I 

114TH CONGRESS 

2D SESSION H. R. 5506 

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

program to provide integrated care for Medicare beneficiaries with endstage renal disease, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

JUNE 16, 2016 

Mr. YOUNG of Indiana (for himself, Mr. BLUMENAUER, Mrs. MCMORRIS RODGERS, and Mr. CA ́RDENAS) 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 demonstration program to provide integrated care for 

Medicare beneficiaries with end-stage renal disease, and 

for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Dialysis PATIENT 

5 Demonstration Act of 2016’’ or the ‘‘Patient Access To 


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1 Integrated-care, Empowerment, Nephrologists and Treat2 ment Demonstration Act of 2016’’. 

3 SEC. 2. DEMONSTRATION PROGRAM TO PROVIDE INTE4 GRATED CARE FOR MEDICARE BENE5 FICIARIES WITH END-STAGE RENAL DISEASE. 

6 Title XVIII of the Social Security Act is amended by 

7 inserting after section 1866E the following new section: 

8 ‘‘DEMONSTRATION PROGRAM TO PROVIDE INTEGRATED

9 CARE FOR MEDICARE BENEFICIARIES WITH END10 STAGE RENAL DISEASE

11 ‘‘SEC. 1866F. (a) ESTABLISHMENT.— 

12 ‘‘(1) IN GENERAL.—The Secretary shall con13 duct under this section the ESRD Integrated Care 

14 Demonstration Program (in this section referred to 

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

16 and providers to assess the effects of alternative care 

17 delivery models on patient care improvements under 

18 this title for Program-eligible beneficiaries (as de19 fined in paragraph (2)). Under the Program, eligible 

20 participating providers (as defined in such para21 graph) may form an ESRD Integrated Care Organi22 zation (in this section referred to as an ‘Organiza23 tion’). An Organization shall integrate care and 

24 serve as the medical home for Program-eligible bene25 ficiaries. 

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


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1 ‘‘(A) ELIGIBLE PARTICIPATING PRO2 VIDER.—The term ‘eligible participating pro3 vider’ means the following: 

4 ‘‘(i) A facility certified as a renal di5 alysis facility under this title. 

6 ‘‘(ii) A dialysis organization that owns 

7 one or more of such facilities described in 

8 clause (i). 

9 ‘‘(iii) A nephrologist or nephrology 

10 practice. 

11 ‘‘(iv) Any other physician group prac12 tice or a group of affiliated physicians. 

13 ‘‘(B) ELIGIBLE PARTICIPATING PART14 NER.—The term ‘eligible participating partner’ 

15 means the following: 

16 ‘‘(i) A Medicare Advantage plan de17 scribed in section 1851(a)(2) or a Medi18 care Advantage organization offering such 

19 a plan. 

20 ‘‘(ii) A prescription drug plan (as de21 fined in section 1860D–41(a)(14)). 

22 ‘‘(iii) A medicaid managed care orga23 nization (as defined in section 1903(m)). 

24 ‘‘(iv) An entity able to bear risk as 

25 deemed by a State. 


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1 ‘‘(v) A third party-administrator orga2 nization. 

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

4 The term ‘Program-eligible beneficiary’ means, 

5 with respect to an Organization offering an 

6 ESRD Integrated Care Model, an individual en7 titled to benefits under part A and enrolled 

8 under part B who— 

9 ‘‘(i) is 18 years of age or older; 

10 ‘‘(ii) is identified by the Secretary or 

11 the Organization as receiving renal dialysis 

12 services under the original medicare fee13 for-service program under parts A and B; 

14 ‘‘(iii) resides in the service area of 

15 such Organization; 

16 ‘‘(iv) receives renal dialysis services 

17 primarily from a facility that participates 

18 in such Organization; and 

19 ‘‘(v) has not received a successful kid20 ney transplant. 

21 ‘‘(b) ESRD INTEGRATED CARE ORGANIZATION ELI22 GIBILITY REQUIREMENTS.— 

23 ‘‘(1) ORGANIZATIONS.— 

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

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1 nization or may enter into, subject to subpara2 graph (B), one or more partnership, ownership, 

3 or co-ownership agreements with one or more 

4 eligible participating partners to establish an 

5 Organization. 

6 ‘‘(B) LIMITATION ON NUMBER OF AGREE7 MENTS.—The Secretary may specify a limita8 tion on the number of Organizations in which 

9 an eligible participating partner may participate 

10 under agreements described in subparagraph 

11 (A). 

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

13 ‘‘(A) BENEFITS REQUIREMENTS.— 

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

15 (iii), an Organization shall offer at least 

16 one ESRD Integrated Care Model that is 

17 an open network model (as described in 

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

19 areas and may offer one or more ESRD 

20 Integrated Care Models that is a preferred 

21 network model (as described in subpara22 graph (B)(ii)) in each of its service areas. 

23 For purposes of this section an ESRD In24 tegrated Care Model (in this section re25 ferred to as the ‘Model’)— 


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1 ‘‘(I) shall cover all benefits under 

2 parts A and B (other than hospice 

3 care) and include benefits for transi4 tion (including education) into pallia5 tive care; and 

6 ‘‘(II) may, through a partnership 

7 or other agreement with an MA–PD 

8 plan under part C or prescription 

9 drug plan under part D, cover all pre10 scription drug benefits under such 

11 part D. 

12 ‘‘(ii) TREATMENT OF SAVINGS.— 

13 ‘‘(I) IN GENERAL.—Any Organi14 zation offering an ESRD Integrated 

15 Care Model shall provide for the re16 turn under subclause (IV) to a Pro17 gram-eligible beneficiary enrolled in 

18 the Organization of the amount, if 

19 any, by which the payment amount 

20 described in subclause (III) with re21 spect to the Program-eligible bene22 ficiary for a year exceeds the revenue 

23 amount described in subclause (II) 

24 with respect to the Program-eligible 

25 beneficiary for the year. 


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1 ‘‘(II) REVENUE AMOUNT DE2 SCRIBED.—The revenue amount de3 scribed in this subclause, with respect 

4 to an Organization offering an ESRD 

5 Integrated Care Model and a Pro6 gram-eligible beneficiary enrolled in 

7 such Organization, is the Organiza8 tion’s estimated average revenue re9 quirements, including administrative 

10 costs and return on investment, for 

11 the Organization to provide the bene12 fits described in clause (i) under the 

13 Model for the Program-eligible bene14 ficiary for the year. 

15 ‘‘(III) PAYMENT AMOUNT DE16 SCRIBED.—The payment amount de17 scribed in this subclause, with respect 

18 to an Organization offering an ESRD 

19 Integrated Care Model and a Pro20 gram-eligible beneficiary enrolled in 

21 such Organization, is the payment 

22 amount to the Organization under 

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

24 the Program-eligible beneficiary for 

25 the year. 


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1 ‘‘(IV) MEANS OF RETURNING

2 SAVINGS TO PROGRAM-ELIGIBLE

3 BENEFICIARIES ENROLLED IN ORGA4 NIZATIONS.—An Organization shall 

5 return the amount under subclause (I) 

6 to a Program-eligible beneficiary en7 rolled in the Organization in a man8 ner specified by the Organization, 

9 which may include cost-sharing lower 

10 than otherwise applicable, benefits not 

11 covered under the original medicare 

12 fee-for-service program, or financial 

13 incentives (such as reduced cost shar14 ing) for Program-eligible beneficiaries 

15 enrolled in the Organization to pro16 mote the delivery of high-value and ef17 ficient care and services. 

18 ‘‘(iii) BENEFIT REQUIREMENTS FOR

19 DUAL ELIGIBLES.—In the case of a Pro20 gram-eligible beneficiary who is eligible for 

21 benefits under this title and title XIX, an 

22 Organization, in accordance with an agree23 ment entered into under subsection 

24 (f)(4)— 


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1 ‘‘(I) may be responsible for pro2 viding, or arranging for the provision 

3 of, all benefits (other than long-term 

4 services and supports) for which the 

5 Program-eligible beneficiary is eligible 

6 for under the State Medicaid program 

7 under title XIX in which the Pro8 gram-eligible beneficiary is enrolled; 

9 and 

10 ‘‘(II) may elect to provide, or ar11 range for the provision of, long-term 

12 services and supports available to the 

13 Program-eligible beneficiary under the 

14 State Medicaid program. 

15 ‘‘(B) REQUIREMENTS FOR OPEN NETWORK

16 AND PREFERRED NETWORK MODELS.— 

17 ‘‘(i) OPEN NETWORK MODEL.—Under 

18 an ESRD Integrated Care Model offered 

19 by an Organization that is an open net20 work model, the Organization shall— 

21 ‘‘(I) allow Program-eligible bene22 ficiaries to receive such covered bene23 fits from any provider of services or 

24 supplier regardless of whether such 


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1 provider is within the network assem2 bled under subclause (I); 

3 ‘‘(II) pay any Medicare-certified 

4 provider or supplier that is not within 

5 the network assembled under sub6 clause (I) for such covered benefits an 

7 amount equal to the amount the pro8 vider or supplier would otherwise re9 ceive under this title; and 

10 ‘‘(III) not apply any additional 

11 premium or cost sharing requirements 

12 for such covered benefits in addition 

13 to premium or cost sharing require14 ments, respectively, that would be ap15 plicable under part A or part B for 

16 such benefits. 

17 ‘‘(ii) PREFERRED NETWORK

18 MODEL.—Under an ESRD Integrated 

19 Care Model offered by an Organization 

20 that is a preferred network model, the Or21 ganization— 

22 ‘‘(I) shall assemble a network of 

23 providers of services and suppliers 

24 identified by the Organization and 

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1 ing providers of services and suppliers 

2 with significant expertise in caring for 

3 individuals with end-stage renal dis4 ease through which Program-eligible 

5 beneficiaries shall receive covered ben6 efits as described in subparagraph (A) 

7 that are required to be covered under 

8 the Model; 

9 ‘‘(II) may apply premium and 

10 cost-sharing requirements, in addition 

11 to premium or cost-sharing require12 ments, respectively, that would be ap13 plicable under part B, for benefits in 

14 addition to those required to be cov15 ered under the Model; and 

16 ‘‘(III) shall apply network stand17 ards as defined by the Secretary. 

18 ‘‘(iii) PROMOTING ACCESS TO HIGH19 QUALITY PROVIDERS.—An Organization 

20 offering an ESRD Integrated Care Model 

21 may develop and implement performance22 based incentives for providers of services 

23 and suppliers to promote delivery of high 

24 quality and efficient care. Such incentives 

25 shall be based on clinical measures and 


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1 non-clinical measures, such as with respect 

2 to notification of patient discharge from a 

3 hospital, patient education (such as with 

4 respect to treatment options and nutri5 tion), and the interoperability of electronic 

6 health records developed by an Organiza7 tion according to requirements and stand8 ards specified by the Secretary pursuant to 

9 subparagraph (C). 

10 ‘‘(C) QUALITY AND REPORTING REQUIRE11 MENTS.— 

12 ‘‘(i) CLINICAL MEASURES.—Under the 

13 Program, the Secretary shall— 

14 ‘‘(I) require each participating 

15 Organization to submit to the Sec16 retary data on clinical measures con17 sistent with those measures submitted 

18 by organizations participating in the 

19 Comprehensive ESRD Care Initiative 

20 operated by the Center for Medicare 

21 and Medicaid Innovation as of Octo22 ber 1, 2016, to assess the quality of 

23 care provided; 

24 ‘‘(II) establish requirements for 

25 participating Organizations to report 


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1 to the Secretary, in a form and man2 ner specified by the Secretary, infor3 mation on such measures; and 

4 ‘‘(III) establish quality perform5 ance standards on such measures to 

6 assess the quality of care. 

7 ‘‘(ii) REQUIREMENT FOR STAKE8 HOLDER INPUT.—In developing require9 ments and standards under subclauses (II) 

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

11 request and consider input from a stake12 holder board, at least one nephrologist, 

13 other suppliers and providers of services, 

14 renal dialysis facilities, and beneficiary ad15 vocates, and respond in writing to such 

16 input. 

17 ‘‘(iii) ADDITIONAL ASSESSMENTS AND

18 REPORTING REQUIREMENTS.—The Sec19 retary shall assess the extent to which an 

20 Organization delivers integrated and pa21 tient-centered care through analysis of in22 formation obtained from Program-eligible 

23 beneficiaries enrolled in the Organization 

24 through surveys, such as the In-Center 


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1 Hemodialysis Consumer Assessment of 

2 Healthcare Providers and Systems. 

3 ‘‘(D) REQUIREMENTS FOR ESRD INTE4 GRATED CARE STRATEGY.— 

5 ‘‘(i) IN GENERAL.—An Organization 

6 seeking a contract under this section to 

7 offer one or more ESRD Integrated Care 

8 Models must develop and submit for the 

9 Secretary’s approval, subject to clause (ii), 

10 an ESRD Integrated Care Strategy. 

11 ‘‘(ii) ESRD INTEGRATED CARE

12 STRATEGY.—In assessing an ESRD Inte13 grated Care Strategy under clause (i), the 

14 Secretary shall consider the extent to 

15 which the Strategy includes elements, such 

16 as the following: 

17 ‘‘(I) Interdisciplinary care teams 

18 led by at least one nephrologist, and 

19 comprised of registered nurses, social 

20 workers, renal dialysis facility man21 agers, and other representatives from 

22 alternative settings described in sub23 clause (VI). 

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


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

5 ‘‘(III) Development and at least 

6 annual updating of individualized care 

7 plans that incorporate at least the 

8 medical, social, and functional needs, 

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

11 the Organization. 

12 ‘‘(IV) Coordination and delivery 

13 of non-clinical services, such as trans14 portation, aimed at improving the ad15 herence of Program-eligible bene16 ficiaries enrolled in the Organization 

17 with care recommendations. 

18 ‘‘(V) Services, such as transplant 

19 evaluation and vascular access care. 

20 ‘‘(VI) In the case of an individual 

21 who, while enrolled in the Organiza22 tion, receives confirmation that a kid23 ney transplant is imminent, the provi24 sion by an interdisciplinary care team 

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1 seling services to such individual on 

2 preparation for and potential chal3 lenges surrounding such transplant. 

4 ‘‘(VII) Delivery of benefits and 

5 services in alternative settings, such 

6 as the home of the Program-eligible 

7 beneficiary enrolled in the Organiza8 tion, in coordination with the provider 

9 or other appropriate stakeholder in10 volved in such delivery serving on an 

11 interdisciplinary care team described 

12 in subclause (I). 

13 ‘‘(VIII) Use of patient reminder 

14 systems. 

15 ‘‘(IX) Education programs for 

16 patients, families, and caregivers. 

17 ‘‘(X) Use of health care advice 

18 resources, such as nurse advice lines. 

19 ‘‘(XI) Use of team-based health 

20 care delivery models that provide com21 prehensive and continuous medical 

22 care, such as medical homes. 

23 ‘‘(XII) Co-location of providers 

24 and services. 


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1 ‘‘(XIII) Use of a demonstrated 

2 capacity to share electronic health 

3 record information across sites of 

4 care. 

5 ‘‘(XIV) Use of programs to pro6 mote better adherence to recommend7 ed treatment regimens by individuals, 

8 including by addressing barriers to ac9 cess to care by such individuals. 

10 ‘‘(XV) Other services, strategies, 

11 and approaches identified by the Or12 ganization to improve care coordina13 tion and delivery. 

14 ‘‘(3) DIALYSIS FACILITY OWNERSHIP REQUIRE15 MENT.—The Secretary shall enter into contracts 

16 under this section only with Organizations that have 

17 at least one eligible participating provider with an 

18 ownership interest in a renal dialysis facility in the 

19 Organization’s service area. 

20 ‘‘(4) REQUIREMENT FOR CAPITAL RESERVES.— 

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

22 enter into contracts under this section only with 

23 Organizations that demonstrate sufficient cap24 ital reserves, measured as a percentage of 

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1 ments established by the State in which the Or2 ganization operates. 

3 ‘‘(B) ALTERNATIVE MECHANISM TO DEM4 ONSTRATE CAPACITY TO BEAR RISK.—An Orga5 nization shall be considered to meet the require6 ment in subparagraph (A) if the Organization 

7 includes at least one eligible participating pro8 vider or eligible participating partner that is li9 censed as a risk-bearing entity or deemed by a 

10 State as able to bear risk. 

11 ‘‘(5) NON-APPLICATION OF CERTAIN PROVI12 SIONS OF LAW.—For purposes of sections 162(m)(6) 

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

14 and section 9010 of the Patient Protection and Af15 fordable Care Act (26 U.S.C. 4001 note prec.), in 

16 the case of an eligible participating provider that es17 tablishes an Organization or that enters into a part18 nership, ownership, or co-ownership agreement to es19 tablish an Organization, or an Organization with a 

20 contract under this section, risk-based payments in 

21 exchange for providing medical care shall not be con22 sidered premiums for health insurance coverage. 

23 ‘‘(6) TREATMENT AS MEDICARE ADVANCED AL24 TERNATIVE PAYMENT MODEL.—Alternative care de25 livery models under the Program shall be treated 


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1 under this title as an advanced alternative payment 

2 model. 

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

4 ‘‘(1) IN GENERAL.—Not later than 6 months 

5 after the date of enactment of this section, the Sec6 retary shall establish a process through which an 

7 Organization can apply to offer one or more ESRD 

8 Integrated Care Models. Such application shall in9 clude information on at least the following: 

10 ‘‘(A) The estimated average revenue 

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

12 for the Organization to deliver benefits de13 scribed in subsection (b)(2)(A). 

14 ‘‘(B) Any benefits offered by the Organiza15 tion beyond those described in such subsection. 

16 ‘‘(C) A listing of network providers of serv17 ices and supplier. 

18 ‘‘(D) Information on the expertise of net19 work providers of services and suppliers in serv20 ing ESRD patients. 

21 ‘‘(E) A description of the ESRD Inte22 grated Care Strategy of the Organization de23 scribed in subsection (b)(2)(D). 

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

25 shall initiate the Program such that Organizations 


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1 begin serving Program-eligible beneficiaries not later 

2 than January 1, 2018. 

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

4 Secretary shall enter into contracts for an initial pe5 riod of not less than 5 years with all Organizations 

6 that meet Program requirements. 

7 ‘‘(4) PROGRAM EXPANSION.—The Secretary 

8 may expand the duration and scope of the Program 

9 under this section, to the extent determined appro10 priate by the Secretary, if the Secretary determines 

11 that such expansion will result in improved quality 

12 of care under the Medicare program under this title. 

13 ‘‘(5) ALLOWANCE FOR LARGER SERVICE AREAS

14 AND EXPANSION OF SERVICE AREAS.—Organizations 

15 shall demonstrate in their application that the pro16 posed service area has the capacity to serve Pro17 gram-eligible beneficiaries through an adequate pro18 vider network and is reflective of the communities in 

19 which beneficiaries live, work, and obtain health care 

20 services. 

21 ‘‘(6) CONTRACT TERMINATION.— 

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

23 terminate a contract with an Organization 

24 under this section if the Secretary determines 

25 that an Organization has failed to meet quality 


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1 requirements described in subsection (b) or vio2 lates other terms of the contract. 

3 ‘‘(B) REMEDY AND APPEALS PROCESS.— 

4 Prior to the Secretary terminating a contract 

5 with an Organization under this section, the 

6 Secretary shall afford such Organization suffi7 cient opportunity to remedy any contract viola8 tions and appeal a contract termination. 

9 ‘‘(C) PROGRAM-ELIGIBLE BENEFICIARY

10 NOTICE AT TIME OF CONTRACT TERMI11 NATION.—Each contract under this section with 

12 an Organization shall require the Organization 

13 to provide (and pay for) written notice in ad14 vance of the contract’s termination, as well as 

15 a description of alternatives for obtaining bene16 fits under this title, to each Program-eligible 

17 beneficiary assigned to or who elected to receive 

18 benefits through the Organization under this 

19 section. 

20 ‘‘(d) IDENTIFICATION OF PROGRAM-ELIGIBLE BENE21 FICIARIES.—The Secretary shall establish a process for 

22 the initial and ongoing identification of Program-eligible 

23 beneficiaries that provides for the identification of Pro24 gram-eligible beneficiaries by Organizations. 


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1 ‘‘(e) PROGRAM-ELIGIBLE BENEFICIARIES ASSIGNED

2 INTO AN ESRD INTEGRATED CARE ORGANIZATION OPEN

3 NETWORK MODEL.— 

4 ‘‘(1) ASSIGNMENT.— 

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

6 subject to the succeeding provisions of this 

7 paragraph, the Secretary shall, upon the Sec8 retary or an Organization identifying a bene9 ficiary as a Program-eligible beneficiary, assign 

10 such Program-eligible beneficiary to an open 

11 network model offered by an Organization that 

12 includes the dialysis facility at which the Pro13 gram-eligible beneficiary primarily receives 

14 renal dialysis services. 

15 ‘‘(B) PROGRAM-ELIGIBLE BENEFICIARY

16 NOTIFICATION OF ASSIGNMENT.— 

17 ‘‘(i) IN GENERAL.—Upon assignment 

18 of a Program-eligible beneficiary to an Or19 ganization, the Secretary shall provide to 

20 the Organization written notification of 

21 such assignment of such Program-eligible 

22 beneficiary and not later than 15 business 

23 days after the date of receipt of such noti24 fication, the Organization shall provide 


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1 written notice of such assignment to the 

2 Program-eligible beneficiary. 

3 ‘‘(ii) OPT–OUT PERIOD AND CHANGES

4 UPON INITIAL ASSIGNMENT.—The Sec5 retary shall provide for a 75-day period be6 ginning on the date on which the assign7 ment of a Program-eligible beneficiary into 

8 an open network model offered by an Or9 ganization becomes effective during which 

10 a Program-eligible beneficiary may— 

11 ‘‘(I) opt out of the Program; 

12 ‘‘(II) make a one-time change of 

13 assignment into an open network 

14 model offered by a different Organiza15 tion; or 

16 ‘‘(III) elect a preferred network 

17 model offered by the same or different 

18 Organization. 

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

21 paragraph to an ESRD Integrated Care Model 

22 offered by an Organization with respect to a 

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


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1 continue such assignment with respect to the 

2 subsequent year. 

3 ‘‘(D) ADDITIONAL OPPORTUNITY TO OPT

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

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

8 model offered by an Organization (and annually 

9 thereafter), a Program-eligible beneficiary shall 

10 be given the opportunity to— 

11 ‘‘(i) opt out of the Program; 

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

15 ‘‘(iii) elect a preferred network model 

16 offered by the same or different Organiza17 tion. 

18 ‘‘(E) CHANGE IN PRINCIPAL DIAGNOSIS

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

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

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1 stage renal disease, such individual shall be 

2 given the opportunity to opt out of the Program 

3 during such period as specified by the Sec4 retary. 

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

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

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

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

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

12 notify Program-eligible beneficiaries about the 

13 Program under this section and provide them 

14 with information about receiving benefits under 

15 this title through an Organization. 

16 ‘‘(B) REQUIREMENTS.—Notwithstanding 

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

20 Organization to— 

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

23 ‘‘(ii) distribute Program materials to 

24 Program-eligible beneficiaries; and 


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

3 beneficiaries under the Program. 

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

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

8 may not provide marketing information or 

9 materials, including information, materials, 

10 and assistance described in subparagraph 

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

15 ‘‘(ii) EXCEPTION FOR PROVIDERS

16 TREATING BENEFICIARIES.—An eligible 

17 participating provider that is part of an 

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

23 renal dialysis services from such provider. 

24 ‘‘(3) PROGRAM-ELIGIBLE BENEFICIARY PRO25 TECTIONS.—Program-eligible beneficiaries enrolled 


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1 in an Organization shall have the same right to ap2 peal any denial of benefits under this title as such 

3 a Program-eligible beneficiary would have under this 

4 title if such Program-eligible beneficiary were not so 

5 enrolled. 

6 ‘‘(f) PAYMENT.— 

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

8 beneficiary receiving care through an Organization, 

9 the Secretary shall make a monthly capitated pay10 ment equal to the amount that would be determined 

11 under section 1853(a)(1)(H). 

12 ‘‘(2) APPLICATION OF HEALTH STATUS RISK

13 ADJUSTMENT METHODOLOGY.—The Secretary shall 

14 adjust the payment amount to an Organization 

15 under this subsection in the same manner in which 

16 the payment amount to a Medicare Advantage plan 

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

18 ‘‘(3) PAYMENT FOR PART D BENEFITS.—In the 

19 case where an Organization elects to offer part D 

20 prescription drug coverage under the Program under 

21 this section, payments to the Organization for such 

22 benefits provided to Program-eligible beneficiaries by 

23 the Organization shall be made in the same manner 

24 and amount as those payments would be made in 


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1 the case of an Organization with a contract under 

2 such part. 

3 ‘‘(4) AGREEMENT WITH STATE MEDICAID

4 AGENCY.—In the event of an Organization that 

5 elects to cover benefits under title XIX for Program6 eligible beneficiaries eligible for benefits under this 

7 title and title XIX such Organization shall enter into 

8 an agreement with the State Medicaid agency to 

9 provide benefits, or arrange for benefits to be pro10 vided, for which such beneficiaries are entitled to re11 ceive medical assistance under title XIX and to re12 ceive payment from the State for providing or ar13 ranging for the provision of such benefits. 

14 ‘‘(5) AFFIRMATION OF STATE OBLIGATIONS TO

15 PAY PREMIUM AND COST-SHARING AMOUNTS.— 

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

17 to make medical assistance under the State 

18 plan under title XIX available in the amount 

19 described in subparagraph (B) for the duration 

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

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

22 medicare beneficiaries described in section 

23 1905(p)(1) and other individuals who are Pro24 gram-eligible beneficiaries enrolled in an Orga25 nization and entitled to medical assistance for 


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1 premiums and such cost-sharing under the 

2 State plan under title XIX. 

3 ‘‘(B) AMOUNTS MADE AVAILABLE FOR

4 COST-SHARING.—For purposes of subparagraph 

5 (A): 

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

7 (ii), the amount of medical assistance de8 scribed in this clause to be made available 

9 for cost-sharing pursuant to subparagraph 

10 (A) for an individual described in such 

11 subparagraph entitled to medical assist12 ance for such cost-sharing under a State 

13 plan under title XIX shall be equal to the 

14 amount of medical assistance that would 

15 be made available under such State plan as 

16 in effect as of January 1, 2016. 

17 ‘‘(ii) AMOUNTS IN THE CASE OF A

18 STATE THAT INCREASES PAYMENTS FOR

19 COST-SHARING.—If a State increases the 

20 amount of medical assistance made avail21 able under the State plan under title XIX 

22 for cost-sharing described in subparagraph 

23 (A) after such date, such increased 

24 amounts shall be made available under 


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1 subparagraph (A) for the remaining dura2 tion of the Program. 

3 ‘‘(g) WAIVER AUTHORITY.— 

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

5 Program under this section, the Secretary shall 

6 waive those requirements waived under section 1899 

7 and may waive such additional requirements con8 sistent with those waived under programs adminis9 tered through the Center for Medicare and Medicaid 

10 Innovation as may be necessary. 

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

12 months after the date of enactment of this section, 

13 the Secretary shall publish a notice of waivers that 

14 will apply in connection with the Program. The no15 tice shall include the specific conditions that an Or16 ganization must meet to qualify for each waiver, and 

17 commentary explaining the waiver requirements.’’. 

Æ 


emcdonald on DSK9F6TC42PROD with BILLS