II 

114TH CONGRESS 

2D SESSION S. 3504 

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

payment policies designed to improve management of chronic disease, 

streamline care coordination, and improve quality outcomes without adding to the deficit. 

IN THE SENATE OF THE UNITED STATES 

DECEMBER 6, 2016 

Mr. HATCH (for himself, Mr. WYDEN, Mr. ISAKSON, and Mr. WARNER) introduced the following bill; which was read twice and referred to the Committee on Finance 

A BILL 

To amend title XVIII of the Social Security Act to implement 

Medicare payment policies designed to improve management of chronic disease, streamline care coordination, 

and improve quality outcomes without adding to the deficit. 

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 ‘‘Creating High-Quality Results and Outcomes Necessary 

6 to Improve Chronic (CHRONIC) Care Act of 2016’’. 


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

2 this Act is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—RECEIVING HIGH QUALITY CARE IN THE HOME 

Sec. 101. Extending the Independence at Home Demonstration Program. 

Sec. 102. Expanding access to home dialysis therapy. 

TITLE II—ADVANCING TEAM-BASED CARE 

Sec. 201. Providing continued access to Medicare Advantage special needs 

plans for vulnerable populations. 

TITLE III—EXPANDING INNOVATION AND TECHNOLOGY 

Sec. 301. Adapting benefits to meet the needs of chronically ill Medicare Advantage enrollees. 

Sec. 302. Expanding supplemental benefits to meet the needs of chronically ill 

Medicare Advantage enrollees. 

Sec. 303. Increasing convenience for Medicare Advantage enrollees through 

telehealth. 

Sec. 304. Providing accountable care organizations the ability to expand the use 

of telehealth. 

Sec. 305. Expanding the use of telehealth for individuals with stroke. 

TITLE IV—IDENTIFYING THE CHRONICALLY ILL POPULATION 

Sec. 401. Providing flexibility for beneficiaries to be part of an accountable care 

organization. 

TITLE V—EMPOWERING INDIVIDUALS AND CAREGIVERS IN CARE 

DELIVERY 

Sec. 501. Eliminating barriers to care coordination under accountable care organizations. 

Sec. 502. GAO study and report on longitudinal comprehensive care planning 

services under Medicare part B. 

TITLE VI—OTHER POLICIES TO IMPROVE CARE FOR THE 

CHRONICALLY ILL 

Sec. 601. GAO study and report on improving medication synchronization. 

Sec. 602. GAO study and report on impact of obesity drugs on patient health 

and spending. 


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1 TITLE I—RECEIVING HIGH 

2 QUALITY CARE IN THE HOME 

3 SEC. 101. EXTENDING THE INDEPENDENCE AT HOME DEM4 ONSTRATION PROGRAM. 

5 Section 1866E of the Social Security Act (42 U.S.C. 

6 1395cc–5) is amended— 

7 (1) in subsection (e)— 

8 (A) in paragraph (1), by striking ‘‘5-year 

9 period’’ and inserting ‘‘7-year period’’; and 

10 (B) in paragraph (5), by striking ‘‘10,000’’ 

11 and inserting ‘‘15,000’’; and 

12 (2) in subsection (i), by striking ‘‘second of 2’’ 

13 and inserting ‘‘third of 3’’. 

14 SEC. 102. EXPANDING ACCESS TO HOME DIALYSIS THER15 APY. 

16 (a) IN GENERAL.—Section 1881(b)(3) of the Social 

17 Security Act (42 U.S.C. 1395rr(b)(3)) is amended— 

18 (1) by redesignating subparagraphs (A) and 

19 (B) as clauses (i) and (ii), respectively; 

20 (2) in clause (ii), as redesignated by subpara21 graph (A), strike ‘‘on a comprehensive’’ and insert 

22 ‘‘subject to subparagraph (B), on a comprehensive’’; 

23 (3) by striking ‘‘With respect to’’ and inserting 

24 ‘‘(A) With respect to’’; and 


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1 (4) by adding at the end the following new sub2 paragraph: 

3 ‘‘(B) For purposes of subparagraph (A)(ii), an indi4 vidual determined to have end stage renal disease receiv5 ing home dialysis may choose to receive the monthly end 

6 stage renal disease-related visits furnished on or after 

7 January 1, 2018, via telehealth if the individual receives 

8 a face-to-face visit, without the use of telehealth, at least 

9 once every three consecutive months.’’. 

10 (b) ORIGINATING SITE REQUIREMENTS.— 

11 (1) IN GENERAL.—Section 1834(m) of the So12 cial Security Act (42 U.S.C. 1395m(m)) is amend13 ed— 

14 (A) in paragraph (4)(C)(ii), by adding at 

15 the end the following new subclauses: 

16 ‘‘(IX) A renal dialysis facility, 

17 but only for purposes of section 

18 1881(b)(3)(B). 

19 ‘‘(X) The home of an individual, 

20 but only for purposes of section 

21 1881(b)(3)(B).’’; and 

22 (B) by adding at the end the following new 

23 paragraph: 

24 ‘‘(5) TREATMENT OF HOME DIALYSIS MONTHLY

25 ESRD-RELATED VISIT.—The geographic requireVerDate Sep 11 2014 01:37 Dec 07, 2016 Jkt 069200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S3504.IS S3504

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1 ments described in paragraph (4)(C)(i) shall not 

2 apply with respect to telehealth services furnished on 

3 or after January 1, 2018, for purposes of section 

4 1881(b)(3)(B), at an originating site described in 

5 subclause (VI), (IX), or (X) of paragraph 

6 (4)(C)(ii).’’. 

7 (2) NO FACILITY FEE IF ORIGINATING SITE

8 FOR HOME DIALYSIS THERAPY IS THE HOME.—Sec9 tion 1834(m)(2)(B) of the Social Security (42 

10 U.S.C. 1395m(m)(2)(B)) is amended— 

11 (A) by redesignating clauses (i) and (ii) as 

12 subclauses (I) and (II), and indenting appro13 priately; 

14 (B) in subclause (II), as redesignated by 

15 subparagraph (A), by striking ‘‘clause (i) or 

16 this clause’’ and inserting ‘‘subclause (I) or this 

17 subclause’’; 

18 (C) by striking ‘‘SITE.—With respect to’’ 

19 and inserting ‘‘SITE.— 

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

21 (ii), with respect to’’; and 

22 (D) by adding at the end the following new 

23 clause: 

24 ‘‘(ii) NO FACILITY FEE IF ORIGI25 NATING SITE FOR HOME DIALYSIS THERVerDate Sep 11 2014 01:37 Dec 07, 2016 Jkt 069200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S3504.IS S3504

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1 APY IS THE HOME.—No facility fee shall 

2 be paid under this subparagraph to an 

3 originating site described in paragraph 

4 (4)(C)(ii)(X).’’. 

5 (c) CONFORMING AMENDMENT.—Section 1881(b)(1) 

6 of the Social Security Act (42 U.S.C. 1395rr(b)(1)) is 

7 amended by striking ‘‘paragraph (3)(A)’’ and inserting 

8 ‘‘paragraph (3)(A)(i)’’. 

9 TITLE II—ADVANCING TEAM10 BASED CARE 

11 SEC. 201. PROVIDING CONTINUED ACCESS TO MEDICARE 

12 ADVANTAGE SPECIAL NEEDS PLANS FOR 

13 VULNERABLE POPULATIONS. 

14 (a) EXTENSION.—Section 1859(f)(1) of the Social 

15 Security Act (42 U.S.C. 1395w–28(f)(1)) is amended by 

16 striking ‘‘and for periods before January 1, 2019’’. 

17 (b) INCREASED INTEGRATION OF DUAL SNPS.— 

18 (1) IN GENERAL.—Section 1859(f) of the Social 

19 Security Act (42 U.S.C. 1395w–28(f)) is amended— 

20 (A) in paragraph (3), by adding at the end 

21 the following new subparagraph: 

22 ‘‘(F) The plan meets the requirements ap23 plicable under paragraph (8).’’; and 

24 (B) by adding at the end the following new 

25 paragraph: 


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1 ‘‘(8) INCREASED INTEGRATION OF DUAL

2 SNPS.— 

3 ‘‘(A) DESIGNATED CONTACT.—The Sec4 retary, acting through the Federal Coordinated 

5 Health Care Office established under section 

6 2602 of the Patient Protection and Affordable 

7 Care Act, shall serve as a dedicated point of 

8 contact for States to address misalignments 

9 that arise with the integration of specialized 

10 MA plans for special needs individuals de11 scribed in subsection (b)(6)(B)(ii) under this 

12 paragraph and, consistent with such role, 

13 shall— 

14 ‘‘(i) establish a uniform process for 

15 disseminating to State Medicaid agencies 

16 information under this title impacting con17 tracts between such agencies and such 

18 plans under this subsection; and 

19 ‘‘(ii) establish basic resources for 

20 States interested in exploring such plans 

21 as a platform for integration, such as a 

22 model contract or other tools to achieve 

23 those goals. 

24 ‘‘(B) UNIFIED GRIEVANCES AND APPEALS

25 PROCESS.— 


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1 ‘‘(i) IN GENERAL.—Not later than 

2 April 1, 2019, the Secretary shall establish 

3 procedures, to the extent feasible, unifying 

4 grievances and appeals procedures under 

5 sections 1852(f), 1852(g), 1902(a)(3), 

6 1902(a)(5), and 1932(b)(4) for items and 

7 services provided by specialized MA plans 

8 for special needs individuals described in 

9 subsection (b)(6)(B)(ii) under this title 

10 and title XIX. The Secretary shall solicit 

11 comment in developing such procedures 

12 from States, plans, beneficiaries and their 

13 representatives, and other relevant stake14 holders. 

15 ‘‘(ii) PROCEDURES.—The procedures 

16 established under clause (i) shall be in17 cluded in the plan contract under para18 graph (3)(D) and shall— 

19 ‘‘(I) adopt the provisions for the 

20 enrollee that are most protective for 

21 the enrollee and, to the extent feasible 

22 as determined by the Secretary, are 

23 compatible with unified timeframes 

24 and consolidated access to external re25 view under an integrated process; 


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1 ‘‘(II) take into account dif2 ferences in State plans under title 

3 XIX to the extent necessary; 

4 ‘‘(III) be easily navigable by an 

5 enrollee; and 

6 ‘‘(IV) include the elements de7 scribed in clause (iii), as applicable. 

8 ‘‘(iii) ELEMENTS DESCRIBED.—Both 

9 unified appeals and unified grievance pro10 cedures shall include, as applicable, the fol11 lowing elements described in this clause: 

12 ‘‘(I) Single written notification of 

13 all applicable grievances and appeal 

14 rights under this title and title XIX. 

15 For purposes of this subparagraph, 

16 the Secretary may waive the require17 ments under section 1852(g)(1)(B) 

18 when the specialized MA plan covers 

19 items or services under this part or 

20 under title XIX. 

21 ‘‘(II) Single pathways for resolu22 tion of any grievance or appeal related 

23 to a particular item or service pro24 vided by specialized MA plans for spe25 cial needs individuals described in 


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1 subsection (b)(6)(B)(ii) under this 

2 title and title XIX. 

3 ‘‘(III) Notices written in plain 

4 language and available in a language 

5 and format that is accessible to the 

6 enrollee, including in non-English lan7 guages that are prevalent in the serv8 ice area of the specialized MA plan. 

9 ‘‘(IV) Unified timeframes for 

10 grievances and appeals processes, 

11 such as an individual’s filing of a 

12 grievance or appeal, a plan’s acknowl13 edgment and resolution of a grievance 

14 or appeal, and notification of decisions 

15 with respect to a grievance or appeal. 

16 ‘‘(V) Requirements for how the 

17 plan must process, track, and resolve 

18 grievances and appeals, to ensure 

19 beneficiaries are notified on a timely 

20 basis of decisions that are made 

21 throughout the grievance or appeals 

22 process and are able to easily deter23 mine the status of a grievance or ap24 peal. 


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1 ‘‘(iv) CONTINUATION OF BENEFITS

2 PENDING APPEAL.—The unified procedures 

3 under clause (i) shall, with respect to all 

4 benefits under parts A and B and title 

5 XIX subject to appeal under such proce6 dures, incorporate provisions under current 

7 law and implementing regulations that pro8 vide continuation of benefits pending ap9 peal under this title and title XIX. 

10 ‘‘(C) REQUIREMENT FOR UNIFIED GRIEV11 ANCES AND APPEALS.—For 2020 and subse12 quent years, the contract of a specialized MA 

13 plan for special needs individuals described in 

14 subsection (b)(6)(B)(ii) with a State Medicaid 

15 agency under paragraph (3)(D) shall require 

16 the use of unified grievances and appeals proce17 dures as described in subparagraph (B). 

18 ‘‘(D) REQUIREMENTS FOR INTEGRA19 TION.—For 2021 and subsequent years, a spe20 cialized MA plan for special needs individuals 

21 described in subsection (b)(6)(B)(ii) shall meet 

22 one or more of the following requirements, to 

23 the extent permitted under State law, for inte24 gration of benefits under this title and title 

25 XIX: 


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1 ‘‘(i) The specialized MA plan must 

2 meet the requirements of contracting with 

3 the State Medicaid agency described in 

4 paragraph (3)(D) in addition to coordi5 nating long-term services and supports or 

6 behavioral health services, or both, by 

7 meeting an additional minimum set of re8 quirements determined by the Secretary 

9 through the Federal Coordinated Health 

10 Care Office established under section 2018 

11 of the Patient Protection and Affordable 

12 Care Act based on input from stake13 holders, such as notifying the State in a 

14 timely manner of hospitalizations, emer15 gency room visits, and hospital or nursing 

16 home discharges of enrollees, assigning one 

17 primary care provider for each enrollee, or 

18 sharing data that would benefit the coordi19 nation of items and services under this 

20 title and the State plan under title XIX. 

21 Such minimum set of requirements must 

22 be included in the contract of the special23 ized MA plan with the State Medicaid 

24 agency under such paragraph. 


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1 ‘‘(ii) The specialized MA plan must 

2 meet the requirements of a fully integrated 

3 plan described in section 

4 1853(a)(1)(B)(iv)(II) (other than the re5 quirement that the plan have similar aver6 age levels of frailty, as determined by the 

7 Secretary, as the PACE program), or enter 

8 into a capitated contract with the State 

9 Medicaid agency to provide long-term serv10 ices and supports or behavioral health 

11 services, or both. 

12 ‘‘(iii) In the case where an individual 

13 is enrolled in the specialized MA plan and 

14 a Medicaid managed care organization (as 

15 defined in section 1903(m)(1)(A)) that 

16 provides long term services and supports 

17 or behavioral health services with the same 

18 parent organization, the parent organiza19 tion offering both the specialized MA plan 

20 and the Medicaid managed care plan must 

21 assume clinical and financial responsibility 

22 for benefits provided under this title and 

23 title XIX.’’. 

24 (2) CONFORMING AMENDMENT TO RESPON25 SIBILITIES OF FEDERAL COORDINATED HEALTH


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1 CARE OFFICE.—Section 2602(d) of the Patient Pro2 tection and Affordable Care Act (42 U.S.C. 

3 1315b(d)) is amended by adding at the end the fol4 lowing new paragraphs: 

5 ‘‘(6) To act as a designated contact for States 

6 under subsection (f)(8)(A) of section 1859 of the So7 cial Security Act (42 U.S.C. 1395w–28) with respect 

8 to the integration of specialized MA plans for special 

9 needs individuals described in subsection 

10 (b)(6)(B)(ii) of such section. 

11 ‘‘(7) To be responsible for developing regula12 tions and guidance related to the implementation of 

13 a unified grievance and appeals process as described 

14 in subparagraphs (B) and (C) of section 1859(f)(8) 

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

16 28(f)(8)).’’. 

17 (c) IMPROVEMENTS TO SEVERE OR DISABLING

18 CHRONIC CONDITION SNPS.— 

19 (1) CARE MANAGEMENT REQUIREMENTS.—Sec20 tion 1859(f)(5) of the Social Security Act (42 

21 U.S.C. 1395w–28(f)(5)) is amended— 

22 (A) by striking ‘‘ALL SNPS.—The require23 ments’’ and inserting ‘‘ALL SNPS.— 

24 ‘‘(A) IN GENERAL.—Subject to subpara25 graph (B), the requirements’’; 


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1 (B) by redesignating subparagraphs (A) 

2 and (B) as clauses (i) and (ii), respectively, and 

3 indenting appropriately; 

4 (C) in clause (ii), as redesignated by sub5 paragraph (B), by redesignating clauses (i) 

6 through (iii) as subclauses (I) through (III), re7 spectively, and indenting appropriately; and 

8 (D) by adding at the end the following new 

9 subparagraph: 

10 ‘‘(B) IMPROVEMENTS TO CARE MANAGE11 MENT REQUIREMENTS FOR SEVERE OR DIS12 ABLING CHRONIC CONDITION SNPS.—For 2020 

13 and subsequent years, in the case of a special14 ized MA plan for special needs individuals de15 scribed in subsection (b)(6)(B)(iii), the require16 ments described in this paragraph include the 

17 following: 

18 ‘‘(i) The interdisciplinary team under 

19 subparagraph (A)(ii)(III) includes a team 

20 of providers with demonstrated expertise, 

21 including training in an applicable spe22 cialty, in treating individuals similar to the 

23 targeted population of the plan. 

24 ‘‘(ii) Requirements developed by the 

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1 ters with individuals enrolled in the plan 

2 not less frequently than on an annual 

3 basis. 

4 ‘‘(iii) As part of the model of care 

5 under clause (i) of subparagraph (A), the 

6 results of the initial assessment and an7 nual reassessment under clause (ii)(I) of 

8 such subparagraph of each individual en9 rolled in the plan are addressed in the indi10 vidual’s individualized care plan under 

11 clause (ii)(II) of such subparagraph. 

12 ‘‘(iv) As part of the annual evaluation 

13 and approval of such model of care, the 

14 Secretary shall take into account whether 

15 the plan fulfilled the previous year’s goals 

16 (as required under the model of care). 

17 ‘‘(v) The Secretary shall establish a 

18 minimum benchmark for each element of 

19 the model of care of a plan. The Secretary 

20 shall only approve a plan’s model of care 

21 under this paragraph if each element of 

22 the model of care meets the minimum 

23 benchmark applicable under the preceding 

24 sentence.’’. 


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1 (2) REVISIONS TO THE DEFINITION OF A SE2 VERE OR DISABLING CHRONIC CONDITIONS SPECIAL3 IZED NEEDS INDIVIDUAL.— 

4 (A) IN GENERAL.—Section 

5 1859(b)(6)(B)(iii) of the Social Security Act 

6 (42 U.S.C. 1395w–28(b)(6)(B)(iii)) is amend7 ed— 

8 (i) by striking ‘‘who have’’ and insert9 ing ‘‘who— 

10 ‘‘(I) before January 1, 2022, 

11 have’’; 

12 (ii) in subclause (I), as added by 

13 clause (i), by striking the period at the end 

14 and inserting ‘‘; and’’; and 

15 (iii) by adding at the end the fol16 lowing new subclause: 

17 ‘‘(II) on or after January 1, 

18 2022, have one or more comorbid and 

19 medically complex chronic conditions 

20 that is life threatening or significantly 

21 limits overall health or function, have 

22 a high risk of hospitalization or other 

23 adverse health outcomes, and require 

24 intensive care coordination and that is 

25 listed under subsection (f)(9)(A).’’. 


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1 (B) PANEL OF CLINICAL ADVISORS.—Sec2 tion 1859(f) of the Social Security Act (42 

3 U.S.C. 1395w–28(f)), as amended by subsection 

4 (b), is amended by adding at the end the fol5 lowing new paragraph: 

6 ‘‘(9) LIST OF CONDITIONS FOR CLARIFICATION

7 OF THE DEFINITION OF A SEVERE OR DISABLING

8 CHRONIC CONDITIONS SPECIALIZED NEEDS INDI9 VIDUAL.— 

10 ‘‘(A) IN GENERAL.—Not later than De11 cember 31, 2020, and every 5 years thereafter, 

12 the Secretary shall convene a panel of clinical 

13 advisors to establish and update a list of condi14 tions that meet each of the following criteria: 

15 ‘‘(i) Conditions that meet the defini16 tion of a severe or disabling chronic condi17 tion under subsection (b)(6)(B)(iii) on or 

18 after January 1, 2022. 

19 ‘‘(ii) Conditions that— 

20 ‘‘(I) require prescription drugs, 

21 providers, and models of care that are 

22 unique to the specific population of 

23 enrollees in a specialized MA plan for 

24 special needs individuals described in 

25 such subsection on or after such date 


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1 and would not be needed by the gen2 eral population of beneficiaries under 

3 this title; and 

4 ‘‘(II) have a low prevalence in the 

5 general population of beneficiaries 

6 under this title or a disproportionally 

7 high per-beneficiary cost under this 

8 title. 

9 ‘‘(B) REQUIREMENT.—In establishing and 

10 updating the list under subparagraph (A), the 

11 panel shall take into account the availability of 

12 varied benefits, cost-sharing, and supplemental 

13 benefits under the model described in para14 graph (2) of section 1859(h), including the ex15 pansion under paragraph (1) of such section.’’. 

16 (d) QUALITY MEASUREMENT AT THE PLAN LEVEL

17 FOR SNPS AND DETERMINATION OF FEASABILITY OF

18 QUALITY MEASUREMENT AT THE PLAN LEVEL FOR ALL

19 MA PLANS.—Section 1853(o) of the Social Security Act 

20 (42 U.S.C. 1395w–23(o)) is amended by adding at the end 

21 the following new paragraphs: 

22 ‘‘(6) QUALITY MEASUREMENT AT THE PLAN

23 LEVEL FOR SNPS.— 

24 ‘‘(A) IN GENERAL.—Subject to subpara25 graph (B), the Secretary may require reporting 


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1 of data under section 1852(e) for, and apply 

2 under this subsection, quality measures at the 

3 plan level for specialized MA plans for special 

4 needs individuals instead of at the contract 

5 level. 

6 ‘‘(B) CONSIDERATIONS.—Prior to applying 

7 quality measurement at the plan level under 

8 this paragraph, the Secretary shall— 

9 ‘‘(i) take into consideration the min10 imum number of enrollees in a specialized 

11 MA plan for special needs individuals in 

12 order to determine if a statistically signifi13 cant or valid measurement of quality at 

14 the plan level is possible under this para15 graph; 

16 ‘‘(ii) if quality measures are reported 

17 at the plan level, ensure that MA plans are 

18 not required to provide duplicative infor19 mation; and 

20 ‘‘(iii) ensure that such reporting does 

21 not interfere with the collection of encoun22 ter data submitted by MA organizations or 

23 the administration of any changes to the 

24 program under this part as a result of the 

25 collection of such data. 


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1 ‘‘(C) APPLICATION.—If the Secretary ap2 plies quality measurement at the plan level 

3 under this paragraph, such quality measure4 ment may include Medicare Health Outcomes 

5 Survey (HOS), Healthcare Effectiveness Data 

6 and Information Set (HEDIS), Consumer As7 sessment of Healthcare Providers and Systems 

8 (CAHPS) measures and quality measures under 

9 part D. 

10 ‘‘(7) DETERMINATION OF FEASIBILITY OF

11 QUALITY MEASUREMENT AT THE PLAN LEVEL FOR

12 ALL MA PLANS.— 

13 ‘‘(A) DETERMINATION OF FEASIBILITY.— 

14 The Secretary shall determine the feasibility of 

15 requiring reporting of data under section 

16 1852(e) for, and applying under this subsection, 

17 quality measures at the plan level for all MA 

18 plans under this part. 

19 ‘‘(B) CONSIDERATION OF CHANGE.—After 

20 making a determination under subparagraph 

21 (A), the Secretary shall consider requiring such 

22 reporting and applying such quality measures 

23 at the plan level as described in such subpara24 graph.’’. 


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1 (e) GAO STUDY AND REPORT ON STATE-LEVEL IN2 TEGRATION BETWEEN DUAL SNPS AND MEDICAID.— 

3 (1) STUDY.—The Comptroller General of the 

4 United States (in this paragraph referred to as the 

5 ‘‘Comptroller General’’) shall conduct a study on 

6 State-level integration between specialized MA plans 

7 for special needs individuals described in subsection 

8 (b)(6)(B)(ii) of section 1859 of the Social Security 

9 Act (42 U.S.C. 1395w–28) and the Medicaid pro10 gram under title XIX of such Act (42 U.S.C. 1396 

11 et seq.). Such study shall include an analysis of the 

12 following: 

13 (A) The characteristics of States in which 

14 the State agency responsible for administering 

15 the State plan under such title XIX has a con16 tract with such a specialized MA plan and that 

17 delivers long term services and supports under 

18 the State plan under such title XIX through a 

19 managed care program, including the require20 ments under such State plan with respect to 

21 long term services and supports. 

22 (B) The types of such specialized MA 

23 plans, which may include the following: 


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1 (i) A plan described in section 

2 1853(a)(1)(B)(iv)(II) of such Act (42 

3 U.S.C. 1395w–23(a)(1)(B)(iv)(II)). 

4 (ii) A plan that meets the require5 ments described in subsection (f)(3)(D) of 

6 such section 1859. 

7 (iii) A plan described in clause (ii) 

8 that also meets additional requirements es9 tablished by the State. 

10 (C) The characteristics of individuals en11 rolled in such specialized MA plans. 

12 (D) As practicable, the following with re13 spect to State programs for the delivery of long 

14 term services and supports under such title 

15 XIX through a managed care program: 

16 (i) Which populations of individuals 

17 are eligible to receive such services and 

18 supports. 

19 (ii) Whether all such services and sup20 ports are provided on a capitated basis or 

21 if any of such services and supports are 

22 carved out and provided through fee-for23 service. 

24 (E) How the availability and variation of 

25 integration arrangements of such specialized 


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1 MA plans offered in States affects spending, 

2 service delivery options, access to community3 based care, and utilization of care. 

4 (2) REPORT.—Not later than 2 years after the 

5 date of the enactment of this Act, the Comptroller 

6 General shall submit to Congress a report containing 

7 the results of the study conducted under paragraph 

8 (1), together with recommendations for such legisla9 tion and administrative action as the Comptroller 

10 General determines appropriate. 

11 TITLE III—EXPANDING 

12 INNOVATION AND TECHNOLOGY 

13 SEC. 301. ADAPTING BENEFITS TO MEET THE NEEDS OF 

14 CHRONICALLY ILL MEDICARE ADVANTAGE 

15 ENROLLEES. 

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

17 1395w–28) is amended by adding at the end the following 

18 new subsection: 

19 ‘‘(h) NATIONAL TESTING OF MODEL FOR MEDICARE

20 ADVANTAGE VALUE-BASED INSURANCE DESIGN.— 

21 ‘‘(1) IN GENERAL.—In implementing the model 

22 described in paragraph (2) proposed to be tested 

23 under section 1115A(b), the Secretary shall revise 

24 the testing of the model under such section to cover, 

25 effective not later than January 1, 2019, all States. 


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1 ‘‘(2) MODEL DESCRIBED.—The model described 

2 in this paragraph is the testing of a model of Medi3 care Advantage value-based insurance design that 

4 would allow Medicare Advantage plans the option to 

5 propose and design benefit structures that vary ben6 efits, cost-sharing, and supplemental benefits offered 

7 to enrollees with specific chronic diseases proposed 

8 to be carried out in Oregon, Arizona, Texas, Iowa, 

9 Michigan, Indiana, Tennessee, Alabama, Pennsyl10 vania, and Massachusetts. 

11 ‘‘(3) TERMINATION AND MODIFICATION PROVI12 SION NOT APPLICABLE UNTIL JANUARY 1, 2022.— 

13 The provisions of section 1115A(b)(3)(B) shall apply 

14 to the model described in paragraph (2), including 

15 such model as expanded under paragraph (1), begin16 ning January 1, 2022, but shall not apply to such 

17 model, as so expanded, prior to such date. 

18 ‘‘(4) FUNDING.—The Secretary shall allocate 

19 funds made available under section 1115A(f)(1) to 

20 design, implement, and evaluate the model described 

21 in paragraph (2), as expanded under paragraph 

22 (1).’’. 


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1 SEC. 302. EXPANDING SUPPLEMENTAL BENEFITS TO MEET 

2 THE NEEDS OF CHRONICALLY ILL MEDICARE 

3 ADVANTAGE ENROLLEES. 

4 (a) IN GENERAL.—Section 1852(a)(3) of the Social 

5 Security Act (42 U.S.C. 1395w–22(a)(3)) is amended— 

6 (1) in subparagraph (A), by striking ‘‘Each’’ 

7 and inserting ‘‘Subject to subparagraph (D), each’’; 

8 and 

9 (2) by adding at the end the following new sub10 paragraph: 

11 ‘‘(D) EXPANDING SUPPLEMENTAL BENE12 FITS TO MEET THE NEEDS OF CHRONICALLY

13 ILL ENROLLEES.— 

14 ‘‘(i) IN GENERAL.—For plan year 

15 2019 and subsequent plan years, in addi16 tion to any supplemental health care bene17 fits otherwise provided under this para18 graph, an MA plan may provide supple19 mental benefits described in clause (ii) to 

20 a chronically ill enrollee (as defined in 

21 clause (iii)). 

22 ‘‘(ii) SUPPLEMENTAL BENEFITS DE23 SCRIBED.— 

24 ‘‘(I) IN GENERAL.—Supplemental 

25 benefits described in this clause are 

26 supplemental benefits that, with reVerDate Sep 11 2014 01:37 Dec 07, 2016 Jkt 069200 PO 00000 Frm 00026 Fmt 6652 Sfmt 6201 E:\BILLS\S3504.IS S3504

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1 spect to a chronically ill enrollee, have 

2 a reasonable expectation of improving 

3 or maintaining the health or overall 

4 function of the chronically ill enrollee 

5 and may not be limited to being pri6 marily health related benefits. 

7 ‘‘(II) AUTHORITY TO WAIVE UNI8 FORMITY REQUIREMENTS.—The Sec9 retary may, only with respect to sup10 plemental benefits provided to a 

11 chronically ill enrollee under this sub12 paragraph, waive the uniformity re13 quirement under subsection (d)(1)(A), 

14 as determined appropriate by the Sec15 retary. 

16 ‘‘(iii) CHRONICALLY ILL ENROLLEE

17 DEFINED.—In this subparagraph, the term 

18 ‘chronically ill enrollee’ means an enrollee 

19 in an MA plan that the Secretary deter20 mines— 

21 ‘‘(I) has one or more comorbid 

22 and medically complex chronic condi23 tions that is life threatening or signifi24 cantly limits the overall health or 

25 function of the enrollee; 


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1 ‘‘(II) has a high risk of hos2 pitalization or other adverse health 

3 outcomes; and 

4 ‘‘(III) requires intensive care co5 ordination.’’. 

6 (b) GAO STUDY AND REPORT.— 

7 (1) STUDY.—The Comptroller General of the 

8 United States (in this subsection referred to as the 

9 ‘‘Comptroller General’’) shall conduct a study on 

10 supplemental benefits provided to enrollees in Medi11 care Advantage plans under part C of title XVIII of 

12 the Social Security Act. Such study shall include an 

13 analysis of the following: 

14 (A) The type of supplemental benefits pro15 vided to such enrollees, the total number of en16 rollees receiving each supplemental benefit, and 

17 whether the supplemental benefit is covered by 

18 the standard benchmark cost of the benefit or 

19 with an additional premium. 

20 (B) The frequency in which supplemental 

21 benefits are utilized by such enrollees. 

22 (C) The impact supplemental benefits have 

23 on— 


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1 (i) indicators of the quality of care re2 ceived by such enrollees, including overall 

3 health and function of the enrollees; 

4 (ii) the utilization of items and serv5 ices for which benefits are available under 

6 the original Medicare fee-for-service pro7 gram option under parts A and B of such 

8 title XVIII by such enrollees; and 

9 (iii) the amount of the bids submitted 

10 by Medicare Advantage Organizations for 

11 Medicare Advantage plans under such part 

12 C. 

13 (2) REPORT.—Not later than 5 years after the 

14 date of the enactment of this Act, the Comptroller 

15 General shall submit to Congress a report containing 

16 the results of the study conducted under paragraph 

17 (1), together with recommendations for such legisla18 tion and administrative action as the Comptroller 

19 General determines appropriate. 

20 SEC. 303. INCREASING CONVENIENCE FOR MEDICARE AD21 VANTAGE ENROLLEES THROUGH TELE22 HEALTH. 

23 (a) IN GENERAL.—Section 1852 of the Social Secu24 rity Act (42 U.S.C. 1395w–22) is amended— 


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1 (1) in subsection (a)(1)(B)(i), by inserting ‘‘, 

2 subject to subsection (m),’’ after ‘‘means’’; and 

3 (2) by adding at the end the following new sub4 section: 

5 ‘‘(m) PROVISION OF ADDITIONAL TELEHEALTH

6 BENEFITS.— 

7 ‘‘(1) MA PLAN OPTION.—For plan year 2019 

8 and subsequent plan years, subject to the require9 ments of paragraph (3), an MA plan may provide 

10 additional telehealth benefits (as defined in para11 graph (2)) to individuals enrolled under this part. 

12 ‘‘(2) ADDITIONAL TELEHEALTH BENEFITS DE13 FINED.— 

14 ‘‘(A) IN GENERAL.—For purposes of this 

15 subsection and section 1854: 

16 ‘‘(i) DEFINITION.—The term ‘addi17 tional telehealth benefits’ means services— 

18 ‘‘(I) for which benefits are avail19 able under part B, including services 

20 for which payment is not made under 

21 section 1834(m) due to the conditions 

22 for payment under such section; and 

23 ‘‘(II) that are identified as clini24 cally appropriate to furnish using elec25 tronic information and telecommuniVerDate Sep 11 2014 01:37 Dec 07, 2016 Jkt 069200 PO 00000 Frm 00030 Fmt 6652 Sfmt 6201 E:\BILLS\S3504.IS S3504

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1 cations technology when a physician 

2 (as defined in section 1861(r)) or 

3 practitioner (described in section 

4 1842(b)(18)(C)) providing the service 

5 is not at the same location as the plan 

6 enrollee. 

7 ‘‘(ii) EXCLUSION OF CAPITAL AND IN8 FRASTRUCTURE COSTS AND INVEST9 MENTS.—The term ‘additional telehealth 

10 benefits’ does not include capital and infra11 structure costs and investments relating to 

12 such benefits. 

13 ‘‘(B) PUBLIC COMMENT.—Not later than 

14 November 30, 2017, the Secretary shall solicit 

15 comments on what types of telehealth services 

16 currently offered to enrollees under this part 

17 through supplemental health care benefits 

18 should be considered to meet the definition of 

19 additional telehealth benefits under this para20 graph. 

21 ‘‘(3) REQUIREMENTS FOR ADDITIONAL TELE22 HEALTH BENEFITS.—The Secretary shall specify re23 quirements for the provision or furnishing of addi24 tional telehealth benefits, including with respect to 

25 the following: 


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1 ‘‘(A) Physician or practitioner licensure 

2 and other requirements such as specific train3 ing. 

4 ‘‘(B) Factors necessary to ensure the co5 ordination of such benefits with items and serv6 ices furnished in-person. 

7 ‘‘(C) Such other areas as determined by 

8 the Secretary. 

9 ‘‘(4) ENROLLEE CHOICE.—If an MA plan pro10 vides a service as an additional telehealth benefit (as 

11 defined in paragraph (2)), an individual enrollee 

12 shall have discretion as to whether to receive such 

13 service as an additional telehealth benefit. 

14 ‘‘(5) CONSTRUCTION REGARDING NETWORK AC15 CESS ADEQUACY.—Provision of additional telehealth 

16 benefits under this subsection shall not be construed 

17 as making such benefits available and accessible for 

18 purposes of compliance with subsection (d). 

19 ‘‘(6) TREATMENT UNDER MA.—For purposes of 

20 this subsection and section 1854, additional tele21 health benefits shall be treated as if they were bene22 fits under the original Medicare fee-for-service pro23 gram option. 

24 ‘‘(7) CONSTRUCTION.—Nothing in this sub25 section shall be construed as affecting the requireVerDate Sep 11 2014 01:37 Dec 07, 2016 Jkt 069200 PO 00000 Frm 00032 Fmt 6652 Sfmt 6201 E:\BILLS\S3504.IS S3504

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1 ment under subsection (a)(1) that MA plans provide 

2 enrollees with items and services (other than hospice 

3 care) for which benefits are available under parts A 

4 and B, including benefits available under section 

5 1834(m).’’. 

6 (b) CLARIFICATION REGARDING INCLUSION IN BID

7 AMOUNT.—Section 1854(a)(6)(A)(ii)(I) of the Social Se8 curity Act (42 U.S.C. 1395w–24(a)(6)(A)(ii)(I)) is 

9 amended by inserting ‘‘, including, for plan year 2019 and 

10 subsequent plan years, the provision of additional tele11 health benefits as described in section 1852(m)’’ before 

12 the semicolon at the end. 

13 SEC. 304. PROVIDING ACCOUNTABLE CARE ORGANIZA14 TIONS THE ABILITY TO EXPAND THE USE OF 

15 TELEHEALTH. 

16 (a) IN GENERAL.—Section 1899 of the Social Secu17 rity Act (42 U.S.C. 1395jjj) is amended by adding at the 

18 end the following new subsection: 

19 ‘‘(l) PROVIDING ACOS THE ABILITY TO EXPAND

20 THE USE OF TELEHEALTH SERVICES.— 

21 ‘‘(1) IN GENERAL.—In the case of telehealth 

22 services for which payment would otherwise be made 

23 under this title furnished on or after January 1, 

24 2019, for purposes of this subsection only, the fol25 lowing shall apply with respect to such services furVerDate Sep 11 2014 01:37 Dec 07, 2016 Jkt 069200 PO 00000 Frm 00033 Fmt 6652 Sfmt 6201 E:\BILLS\S3504.IS S3504

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1 nished by a physician or practitioner participating in 

2 an applicable ACO (as defined in paragraph (2)) to 

3 a Medicare fee-for-service beneficiary assigned to the 

4 applicable ACO: 

5 ‘‘(A) INCLUSION OF HOME AS ORIGINATING

6 SITE.—Subject to paragraph (3), the home of a 

7 beneficiary shall be treated as an originating 

8 site described in section 1834(m)(4)(C)(ii). 

9 ‘‘(B) NO APPLICATION OF GEOGRAPHIC

10 LIMITATION.—The geographic limitation under 

11 section 1834(m)(4)(C)(i) shall not apply with 

12 respect to an originating site described in sec13 tion 1834(m)(4)(C)(ii) (including the home of a 

14 beneficiary under subparagraph (A)), subject to 

15 State licensing requirements. 

16 ‘‘(2) DEFINITIONS.—In this subsection: 

17 ‘‘(A) APPLICABLE ACO.—The term ‘appli18 cable ACO’ means an ACO participating in a 

19 model tested or expanded under section 1115A 

20 or under this section— 

21 ‘‘(i) that operates under a two-sided 

22 model— 

23 ‘‘(I) described in section 

24 425.600(a) of title 42, Code of Fed25 eral Regulations; or 


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1 ‘‘(II) tested or expanded under 

2 section 1115A; and 

3 ‘‘(ii) for which Medicare fee-for-serv4 ice beneficiaries are assigned to the ACO 

5 using a prospective assignment method, as 

6 determined appropriate by the Secretary. 

7 ‘‘(B) HOME.—The term ‘home’ means, 

8 with respect to a Medicare fee-for-service bene9 ficiary, the place of residence used as the home 

10 of the beneficiary. 

11 ‘‘(3) TELEHEALTH SERVICES RECEIVED IN THE

12 HOME.—In the case of telehealth services described 

13 in paragraph (1) where the home of a Medicare fee14 for-service beneficiary is the originating site, the fol15 lowing shall apply: 

16 ‘‘(A) NO FACILITY FEE.—There shall be 

17 no facility fee paid to the originating site under 

18 section 1834(m)(2)(B). 

19 ‘‘(B) EXCLUSION OF CERTAIN SERVICES.— 

20 No payment may be made for such services that 

21 are inappropriate to furnish in the home setting 

22 such as services that are typically furnished in 

23 inpatient settings such as a hospital.’’. 

24 (b) STUDY AND REPORT.— 

25 (1) STUDY.— 


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1 (A) IN GENERAL.—The Secretary of 

2 Health and Human Services (in this subsection 

3 referred to as the ‘‘Secretary’’) shall conduct a 

4 study on the implementation of section 1899(l) 

5 of the Social Security Act, as added by sub6 section (a). Such study shall include an analysis 

7 of the utilization of, and expenditures for, tele8 health services under such section. 

9 (B) COLLECTION OF DATA.—The Sec10 retary may collect such data as the Secretary 

11 determines necessary to carry out the study 

12 under this paragraph. 

13 (2) REPORT.—Not later than January 1, 2025, 

14 the Secretary shall submit to Congress a report con15 taining the results of the study conducted under 

16 paragraph (1), together with recommendations for 

17 such legislation and administrative action as the 

18 Secretary determines appropriate. 

19 SEC. 305. EXPANDING THE USE OF TELEHEALTH FOR INDI20 VIDUALS WITH STROKE. 

21 Section 1834(m) of the Social Security Act (42 

22 U.S.C. 1395m(m)), as amended by section 102(b)(2), is 

23 amended by adding at the end the following new para24 graph: 


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1 ‘‘(6) TREATMENT OF STROKE TELEHEALTH

2 SERVICES.— 

3 ‘‘(A) NON-APPLICATION OF ORIGINATING

4 SITE REQUIREMENTS.—The requirements de5 scribed in paragraph (4)(C) shall not apply with 

6 respect to telehealth services furnished on or 

7 after January 1, 2018, for purposes of evalua8 tion of an acute stroke, as determined by the 

9 Secretary. 

10 ‘‘(B) NO ORIGINATING SITE FACILITY

11 FEE.—The Secretary shall not pay an origi12 nating site facility fee (as described in para13 graph (2)(B)) with respect to such telehealth 

14 services.’’. 

15 TITLE IV—IDENTIFYING THE 

16 CHRONICALLY ILL POPULATION 

17 SEC. 401. PROVIDING FLEXIBILITY FOR BENEFICIARIES TO 

18 BE PART OF AN ACCOUNTABLE CARE ORGA19 NIZATION. 

20 Section 1899(c) of the Social Security Act (42 U.S.C. 

21 1395jjj(c)) is amended— 

22 (1) by striking ‘‘ACOS.—The Secretary’’ and 

23 inserting ‘‘ACOS.— 

24 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

25 the Secretary’’; and 


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

2 paragraph: 

3 ‘‘(2) PROVIDING FLEXIBILITY.— 

4 ‘‘(A) CHOICE OF PROSPECTIVE ASSIGN5 MENT.—For each agreement period (effective 

6 for agreements entered into or renewed on or 

7 after January 1, 2019), in the case where an 

8 ACO established under the program is in a 

9 Track that provides for the retrospective assign10 ment of Medicare fee-for-service beneficiaries to 

11 the ACO, the Secretary shall permit the ACO 

12 to choose to have Medicare fee-for-service bene13 ficiaries assigned prospectively, rather than ret14 rospectively, to the ACO for an agreement pe15 riod. 

16 ‘‘(B) ASSIGNMENT BASED ON VOLUNTARY

17 IDENTIFICATION BY MEDICARE FEE-FOR-SERV18 ICE BENEFICIARIES.— 

19 ‘‘(i) IN GENERAL.—For performance 

20 year 2018 and each subsequent perform21 ance year, if a system is available for elec22 tronic designation, the Secretary shall per23 mit a Medicare fee-for-service beneficiary 

24 to voluntarily identify an ACO professional 

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1 ficiary for purposes of assigning such bene2 ficiary to an ACO, as determined by the 

3 Secretary. 

4 ‘‘(ii) NOTIFICATION PROCESS.—The 

5 Secretary shall establish a process under 

6 which a Medicare fee-for-service bene7 ficiary is— 

8 ‘‘(I) notified of their ability to 

9 make an identification described in 

10 clause (i); and 

11 ‘‘(II) informed of the process by 

12 which they may make and change 

13 such identification. 

14 ‘‘(iii) SUPERSEDING CLAIMS-BASED

15 ASSIGNMENT.—A voluntary identification 

16 by a Medicare fee-for-service beneficiary 

17 under this subparagraph shall supersede 

18 any claims-based assignment otherwise de19 termined by the Secretary.’’. 


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1 TITLE V—EMPOWERING INDI2 VIDUALS AND CAREGIVERS IN 

3 CARE DELIVERY 

4 SEC. 501. ELIMINATING BARRIERS TO CARE COORDINA5 TION UNDER ACCOUNTABLE CARE ORGANI6 ZATIONS. 

7 (a) IN GENERAL.—Section 1899 of the Social Secu8 rity Act (42 U.S.C. 1395jjj), as amended by section 

9 304(a), is amended— 

10 (1) in subsection (b)(2), by adding at the end 

11 the following new subparagraph: 

12 ‘‘(I) An ACO that seeks to operate an 

13 ACO Beneficiary Incentive Program pursuant 

14 to subsection (m) shall apply to the Secretary 

15 at such time, in such manner, and with such in16 formation as the Secretary may require.’’; 

17 (2) by adding at the end the following new sub18 section: 

19 ‘‘(m) AUTHORITY TO PROVIDE INCENTIVE PAY20 MENTS TO BENEFICIARIES WITH RESPECT TO QUALI21 FYING PRIMARY CARE SERVICES.— 

22 ‘‘(1) PROGRAM.— 

23 ‘‘(A) IN GENERAL.—In order to encourage 

24 Medicare fee-for-service beneficiaries to obtain 

25 medically necessary primary care services, an 


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1 ACO participating under this section under a 

2 payment model described in clause (i) or (ii) of 

3 paragraph (2)(B) may apply to establish an 

4 ACO Beneficiary Incentive Program to provide 

5 incentive payments to such beneficiaries who 

6 are furnished qualifying services in accordance 

7 with this subsection. The Secretary shall permit 

8 such an ACO to establish such a program at 

9 the Secretary’s discretion and subject to such 

10 requirements, including program integrity re11 quirements, as the Secretary determines nec12 essary. 

13 ‘‘(B) IMPLEMENTATION.—The Secretary 

14 shall implement this subsection on a date deter15 mined appropriate by the Secretary. Such date 

16 shall be no earlier than January 1, 2018, and 

17 no later than January 1, 2019. 

18 ‘‘(2) CONDUCT OF PROGRAM.— 

19 ‘‘(A) DURATION.—Subject to subpara20 graph (H), an ACO Beneficiary Incentive Pro21 gram established under this subsection shall be 

22 conducted for such period (of not less than 1 

23 year) as the Secretary may approve. 

24 ‘‘(B) SCOPE.—An ACO Beneficiary Incen25 tive Program established under this subsection 


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1 shall provide incentive payments to all of the 

2 following Medicare fee-for-service beneficiaries 

3 who are furnished qualifying services by the 

4 ACO: 

5 ‘‘(i) With respect to the Track 2 and 

6 Track 3 payment models described in sec7 tion 425.600(a) of title 42, Code of Fed8 eral Regulations (or in any successor regu9 lation), Medicare fee-for-service bene10 ficiaries who are preliminarily prospectively 

11 or prospectively assigned (or otherwise as12 signed, as determined by the Secretary) to 

13 the ACO. 

14 ‘‘(ii) With respect to any future pay15 ment models involving two-sided risk, 

16 Medicare fee-for-service beneficiaries who 

17 are assigned to the ACO, as determined by 

18 the Secretary. 

19 ‘‘(C) QUALIFYING SERVICE.—For purposes 

20 of this subsection, a qualifying service is a pri21 mary care service, as defined in section 425.20 

22 of title 42, Code of Federal Regulations (or in 

23 any successor regulation), with respect to which 

24 coinsurance applies under part B, furnished 

25 through an ACO by— 


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1 ‘‘(i) an ACO professional described in 

2 subsection (h)(1)(A) who has a primary 

3 care specialty designation included in the 

4 definition of primary care physician under 

5 section 425.20 of title 42, Code of Federal 

6 Regulations (or any successor regulation); 

7 ‘‘(ii) an ACO professional described in 

8 subsection (h)(1)(B); or 

9 ‘‘(iii) a Federally qualified health cen10 ter or rural health clinic (as such terms 

11 are defined in section 1861(aa)). 

12 ‘‘(D) INCENTIVE PAYMENTS.—An incentive 

13 payment made by an ACO pursuant to an ACO 

14 Beneficiary Incentive Program established 

15 under this subsection shall be— 

16 ‘‘(i) in an amount up to $20, with 

17 such maximum amount updated annually 

18 by the percentage increase in the consumer 

19 price index for all urban consumers 

20 (United States city average) for the 12- 

21 month period ending with June of the pre22 vious year; 

23 ‘‘(ii) in the same amount for each 

24 Medicare fee-for-service beneficiary de25 scribed in clause (i) or (ii) of subparagraph 


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1 (B) without regard to enrollment of such a 

2 beneficiary in a medicare supplemental pol3 icy (described in section 1882(g)(1)), in a 

4 State Medicaid plan under title XIX or a 

5 waiver of such a plan, or in any other 

6 health insurance policy or health benefit 

7 plan; 

8 ‘‘(iii) made for each qualifying service 

9 furnished to such a beneficiary described 

10 in clause (i) or (ii) of subparagraph (B) 

11 during a period specified by the Secretary; 

12 and 

13 ‘‘(iv) made no later than 30 days after 

14 a qualifying service is furnished to such a 

15 beneficiary described in clause (i) or (ii) of 

16 subparagraph (B). 

17 ‘‘(E) NO SEPARATE PAYMENTS FROM THE

18 SECRETARY.—The Secretary shall not make 

19 any separate payment to an ACO for the costs, 

20 including incentive payments, of carrying out 

21 an ACO Beneficiary Incentive Program estab22 lished under this subsection. Nothing in this 

23 subparagraph shall be construed as prohibiting 

24 an ACO from using shared savings received 


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1 under this section to carry out an ACO Bene2 ficiary Incentive Program. 

3 ‘‘(F) NO APPLICATION TO SHARED SAV4 INGS CALCULATION.—Incentive payments made 

5 by an ACO under this subsection shall be dis6 regarded for purposes of calculating bench7 marks, estimated average per capita Medicare 

8 expenditures, and shared savings under this 

9 section. 

10 ‘‘(G) REPORTING REQUIREMENTS.—An 

11 ACO conducting an ACO Beneficiary Incentive 

12 Program under this subsection shall, at such 

13 times and in such format as the Secretary may 

14 require, report to the Secretary such informa15 tion and retain such documentation as the Sec16 retary may require, including the amount and 

17 frequency of incentive payments made and the 

18 number of Medicare fee-for-service beneficiaries 

19 receiving such payments. 

20 ‘‘(H) TERMINATION.—The Secretary may 

21 terminate an ACO Beneficiary Incentive Pro22 gram established under this subsection at any 

23 time for reasons determined appropriate by the 

24 Secretary. 


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1 ‘‘(3) EXCLUSION OF INCENTIVE PAYMENTS.— 

2 Any payment made under an ACO Beneficiary In3 centive Program established under this subsection 

4 shall not be considered income or resources or other5 wise taken into account for purposes of— 

6 ‘‘(A) determining eligibility for benefits or 

7 assistance (or the amount or extent of benefits 

8 or assistance) under any Federal program or 

9 under any State or local program financed in 

10 whole or in part with Federal funds; or 

11 ‘‘(B) any Federal or State laws relating to 

12 taxation.’’; 

13 (3) in subsection (e), by inserting ‘‘, including 

14 an ACO Beneficiary Incentive Program under sub15 sections (b)(2)(I) and (m)’’ after ‘‘the program’’; 

16 and 

17 (4) in subsection (g)(6), by inserting ‘‘or of an 

18 ACO Beneficiary Incentive Program under sub19 sections (b)(2)(I) and (m)’’ after ‘‘under subsection 

20 (d)(4)’’. 

21 (b) AMENDMENT TO SECTION 1128B.—Section 

22 1128B(b)(3) of the Social Security Act (42 U.S.C. 1320a– 

23 7b(b)(3)) is amended— 

24 (1) by striking ‘‘and’’ at the end of subpara25 graph (I); 


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1 (2) by striking the period at the end of sub2 paragraph (J) and inserting ‘‘; and’’; and 

3 (3) by adding at the end the following new sub4 paragraph: 

5 ‘‘(K) an incentive payment made to a 

6 Medicare fee-for-service beneficiary by an ACO 

7 under an ACO Beneficiary Incentive Program 

8 established under subsection (m) of section 

9 1899, if the payment is made in accordance 

10 with the requirements of such subsection and 

11 meets such other conditions as the Secretary 

12 may establish.’’. 

13 (c) EVALUATION AND REPORT.— 

14 (1) EVALUATION.—The Secretary of Health 

15 and Human Services (in this subsection referred to 

16 as the ‘‘Secretary’’) shall conduct an evaluation of 

17 the ACO Beneficiary Incentive Program established 

18 under subsections (b)(2)(I) and (m) of section 1899 

19 of the Social Security Act (42 U.S.C. 1395jjj), as 

20 added by subsection (a). The evaluation shall include 

21 an analysis of the impact of the implementation of 

22 the Program on expenditures and beneficiary health 

23 outcomes under title XVIII of the Social Security 

24 Act (42 U.S.C. 1395 et seq.). 


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1 (2) REPORT.—Not later than October 1, 2022, 

2 the Secretary shall submit to Congress a report con3 taining the results of the evaluation under para4 graph (1), together with recommendations for such 

5 legislation and administrative action as the Sec6 retary determines appropriate. 

7 SEC. 502. GAO STUDY AND REPORT ON LONGITUDINAL 

8 COMPREHENSIVE CARE PLANNING SERVICES 

9 UNDER MEDICARE PART B. 

10 (a) STUDY.—The Comptroller General shall conduct 

11 a study on the establishment under part B of the Medicare 

12 program under title XVIII of the Social Security Act of 

13 a payment code for a visit for longitudinal comprehensive 

14 care planning services. Such study shall include an anal15 ysis of the following to the extent such information is 

16 available: 

17 (1) The frequency with which services similar to 

18 longitudinal comprehensive care planning services 

19 are furnished to Medicare beneficiaries, which pro20 viders of services and suppliers are furnishing those 

21 services, whether Medicare reimbursement is being 

22 received for those services, and, if so, through which 

23 codes those services are being reimbursed. 

24 (2) Whether, and the extent to which, longitu25 dinal comprehensive care planning services would 


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1 overlap, and could therefore result in duplicative 

2 payment, with services covered under the hospice 

3 benefit as well as the chronic care management code, 

4 evaluation and management codes, or other codes 

5 that already exist under part B of the Medicare pro6 gram. 

7 (3) Any barriers to hospitals, skilled nursing fa8 cilities, hospice programs, home health agencies, and 

9 other applicable providers working with a Medicare 

10 beneficiary to engage in the care planning process 

11 and complete the necessary documentation to sup12 port the treatment and care plan of the beneficiary 

13 and provide such documentation to other providers 

14 and the beneficiary or his representative. 

15 (4) Any barriers to providers, other than the 

16 provider furnishing longitudinal comprehensive care 

17 planning services, accessing the care plan and asso18 ciated documentation for use related to the care of 

19 the Medicare beneficiary. 

20 (5) Potential options for ensuring that applica21 ble providers are notified of a patient’s existing lon22 gitudinal care plan and that applicable providers 

23 consider that plan in making their treatment deci24 sions, and what the challenges might be in imple25 menting such options. 


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1 (6) Stakeholder’s views on the need for the de2 velopment of quality metrics with respect to longitu3 dinal comprehensive care planning services, such as 

4 measures related to— 

5 (A) the process of eliciting input from the 

6 Medicare beneficiary or from a legally author7 ized representative and documenting in the 

8 medical record the patient-directed care plan; 

9 (B) the effectiveness and patient10 centeredness of the care plan in organizing de11 livery of services consistent with the plan; 

12 (C) the availability of the care plan and as13 sociated documentation to other providers that 

14 care for the beneficiary; and 

15 (D) the extent to which the beneficiary re16 ceived services and support that is free from 

17 discrimination based on advanced age, disability 

18 status, or advanced illness. 

19 (7) Stakeholder’s views on how such quality 

20 metrics would provide information on— 

21 (A) the goals, values, and preferences of 

22 the beneficiary; 

23 (B) the documentation of the care plan; 

24 (C) services furnished to the beneficiary; 

25 and 


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1 (D) outcomes of treatment. 

2 (8) Stakeholder’s views on— 

3 (A) the type of training and education 

4 needed for applicable providers, individuals, and 

5 caregivers in order to facilitate longitudinal 

6 comprehensive care planning services; 

7 (B) the types of providers of services and 

8 suppliers that should be included in the inter9 disciplinary team of an applicable provider; and 

10 (C) the characteristics of Medicare bene11 ficiaries that would be most appropriate to re12 ceive longitudinal comprehensive care planning 

13 services, such as individuals with advanced dis14 ease and individuals who need assistance with 

15 multiple activities of daily living. 

16 (9) Stakeholder’s views on the frequency with 

17 which longitudinal comprehensive care planning 

18 services should be furnished. 

19 (b) REPORT.—Not later than 18 months after the 

20 date of the enactment of this Act, the Comptroller General 

21 shall submit to Congress a report containing the results 

22 of the study conducted under subsection (a), together with 

23 recommendations for such legislation and administrative 

24 action as the Comptroller General determines appropriate. 

25 (c) DEFINITIONS.—In this section: 


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1 (1) APPLICABLE PROVIDER.—The term ‘‘appli2 cable provider’’ means a hospice program (as defined 

3 in subsection (dd)(2) of section 1861 of the Social 

4 Security Act (42 U.S.C. 1395ww)) or other provider 

5 of services (as defined in subsection (u) of such sec6 tion) or supplier (as defined in subsection (d) of 

7 such section) that— 

8 (A) furnishes longitudinal comprehensive 

9 care planning services through an interdiscipli10 nary team; and 

11 (B) meets such other requirements as the 

12 Secretary may determine to be appropriate. 

13 (2) COMPTROLLER GENERAL.—The term 

14 ‘‘Comptroller General’’ means the Comptroller Gen15 eral of the United States. 

16 (3) INTERDISCIPLINARY TEAM.—The term 

17 ‘‘interdisciplinary team’’ means a group that— 

18 (A) includes the personnel described in 

19 subsection (dd)(2)(B)(i) of such section 1861; 

20 (B) may include a chaplain, minister, or 

21 other clergy; and 

22 (C) may include other direct care per23 sonnel. 

24 (4) LONGITUDINAL COMPREHENSIVE CARE

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1 prehensive care planning services’’ means a vol2 untary shared decisionmaking process that is fur3 nished by an applicable provider through an inter4 disciplinary team and includes a conversation with 

5 Medicare beneficiaries who have received a diagnosis 

6 of a serious or life-threatening illness. The purpose 

7 of such services is to discuss a longitudinal care plan 

8 that addresses the progression of the disease, treat9 ment options, the goals, values, and preferences of 

10 the beneficiary, and the availability of other re11 sources and social supports that may reduce the 

12 beneficiary’s health risks and promote self-manage13 ment and shared decisionmaking. 

14 (5) SECRETARY.—The term ‘‘Secretary’’ means 

15 the Secretary of Health and Human Services. 

16 TITLE VI—OTHER POLICIES TO 

17 IMPROVE CARE FOR THE 

18 CHRONICALLY ILL 

19 SEC. 601. GAO STUDY AND REPORT ON IMPROVING MEDI20 CATION SYNCHRONIZATION. 

21 (a) STUDY.—The Comptroller General of the United 

22 States (in this section referred to as the ‘‘Comptroller 

23 General’’) shall conduct a study on the extent to which 

24 Medicare prescription drug plans (MA–PD plans and 

25 standalone prescription drug plans) under part D of title 


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1 XVIII of the Social Security Act and private payors use 

2 programs that synchronize pharmacy dispensing so that 

3 individuals may receive multiple prescriptions on the same 

4 day to facilitate comprehensive counseling and promote 

5 medication adherence. The study shall include a review of 

6 the following: 

7 (1) The extent to which pharmacies have adopt8 ed such programs. 

9 (2) The common characteristics of such pro10 grams, including how pharmacies structure coun11 seling sessions under such programs and the types 

12 of payment and other arrangements that Medicare 

13 prescription drug plans and private payors employ 

14 under such programs to support the efforts of phar15 macies. 

16 (3) How such programs compare for Medicare 

17 prescription drug plans and private payors. 

18 (4) What is known about how such programs 

19 affect patient medication adherence and overall pa20 tient health outcomes and health outcomes, includ21 ing if adherence and outcomes vary by patient sub22 populations, such as disease state and socioeconomic 

23 status. 

24 (5) What is known about overall patient satis25 faction with such programs and satisfaction with 


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1 such programs, including within patient subpopula2 tions, such as disease state and socioeconomic sta3 tus. 

4 (6) The extent to which laws and regulations of 

5 the Medicare program support such programs. 

6 (7) Barriers to the use of medication synchroni7 zation programs by Medicare prescription drug 

8 plans. 

9 (b) REPORT.—Not later than 18 months after the 

10 date of the enactment of this Act, the Comptroller General 

11 shall submit to Congress a report containing the results 

12 of the study under subsection (a), together with rec13 ommendations for such legislation and administrative ac14 tion as the Comptroller General determines appropriate. 

15 SEC. 602. GAO STUDY AND REPORT ON IMPACT OF OBESITY 

16 DRUGS ON PATIENT HEALTH AND SPENDING. 

17 (a) STUDY.—The Comptroller General of the United 

18 States (in this section referred to as the ‘‘Comptroller 

19 General’’) shall conduct a study on the use of prescription 

20 drugs to manage the weight of obese patients and the im21 pact of coverage of such drugs on patient health and on 

22 health care spending. Such study shall examine the use 

23 and impact of these obesity drugs in the non-Medicare 

24 population and for Medicare beneficiaries who have such 

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1 tion 1860D–1(a)(3)(C) of the Social Security Act (42 

2 U.S.C. 1395w–101(a)(3)(C))) as a supplemental health 

3 care benefit. The study shall include an analysis of the 

4 following: 

5 (1) The prevalence of obesity in the Medicare 

6 and non-Medicare population. 

7 (2) The utilization of obesity drugs. 

8 (3) The distribution of Body Mass Index by in9 dividuals taking obesity drugs, to the extent prac10 ticable. 

11 (4) What is known about the use of obesity 

12 drugs in conjunction with the receipt of other items 

13 or services, such as behavioral counseling, and how 

14 these compare to items and services received by 

15 obese individuals who do not take obesity drugs. 

16 (5) Physician considerations and attitudes re17 lated to prescribing obesity drugs. 

18 (6) The extent to which coverage policies cease 

19 or limit coverage for individuals who fail to receive 

20 clinical benefit. 

21 (7) What is known about the extent to which 

22 individuals who take obesity drugs adhere to the pre23 scribed regimen. 


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1 (8) What is known about the extent to which 

2 individuals who take obesity drugs maintain weight 

3 loss over time. 

4 (9) What is known about the subsequent impact 

5 such drugs have on medical services that are directly 

6 related to obesity, including with respect to sub7 populations determined based on the extent of obe8 sity. 

9 (10) What is known about the spending associ10 ated with the care of individuals who take obesity 

11 drugs, compared to the spending associated with the 

12 care of individuals who do not take such drugs. 

13 (b) REPORT.—Not later than 18 months after the 

14 date of the enactment of this Act, the Comptroller General 

15 shall submit to Congress a report containing the results 

16 of the study under subsection (a), together with rec17 ommendations for such legislation and administrative ac18 tion as the Comptroller General determines appropriate. 

Æ 


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