I 

112TH CONGRESS 

1ST SESSION H. R. 3315 

To establish a pilot program providing for monthly fee-based payments for 

direct primary care medical homes for Medicare-Medicaid dual eligibles 

and other Medicare beneficiaries. 

IN THE HOUSE OF REPRESENTATIVES 

NOVEMBER 2, 2011 

Mr. CASSIDY introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on 

Ways and Means, for a period to be subsequently determined by the 

Speaker, in each case for consideration of such provisions as fall within 

the jurisdiction of the committee concerned 

A BILL 

To establish a pilot program providing for monthly fee-based 

payments for direct primary care medical homes for 

Medicare-Medicaid dual eligibles and other 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 ‘‘Direct M.D. Care Act 

5 of 2011’’. 


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1 SEC. 2. QUALIFIED DIRECT PRIMARY CARE MEDICAL HOME 

2 PILOT FOR MEDICARE PART B BENE3 FICIARIES. 

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

5 Human Services (in this section referred to as the ‘‘Sec6 retary’’) shall establish a program of pilot projects (each 

7 in this section referred to as the ‘‘pilot project’’) under 

8 part B of title XVIII of the Social Security Act under 

9 which the Secretary reimburses a qualified direct primary 

10 care medical home practice, as described in section 

11 1301(a)(3) of the Patient Protection and Affordable Care 

12 Act (as amended by section 10104(a) of such Act), using 

13 a monthly fee-based payment methodology. 

14 (b) AFFORDABLE PRIMARY CARE.—No pilot project 

15 may be established under this section with respect to a 

16 medical home if the monthly fee under this section for an 

17 enrolled individual exceeds $100 (or $125 in the case of 

18 a dual eligible individual (as defined in subsection (i)). The 

19 Secretary shall adjust from time to time the dollar 

20 amounts specified in the previous sentence for inflation. 

21 (c) SCOPE OF SERVICES.—Each pilot project shall 

22 employ the following activities and functions associated 

23 with direct primary care medical homes: 

24 (1) Provision of preventive care. 

25 (2) Wellness counseling. 

26 (3) Primary care. 


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1 (4) Coordination of primary care with specialty 

2 and hospital care. 

3 (5) Urgent care services. 

4 (6) Availability of office appointments 7 days 

5 per week. 

6 (7) E-mail and telephone consultation. 

7 (8) Availability of telephone access for urgent 

8 care consultation on a 7-day per week, 24-hour per 

9 day basis. 

10 (9) Use of a primary care provider panel size 

11 that promotes the ability of participating providers 

12 to appropriately provide the scope of services de13 scribed in this subparagraph. 

14 (d) PRIORITIES.— 

15 (1) QUALIFIED STATE.—At least one such pilot 

16 project shall be conducted in a State that— 

17 (A) has enacted legislation to enable direct 

18 primary care practices to deliver monthly fee19 based primary care without being regulated as 

20 an insurer or health maintenance organization; 

21 and 

22 (B) has direct primary care practices 

23 which enroll, in the aggregate as of September 

24 1, 2011, at least 3,000 individuals using the 

25 monthly fee-based primary care model. 


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1 (2) PROJECTS INCLUDING DUAL ELIGIBLES.— 

2 Subject to paragraph (1), the Secretary shall provide 

3 priority to pilot projects that seek to enroll individ4 uals who are dual eligible individuals. 

5 (e) NO INSURANCE.—Care provided under a pilot 

6 project shall not be considered an insurance product and 

7 shall not be subject to regulation as insurance product or 

8 health maintenance organization by State insurance com9 missioners. 

10 (f) APPLICATION OF PROVISIONS.—The provisions of 

11 subsections (b)(3) and (d) of section 1115A of the Social 

12 Security Act (42 U.S.C. 1315a) shall apply in carrying 

13 out the program of pilot projects under this section in the 

14 same manner as such provisions apply to testing models 

15 under subsection (b)(1) of such section and, notwith16 standing any other provision of law, funds appropriated 

17 under subsection (f)(1)(B) of such section for activities 

18 under such section shall be available to carry out pilot 

19 projects under this section. 

20 (g) REPORTING TO SECRETARY.—An entity that es21 tablishes a pilot project shall submit to the Secretary an 

22 annual report that measures the progress, of patients en23 rolled in the project with one or more chronic conditions, 

24 on the following: 

25 (1) Emergency room visits. 


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1 (2) Hospitalizations. 

2 (3) Surgeries (including type of surgery). 

3 (4) Specialist visits. 

4 (5) Use of advanced radiology (other than 

5 mammograms and DEXA scans). 

6 (h) PROVISION OF DATA.—The Secretary shall pro7 vide the entities operating pilot projects with all necessary 

8 and relevant patient data, including any prior claims data, 

9 needed for clinical purposes and for the purpose of pro10 viding an evaluation of such projects. 

11 (i) DUAL ELIGIBLE INDIVIDUAL DEFINED.—In this 

12 section, the term ‘‘dual eligible individual’’ means a Medi13 care beneficiary who is described in subparagraph (A)(ii) 

14 of section 1935(c)(6) of the Social Security Act (42 U.S.C. 

15 1396u–5(c)(6)), taking into account the application of 

16 subparagraph (B) of such section. 

Æ 


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