II 

114TH CONGRESS 

1ST SESSION S. 395 

To implement a demonstration project under titles XVIII and XIX of the 

Social Security Act to examine the costs and benefits of providing payments for comprehensive coordinated health care services provided by 

purpose-built, continuing care retirement communities to Medicare beneficiaries. 

IN THE SENATE OF THE UNITED STATES 

FEBRUARY 5, 2015 

Mr. GRASSLEY (for himself, Mr. CASEY, and Mr. CASSIDY) introduced the 

following bill; which was read twice and referred to the Committee on Finance 

A BILL 

To implement a demonstration project under titles XVIII 

and XIX of the Social Security Act to examine the 

costs and benefits of providing payments for comprehensive coordinated health care services provided by purposebuilt, continuing care retirement communities to Medicare beneficiaries. 

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 ‘‘Medicare Residential 

5 Care Coordination Act of 2015’’. 


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1 SEC. 2. MEDICARE AND MEDICAID RESIDENTIAL CARE CO2 ORDINATION DEMONSTRATION PROJECT. 

3 (a) ESTABLISHMENT AND IMPLEMENTATION.— 

4 (1) IN GENERAL.—The Secretary of Health and 

5 Human Services (in this section referred to as the 

6 ‘‘Secretary’’) shall establish and implement a dem7 onstration project (in this section referred to as the 

8 ‘‘demonstration project’’) under titles XVIII and 

9 XIX of the Social Security Act to evaluate the use 

10 of capitated payments made to eligible continuing 

11 care retirement communities for residential care co12 ordination programs. 

13 (2) TIMETABLE FOR IMPLEMENTATION.—In 

14 carrying out this section— 

15 (A) not later than 1 year after the date of 

16 the enactment of this Act the Secretary shall 

17 complete the design for the demonstration 

18 project and enter into one or more agreements 

19 with eligible CCRCs for the implementation of 

20 the project with respect to such CCRCs; and 

21 (B) not later than 4 years after the date 

22 of entering into such agreements, first provide 

23 for implementation of the project through such 

24 CCRCs. 

25 (b) BUDGET NEUTRALITY.—With respect to the pe26 riod of the demonstration project under this section, the 


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1 aggregate expenditures under titles XVIII and XIX of the 

2 Social Security Act for such period shall not exceed the 

3 aggregate expenditures that would have been expended 

4 under such titles if the demonstration project had not been 

5 implemented. 

6 (c) STATE ELECTION REQUIRED.— 

7 (1) IN GENERAL.—The Secretary may only im8 plement the demonstration project in a State that 

9 elects to participate in the demonstration project. 

10 (2) BENEFITS AND PAYMENTS.—A State that 

11 elects to participate in the demonstration project 

12 shall provide medical assistance through title XIX of 

13 the Social Security Act for each eligible CCRC resi14 dent who is eligible for medical assistance under the 

15 State plan under such title (including such residents 

16 who are made eligible under subsection 

17 (d)(3)(B)(iii)) and who is enrolled in a residential 

18 care coordination program in a manner that is con19 sistent with the requirements of this section, includ20 ing making the payments under subsection (e). 

21 (3) LIMITATION.—A State may establish a nu22 merical limit on— 

23 (A) the number of eligible CCRC residents 

24 who may be enrolled in residential care coordi25 nation programs in the State; and 


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1 (B) the number of eligible CCRCs that 

2 may operate residential care coordination pro3 grams in the State. 

4 (d) RESIDENTIAL CARE COORDINATION PROGRAM

5 (RCCP); ELIGIBLE CONTINUE CARE RETIREMENT COM6 MUNITY (CCRC); ELIGIBLE CCRC RESIDENTS; COM7 PREHENSIVE COORDINATED HEALTH CARE SERVICES

8 DEFINED.— 

9 (1) RESIDENTIAL CARE COORDINATION PRO10 GRAM; RCCP.—For purposes of this section, the 

11 terms ‘‘residential care coordination program’’ and 

12 ‘‘RCCP’’ mean a program that— 

13 (A) is operated within one or more eligible 

14 continuing care retirement communities (as de15 fined in paragraph (2)); 

16 (B) is designed with a capacity of serving 

17 at least 1,000, but not more than 1,500, eligible 

18 CCRC residents (as defined in paragraph (3)) 

19 at any one time; and 

20 (C) provides comprehensive coordinated 

21 health care services (as defined in paragraph 

22 (4)) to participating CCRC residents enrolled in 

23 the program in accordance with the program 

24 agreement under subsection (f) and the require25 ments of this section. 


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1 (2) ELIGIBLE CONTINUING CARE RETIREMENT

2 COMMUNITY; ELIGIBLE CCRC.—In this section, the 

3 terms ‘‘eligible continuing care retirement commu4 nity’’ and ‘‘eligible CCRC’’ mean an entity that is a 

5 continuing care retirement community (as defined in 

6 section 1852(l)(4)(B) of the Social Security Act (42 

7 U.S.C. 1395w–22(l)(4)(B))) that— 

8 (A) is built for the purposes of partici9 pating in the demonstration project; 

10 (B) provides onsite— 

11 (i) housing accommodations for eligi12 ble CCRC residents, including apartments 

13 for independent living; and 

14 (ii) additional services to facilitate 

15 aging in place for such residents, including 

16 assisted living and skilled nursing facilities 

17 or alternatives; and 

18 (C) has entered into a program agreement 

19 with the Secretary and the State with respect 

20 to its operation of the residential care coordina21 tion program and such agreement is consistent 

22 with the requirements of this section. 

23 (3) ELIGIBLE CCRC RESIDENT; PARTICIPATING

24 CCRC RESIDENT.— 


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1 (A) IN GENERAL.—For purposes of this 

2 section: 

3 (i) ELIGIBLE CCRC RESIDENT.—The 

4 term ‘‘eligible CCRC resident’’ means an 

5 individual who— 

6 (I) is entitled to, or enrolled for, 

7 benefits under part A of title XVIII of 

8 the Social Security Act, and enrolled 

9 for benefits under part B of such title; 

10 and 

11 (II) resides in an eligible CCRC. 

12 (ii) PARTICIPATING CCRC RESI13 DENT.—The term ‘‘participating CCRC 

14 resident’’ means, with respect to a resident 

15 care coordination program, an eligible 

16 CCRC resident who is enrolled in that pro17 gram. 

18 (B) PARTICIPATION BY DUAL-ELIGIBLE IN19 DIVIDUALS; EXPANDED ELIGIBILITY.— 

20 (i) IN GENERAL.—An eligible CCRC 

21 resident may be, but is not required to be, 

22 a dual-eligible individual. 

23 (ii) DUAL-ELIGIBLE INDIVIDUAL DE24 FINED.—In this section, the term ‘‘dual-elVerDate Sep 11 2014 00:41 Feb 14, 2015 Jkt 049200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S395.IS S395

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1 igible individual’’ means any individual 

2 who is— 

3 (I) a full-benefit dual eligible in4 dividual (as defined in section 

5 1935(c)(6) of the Social Security 

6 Act); or 

7 (II) is described in clause (iii). 

8 (iii) QUALIFICATION OF PARTICI9 PATING CCRC RESIDENTS FOR MEDICAID

10 BENEFITS.—An individual who is a partici11 pating CCRC resident, regardless of the 

12 level of care, who meets income and re13 source eligibility criteria established under 

14 the State Medicaid plan for an individual 

15 to obtain coverage for nursing facility serv16 ices on the basis of the individual’s re17 quirement for the level of care for such 

18 services, shall be treated as a dual-eligible 

19 individual under this section and under 

20 title XIX of the Social Security Act so long 

21 as the individual remains a participating 

22 CCRC resident. 

23 (C) ENROLLMENT AND DISENROLLMENT

24 RULES.— 


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1 (i) DEEMED ENROLLMENT AT TIME

2 OF INITIAL RESIDENCY.—An individual 

3 who is described in subclause (I) of sub4 paragraph (A)(i) is deemed, at the time of 

5 becoming a resident in an eligible CCRC, 

6 to have voluntarily consented to enroll in 

7 the RCCP operated by that CCRC for pur8 poses of subparagraph (A)(ii). 

9 (ii) DISENROLLMENT PROCESS.—The 

10 demonstration project shall provide a 

11 method for the disenrollment from the 

12 project of participating CCRC residents, 

13 which method shall take into account the 

14 unique circumstances of residents who are 

15 required to leave the CCRC and shall per16 mit disenrollment at least in the same cir17 cumstances as would permit an individual 

18 to disenroll from a Medicare Advantage 

19 plan under part C of title XVIII of the So20 cial Security Act for cause. 

21 (D) RELATION TO MEDICARE ADVANTAGE

22 AND PRESCRIPTION DRUG PROGRAM.— 

23 (i) SUPERCEDES ENROLLMENT.—A 

24 participating CCRC resident is not eligible 

25 to enroll in an MA plan under part C of 


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1 title XVIII of the Social Security Act or 

2 under a prescription drug plan under part 

3 D of such title. 

4 (ii) COORDINATION IN CASE OF

5 DISENROLLMENT.—In the case of a par6 ticipating CCRC resident who disenrolls 

7 from the demonstration project, the 

8 disenrollment shall be treated, for purposes 

9 of parts C and D of such title, as if the in10 dividual had been previously enrolled in, 

11 and disenrolled from, an MA–PD plan 

12 under part C of such title. 

13 (E) PREMIUM PAYMENTS.—During the pe14 riod in which an individual is a participating 

15 CCRC resident— 

16 (i) for purposes of payment of pre17 miums under parts B, C, and D of title 

18 XVIII of the Social Security Act, the indi19 vidual shall be treated as if the individual 

20 were enrolled under an MA–PD plan with 

21 a premium equal to an amount specified in 

22 the program agreement; and 

23 (ii) the individual shall be eligible for 

24 assistance with respect to such premiums 

25 under part D and Medicare cost-sharing in 


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1 the same manner and in the equivalent 

2 amounts as if the individual had not been 

3 enrolled as a participating CCRC resident. 

4 (4) COMPREHENSIVE COORDINATED HEALTH

5 CARE SERVICES DEFINED.—For purposes of this 

6 section, the term ‘‘comprehensive coordinated health 

7 care services’’, with respect to an eligible CCRC resi8 dent— 

9 (A) means all items and services that are 

10 otherwise payable under title XVIII of the So11 cial Security Act, including the minimum pre12 scription drug coverage required under a pre13 scription drug plan under part D of such title; 

14 (B) includes in the case of a dual eligible 

15 individual all items and services that are other16 wise payable under the State plan under title 

17 XIX of such Act of the State in which the resi18 dent resides; and 

19 (C) also includes— 

20 (i) care management services that co21 ordinate acute and specialty services (in22 cluding inpatient hospital services, services 

23 provided by specialty physicians, and other 

24 necessary services) provided to eligible 

25 CCRC residents; 


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1 (ii) wellness services, including assist2 ance and instruction in healthy living (in3 cluding diet and exercise); and 

4 (iii) other health care items and serv5 ices to manage chronic conditions, treat 

6 subacute conditions, and provide preventive 

7 care. 

8 (e) PAYMENT UNDER MEDICARE AND MEDICAID.— 

9 (1) IN GENERAL.—In the case of an individual 

10 who is a participating CCRC resident who is en11 rolled in a residential care coordination program op12 erated by an eligible CCRC— 

13 (A) the individual shall receive benefits 

14 under title XVIII of the Social Security Act, 

15 and, if such individual is a dual-eligible indi16 vidual (as defined in subsection (d)(3)(B)(ii)), 

17 under the State Medicaid plan or waiver under 

18 title XIX of such Act, solely through the resi19 dential care coordination program, which shall 

20 provide such individual with comprehensive co21 ordinated health care services; and 

22 (B) the eligible CCRC shall receive 

23 capitated payments for the provision of such 

24 services (from the Secretary for benefits under 

25 title XVIII and from the State for benefits 


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1 under such State plan or waiver), in accordance 

2 with this section. 

3 (2) PAYMENT METHODOLOGY.— 

4 (A) PAYMENT UNDER MEDICARE.— 

5 (i) PAYMENT ON MONTHLY BASIS.— 

6 With respect to each eligible CCRC, the 

7 Secretary shall make prospective monthly 

8 payments of a capitated amount, based on 

9 the rate established under clause (ii), for 

10 each participating CCRC resident enrolled 

11 in the residential care coordination pro12 gram operated by such CCRC in the same 

13 manner and from the same sources as pay14 ments are made to a Medicare Advantage 

15 organization under section 1853 of the So16 cial Security Act. Such payments shall be 

17 subject to adjustment in the manner de18 scribed in paragraphs (2) and (3) of sec19 tion 1853(a). 

20 (ii) ESTABLISHMENT OF PAYMENT

21 RATE.— 

22 (I) IN GENERAL.—The Secretary 

23 shall establish a risk-adjusted 

24 capitated payment rate under title 

25 XVIII of the Social Security Act for 


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1 comprehensive coordinated health care 

2 services provided to eligible CCRC 

3 residents through a residential care 

4 coordination program operated by an 

5 eligible CCRC. The payment rate shall 

6 be 90 percent of the adjusted average 

7 per capita cost described in section 

8 1853(c)(1)(D)(i) of such Act (42 

9 U.S.C. 1395w–23(c)(1)(D)(i)), plus 

10 an amount equivalent to 90 percent of 

11 the amount that would have been paid 

12 to a prescription drug plan the stand13 ardized bid amount of which (as de14 fined in 1860D–13(a)(5) of such Act) 

15 was equal to the adjusted national av16 erage monthly bid amount (as defined 

17 in section 1860D–13(a)(1)(B)(iii) of 

18 such Act) and taking into account 

19 low-income subsidies paid under sec20 tion 1860D–14. 

21 (II) PROGRAM AGREEMENT.— 

22 The mechanism for establishing the 

23 capitated amount under this subpara24 graph for a specific eligible CCRC 


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1 shall be specified in the program 

2 agreement. 

3 (B) PAYMENT UNDER MEDICAID.— 

4 (i) PAYMENT ON A MONTHLY BASIS.— 

5 With respect to an eligible CCRC oper6 ating an RCCP, the State shall make pro7 spective monthly payments of the capitated 

8 amount determined under and specified in 

9 the program agreement for each eligible 

10 CCRC resident of such community who is 

11 a dual-eligible individual. 

12 (ii) RELATIONSHIP TO MEDICARE PAY13 MENTS.—The payment made under this 

14 subparagraph shall be in addition to any 

15 payment made under subparagraph (A) to 

16 an eligible CCRC for eligible CCRC resi17 dents who are dual-eligible individuals. 

18 (iii) PROGRAM AGREEMENT.—The 

19 capitated amount under this subparagraph 

20 for a specific eligible CCRC shall be speci21 fied in the program agreement. 

22 (iv) PAYMENTS TO THE STATE.—The 

23 Secretary shall treat the payments made 

24 under clause (i) as medical assistance 

25 under title XIX of the Social Security Act 


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1 for purposes of making payments to the 

2 State under section 1903 of such Act (42 

3 U.S.C. 1396b). 

4 (v) PAYMENTS TO REFLECT SPEND

5 DOWN AMOUNTS AND PERSONAL NEEDS

6 ALLOWANCES.—The payments under this 

7 subparagraph shall be made in a manner 

8 that takes into account the financial con9 tributions required of dual-eligible individ10 uals and the personal needs allowance es11 tablished under the State plan. Such per12 sonal needs allowances may vary depending 

13 upon the level of care required by such an 

14 individual. 

15 (3) TREATMENT OF SERVICES FURNISHED BY

16 NONCONTRACT PHYSICIANS AND OTHER ENTITIES.— 

17 (A) APPLICATION OF MEDICARE ADVAN18 TAGE REQUIREMENTS.—Section 1852(k)(1) of 

19 the Social Security Act (42 U.S.C. 1395w– 

20 22(k)(1)) (relating to limitations on balance 

21 billing against Medicare Advantage organiza22 tions for noncontract physicians and other enti23 ties with respect to services covered under title 

24 XVIII of such Act) shall apply to eligible 

25 CCRCs, eligible CCRC residents enrolled in a 


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1 residential care coordination program, and phy2 sicians and other entities that do not have a 

3 contract or other agreement establishing pay4 ment amounts for services furnished to such a 

5 resident in the same manner as such section ap6 plies to Medicare Advantage organizations, indi7 viduals enrolled with such organizations, and 

8 physicians and other entities referred to in such 

9 section. 

10 (B) APPLICATION OF BALANCED BILLING

11 LIMITATIONS.—Section 1866(a)(1)(O) shall 

12 apply to services that are covered under title 

13 XVIII of the Social Security Act and are fur14 nished to any eligible CCRC residents enrolled 

15 in a residential care coordination program in 

16 the same manner that such section applies to 

17 services furnished to an individual enrolled with 

18 a PACE provider under section 1894 or 1934 

19 of such Act. 

20 (f) PROGRAM AGREEMENT.— 

21 (1) REQUIREMENT.—The Secretary, in close co22 operation with the single State agency that admin23 isters or supervises the administration of the State 

24 plan under title XIX of the Social Security Act (42 

25 U.S.C. 1396 et seq.) (in this section referred to as 


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1 the ‘‘State Medicaid agency’’), shall establish proce2 dures for entering into, extending, and terminating 

3 program agreements (each in this section referred to 

4 as a ‘‘program agreement’’) for the operation of resi5 dential care coordination programs by eligible 

6 CCRCs. 

7 (2) AGREEMENT REQUIRED FOR PAYMENT.—In 

8 order to receive payment under subsection (e), each 

9 eligible CCRC operating a residential care coordina10 tion program shall enter into a program agreement 

11 with the Secretary and the State, which shall con12 tain such terms and conditions as the parties may 

13 agree to, so long as such terms and conditions are 

14 consistent with this section. 

15 (3) DURATION.— 

16 (A) IN GENERAL.—A program agreement 

17 under this section shall be effective for a con18 tract year, beginning consistent with subsection 

19 (a)(2)(B) not later than the fourth calendar 

20 year to begin after the establishment of the 

21 demonstration project, and shall be extended 

22 for additional contract years in the absence of 

23 notice by a party to terminate. 

24 (B) TERMINATION.— 


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1 (i) END OF DEMONSTRATION

2 PROJECT.—The Secretary and the State 

3 Medicaid agency shall terminate the pro4 gram agreement at the termination of the 

5 demonstration project under subsection (i). 

6 (ii) NOTICE OF PROVIDER TERMI7 NATION.—The eligible CCRC may termi8 nate the agreement after appropriate no9 tice to the Secretary, the State Medicaid 

10 agency, and eligible CCRC residents. 

11 (iii) TERMINATION FOR CAUSE.—The 

12 Secretary and the State Medicaid agency 

13 may terminate the program agreement at 

14 any time for cause (as provided under the 

15 agreement). Reasons for terminating an 

16 agreement under this clause include that 

17 the Secretary or State administering agen18 cy determines that— 

19 (I) there are significant defi20 ciencies in the quality of care provided 

21 to eligible CCRC residents enrolled in 

22 the program or the eligible CCRC has 

23 failed to comply substantially with the 

24 requirements of this section; and 


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1 (II) the entity has failed to de2 velop and successfully initiate, within 

3 30 days of the date of the receipt of 

4 written notice of such a determina5 tion, a plan to correct the deficiencies, 

6 or has failed to continue implementa7 tion of such a plan. 

8 (iv) RIGHT TO REMAIN.—Nothing in 

9 this paragraph shall be construed, in the 

10 case that a program agreement is termi11 nated— 

12 (I) for a previously participating 

13 CCRC resident continuing, as affect14 ing the individual’s right to continue 

15 to reside in the CCRC and to receive 

16 traditional CCRC care and services in 

17 accordance with the contract between 

18 the CCRC resident and the CCRC; 

19 and 

20 (II) as relieving the State from 

21 continuing to provide medical assist22 ance with respect to such services for 

23 individuals who would qualify as dual24 eligible individuals if the agreement 

25 had not been terminated. 


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1 (4) SCOPE OF BENEFITS.— 

2 (A) IN GENERAL.—Under the agreement 

3 under paragraph (2), the eligible CCRC shall— 

4 (i) provide to participating CCRC 

5 residents of such community, regardless of 

6 source of payment, directly or under con7 tracts with other entities, at a minimum, 

8 all comprehensive coordinated health care 

9 services, without regard to any limitation 

10 or condition as to amount, duration, or 

11 scope under title XVIII or title XIX of the 

12 Social Security Act; 

13 (ii) provide such residents with access 

14 to necessary covered items and services 24 

15 hours a day, every day of the year; 

16 (iii) provide services to such residents 

17 onsite at the eligible CCRC through a mul18 tidisciplinary team that is led by a primary 

19 care physician and includes care coordina20 tors, case managers, and nurses; 

21 (iv) has a ratio of accessible physi22 cians to eligible CCRC residents that the 

23 Secretary determines is adequate; and 


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1 (v) specify the covered items and serv2 ices that will not be provided directly by 

3 the eligible CCRC and— 

4 (I) provide for delivery of those 

5 items and services through contracts 

6 to ensure compliance with the require7 ments of this section; and 

8 (II) provides, on an as needed 

9 basis for those residents who cannot 

10 transport themselves, for necessary 

11 transportation services to the pro12 viders of such items and services, if 

13 such items and services are provided 

14 outside of the eligible CCRC. 

15 (B) APPLICATION OF REGULAR COST16 SHARING RULES.—Under such agreement the 

17 eligible CCRC may apply deductibles, copay18 ments, coinsurance, or other cost sharing that 

19 would otherwise apply under titles XVIII and 

20 XIX of the Social Security Act in the case of 

21 a MA–PD plan under part C of title XVIII of 

22 such Act. 

23 (5) QUALITY CONTROL.— 

24 (A) IN GENERAL.—Under the program 

25 agreement, the eligible CCRC shall— 


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1 (i) collect data; 

2 (ii) maintain, and afford the Secretary 

3 and the State Medicaid agency access to, 

4 the records relating to the program, in5 cluding pertinent financial, medical, and 

6 personnel records; and 

7 (iii) submit to the Secretary and the 

8 State Medicaid agency such reports as the 

9 Secretary finds (in consultation with State 

10 Medicaid agencies) necessary to monitor 

11 the operation, cost, and effectiveness of the 

12 demonstration project, including data rel13 evant to the measurements established by 

14 the Secretary under subparagraph (B), to 

15 permit the Secretary and the State to 

16 evaluate such demonstration project. 

17 (B) QUALITY AND OUTCOME MEASURES.— 

18 The Secretary shall establish clinical and other 

19 outcome measurements to assess the efficacy of 

20 the demonstration project in— 

21 (i) improving— 

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1 onstration project, compared to Medi2 care beneficiaries (including tradi3 tional dual-eligible individuals de4 scribed in subsection (d)(3)(B)(ii)(I)) 

5 who are not enrolled in such pro6 grams; and 

7 (II) the quality of health care 

8 provided to such participating CCRC 

9 residents; and 

10 (ii) controlling the overall cost of pro11 viding health care items and services to 

12 such participating CCRC residents, com13 pared to the cost of providing such items 

14 and services to other Medicare bene15 ficiaries. 

16 (6) PATIENT SAFEGUARDS.—The agreement 

17 under paragraph (2) shall provide for written safe18 guards of the rights of participating CCRC residents 

19 enrolled in a residential care coordination program 

20 (including a patient bill of rights and procedures for 

21 grievances and appeals). Such safeguards shall be 

22 similar to the safeguards required under the section 

23 1894(b)(2)(B) of the Social Security Act (42 U.S.C. 

24 1395eee(b)(2)(B)) with respect to the PACE pro25 gram. 


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1 (7) TRANSITION.—If a participating CCRC 

2 resident who is enrolled in a residential care coordi3 nation program is disenrolled from such program, 

4 the eligible CCRC shall provide assistance to the in5 dividual in obtaining necessary care through appro6 priate referrals and making the individual’s medical 

7 records available to new providers. 

8 (8) RULE OF CONSTRUCTION.—Nothing is this 

9 subsection shall be construed as preventing the eligi10 ble CCRC from assessing typical and appropriate 

11 fees to eligible CCRC residents. 

12 (g) SECRETARY’S OVERSIGHT; ENFORCEMENT AU13 THORITY.— 

14 (1) OVERSIGHT.— 

15 (A) IN GENERAL.—During the duration of 

16 the demonstration project, with respect to an el17 igible CCRC operating a residential care coordi18 nation program under a program agreement 

19 under subsection (f), the Secretary (acting in 

20 cooperation with the State Medicaid agency) 

21 shall conduct a comprehensive annual review of 

22 the operation of the eligible CCRC in order to 

23 ensure compliance with the requirements of this 

24 section. Such review shall include— 


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1 (i) an onsite visit to the eligible 

2 CCRC; 

3 (ii) a comprehensive assessment of the 

4 community’s fiscal soundness; 

5 (iii) a comprehensive assessment of 

6 the eligible CCRC’s capacity to provide all 

7 comprehensive coordinated health care 

8 services to participating CCRC residents; 

9 (iv) detailed analysis of the commu10 nity’s substantial compliance with the re11 quirements of this section; and 

12 (v) any other elements that the Sec13 retary or the State Medicaid agency con14 siders necessary or appropriate. 

15 (B) DISCLOSURE.—The results of reviews 

16 under this paragraph shall be reported prompt17 ly to the eligible CCRC, along with any rec18 ommendations for changes to the community’s 

19 program, and shall be made available to the 

20 public through a public Web site of the Depart21 ment of Health and Human Services. 

22 (2) SANCTIONS.— 

23 (A) IN GENERAL.—If the Secretary deter24 mines (after consultation with the State Med25 icaid agency) that an eligible CCRC operating 


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1 a residential care coordination program under a 

2 program agreement under subsection (f) is fail3 ing substantially to comply with the require4 ments of this section, the Secretary (and the 

5 State Medicaid agency) may take any or all of 

6 the following actions: 

7 (i) Condition the continuation of the 

8 program agreement upon timely execution 

9 of a corrective action plan. 

10 (ii) Withhold some or all further pay11 ments under the program agreement under 

12 this section with respect to services fur13 nished by such community until the defi14 ciencies have been corrected. 

15 (iii) Terminate such agreement under 

16 subsection (f)(3)(B). 

17 (B) APPLICATION OF INTERMEDIATE

18 SANCTIONS.—The Secretary may, by regulation, 

19 provide for the application against an eligible 

20 CCRC operating a residential care coordination 

21 program under a program agreement under this 

22 section of remedies described in section 

23 1857(g)(2) of the Social Security Act (42 

24 U.S.C. 1395w–27(g)(2)) or section 

25 1903(m)(5)(B) of such Act (42 U.S.C. 


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1 1396b(m)(5)(B)) in the case of violations by 

2 the community of the type described in section 

3 1857(g)(1) or 1903(m)(5)(A) of such Act, re4 spectively (in relation to agreements, enrollees, 

5 and requirements under this section). 

6 (C) PROCEDURES FOR TERMINATION OR

7 IMPOSITION OF SANCTIONS.—The provisions of 

8 section 1857(h) of the Social Security Act (42 

9 U.S.C. 1395w–27(h)) shall apply, by regulation, 

10 to termination and sanctions respecting a pro11 gram agreement and an eligible CCRC oper12 ating a residential care coordination program 

13 under a program agreement under this sub14 section in the same manner as they apply to a 

15 termination and sanctions with respect to a 

16 contract and a Medicare Advantage organiza17 tion under part C of title XVIII of such Act. 

18 (h) WAIVER.—Notwithstanding section 1115(a) of 

19 the Social Security Act (42 U.S.C. 1315(a)), the Secretary 

20 may waive such provisions of titles XI, XVIII, and XIX 

21 of that Act as may be necessary to— 

22 (1) accomplish the goals of the demonstration 

23 project under this section; and 


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1 (2) maximize the quality of life of eligible 

2 CCRC beneficiaries, as determined using the meas3 ures established under subsection (f)(5)(B). 

4 (i) DURATION OF 10 YEARS.— 

5 (1) IN GENERAL.—Subject to paragraph (2) 

6 and subsection (f)(3)(B), the demonstration project 

7 shall terminate 10 years after the date on which the 

8 demonstration project is first implemented under 

9 subsection (a)(2)(B). 

10 (2) EXTENSION.—The Secretary, acting 

11 through the Center for Medicare and Medicaid Inno12 vation, may extend the use of capitated payments 

13 for eligible CCRCs for residential care coordination 

14 programs under this section if, by the termination 

15 date that would otherwise apply under paragraph 

16 (1), the Secretary has demonstrated that the dem17 onstration project has improved the coordination, 

18 quality, and efficiency of health care services fur19 nished to Medicare beneficiaries. 

20 (j) STUDY AND REPORT TO CONGRESS.— 

21 (1) INTERIM EVALUATION AND REPORT.—Not 

22 later than 3 years after the date on which the dem23 onstration project is first implemented under sub24 section (a)(2)(B), the Secretary shall submit to Con25 gress a report that contains the following: 


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1 (A) An interim evaluation of the costs and 

2 benefits of providing comprehensive coordinated 

3 health care services to Medicare beneficiaries 

4 (including dual-eligible individuals) through res5 idential care coordination programs, including 

6 the costs and benefits of using payments under 

7 title XIX of the Social Security Act to provide 

8 continuity of care by permitting certain individ9 uals to continue to participate in such programs 

10 after qualifying for enrollment in the Medicaid 

11 program under this section due to reduced in12 come and assets. 

13 (B) An analysis of the appropriateness of 

14 implementing a new payment methodology 

15 under titles XVIII and XIX of the Social Secu16 rity Act for such services in the future. 

17 (2) FINAL EVALUATION AND REPORT.—Not 

18 later than 10 years after the date on which the dem19 onstration project is first so implemented, the Sec20 retary shall submit to Congress a report that con21 tains a final evaluation of the impact of the dem22 onstration project. 

Æ 


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