II 

114TH CONGRESS 

1ST SESSION S. 1989 

To improve access to primary care services. 

IN THE SENATE OF THE UNITED STATES 

AUGUST 5, 2015 

Mr. CASSIDY introduced the following bill; which was read twice and referred 

to the Committee on Finance 

A BILL 

To improve access to primary care services. 

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 ‘‘Primary Care En5 hancement Act of 2015’’. 

6 SEC. 2. TREATMENT OF DIRECT PRIMARY CARE SERVICE 

7 ARRANGEMENTS. 

8 (a) IN GENERAL.—Section 223(c) of the Internal 

9 Revenue Code of 1986 is amended by adding at the end 

10 the following new paragraph: 

11 ‘‘(6) TREATMENT OF DIRECT PRIMARY CARE

12 SERVICE ARRANGEMENTS.—An arrangement under 


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1 which an individual is provided ongoing primary care 

2 services in exchange for a fixed periodic fee which is 

3 not billed to any third party on a fee for service 

4 basis— 

5 ‘‘(A) shall not be treated as a health plan 

6 for purposes of paragraph (1)(A)(ii), and 

7 ‘‘(B) shall not be treated as insurance for 

8 purposes of subsection (d)(2)(B).’’. 

9 (b) EFFECTIVE DATE.—The amendment made by 

10 this section shall apply to taxable years beginning after 

11 the date of the enactment of this Act. 

12 SEC. 3. CERTAIN PROVIDER FEES TO BE TREATED AS MED13 ICAL CARE. 

14 (a) IN GENERAL.—Subsection (d) of section 213 of 

15 the Internal Revenue Code of 1986 is amended by adding 

16 at the end the following new paragraph: 

17 ‘‘(12) PERIODIC PROVIDER FEES.—The term 

18 ‘medical care’ shall include periodic fees paid to a 

19 primary care physician for a defined set of medical 

20 services on an as-needed basis.’’. 

21 (b) EFFECTIVE DATE.—The amendment made by 

22 this section shall apply to taxable years beginning after 

23 the date of the enactment of this Act. 


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1 SEC. 4. MEDICARE PRIMARY CARE MEDICAL HOME DEM2 ONSTRATION PROGRAM. 

3 Section 1115A of title XI of the Social Security Act 

4 (42 U.S.C. 1315a) is amended— 

5 (1) in subsection (b)(2)(A), in the last sentence, 

6 by inserting ‘‘, and shall include the model described 

7 in subsection (h)’’ before the period at the end; and 

8 (2) by adding at the end the following new sub9 section: 

10 ‘‘(h) PRIMARY CARE MEDICAL HOME MODEL.— 

11 ‘‘(1) MODEL.— 

12 ‘‘(A) IN GENERAL.—The model described 

13 in this subsection is a model under which quali14 fied direct primary care medical home practices 

15 are reimbursed a periodic fee for furnishing 

16 services to an individual enrolled under part B 

17 of title XVIII. 

18 ‘‘(B) QUALIFIED DIRECT PRIMARY CARE

19 MEDICAL HOME PRACTICE.—In this subsection, 

20 the term ‘qualified direct primary care medical 

21 home practice’ means a qualified direct primary 

22 care medical home practice described in section 

23 1301(a)(3) of the Patient Protection and Af24 fordable Care Act (as amended by section 

25 10104(a) of such Act). 

26 ‘‘(2) PERIODIC FEE.— 


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1 ‘‘(A) IN GENERAL.—Subject to the suc2 ceeding provisions of this paragraph, the Sec3 retary shall establish the periodic fee to be paid 

4 to qualified direct primary care medical home 

5 practices participating in the model under this 

6 subsection for each individual enrolled in the 

7 practice. 

8 ‘‘(B) AFFORDABLE PRIMARY CARE.—In no 

9 case may a monthly equivalent of the periodic 

10 fee established by the Secretary under subpara11 graph (A) exceed an amount equal to twenty 

12 percent of the average per capita monthly 

13 amount that the Secretary estimates will be 

14 payable from the Federal Hospital Insurance 

15 Trust Fund under section 1817 and from the 

16 Federal Supplementary Medical Insurance 

17 Trust Fund for services and related administra18 tive costs for an individual under parts A and 

19 B of title XVIII. 

20 ‘‘(C) ADJUSTMENT TO PERIODIC FEE.— 

21 ‘‘(i) PERFORMANCE BENCHMARK.— 

22 The Secretary shall establish a perform23 ance benchmark for a year using the ACO 

24 quality measures in the Medicare shared 

25 savings program under section 1899. 


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1 ‘‘(ii) ADJUSTMENT.—Beginning with 

2 the second year the model under this sub3 section is conducted, in the case of a quali4 fied direct primary care medical home 

5 practice participating in the model under 

6 this subsection— 

7 ‘‘(I) that meets or exceeds the 

8 performance benchmark for the year 

9 under clause (i), the periodic fee paid 

10 to the practice for each individual en11 rolled in the practice shall be in12 creased by 5 percent; and 

13 ‘‘(II) that does not meet the per14 formance benchmark for the year 

15 under clause (i), the periodic fee paid 

16 to the practice for each individual en17 rolled in the practice shall be reduced 

18 by 5 percent. 

19 ‘‘(3) TERMINATION IF PERFORMANCE BENCH20 MARK NOT NET FOR 2 CONSECUTIVE YEARS.—The 

21 Secretary shall terminate the participation of a 

22 qualified direct primary care medical home practice 

23 in the model under this subsection if the practice 

24 would otherwise be subject to the adjustment under 

25 paragraph (2)(C)(ii)(II) for 2 consecutive years. 


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1 ‘‘(4) SCOPE OF SERVICES.—Each qualified di2 rect primary care medical home practice shall em3 ploy the following activities and functions associated 

4 with direct primary care medical homes: 

5 ‘‘(A) Preventive care. 

6 ‘‘(B) Wellness counseling. 

7 ‘‘(C) Primary care. 

8 ‘‘(D) Coordination of primary care with 

9 specialty and hospital care. 

10 ‘‘(E) Availability of ongoing care appoint11 ments 7 days per week. 

12 ‘‘(F) Secure e-mail and telephone consulta13 tion. 

14 ‘‘(G) Availability of telephone access for 

15 ongoing care consultation on a 7-day-per-week, 

16 24-hour-per-day basis. 

17 ‘‘(H) Use of a primary care provider panel 

18 size that promotes the ability of participating 

19 providers to appropriately provide the scope of 

20 services described in this paragraph. 

21 ‘‘(5) PRIORITY.— 

22 ‘‘(A) IN GENERAL.—In selecting qualified 

23 direct primary care medical home practices to 

24 participate under this subsection, the Secretary 

25 shall provide priority to practices that seek to 


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1 enroll individuals who are dual eligible individ2 uals. 

3 ‘‘(B) DUAL ELIGIBLE INDIVIDUAL.—In 

4 subparagraph (A), the term ‘dual eligible indi5 vidual’ means an individual who is— 

6 ‘‘(i) enrolled under part B of title 

7 XVIII; and 

8 ‘‘(ii) described in subparagraph (A)(ii) 

9 of section 1935(c)(6) of the Social Security 

10 Act (42 U.S.C. 1396u–5(c)(6)), taking into 

11 account the application of subparagraph 

12 (B) of such section. 

13 ‘‘(6) NOT INSURANCE.—Care provided in a 

14 qualified direct primary care medical home practice 

15 participating in the model under this subsection 

16 shall not be considered an insurance product and 

17 shall not be subject to regulation as an insurance 

18 product or health maintenance organization by State 

19 insurance commissioners. 

20 ‘‘(7) REPORTING TO SECRETARY.—A qualified 

21 direct primary care medical home practice partici22 pating in the model under this subsection shall sub23 mit to the Secretary an annual report on— 


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1 ‘‘(A) the progress, of individuals enrolled 

2 in the practice with one or more chronic condi3 tions, on the following: 

4 ‘‘(i) Emergency room visits. 

5 ‘‘(ii) Hospitalizations. 

6 ‘‘(iii) Surgeries (including type of sur7 gery). 

8 ‘‘(iv) Specialist visits. 

9 ‘‘(v) Use of advanced radiology (other 

10 than mammograms and DEXA scans); and 

11 ‘‘(B) such other areas determined appro12 priate by the Secretary. 

13 ‘‘(8) PROVISION OF DATA TO PRACTICES.—The 

14 Secretary shall provide qualified direct primary care 

15 medical home practices participating in the model 

16 under this subsection with all necessary and relevant 

17 patient data, including any prior claims data, needed 

18 for clinical purposes and for the purpose of pro19 viding an evaluation of such the model under this 

20 subsection. 

21 ‘‘(9) PROVIDERS CURRENTLY OPTED OUT OF

22 MEDICARE.—Notwithstanding section 1802(b), a 

23 physician or practitioner who has currently opted 

24 out of the Medicare program under such section may 

25 participate in a qualified direct primary care medical 


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1 home practice participating in the model under this 

2 subsection and payment may be made under this 

3 title with respect to items and services furnished by 

4 such physician or practitioner under such model to 

5 Medicare beneficiaries with whom the physician or 

6 practitioner has in effect a private contract under 

7 such section. 

8 ‘‘(10) FRAUD.—A physician or practitioner who 

9 has been excluded from participation in a Federal 

10 health care program (as defined in section 1128C(f)) 

11 shall not be permitted to participate in a qualified 

12 direct primary care medical home practice under the 

13 model under this subsection. 

14 ‘‘(11) DURATION.—Subject to subsection 

15 (b)(3), the Secretary shall conduct the model under 

16 this subsection for a period of not less than 3 years. 

17 ‘‘(12) EXPANSION.—Notwithstanding sub18 section (c), if the Secretary determines, after the 

19 third year that the model under this subsection is 

20 conducted, that— 

21 ‘‘(A) a qualified direct primary care med22 ical home practice participating in the model 

23 under this subsection meets the requirements 

24 under paragraphs (1), (2), and (3) of such sub25 section, such practice shall continue permaVerDate Sep 11 2014 23:39 Aug 12, 2015 Jkt 049200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S1989.IS S1989

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1 nently as long as it continues to meet such re2 quirements and the other requirements of this 

3 subsection; and 

4 ‘‘(B) a majority of qualified direct primary 

5 care medical home practice participating in the 

6 model under this subsection meet the require7 ments under paragraphs (1), (2), and (3) of 

8 such subsection, the Secretary shall expand the 

9 model on a nationwide basis.’’. 

10 SEC. 5. USE OF DIRECT PRIMARY CARE MEDICAL HOMES 

11 UNDER THE MEDICARE ADVANTAGE PRO12 GRAM. 

13 (a) IN GENERAL.—Nothing in title XVIII of the So14 cial Security Act or any other provision of law shall be 

15 construed to prohibit a Medicare Advantage organization 

16 offering a Medicare Advantage plan under part C of such 

17 title from— 

18 (1) contracting with a qualified direct primary 

19 care medical home practice to offer primary care 

20 services under such plan; or 

21 (2) including in such contract provisions for 

22 shared savings agreed upon between the Medicare 

23 Advantage organization and the the qualified direct 

24 primary care medical home practice. 


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1 (b) QUALIFIED DIRECT PRIMARY CARE MEDICAL

2 HOME PRACTICE.—In this section, the term ‘‘qualified di3 rect primary care medical home practice’’ means a quali4 fied direct primary care medical home practice described 

5 in section 1301(a)(3) of the Patient Protection and Af6 fordable Care Act (as amended by section 10104(a) of 

7 such Act). 

Æ 


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