consultation 

13 with the beneficiary as feasible, that identi14 fies goals and objectives with respect to the 

15 beneficiary, including measurable outcomes 

16 as well as specific services and benefits to 

17 be provided. 

18 ‘‘(e) PAYMENTS.— 

19 ‘‘(1) IN GENERAL.—For each individual en20 rolled with a participating organization under the 

21 program, the Secretary shall make a monthly 

22 capitated payment to the organization in the same 

23 manner as such a payment would be made under 

24 part C for an individual enrolled in an MA-plan 


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1 (that was not an MA–PD plan) offered by a Medi2 care Advantage organization, except that— 

3 ‘‘(A) notwithstanding section 1853, the 

4 amount of the payment shall be determined, 

5 subject to subparagraph (B), in an amount 

6 equivalent to 98 percent of the projected cost, 

7 under the Medicare fee-for-service program 

8 under parts A and B for the highest cost Medi9 care fee-for-service beneficiaries; and 

10 ‘‘(B) the amount of such payment shall be 

11 adjusted, in a manner specified by the Sec12 retary, to take into account differences in costs 

13 among different geographic areas and among 

14 high cost Medicare fee-for-service beneficiaries 

15 (including outlier costs for the most costly such 

16 beneficiaries). 

17 ‘‘(2) PROJECTION BASED UPON HISTORICAL

18 DATA.—In applying paragraph (1)(A), the Secretary 

19 shall use historical fee-for-service spending and en20 rollment data for the highest cost Medicare fee-for21 service beneficiaries, trended forward to the first 

22 year of the program, and, for subsequent years of 

23 the program, increased by projected growth in such 

24 spending for such beneficiaries. 


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1 ‘‘(3) RELATIONSHIP TO PAYMENT FOR COV2 ERED PART D DRUGS.—In the case of an individual 

3 who is enrolled with a participating organization 

4 under the program— 

5 ‘‘(A) if the individual is enrolled with a 

6 prescription drug plan under part D, payment 

7 for covered part D drugs for such individual is 

8 made under such prescription drug plan under 

9 such part and not under the program; and 

10 ‘‘(B) if the individual is covered under a 

11 qualified retiree prescription drug plan under 

12 section 1860D–22, payment for covered part D 

13 drugs for such individual is made under such 

14 plan and not under the program. 

15 ‘‘(f) EVALUATION AND REPORT TO CONGRESS.— 

16 ‘‘(1) EVALUATION.—The Secretary shall con17 duct an independent evaluation of the program. 

18 Such evaluation shall include an analysis of the im19 pact of the program on coordination of care, expend20 itures by participating organizations and plans, the 

21 program’s impact on reducing expenditures under 

22 this title, beneficiary access to services and pro23 viders, the quality of health care services furnished 

24 to beneficiaries, and beneficiary experiences with 


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1 auto-enrollment and disenrollment under the pro2 gram. 

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

4 date that Medicare beneficiaries are first enrolled 

5 under the program, the Secretary shall submit to 

6 Congress a report on the performance of the pro7 gram. Such report shall include the results of the 

8 evaluation conducted under paragraph (1) and the 

9 program’s impact on reducing expenditures under 

10 this title and on improving the quality of care for 

11 the highest cost Medicare fee-for-service beneficiaries 

12 enrolled under the program. 

13 ‘‘(g) DEFINITIONS.—In this section: 

14 ‘‘(1) HIGHEST COST MEDICARE FEE-FOR-SERV15 ICE BENEFICIARY.—The term ‘highest cost Medicare 

16 fee-for-service beneficiary’ means a Medicare fee-for17 service beneficiary who has been identified under 

18 subsection (c). 

19 ‘‘(2) MEDICARE FEE-FOR-SERVICE BENE20 FICIARY DEFINED.—The term ‘Medicare fee-for21 service beneficiary’ means an individual who— 

22 ‘‘(A) is entitled to benefits under part A, 

23 and enrolled under part B, regardless of the 

24 basis for entitlement or eligibility to benefits 

25 under any such part; and 


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1 ‘‘(B) is not enrolled in a Medicare Advan2 tage plan under part C. 

3 ‘‘(3) PROGRAM.—Unless the context indicates 

4 otherwise, the term ‘program’ means the program 

5 under this section. 

6 ‘‘(4) PARTICIPATING ORGANIZATION.—The 

7 term ‘participating organization’ means a selected 

8 organization that has entered into a contract to par9 ticipate in the program. 

10 ‘‘(5) SELECTED ORGANIZATION.—The term ‘se11 lected organization’ means a provider-based organi12 zation (such as an accountable care organization) or 

13 MA organization (as defined for purposes of part C) 

14 that the Secretary determines— 

15 ‘‘(A) meets the requirements to provide 

16 services to the highest cost Medicare fee-for17 services beneficiaries under the program; and 

18 ‘‘(B) is accredited by the National Com19 mittee for Quality Assurance or otherwise is 

20 certified as meeting quality standards.’’. 

Æ 


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