I 

113TH CONGRESS 

2D SESSION H. R. 5558 

To amend title XVIII of the Social Security Act to improve the Medicare 

accountable care organization (ACO) program, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

SEPTEMBER 18, 2014 

Mrs. BLACK (for herself and Mr. WELCH) introduced the following bill; which 

was referred to the Committee on Ways and Means, and in addition to 

the Committee on Energy and Commerce, for a period to be subsequently 

determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To amend title XVIII of the Social Security Act to improve 

the Medicare accountable care organization (ACO) program, 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 ‘‘ACO Improvement Act 

5 of 2014’’. 


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1 SEC. 2. MEDICARE ACO PROGRAM IMPROVEMENTS. 

2 (a) IN GENERAL.—Section 1899 of the Social Secu3 rity Act (42 U.S.C. 1395jjj) is amended by adding at the 

4 end the following new subsection: 

5 ‘‘(l) IMPROVING OUTCOMES THROUGH GREATER

6 BENEFICIARY ENGAGEMENT.— 

7 ‘‘(1) USE OF BENEFICIARY INCENTIVES.—Sub8 ject to approval of the Secretary and in the case of 

9 an ACO that has elected a two-sided risk model (as 

10 provided for under regulations), the Secretary shall 

11 permit the ACO— 

12 ‘‘(A) to reduce or eliminate cost-sharing 

13 otherwise applicable under part B for some or 

14 all primary care services (as identified by the 

15 ACO) furnished by health care professionals 

16 (including, as applicable, professionals fur17 nishing services through a rural health clinic or 

18 Federally qualified health center) within the 

19 network of the ACO; and 

20 ‘‘(B) to develop additional incentive pro21 grams to encourage patient engagement and 

22 participation in their own wellness. 

23 The cost of the such incentives shall be borne by the 

24 ACO and shall not affect the payments under sub25 section (d). 


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1 ‘‘(2) FOSTERING STRONGER PATIENT-PROVIDER

2 TIES.— 

3 ‘‘(A) PROVIDING PROSPECTIVE ASSIGN4 MENT OF BENEFICIARIES.— 

5 ‘‘(i) IN GENERAL.—In carrying out 

6 subsection (c), the Secretary shall provide 

7 for a prospective assignment of Medicare 

8 fee-for-service beneficiaries before the be9 ginning of a year to an ACO and primary 

10 care ACO professional in accordance with 

11 the practice under this section for Pioneer 

12 ACOs, subject to clause (ii). 

13 ‘‘(ii) CHANGING PRIMARY CARE ACO

14 PROFESSIONALS.—An ACO shall permit a 

15 beneficiary to select the primary care ACO 

16 professional within the ACO to which the 

17 beneficiary is assigned. 

18 ‘‘(B) INCLUSION OF ACO INFORMATION IN

19 WELCOME TO MEDICARE VISIT AND ANNUAL

20 WELLNESS VISITS.—The Secretary shall require 

21 a primary care ACO professional to include, as 

22 part of the initial preventive physical examina23 tion under section 1861(ww)(1) or personalized 

24 prevention plan services under section 

25 1861(hhh)(1) for a Medicare fee-for-service 


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1 beneficiary assigned to that professional under 

2 this section, to provide the beneficiary with in3 formation concerning the ACO program under 

4 this section, including information on any cost5 sharing reductions allowed under this section. 

6 ‘‘(C) STAKEHOLDER ADVISORY GROUP.— 

7 The Secretary shall form a stakeholder group, 

8 including representatives of ACOs, health care 

9 providers (including ACO professionals), Medi10 care beneficiaries, and ACO experts, to advise 

11 the Secretary with recommendations to improve 

12 the process of ACO-to-beneficiary communica13 tion. 

14 ‘‘(3) MOVING FROM VOLUME TO VALUE.— 

15 ‘‘(A) REGULATORY RELIEF FOR MOVING

16 TO TWO-SIDED RISK.—In the case of an ACO 

17 that has elected a two-sided risk model (as de18 scribed in paragraph (1)), in addition to the au19 thority provided under paragraph (1), the Sec20 retary shall provide the following regulatory re21 lief: 

22 ‘‘(i) 3-DAY PRIOR HOSPITALIZATION

23 WAIVER FOR SNF SERVICES.—Waiver of 

24 the 3-day prior hospitalization requirement 


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1 for coverage of skilled nursing facility serv2 ices. 

3 ‘‘(ii) HOMEBOUND REQUIREMENT

4 WAIVER FOR HOME HEALTH SERVICES.— 

5 Waiver of the homebound requirement for 

6 coverage of home health services. 

7 ‘‘(iii) RAC HOSPITAL AUDIT RE8 LIEF.—Relief from reviews of scheduled 

9 admissions by recovery audit contractors 

10 for individuals attributed to an ACO when 

11 admitted on orders of a physician partici12 pating in the ACO. 

13 ‘‘(B) IMPROVING CARE COORDINATION

14 THROUGH ACCESS TO TELEHEALTH.— 

15 ‘‘(i) FLEXIBILITY IN FURNISHING

16 TELEHEALTH SERVICES.—In applying sec17 tion 1834(m) in the case of an ACO that 

18 has elected a two-sided risk model (as de19 scribed in paragraph (1)), the ACO may 

20 elect to have the limitations on originating 

21 site (under paragraph (4)(C) of such sec22 tion) and on the use of store-and-forward 

23 technologies (under paragraph (1) of such 

24 section) not apply. The previous sentence 

25 shall not be construed as affecting the auVerDate Sep 11 2014 22:08 Sep 26, 2014 Jkt 039200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H5558.IH H5558

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1 thority of the Secretary under subsection 

2 (f) to waive other provisions of such sec3 tion. 

4 ‘‘(ii) PROVISION OF REMOTE MONI5 TORING IN CONNECTION WITH HOME

6 HEALTH SERVICES.—Nothing in this sec7 tion shall be construed as preventing an 

8 ACO from including payments for remote 

9 patient monitoring and home-based video 

10 conferencing services in connection with 

11 the provision of home health services 

12 (under conditions for which payment for 

13 such services would not be made under sec14 tion 1895 for such services) in a manner 

15 that is financially equivalent to the fur16 nishing of a home health visit. 

17 ‘‘(4) ESTABLISHING GREATER CERTAINTY FOR

18 ACOS.— 

19 ‘‘(A) BENCHMARKS AND PAYMENTS.—The 

20 Secretary shall conduct a demonstration project 

21 to test the use of payment benchmarks that 

22 take into account geographic area differences, 

23 such as differences in spending trends within 

24 and across regions, and variations in delivery 


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1 and utilization based on the socioeconomic sta2 tus of beneficiaries served. 

3 ‘‘(B) ADVANCE NOTIFICATION OF ACOS OF

4 BENCHMARKS AND PAST PERFORMANCE.—The 

5 Secretary shall inform ACOs, in advance of 

6 each performance period, of the quality bench7 marks applicable to the ACO and period and of 

8 the past performance (if any) of the ACO under 

9 this section. 

10 ‘‘(C) STUDY AND REPORT ON FEASIBILITY

11 ON PROVIDING ELECTRONIC ACCESS TO MEDI12 CARE CLAIMS DATA.—The Secretary shall con13 duct a study regarding the feasibility of estab14 lishing a system of electronic access of pro15 viders of services and suppliers to in-process 

16 and complete patient claims data. Such system 

17 may be a modification of an existing data base, 

18 such as the Virtual Research Data Center. The 

19 study shall take into account the measures 

20 needed to ensure the security and privacy of 

21 beneficiary and provider information. Not later 

22 than one year after the date of the enactment 

23 of this Act, the Secretary shall submit to Con24 gress a report on such study. The Secretary 


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1 shall include in such report such recommenda2 tions as the Secretary deems appropriate.’’. 

3 (b) REQUIRING TESTING OF GLOBAL CAPITATION

4 PAYMENT MODEL.—Section 1899(i) of the Social Security 

5 Act (42 U.S.C. 1395jjj(i)) is amended— 

6 (1) in the heading, by striking ‘‘OPTION TO

7 USE OTHER PAYMENT MODELS’’ and inserting ‘‘AL8 TERNATIVE PAYMENT MODELS’’; 

9 (2) in paragraph (1), by inserting before the pe10 riod at the end the following: ‘‘except that the Sec11 retary shall, beginning no later than January 1, 

12 2016, establish one or more demonstration programs 

13 to test the payment model described in paragraph 

14 (3)(A)’’; and 

15 (3) in paragraph (3)(A), by striking ‘‘is any 

16 payment model’’ and inserting the following: 

17 ‘‘(i) a global capitation model in which an 

18 ACO is at financial risk for all items and serv19 ices covered under parts A and B; and 

20 ‘‘(ii) any other payment model that the 

21 Secretary determines will improve the quality 

22 and efficiency of items and services furnished 

23 under this title.’’. 

24 (c) ASSIGNMENT TAKING INTO ACCOUNT SERVICES

25 OF NON-PHYSICIAN PRACTITIONERS.—Section 1899(c) of 


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1 the Social Security Act (42 U.S.C. 1395jjj(c)) is amended 

2 by inserting ‘‘(or, in the case of an ACO that is located 

3 in a rural or medically underserved area or that is affili4 ated with a Federally qualified health center or rural 

5 health clinic, an ACO professional described in subsection 

6 (h)(1)(B))’’ after ‘‘subsection (h)(1)(A)’’. 

7 (d) CREATING INCENTIVES FOR ACO DEVELOP8 MENT.—The Secretary of Health and Human Services 

9 shall develop a mechanism to make permanent those ACO10 related pilot programs, including the Advance Payment 

11 ACO Model, that have been successful. The Secretary 

12 shall submit to Congress a report on the study and shall 

13 include in the report such recommendations, including 

14 such changes in legislation, as the Secretary deems appro15 priate. 

16 (e) EFFECTIVE DATE.—The amendments made by 

17 subsection (a) shall apply to plan years beginning on or 

18 after January 1, 2016. 

Æ 


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