I 

114TH CONGRESS 

2D SESSION H. R. 4878 

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

Better Care Program to provide integrated care for Medicare beneficiaries with chronic conditions, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MARCH 23, 2016 

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

which was referred to the Committee on Energy and Commerce, and in 

addition to the Committee on Ways and Means, 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 Medicare Better Care Program to provide integrated 

care for Medicare beneficiaries with chronic conditions, 

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; TABLE OF CONTENTS. 

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

5 ‘‘Better Care, Lower Cost Act’’. 

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

7 this Act is as follows: 


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Sec. 1. Short title; table of contents. 

Sec. 2. Findings. 

Sec. 3. Medicare Better Care Program. 

Sec. 4. Chronic special needs plans. 

Sec. 5. Improvements to welcome to Medicare visit and annual wellness visits. 

Sec. 6. Chronic care innovation centers. 

Sec. 7. Curricula requirements for direct and indirect graduate medical education payments. 

1 SEC. 2. FINDINGS. 

2 Congress makes the following findings: 

3 (1) The field of medicine is ever-evolving and 

4 we need a highly skilled, team-oriented workforce 

5 that can meet the health care needs of today as well 

6 as the health care challenges of tomorrow. 

7 (2) The Medicare program should recognize the 

8 growing uses and benefits of health technology in de9 livering quality and cost-efficient care by encour10 aging the use of telemedicine and remote patient 

11 monitoring. 

12 SEC. 3. MEDICARE BETTER CARE PROGRAM. 

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

14 Act (42 U.S.C. 1395 et seq.) is amended by adding at 

15 the end the following new section: 

16 ‘‘MEDICARE BETTER CARE PROGRAM

17 ‘‘SEC. 1899B. (a) ESTABLISHMENT.— 

18 ‘‘(1) IN GENERAL.—Not later than January 1, 

19 2019, the Secretary shall establish an integrated 

20 chronic care delivery program (in this section re21 ferred to as the ‘program’) that promotes accountVerDate Sep 11 2014 04:22 Mar 25, 2016 Jkt 059200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H4878.IH H4878

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1 ability and better care management for chronically 

2 ill patient populations and coordinates items and 

3 services under parts A, B, and D, while encouraging 

4 investment in infrastructure and redesigned care 

5 processes that result in high quality and efficient 

6 service delivery for the most vulnerable and costly 

7 populations. The program shall— 

8 ‘‘(A) focus on long-term cost containment 

9 and better overall health of the Medicare popu10 lation by implementing through qualified BCPs 

11 (as described in paragraph (2)(A)) strategies 

12 that prevent, delay, or minimize the progression 

13 of illness or disability associated with chronic 

14 conditions; and 

15 ‘‘(B) include the program elements de16 scribed in paragraph (2). 

17 ‘‘(2) PROGRAM ELEMENTS.—The following pro18 gram elements are described in this paragraph: 

19 ‘‘(A) A health plan or group of providers 

20 of services and suppliers, or a health plan work21 ing with such a group, that the Secretary cer22 tifies in accordance with subsection (e) as meet23 ing criteria developed by the Secretary to recog24 nize the challenges of managing a chronically ill 

25 population, including patient satisfaction and 


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1 engagement, quality measurement developed 

2 specifically for a chronically ill population, and 

3 effective use of resources and providers, may 

4 manage and coordinate care for BCP eligible 

5 individuals through an integrated care network, 

6 or Better Care Program (referred to in this sec7 tion as a ‘qualified BCP’). A group of providers 

8 of services and suppliers described in the pre9 ceding sentence may also be participating in an10 other alternative payment model (as defined in 

11 subsection (k)). 

12 ‘‘(B) Payments to a qualified BCP shall be 

13 made in accordance with subsection (g). 

14 ‘‘(C) Implementation of the program shall 

15 focus on physical, behavioral, and psychosocial 

16 needs of BCP eligible individuals. 

17 ‘‘(D) Quality and cost containment are 

18 considered interdependent goals of the program. 

19 ‘‘(E) The calculation of long-term cost sav20 ings is dependent on qualified BCPs delivering 

21 the full continuum of covered primary, post22 acute care, and social services using capitated 

23 financing. 

24 ‘‘(3) TARGETED PARTICIPATION.— 


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1 ‘‘(A) IN GENERAL.—In certifying qualified 

2 BCPs throughout the country, the Secretary 

3 shall give priority to areas— 

4 ‘‘(i) that do not have a concentration 

5 of accountable care organizations under 

6 section 1899; and 

7 ‘‘(ii) with a high burden of chronic 

8 conditions. 

9 ‘‘(B) INITIAL REQUIREMENT.—In the first 

10 5 years of the program, at least 50 percent of 

11 all new qualified BCPs certified nationwide by 

12 the Secretary shall be from counties or regions, 

13 as determined by the Secretary, where the prev14 alence of the most costly chronic conditions is 

15 at or greater than 125 percent of the national 

16 average. 

17 ‘‘(C) RESTRICTING THE NUMBER OF PAR18 TICIPATING BCPS.— 

19 ‘‘(i) IN GENERAL.—The Secretary 

20 shall take into account geography, urban 

21 and rural designations, and the population 

22 case mix that will be served, when selecting 

23 BCPs for participation. 

24 ‘‘(ii) LIMITATION DURING THE FIRST

25 FOUR PROGRAM YEARS.—During the first 


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1 four years of the program, the total num2 ber of qualified BCPs certified by the Sec3 retary shall not exceed 250. 

4 ‘‘(iii) NO LIMITATION DURING FIFTH

5 AND SUBSEQUENT PROGRAM YEARS.—Dur6 ing the fifth year and any subsequent year 

7 of the program, the Secretary may certify 

8 any BCP that meets the requirements to 

9 be certified as a qualified BCP. 

10 ‘‘(4) ALIGNMENT WITH APPROVED STATE PLAN

11 WAIVERS.—In certifying qualified BCPs, the Sec12 retary shall ensure alignment with other approved 

13 waivers of State plans under title XIX. 

14 ‘‘(b) DEFINITION OF BCP ELIGIBLE INDIVIDUALS.— 

15 ‘‘(1) DEFINITION.—For purposes of this sec16 tion, the term ‘BCP eligible individual’ means an in17 dividual who— 

18 ‘‘(A) is entitled to benefits under part A 

19 and enrolled under parts B and D, including an 

20 individual who is enrolled in a Medicare Advan21 tage plan under part C, an eligible organization 

22 under section 1876, or a PACE program under 

23 section 1894; and 

24 ‘‘(B) is medically complex given the preva25 lence of chronic disease that actively and perVerDate Sep 11 2014 04:22 Mar 25, 2016 Jkt 059200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H4878.IH H4878

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1 sistently affects their health status, and absent 

2 appropriate care interventions, causes them to 

3 be at enhanced risk for hospitalization, limita4 tions on activities of daily living, or other sig5 nificant health outcomes. 

6 ‘‘(2) DUAL ELIGIBLE INDIVIDUALS.—An indi7 vidual who is dually eligible for Medicare and Med8 icaid shall not be excluded from enrolling in a quali9 fied BCP. Dually eligible beneficiaries enrolled in a 

10 qualified BCP will see the full scope of their benefits 

11 under this title and title XIX (other than long-term 

12 care) managed by the qualified BCP. 

13 ‘‘(c) NOTIFICATION AND ENROLLMENT.— 

14 ‘‘(1) NOTIFICATION.—Not later than October 1 

15 of each year, the Secretary shall use all available 

16 tools, including the notice mailed annually under 

17 section 1804(a) and State health insurance assist18 ance programs, to notify BCP eligible individuals of 

19 qualified BCPs in their area for the upcoming plan 

20 year. Such information shall also be easily accessible 

21 on the Internet website of the Centers for Medicare 

22 & Medicaid Services. 

23 ‘‘(2) ENROLLMENT.—The Secretary shall estab24 lish procedures under which BCP eligible individuals 


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1 may voluntarily enroll in a qualified BCP at the fol2 lowing times: 

3 ‘‘(A) During the annual, coordinated elec4 tion period under section 1851(e)(3)(B). 

5 ‘‘(B) During or following (for a length of 

6 time determined by the Secretary)— 

7 ‘‘(i) an initial preventive physical ex8 amination (as defined in section 

9 1861(ww)); or 

10 ‘‘(ii) any subsequent visit where a 

11 chronic condition is identified or a previous 

12 condition is identified as having escalated 

13 to the level of a chronic condition. 

14 ‘‘(d) PATIENT ASSESSMENT.— 

15 ‘‘(1) STANDARDIZED FUNCTIONAL AND HEALTH

16 RISK ASSESSMENT.— 

17 ‘‘(A) MINIMUM GUIDELINES.—Not later 

18 than January 1, 2018, the Secretary shall pub19 lish minimum guidelines for qualified BCPs to 

20 furnish to enrollees a health information tech21 nology-compatible, standardized, and multi22 dimensional risk assessment that— 

23 ‘‘(i) assesses and quantifies the med24 ical, psychosocial, and functional status of 

25 an enrollee; and 


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1 ‘‘(ii) includes a mechanism to deter2 mine the level of patient activation and 

3 ability to engage in self-care of an enrollee. 

4 ‘‘(B) UPDATING.—Not less frequently than 

5 once every 3 years, the Secretary shall, through 

6 rulemaking, update such minimum guidelines to 

7 reflect new clinical standards and practices, as 

8 appropriate. 

9 ‘‘(2) INDIVIDUAL PATIENT-CENTERED CHRONIC

10 CARE PLAN.— 

11 ‘‘(A) MODEL PLAN.—Not later than Janu12 ary 1, 2018, the Secretary shall publish min13 imum guidelines for qualified BCPs to develop 

14 individual patient-centered chronic care plans 

15 for enrollees. Such a plan shall— 

16 ‘‘(i) allow health professionals to in17 corporate the medical, psychosocial, and 

18 functional components identified in the 

19 risk assessment described in paragraph 

20 (1)(A)(i); 

21 ‘‘(ii) provide a framework that can be 

22 easily integrated into electronic health 

23 records, allowing clinicians to make timely, 

24 accurate, evidence-based decisions at the 

25 point of care; and 


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1 ‘‘(iii) allow for the provider to describe 

2 how services will be provided to the en3 rollee. 

4 ‘‘(B) USE OF TECHNOLOGY FOR PATIENT

5 SELF CARE.— 

6 ‘‘(i) IN GENERAL.—Whenever appro7 priate, the individual patient-centered 

8 chronic care plan of an enrollee shall in9 clude the use of technologies that enhance 

10 communication between patients, pro11 viders, and communities of care, such as 

12 telehealth, remote patient monitoring, 

13 Smartphone applications, and other such 

14 enabling technologies, that promote patient 

15 engagement and self care while maintain16 ing patient safety. 

17 ‘‘(ii) COORDINATION AND DEVELOP18 MENT OF STREAMLINED PATHWAY.—The 

19 Secretary shall work with the Office of the 

20 National Coordinator for Health Informa21 tion Technology and the Department of 

22 Health and Human Services Chief Tech23 nology Officer to develop a streamlined 

24 pathway for the use of mobile applications 

25 and communications devices that effecVerDate Sep 11 2014 04:22 Mar 25, 2016 Jkt 059200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H4878.IH H4878

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1 tively enhance the experience of the patient 

2 while maintaining patient safety and cost3 effectiveness. Such pathway shall not du4 plicate existing efforts. 

5 ‘‘(e) QUALIFIED BCP PROVIDERS.— 

6 ‘‘(1) CRITERIA.— 

7 ‘‘(A) IN GENERAL.—Any health plan, pro8 vider of services, or group of providers of serv9 ices and suppliers, who agrees to meet the re10 quirements described in paragraph (2) and is 

11 specified in subparagraph (C) may form a mul12 tidisciplinary team of health professionals to be 

13 certified as a qualified BCP. Those providers 

14 may also choose to partner with a qualified in15 surer to become a qualified BCP. 

16 ‘‘(B) NO PREEMPTION OF STATE LICEN17 SURE LAWS.—Nothing in this section shall pre18 empt State licensure laws. 

19 ‘‘(C) GROUPS OF PROVIDERS AND SUP20 PLIERS SPECIFIED.— 

21 ‘‘(i) IN GENERAL.—As determined ap22 propriate by the Secretary, the following 

23 health plans, providers of services, or 

24 groups of providers of services and sup25 pliers, that meet the criteria described in 


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1 clause (ii) may be certified as qualified 

2 BCPs under the program: 

3 ‘‘(I) Health professionals acting 

4 as part of a multidisciplinary team. 

5 ‘‘(II) Networks of individual 

6 practices of health professionals that 

7 may include community health cen8 ters, Federally qualified health cen9 ters, rural health clinics, and partner10 ships or affiliations with hospitals. 

11 ‘‘(III) Health plans that meet ap12 propriate network adequacy stand13 ards, as determined by the Secretary, 

14 and that include providers with expe15 rience and interest in managing a 

16 population with chronic conditions. 

17 ‘‘(IV) Independent health profes18 sionals partnering with an inde19 pendent risk manager. 

20 ‘‘(V) Such other groups of pro21 viders of services or suppliers as the 

22 Secretary determines appropriate. 

23 ‘‘(ii) CRITERIA DESCRIBED.—The fol24 lowing criteria are described in this clause: 


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1 ‘‘(I) Demonstrated capacity to 

2 manage the full continuum of care 

3 (other than long-term care) for the 

4 specialized population of BCP eligible 

5 individuals. 

6 ‘‘(II) Having a high rate of Medi7 care customer satisfaction, when ap8 plicable, or partnering with providers 

9 of services or suppliers with such a 

10 demonstrated high satisfaction rate. 

11 ‘‘(2) REQUIREMENTS.—A qualified BCP shall 

12 meet the following requirements: 

13 ‘‘(A) The qualified BCP shall be account14 able for the quality, cost, and overall care of en15 rolled BCP eligible individuals and agree to be 

16 at financial risk for that enrolled population. A 

17 qualified BCP shall be established with the ob18 jective of serving BCP eligible individuals. 

19 ‘‘(B) The qualified BCP shall be respon20 sible for the full continuum of care (other than 

21 long-term care) for enrollees. This continuum 

22 shall include medical care, skilled nursing and 

23 home health services, behavioral health care, 

24 and social services. The qualified BCP may not 

25 actively restrict an enrollee’s access to providers 


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1 based on a practitioner’s license or medical spe2 cialty based on cost alone. 

3 ‘‘(C) The qualified BCP shall primarily 

4 consist of a care team tasked with responding 

5 to, treating, and actively supporting the needs 

6 of BCP eligible individuals. The care team shall 

7 also develop a care plan for each eligible BCP 

8 enrollee and use it as a tool to execute effective 

9 care management and transitions. 

10 ‘‘(D) The qualified BCP shall include phy11 sicians, nurse practitioners, registered nurses, 

12 social workers, pharmacists, and behavioral 

13 health providers who commit to caring for BCP 

14 eligible individuals. 

15 ‘‘(E) The qualified BCP shall enter into an 

16 agreement with the Secretary to participate in 

17 the program under this section for not less than 

18 a 3-year period. 

19 ‘‘(F) The qualified BCP shall include ade20 quate numbers of primary care and other rel21 evant professionals that can effectively care for 

22 the number of BCP eligible individuals enrolled 

23 in the qualified BCP. 

24 ‘‘(G) The qualified BCP shall provide the 

25 Secretary with such information regarding 


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1 qualified BCP professionals participating in the 

2 qualified BCP necessary to support the enroll3 ment of BCP eligible individuals in a qualified 

4 BCP, including evidence relating to high pa5 tient satisfaction when available, the implemen6 tation of quality reporting and other reporting 

7 requirements, and evidence to support a deter8 mination of capitated payments in accordance 

9 with subsection (g). 

10 ‘‘(H) The qualified BCP shall have in 

11 place a structure that includes clinical and ad12 ministrative systems, including health informa13 tion technology, that supports the integration of 

14 services and providers across sites of care. 

15 ‘‘(I) The qualified BCP may develop a col16 laborative partnership that supports the mission 

17 of the BCP with each of the following: 

18 ‘‘(i) A regional or national Chronic 

19 Care Innovation Center under section 6 of 

20 the Better Care, Lower Cost Act. 

21 ‘‘(ii) A regional or national Center of 

22 Innovation (COIN) of the Department of 

23 Veterans Affairs Health Services Research 

24 and Development Service to identify and 

25 implement best practices— 


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1 ‘‘(I) to increase access to, and 

2 implementation of, prevention and 

3 wellness tools; 

4 ‘‘(II) to integrate physical and 

5 behavior health care with social serv6 ices; 

7 ‘‘(III) to promote evidence-based 

8 medicine and patient engagement; 

9 ‘‘(IV) to coordinate care across 

10 providers and care settings; 

11 ‘‘(V) to allow more patients to be 

12 cared for in their homes and commu13 nities; 

14 ‘‘(VI) to reduce hospital readmis15 sions; 

16 ‘‘(VII) to improve health out17 comes for patients with chronic condi18 tions; and 

19 ‘‘(VIII) to report on quality im20 provement and cost measures. 

21 ‘‘(iii) A regional or national Tele22 health Resource Center of the Health Re23 sources and Services Administration 

24 (HRSA) Office for the Advancement of 

25 Telehealth to create an interactive, online 


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1 resource for qualified BCP professionals 

2 who may need additional training or assist3 ance in managing the needs of a complex 

4 patient population, including— 

5 ‘‘(I) continuing training and edu6 cation and mentoring for qualified 

7 BCP professionals at any level of li8 censure; 

9 ‘‘(II) clinician support for com10 plex patients by an expert panel; 

11 ‘‘(III) remote access to regional, 

12 national, and international experts in 

13 the field; 

14 ‘‘(IV) forums for best practices 

15 to be discussed among qualified BCP 

16 professionals; 

17 ‘‘(V) inter-professional education 

18 supporting optimal communication be19 tween members of a chronic care 

20 team; and 

21 ‘‘(VI) continuing training on the 

22 use of telehealth, remote patient mon23 itoring, and other such enabling tech24 nologies. 


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1 ‘‘(J) The qualified BCP shall demonstrate 

2 to the Secretary that it meets person3 centeredness criteria specified by the Secretary 

4 in collaboration with accreditation organiza5 tions, including the use of patient and caregiver 

6 assessments and the use of individual patient7 centered chronic care plans for each enrollee (as 

8 described in subsection (d)(2)). 

9 ‘‘(K) The qualified BCP may identify and 

10 respond to unique cultural, social, and economic 

11 needs of a community that impact access to, 

12 and quality of, healthcare. 

13 ‘‘(L) The qualified BCP shall provide care 

14 across settings, including in the home as need15 ed. 

16 ‘‘(M) The qualified BCP shall demonstrate 

17 financial solvency (as determined by the Sec18 retary). 

19 ‘‘(N) The qualified BCP shall demonstrate 

20 the ability to partner with providers of social 

21 and behavioral health services within the com22 munity. 

23 ‘‘(O) The qualified BCP shall engage in 

24 continuing education on chronic care, on an on25 going basis (as determined necessary by the 


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1 Chronic Care Innovation Center under the part2 nership under subparagraph (J)(i)), in collabo3 ration with the Agency for Healthcare Research 

4 and Quality, the Health Resources and Services 

5 Administration, and the Department of Vet6 erans Affairs. 

7 ‘‘(f) IMPLEMENTING VALUE-BASED INSURANCE DE8 SIGN.— 

9 ‘‘(1) IN GENERAL.— 

10 ‘‘(A) ELECTION.—A qualified BCP may 

11 elect to provide value-based Medicare coverage 

12 in accordance with this subsection. 

13 ‘‘(B) INCLUSION OF ORIGINAL MEDICARE

14 FEE-FOR-SERVICE PROGRAM BENEFITS.—Sub15 ject to subparagraph (C), enrollees in a quali16 fied BCP that elects to provide value-based 

17 Medicare coverage under this subsection shall 

18 receive such coverage that includes items and 

19 services for which benefits are available under 

20 parts A and B to individuals entitled to benefits 

21 under part A and enrolled under part B, with 

22 cost-sharing for those items and services as de23 scribed in subparagraph (C). 

24 ‘‘(C) COST-SHARING.—Cost-sharing de25 scribed in this subparagraph, with respect to an 


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1 enrollee in a qualified BCP that makes such an 

2 election, is varied cost-sharing approved by the 

3 Secretary to incentivize the use of high-value, 

4 high-quality services that have been clinically 

5 proven to benefit BCP eligible individuals. 

6 ‘‘(D) CHANGES IN COVERAGE.—The Sec7 retary, in consultation with experts in the field, 

8 shall establish a process for qualified BCPs to 

9 submit value-based Medicare coverage changes 

10 that encourage and incentivize the use of evi11 dence-based practices that will drive better out12 comes while ensuring patient protections and 

13 access are maintained. 

14 ‘‘(E) NO REQUIREMENT FOR COVERAGE OF

15 LONG-TERM CARE SERVICES.—In no case shall 

16 a qualified BCP be required to provide to en17 rollees coverage for long-term care services. 

18 ‘‘(2) QUALIFIED BCP PARTICIPATION.— 

19 ‘‘(A) CONTINUED ACCESS.—Subject to 

20 subparagraph (B), enrollees in a qualified BCP 

21 shall continue to have access to all providers of 

22 services and suppliers under this title. 

23 ‘‘(B) NO APPLICATION OF VARIED COST24 SHARING FOR NONPARTICIPATING PROVIDERS

25 OF SERVICES AND SUPPLIERS.— 


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1 ‘‘(i) IN GENERAL.—The varied cost2 sharing under paragraph (1)(B) shall only 

3 apply to items and services furnished by 

4 qualified BCP professionals of a qualified 

5 BCP that makes an election under para6 graph (1). In the case where items and 

7 services are furnished by a provider of 

8 services or supplier who is not such a 

9 qualified BCP professional, the cost-shar10 ing applicable for those items and services 

11 will be the cost-sharing as required under 

12 parts A and B, or an actuarially equivalent 

13 level of cost-sharing as determined by the 

14 Secretary. 

15 ‘‘(ii) NOTIFICATION.—A BCP eligible 

16 individual shall be notified and counseled 

17 prior to the time of enrollment on potential 

18 changes in out-of-pocket costs that may 

19 occur if care is provided by a provider of 

20 services or supplier that is not a qualified 

21 BCP professional. 

22 ‘‘(3) LIMITATIONS ON OUT-OF-POCKET EX23 PENSES OUTSIDE A QUALIFIED BCP.— 

24 ‘‘(A) IN GENERAL.—Out-of-pocket costs, 

25 including individual beneficiary copayments, 


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1 with respect to items and services furnished by 

2 a provider of services or supplier who is not a 

3 qualified BCP professional shall not exceed 

4 what would otherwise have been paid with re5 spect to the item or service under the original 

6 Medicare fee-for-service program under parts A 

7 and B for the same services or an actuarially 

8 equivalent level of cost-sharing as determined 

9 by the Secretary, or, in the case of a dual eligi10 ble individual, under the Medicaid program 

11 under title XIX. 

12 ‘‘(B) PROHIBITION ON COVERAGE OF

13 COST-SHARING FOR CERTAIN ITEMS AND SERV14 ICES FURNISHED TO AN ENROLLEE OUTSIDE

15 OF A QUALIFIED BCP UNDER MEDIGAP POLI16 CIES.—For provisions relating to prohibition on 

17 coverage of cost-sharing for items and services 

18 (other than emergent services, as defined by the 

19 Secretary) furnished to an enrollee outside of a 

20 qualified BCP under Medigap policies, see sec21 tion 1882(z). 

22 ‘‘(4) PRESCRIPTION DRUG COVERAGE.— 

23 ‘‘(A) DRUG PLAN OPTION.— 

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1 rollees with a drug plan option specifically 

2 designed to reflect the medication needs of 

3 enrollees. 

4 ‘‘(ii) APPLICATION OF PART D PROVI5 SIONS.— 

6 ‘‘(I) IN GENERAL.—Except as 

7 otherwise provided in this section, the 

8 provisions of part D shall apply to a 

9 drug plan option offered by a qualified 

10 BCP under clause (i) in the same 

11 manner as such provisions apply to a 

12 prescription drug plan offered by a 

13 PDP sponsor under such part. 

14 ‘‘(II) LIMITATION OF ENROLL15 MENT.—A qualified BCP offering 

16 such a drug plan option may limit en17 rollment in the drug plan option to 

18 enrollees in the qualified BCP. 

19 ‘‘(III) WAIVER.—The Secretary 

20 may waive such provisions of part D 

21 as are necessary to carry out this sec22 tion. 

23 ‘‘(B) AGREEMENT WITH PRESCRIPTION

24 DRUG PLANS.—A qualified BCP managed by a 

25 group of providers of services may enter into an 


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1 agreement with a PDP sponsor of a prescrip2 tion drug plan under part D to establish and 

3 encourage individuals enrolled in the qualified 

4 BCP to enroll in a prescription drug plan under 

5 such part that is better suited to the needs of 

6 chronically ill individuals. 

7 ‘‘(C) LIMITATION.—A drug plan option of8 fered by a qualified BCP under subparagraph 

9 (A)(i) shall not have the authority to increase 

10 out-of-pocket limits otherwise applicable under 

11 part D. 

12 ‘‘(g) PAYMENTS AND TREATMENT OF SAVINGS.— 

13 ‘‘(1) PAYMENTS TO QUALIFIED BCPS ON A

14 CAPITATED BASIS.— 

15 ‘‘(A) IN GENERAL.—In the case of a quali16 fied BCP under this section, the Secretary shall 

17 make prospective monthly payments of a capita18 tion amount for each BCP eligible individual 

19 enrolled in the qualified BCP in the same man20 ner and from the same sources as payments are 

21 made to a Medicare Advantage organization 

22 under section 1853. Such payments shall be 

23 subject to adjustment in the manner described 

24 in section 1853(a)(2) or section 1876(a)(1)(E), 

25 as the case may be. 


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1 ‘‘(B) CAPITATION AMOUNT.—The capita2 tion amount to be applied under this paragraph 

3 for a qualified BCP for each enrollee for a year 

shall be 1 4 ⁄12 of the benchmark rate under sub5 paragraph (C)(ii) for the year (or the relevant 

6 rate under subparagraph (C)(i) for the first 

7 year of the program under this section) (re8 ferred to in this paragraph as the ‘per member 

9 per month payment’), as adjusted under clause 

10 (iii). 

11 ‘‘(C) DETERMINING THE RATE USING RISK

12 RELEVANT CONTROL GROUP.— 

13 ‘‘(i) RELEVANT RATE.— 

14 ‘‘(I) IDENTIFICATION OF BENE15 FICIARY GROUPING.—Using claims 

16 data, the Secretary shall identify a 

17 group of beneficiaries who have simi18 lar health risk characteristics, and 

19 have sought care in the same county, 

20 multi-county, or State level (as deter21 mined appropriate by the Secretary to 

22 establish a payment area) to the pop23 ulation the qualified BCP is tasked 

24 with serving. To the extent feasible 

25 for a statistically valid control group, 


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1 the health risk of such group shall re2 flect social characteristics, such as in3 come, as well as medical risk. 

4 ‘‘(II) DETERMINATION OF REL5 EVANT RATE.—The per capita spend6 ing amounts under this title and, as 

7 appropriate, title XIX, of the group of 

8 beneficiaries identified under sub9 clause (I) shall determine the ‘rel10 evant rate’ that will serve as the basis 

11 of the benchmark for participating 

12 qualified BCPs. 

13 ‘‘(ii) BENCHMARK RATE.—The Sec14 retary shall establish the benchmark rate 

15 for a qualified BCP service area for each 

16 year of the program by updating the rel17 evant rate determined under clause (i) with 

18 the projected change in per capita spend19 ing for the group of beneficiaries identified 

20 under clause (i)(I) for the payment area 

21 described in such clause, as determined by 

22 the Chief Actuary of the Centers for Medi23 care & Medicaid Services. 

24 ‘‘(iii) ADJUSTMENT FOR HEALTH STA25 TUS.— 


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1 ‘‘(I) COMPARISON OF HEALTH

2 STATUS.—The Secretary shall estab3 lish a risk score mechanism to com4 pare the health status of an enrollee 

5 in a qualified BCP to the average 

6 health risk of group of beneficiaries 

7 identified under clause (i)(I). 

8 ‘‘(II) INCLUSION OF NUMBER OF

9 CONDITIONS.—The Secretary shall 

10 provide that a risk score under the 

11 mechanism under this clause, with re12 spect to an individual, includes an in13 dicator for the number of chronic con14 ditions with which the individual has 

15 been diagnosed. 

16 ‘‘(III) USE OF 2 YEARS OF DIAG17 NOSIS DATA.—The Secretary shall en18 sure that such risk score, with respect 

19 to an individual reflects not less than 

20 2 years of diagnosis data, to the ex21 tent available. 

22 ‘‘(IV) ADJUSTMENT FOR HEALTH

23 STATUS.—The per member per month 

24 payment to the qualified BCP for 

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1 pending on how the individual risk 

2 profile of the enrollee compares to the 

3 average health status of such group of 

4 beneficiaries. If an enrollee has a risk 

5 profile that is not as severe as the av6 erage health status of such group of 

7 beneficiaries, then the per member per 

8 month shall be decreased to reflect the 

9 ‘healthier’ status of the enrollee. If an 

10 enrollee has a risk profile that is more 

11 severe, then the per member per 

12 month payment to the qualified BCP 

13 shall be increased to reflect the more 

14 acutely ill status of the enrollee. 

15 ‘‘(D) SHARED RISK PAYMENTS FOR CER16 TAIN QUALIFIED BCPS DURING FIRST 3 YEARS

17 OF THE PROGRAM.— 

18 ‘‘(i) IN GENERAL.—This subpara19 graph shall only apply to qualified BCPs 

20 offered by a group of providers of services 

21 and suppliers during the first 3 years of 

22 the program under this section. 

23 ‘‘(ii) SHARING OF RISK TO ALLEVIATE

24 OUTLIERS.—The Secretary shall determine 

25 shared risk payments and recoupments 


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1 under this subparagraph for a qualified 

2 BCP described in clause (i) as follows: 

3 ‘‘(I) DETERMINATION OF GAIN

4 OR LOSS.—The Secretary shall, for 

5 each of the first 3 years of the pro6 gram under this section, determine 

7 the percentage of gain or loss for the 

8 qualified BCP in providing benefits to 

9 enrollees under this section. 

10 ‘‘(II) GAIN OR LOSS GREATER

11 THAN 5 PERCENT.—If the Secretary 

12 determines the qualified BCP has a 

13 gain or loss for the year of greater 

14 than 5 percent, the qualified BCP 

15 shall bear 100 percent of the risk or 

16 reward of such loss or gain. 

17 ‘‘(III) GAIN OR LOSS OF NOT

18 LESS THAN 2 AND NOT GREATER

19 THAN 5 PERCENT.—If the Secretary 

20 determines the qualified BCP has a 

21 gain or loss for the year of not less 

22 than 2 percent but not greater than 5 

23 percent— 

24 ‘‘(aa) the qualified BCP 

25 shall bear 80 percent of the risk 


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1 or reward, as applicable, of such 

2 loss or gain; and 

3 ‘‘(bb) the Secretary shall 

4 bear 20 percent of the risk or re5 ward, as applicable, of such loss 

6 or gain. 

7 ‘‘(IV) GAIN OR LOSS BETWEEN 0

8 AND 2 PERCENT.—If the Secretary de9 termines the qualified BCP has a gain 

10 or loss for the year of greater than 0 

11 percent but less than 2 percent— 

12 ‘‘(aa) the qualified BCP 

13 shall bear 50 percent of the risk 

14 or reward, as applicable, of such 

15 loss or gain; and 

16 ‘‘(bb) the Secretary shall 

17 bear 50 percent of the risk or re18 ward, as applicable, of such loss 

19 or gain. 

20 ‘‘(iii) PROVISION OF INFORMATION.— 

21 A qualified BCP shall provide to the Sec22 retary such information as the Secretary 

23 determines is necessary to carry out this 

24 subparagraph. 


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1 ‘‘(E) BID SUBMISSION.—Beginning with 

2 the fourth year of the program, a qualified 

3 BCP shall submit a bid for participation in the 

4 program for the year that reflects the experi5 ence of the qualified BCP— 

6 ‘‘(i) in managing the care of the en7 rolled population; and 

8 ‘‘(ii) in managing such care given the 

9 relevant rate determined under subpara10 graph (C). 

11 ‘‘(F) QUALITY BONUS SYSTEM.— 

12 ‘‘(i) IN GENERAL.—The Secretary 

13 shall establish a quality bonus system 

14 whereby the Secretary distributes bonus 

15 payments to qualified BCPs that meet the 

16 requirements described in clause (iii) and 

17 other standards specified by the Secretary, 

18 which may include a focus on quality 

19 measurement and improvement, delivering 

20 patient-centered care, and practicing in in21 tegrated health systems, including training 

22 in community-based settings. In developing 

23 such standards, the Secretary shall collabo24 rate with relevant stakeholders, including 

25 program accrediting bodies, certifying 


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1 boards, training programs, health care or2 ganizations, health care purchasers, and 

3 patient and consumer groups. 

4 ‘‘(ii) DETERMINATION OF QUALITY

5 BONUSES.—Quality bonuses to the BCP 

6 shall be based on a comparison of the qual7 ity of care provided by the qualified BCP 

8 to enrollees to the quality of care provided 

9 to beneficiaries not enrolled in a qualified 

10 BCP or a Medicare Advantage plan under 

11 part C in the same region. For not less 

12 than the first 5 years of the program 

13 under this section, quality measures for 

14 the geographic region shall be based on 

15 local standards of care, and not on a na16 tional standard. For subsequent years, ap17 propriate national standards shall be con18 sidered for inclusion in the comparison of 

19 the quality of care under this subpara20 graph. 

21 ‘‘(iii) REQUIREMENTS.—A qualified 

22 BCP is eligible for quality bonuses under 

23 this subparagraph if— 


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1 ‘‘(I) the qualified BCP meets 

2 quality performance standards under 

3 subsection (h)(3); and 

4 ‘‘(II) the qualified BCP meets 

5 the requirements under subsection 

6 (e)(2). 

7 ‘‘(h) QUALITY AND OTHER REPORTING REQUIRE8 MENTS.— 

9 ‘‘(1) IN GENERAL.—The Secretary shall develop 

10 and implement, with assistance and input of relevant 

11 experts in the field and the National Strategy for 

12 Quality Improvement in Health Care, appropriate 

13 measures for BCP eligible individuals. The Secretary 

14 shall determine appropriate measures under this title 

15 and title XIX to assess the quality of care furnished 

16 by a qualified BCP, as well as those measures that 

17 are no longer appropriate and shall be removed from 

18 use. Such measures shall include measures— 

19 ‘‘(A) of clinical processes and outcomes; 

20 ‘‘(B) of patient and, where practicable, 

21 caregiver experience of care, including measure22 ment that enhances patient activation and en23 gagement; 


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1 ‘‘(C) of utilization (such as rates of hos2 pital admissions for ambulatory care sensitive 

3 conditions); 

4 ‘‘(D) of care coordination, management, 

5 and transitions; and 

6 ‘‘(E) that appropriately align with the Na7 tional Strategy for Quality Improvement in 

8 Health Care. 

9 The Secretary may use existing measures under this 

10 title, title XIX, or any other health care program, as 

11 appropriate, under this paragraph. 

12 ‘‘(2) REPORTING REQUIREMENTS.—A qualified 

13 BCP shall submit data in a form and manner speci14 fied by the Secretary which is not overly burdensome 

15 to the qualified BCP, on measures the Secretary de16 termines necessary for the qualified BCP to report 

17 in order to evaluate the quality of care furnished by 

18 the qualified BCP. Such data reporting shall empha19 size ‘patient-centered measurement’ and may include 

20 the functional status of patients, case management 

21 and care transitions across health care settings, in22 cluding hospital discharge planning and post-hospital 

23 discharge follow-up by qualified BCP professionals, 

24 as the Secretary determines appropriate. 


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1 ‘‘(3) QUALITY PERFORMANCE STANDARDS.— 

2 The Secretary shall establish quality performance 

3 standards to assess the quality of care furnished by 

4 qualified BCPs. The Secretary shall seek to improve 

5 the quality of care furnished by qualified BCPs over 

6 time by specifying higher standards, new measures, 

7 or both for purposes of assessing such quality of 

8 care. The Secretary shall also include a process for 

9 retiring measures that are no longer adequately con10 tributing to improving standards of care at the 

11 greatest possible value. 

12 ‘‘(4) OTHER REPORTING REQUIREMENTS AND

13 CALL FOR ALIGNMENT.—The Secretary shall, as the 

14 Secretary determines appropriate, incorporate and 

15 align reporting requirements and incentive payments 

16 related to the physician quality reporting system 

17 under section 1848, including those related to re18 porting on quality measures under subsection (m) of 

19 that section, reporting requirements under sub20 section (o) of that section relating to meaningful use 

21 of electronic health records, the establishment of a 

22 value-based payment modifier under subsection (p) 

23 of that section, and other similar initiatives under 

24 that section, and may use alternative criteria than 

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1 mining whether to make such payments to qualified 

2 BCP professionals. The incentive payments de3 scribed in the preceding sentence shall not be taken 

4 into consideration when calculating any payments 

5 otherwise made under subsection (g). 

6 ‘‘(i) BENEFICIARY PROTECTIONS.—The Secretary 

7 shall ensure that, to the extent consistent with this sec8 tion, a qualified BCP offers beneficiary protections appli9 cable to beneficiaries under this title and, as applicable, 

10 title XIX. 

11 ‘‘(j) PAYMENT OF MEDICARE COST-SHARING FOR

12 DUAL ELIGIBLE INDIVIDUALS.—In the case of a dual eli13 gible individual enrolled in a qualified BCP, the Secretary 

14 may provide for the payment of medicare cost-sharing (as 

15 defined in section 1905(p)(3)) that would otherwise be 

16 available under the State plan under title XIX if the indi17 vidual was not enrolled in the qualified BCP. 

18 ‘‘(k) DEFINITIONS.—In this section: 

19 ‘‘(1) ALTERNATIVE PAYMENT MODEL (APM).— 

20 The term ‘alternative payment model’ means any of 

21 the following: 

22 ‘‘(A) A model under section 1115A (other 

23 than a health care innovation award). 

24 ‘‘(B) An accountable care organization 

25 under section 1899. 


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1 ‘‘(C) A demonstration under section 

2 1866C. 

3 ‘‘(D) A demonstration required by Federal 

4 law. 

5 ‘‘(E) A qualified BCP. 

6 ‘‘(2) HOSPITAL.—The term ‘hospital’ means a 

7 subsection (d) hospital (as defined in section 

8 1886(d)(1)(B)). 

9 ‘‘(3) QUALIFIED BCP PROFESSIONAL.—The 

10 term ‘qualified BCP professional’ means a certified 

11 and licensed professional of medical or behavioral 

12 health services that is participating in a qualified 

13 BCP.’’. 

14 (b) FEDERAL ASSUMPTION OF MEDICAID COSTS FOR

15 FULL BENEFIT DUAL ELIGIBLE INDIVIDUALS ENROLLED

16 IN A QUALIFIED BCP.—Title XIX of the Social Security 

17 Act is amended by inserting after section 1943 the fol18 lowing new section: 

19 ‘‘FEDERAL ASSUMPTION OF MEDICAID COSTS FOR FULL

20 BENEFIT ELIGIBLE INDIVIDUALS ENROLLED IN A

21 QUALIFIED BCP

22 ‘‘SEC. 1944. (a) STATE CONTRIBUTION.— 

23 ‘‘(1) IN GENERAL.—The State shall provide for 

24 payment to the Secretary for each month in an 

25 amount determined under paragraph (2)(A) for each 

26 applicable dual eligible BCP enrollee for such State. 


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1 ‘‘(2) STATE CONTRIBUTION AMOUNT.— 

2 ‘‘(A) IN GENERAL.—Subject to subpara3 graph (C), the amount determined under this 

4 paragraph for a State for a month in a year is 

5 equal to the product described in subparagraph 

6 (A) of section 1935(c)(1) for the State for the 

7 month, except that the reference in such sub8 paragraph to the total number of full-benefit 

9 dual eligible individuals shall be deemed a ref10 erence to the total number of applicable dual el11 igible BCP enrollees. 

12 ‘‘(B) FORM AND MANNER OF PAYMENT.— 

13 The provisions of subparagraphs (B) through 

14 (D) of section 1935(c)(1) shall apply to pay15 ment by a State to the Secretary under this 

16 paragraph in the same manner as such sub17 paragraphs apply to payment under section 

18 1935(c)(1)(A). 

19 ‘‘(C) APPLICATION OF DIFFERENT FAC20 TORS.—In applying subparagraph (A), the fol21 lowing shall be substituted under paragraphs 

22 (2) and (3) of section 1935(c): 

23 ‘‘(i) The base year State Medicaid per 

24 capita expenditures for covered part D 

25 drugs described in subparagraph (A)(i)(I) 


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1 of such paragraph (2) shall be deemed to 

2 be the per capita expenditures for health 

3 care items and services that would apply 

4 (including any medicare cost-sharing), with 

5 respect to an applicable dual eligible BCP 

6 enrollee, if such an individual received ben7 efits only under title XVIII (and not the 

8 State plan under this title). 

9 ‘‘(ii) Any reference to expenditures for 

10 covered part D drugs or for prescription 

11 drug benefits shall be deemed a reference 

12 to the expenditures for health care items 

13 and services described in clause (i). 

14 ‘‘(iii) Any reference to 2003 or 2004 

15 shall be deemed a reference to 2019 or 

16 2020, respectively. 

17 ‘‘(iv) Any reference to a full-benefit 

18 dual eligible individual shall be deemed a 

19 reference to an applicable dual eligible 

20 BCP enrollee. 

21 ‘‘(v) The applicable growth factor 

22 under section 1935(c)(4) for a year, with 

23 respect to a State, shall be the average an24 nual percentage change (to that year from 

25 the previous year) of the expenditures of 


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1 the State under the State plan under title 

2 XIX. 

3 ‘‘(vi) The factor described in section 

4 1935(c)(5) is deemed to be 90 percent. 

5 ‘‘(3) APPLICABLE DUAL ELIGIBLE BCP EN6 ROLLEE.—For purposes of this section, the term 

7 ‘applicable dual eligible BCP enrollee’ means, with 

8 respect to a State, an individual described in sub9 paragraph (A)(ii) of section 1935(c)(6) (taking into 

10 account the application of subparagraph (B) of such 

11 section) for such State who is enrolled in a qualified 

12 BCP under section 1899B. Such term includes, in 

13 the case of medical assistance for medicare cost14 sharing under a State plan under this title, an indi15 vidual who is a qualified medicare beneficiary (as de16 fined in section 1905(p)(1)), a qualified disabled and 

17 working individual (described in section 1905(s)), an 

18 individual described in section 1902(a)(10)(E)(iii), 

19 or otherwise entitled to such medicare cost-sharing 

20 and who is enrolled in such a qualified BCP. 

21 ‘‘(b) COORDINATION OF BENEFITS.— 

22 ‘‘(1) MEDICARE AS PRIMARY PAYOR.—In the 

23 case of an applicable dual eligible BCP enrollee, not24 withstanding any other provision of this title, med25 ical assistance is not available under this title for 


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1 health care items or services (or for any cost-sharing 

2 respecting such health care items and services), and 

3 the rules under this title relating to the provision of 

4 medical assistance for such health care items and 

5 services shall not apply. The provision of benefits 

6 with respect to such health care items and services 

7 shall not be considered as the provision of care or 

8 services under the plan under this title. No payment 

9 may be made under section 1903(a) for health care 

10 items and services for which medical assistance is 

11 not available pursuant to this paragraph. 

12 ‘‘(2) COVERAGE OF LONG-TERM CARE SERV13 ICES.—In the case of medical assistance under this 

14 title with respect to coverage of long-term care serv15 ices furnished to an applicable dual eligible BCP en16 rollee, the State may elect to provide such medical 

17 assistance in the manner otherwise provided in the 

18 case of individuals who are not full-benefit dual eligi19 ble individuals or through an arrangement with such 

20 qualified BCP. In no case shall a qualified BCP be 

21 required to provide to enrollees coverage of long22 term care services.’’. 

23 (c) STATE MARKETING MATERIALS FOR DUALLY EL24 IGIBLE INDIVIDUALS.— 


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1 (1) STATE PLAN REQUIREMENT.—Section 

2 1902(a) of the Social Security Act (42 U.S.C. 

3 1396a(a)) is amended— 

4 (A) in paragraph (80), by striking ‘‘and’’ 

5 at the end; 

6 (B) in paragraph (81), by striking the pe7 riod at the end and inserting ‘‘; and’’; and 

8 (C) by inserting after paragraph (81) the 

9 following: 

10 ‘‘(82) provide that any marketing materials dis11 tributed by the State that are directed at dual eligi12 ble individuals (as defined in section 1915(h)(2)(B)) 

13 include information on qualified BCPs offered under 

14 section 1899B.’’. 

15 (2) EFFECTIVE DATE.—The amendments made 

16 by this section shall apply to calendar quarters be17 ginning on or after January 1, 2019, without regard 

18 to whether or not final regulations to carry out such 

19 amendments have been promulgated by such date. 

20 (d) PROHIBITION ON COVERAGE OF COST-SHARING

21 FOR CERTAIN ITEMS AND SERVICES FURNISHED TO AN

22 ENROLLEE OUTSIDE OF A QUALIFIED BCP UNDER

23 MEDIGAP POLICIES.—Section 1882 of the Social Security 

24 Act (42 U.S.C. 1395ss) is amended by adding at the end 

25 the following new subsection: 


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1 ‘‘(aa) PROHIBITION ON COVERAGE OF COST-SHAR2 ING FOR CERTAIN ITEMS AND SERVICES FURNISHED TO

3 AN ENROLLEE OUTSIDE OF A QUALIFIED BCP AND DE4 VELOPMENT OF NEW STANDARDS FOR MEDICARE SUP5 PLEMENTAL POLICIES.— 

6 ‘‘(1) DEVELOPMENT.—The Secretary shall re7 quest the National Association of Insurance Com8 missioners to review and revise the standards for 

9 benefit packages under subsection (p)(1), taking into 

10 account the changes in benefits resulting from the 

11 enactment of the Better Care, Lower Cost Act and 

12 to otherwise update standards to include the require13 ments for cost-sharing described in paragraph (2). 

14 Such revisions shall be made consistent with the 

15 rules applicable under subsection (p)(1)(E) with the 

16 reference to the ‘1991 NAIC Model Regulation’ 

17 deemed a reference to the NAIC Model Regulation 

18 as published in the Federal Register on December 4, 

19 1998, and as subsequently updated by the National 

20 Association of Insurance Commissioners to reflect 

21 previous changes in law and the reference to ‘date 

22 of enactment of this subsection’ deemed a reference 

23 to the date of enactment of the Better Care, Lower 

24 Cost Act. To the extent practicable, such revision 

25 shall provide for the implementation of revised 


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1 standards for benefit packages as of January 1, 

2 2019. 

3 ‘‘(2) COST-SHARING REQUIREMENTS.—The 

4 cost-sharing requirements described in this para5 graph are that, notwithstanding any other provision 

6 of law, no medicare supplemental policy may provide 

7 for coverage of cost-sharing with respect to items 

8 and services (other than emergent services, as de9 fined by the Secretary) furnished to an individual 

10 enrolled in a qualified BCP under section 1899B by 

11 a provider of services or supplier that is not a quali12 fied BCP professional (as defined in section 

13 1899B(k)). 

14 ‘‘(3) RENEWABILITY.—The renewability re15 quirement under subsection (q)(1) shall be satisfied 

16 with the renewal of the revised package under para17 graph (1) that most closely matches the policy in 

18 which the individual was enrolled prior to such revi19 sion.’’. 

20 SEC. 4. CHRONIC SPECIAL NEEDS PLANS. 

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

22 1395w–28) is amended— 

23 (1) in subsection (f)(4)— 


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1 (A) by striking ‘‘In the case of’’ and in2 serting ‘‘Subject to subsection (h), in the case 

3 of’’; and 

4 (B) by adding at the end the following 

5 flush text: 

6 ‘‘Notwithstanding any other provision of this section, 

7 on or after January 1, 2019, the Secretary shall es8 tablish procedures for the transition of those individ9 uals to a Medicare Advantage plan qualified BCP in 

10 accordance with subsection (h).’’; and 

11 (2) by adding at the end the following new sub12 section: 

13 ‘‘(h) MEDICARE ADVANTAGE PLAN QUALIFIED

14 BCPS.— 

15 ‘‘(1) IN GENERAL.—A Medicare Advantage plan 

16 that is certified as a qualified BCP (referred to in 

17 this subsection as a ‘Medicare Advantage plan quali18 fied BCP’)— 

19 ‘‘(A) is deemed to be a specialized MA 

20 plan for special needs individuals described in 

21 subsection (b)(6)(B)(iii); and 

22 ‘‘(B) may enroll such special needs individ23 uals. 

24 ‘‘(2) SPECIALIZED BENEFIT PACKAGES.—A 

25 Medicare Advantage plan qualified BCP shall have 


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1 the flexibility to offer specialized benefit packages to 

2 enrollees described in subsection (b)(6)(B)(iii), con3 sistent with the value-based insurance requirements 

4 under section 1899B(f). 

5 ‘‘(3) APPLICATION OF BCP REQUIREMENTS.—A 

6 Medicare Advantage plan qualified BCP shall be 

7 subject to all requirements applicable to a qualified 

8 BCP under section 1899B, including enrollment pe9 riods under subsection (c) of that section, applicable 

10 criteria relating to network adequacy, requirements 

11 with respect to individual patient-centered chronic 

12 care plans under subsection (d)(2) of that section, 

13 applicable criteria with respect to care management 

14 processes, and quality reporting under subsection (h) 

15 of that section. 

16 ‘‘(4) APPLICATION OF PART C REQUIRE17 MENTS.—The provisions of this part, including the 

18 provisions relating to specialized MA plans for spe19 cial needs individuals described in subsection 

20 (b)(6)(B)(iii), shall apply to a Medicare Advantage 

21 plan qualified BCP to the extent they are consistent 

22 with the provisions of section 1899B.’’. 


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1 SEC. 5. IMPROVEMENTS TO WELCOME TO MEDICARE VISIT 

2 AND ANNUAL WELLNESS VISITS. 

3 (a) WELCOME TO MEDICARE VISIT.—Section 

4 1861(ww)(1) of the Social Security Act (42 U.S.C. 

5 1395x(ww)(1)) is amended by adding at the end the fol6 lowing new sentence: ‘‘In the case of a BCP eligible indi7 vidual (as defined in section 1899B(b)), such term in8 cludes a standardized functional and health risk assess9 ment (as described in section 1899B(d)(1)) furnished by 

10 a qualified BCP professional (as defined in section 

11 1899B(k)).’’. 

12 (b) ANNUAL WELLNESS VISIT.—Section 

13 1861(hhh)(1) of the Social Security Act (42 U.S.C. 

14 1395x(h)(1)) is amended— 

15 (1) in subparagraph (A), by striking ‘‘and’’ at 

16 the end; 

17 (2) in subparagraph (B), by striking the period 

18 at the end and inserting ‘‘; and’’; and 

19 (3) by adding at the end the following new sub20 paragraph: 

21 ‘‘(C) in the case of a BCP eligible indi22 vidual (as defined in section 1899B(b)), that in23 cludes a standardized functional and health risk 

24 assessment (as described in section 

25 1899B(d)(1)) furnished by a qualified BCP 

26 professional (as defined in section 1899B(k)).’’. 


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1 (c) EFFECTIVE DATE.—The amendments made by 

2 this section shall apply to services furnished on or after 

3 the date that is one year after the date of enactment of 

4 this Act. 

5 SEC. 6. CHRONIC CARE INNOVATION CENTERS. 

6 (a) DESIGNATION.—Not later than October 1, 2018, 

7 the Secretary, acting through the Agency for Healthcare 

8 Research and Quality, shall designate and provide core 

9 funding for not less than three Chronic Care Innovation 

10 Centers. The Secretary shall develop a process for entities 

11 seeking to become a Chronic Care Innovation Center, and 

12 shall ensure sufficient geographic representation among 

13 those entities selected. The main objectives of such Cen14 ters shall include the following: 

15 (1) Improving the understanding of how to 

16 measure, monitor, and understand quality and effi17 ciency for a patient population with substantial dis18 ease burden. 

19 (2) Rigorously examining alternative and inno20 vative systems and strategies for efficiently improv21 ing quality and outcomes for common, serious, and 

22 chronic illnesses. 

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1 posed interventions, and assessing barriers to the 

2 implementation of high-priority care. 

3 (4) Studying organization and management 

4 practices that result in higher quality of care. 

5 (5) Defining and improving quality of care for 

6 patients with the chronic diseases prevalent in pri7 mary care settings. 

8 (6) Understanding the influence of race, eth9 nicity, and cultural factors on access, quality, and 

10 outcomes (such as clinical, patient-centered, health 

11 care utilization, and costs). 

12 (7) Evaluating new technology to enhance ac13 cess to, and quality of care (such as telemedicine). 

14 (8) Assessing the use of patient self-manage15 ment and behavioral interventions as a means of im16 proving outcomes for Medicare beneficiaries with 

17 complex chronic conditions. 

18 (9) Understanding how management of care is 

19 affected when patients have multiple chronic condi20 tions in which evidence or recommended guidelines 

21 are lacking, conflict with, or complicate overall care 

22 management. 

23 (10) Characterizing coordination of care within 

24 and across healthcare systems, including the Depart25 ment of Veterans Affairs, the Medicare program 


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1 under title XVIII of the Social Security Act (42 

2 U.S.C. 1395 et seq.), the Medicaid program under 

3 title XIX of such Act, and private sector programs 

4 for veterans with complex chronic conditions. 

5 (b) REQUIREMENTS.—In order to be designated a 

6 Chronic Care Innovation Center under this section, each 

7 eligible entity must meet the following requirements: 

8 (1) Develop and implement a sustained research 

9 agenda in the field of chronic care. 

10 (2) Collaborate with local schools of public 

11 health and universities to carry out its mission. 

12 (3) Actively engage in the development of new, 

13 best practices for the delivery of care to the chron14 ically ill. 

15 (4) Actively engage in the development and rou16 tine updating of quality measures for the chronically 

17 ill. 

18 (5) Have the ability to convene experts prac19 ticed in the needs of a chronically ill patient, includ20 ing pharmacologists, psychiatrists, cardiologists, 

21 pulmonologists, rheumatologists, nutritionists and 

22 dieticians, social workers, and physical therapists. 

23 (6) Partner with the Secretary of Health and 

24 Human Services and the Secretary of Veterans Af25 fairs (including the Center for Health Services ReVerDate Sep 11 2014 04:22 Mar 25, 2016 Jkt 059200 PO 00000 Frm 00050 Fmt 6652 Sfmt 6201 E:\BILLS\H4878.IH H4878

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1 search in Primary Care of the Department of Vet2 erans Affairs Health Services Research and Develop3 ment Service), the medical community, medical 

4 schools, and public health departments through the 

5 Agency for Healthcare Research and Quality, the 

6 Health Resources and Services Administration, and 

7 the Association of American Medical Colleges to rou8 tinely develop new, forward thinking, and evidence9 based curricula that addresses the tremendous need 

10 for team-based care and chronic care management. 

11 Such curricula shall include palliative medicine, 

12 chronic care management, leadership and team13 based skills and planning, and leveraging technology 

14 as a care tool. 

15 (c) OVERSIGHT AND EVALUATION.— 

16 (1) IN GENERAL.—The Agency for Healthcare 

17 Research and Quality shall be responsible for over18 sight and evaluation of all Chronic Care Innovation 

19 Centers under this section. 

20 (2) REPORTS.—Not less frequently than every 

21 3 years, the Agency for Healthcare Research and 

22 Quality shall submit to the Secretary of Health and 

23 Human Services and to Congress a report con24 taining the findings of oversight and evaluations 

25 conducted under paragraph (1). 


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1 (d) CONTRACT AUTHORITY.—In order to carry out 

2 this section, the Secretary may contract with existing Cen3 ters of Innovation (COINs) of the Department of Veterans 

4 Affairs Health Services Research and Development Serv5 ice that meet the requirements described in subsection (c). 

6 (e) AUTHORIZATION.—There are authorized to be ap7 propriated such sums as are necessary to carry out this 

8 section. 

9 SEC. 7. CURRICULA REQUIREMENTS FOR DIRECT AND IN10 DIRECT GRADUATE MEDICAL EDUCATION 

11 PAYMENTS. 

12 (a) DIRECT GRADUATE MEDICAL EDUCATION PAY13 MENTS.—Section 1886(h) of the Social Security Act (42 

14 U.S.C. 1395ww(h)) is amended by adding at the end the 

15 following new paragraph: 

16 ‘‘(9) NEW CURRICULA REQUIREMENTS.— 

17 ‘‘(A) DEVELOPMENT.—The Secretary shall 

18 engage with the medical community and med19 ical schools in developing curricula that meets 

20 the following requirements: 

21 ‘‘(i) The curricula is new, forward 

22 thinking, and evidence-based. 

23 ‘‘(ii) The curricula addresses the need 

24 for team-based care and chronic care man25 agement. 


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1 ‘‘(iii) The curricula includes palliative 

2 medicine, chronic care management, lead3 ership and team-based skills and planning, 

4 and leveraging technology as a care tool. 

5 ‘‘(B) RURAL AREAS.—The curricula devel6 oped under subparagraph (A) shall include ap7 propriate focus on care practices required for 

8 rural and underserved areas. 

9 ‘‘(C) LIMITATION.—Notwithstanding the 

10 preceding provisions of this subsection, for cost 

11 reporting periods beginning on or after the date 

12 that is 5 years after the date of enactment of 

13 the Better Care, Lower Cost Act, if a hospital 

14 has not begun to implement curricula that 

15 meets the requirements described in subpara16 graph (A), payments otherwise made to a hos17 pital under this subsection may be reduced by 

18 a percentage determined appropriate by the 

19 Secretary. For purposes of the preceding sen20 tence, successful development and implementa21 tion of such curricula shall be determined by 

22 program accrediting bodies.’’. 

23 (b) INDIRECT GRADUATE MEDICAL EDUCATION PAY24 MENTS.—Section 1886(d)(5)(B) of the Social Security Act 

25 (42 U.S.C. 1395ww(d)(5)(B)) is amended— 


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1 (1) by redesignating clause (x), as added by 

2 section 5505(b) of the Patient Protection and Af3 fordable Care Act (Public Law 111–148), as clause 

4 (xi) and moving such clause 6 ems to the left; and 

5 (2) by adding at the end the following new 

6 clause: 

7 ‘‘(xii) Notwithstanding the preceding provisions of 

8 this subparagraph, effective for discharges occurring on 

9 or after the date that is 5 years after the date of enact10 ment of the Better Care, Lower Cost Act, if a hospital 

11 has not begun to implement curricula that meets the re12 quirements described in subsection (h)(9)(A), as deter13 mined in accordance with subsection (h)(9)(C), payments 

14 otherwise made to a hospital under this subparagraph may 

15 be reduced by a percentage determined appropriate by the 

16 Secretary.’’. 

Æ 


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