Community Based Independence for Seniors Act

To establish a Community-Based Institutional Special Needs Plan demonstration program to target home and community-based care to eligible Medicare beneficiaries. 1. Short title This Act may be cited as the Community Based Independence for Seniors Act 2. Findings Congress makes the following findings: (1) Community-based services play an essential role in keeping individuals healthy. (2) Without community-based long-term services and supports, which are not typically covered by Medicare, seniors frequently experience negative health outcomes and lose their ability to live independently. (3) Seniors who deplete their resources often have no option but to turn to Medicaid for coverage of long-term care expenses. (4) Targeting community-based services and supports to at-risk seniors can help these individuals avoid depleting their assets and becoming Medicaid dependent. 3. Community-based institutional special needs plan demonstration (a) In general The Secretary of Health and Human Services (in this section referred to as the Secretary CBI-SNP demonstration program (b) Establishment (1) In general The Secretary shall enter into agreements with up to 5 Medicare Advantage plans to conduct the CBI-SNP demonstration program. Each such MA plan may enroll up to 1,000 eligible Medicare beneficiaries (including new enrollees) in such program. (2) Benefits Under the CBI-SNP demonstration program, eligible Medicare beneficiaries shall receive benefits, in addition to those under part C of title XVIII of the Social Security Act (including benefits under section 1852(a)(3) of such Act ( 42 U.S.C. 1395w22(a)(3) 42 U.S.C. 1396n(c) (A) homemaker services; (B) home delivered meals; (C) transportation services; (D) respite care; (E) adult day care services; and (F) non-Medicare-covered safety and other equipment. (3) Payments The Secretary shall establish a benchmark payment amount for reimbursing Medicare Advantage plans participating in the CBI-SNP demonstration program for benefits provided to eligible beneficiaries under such program. Such payments shall be in addition to payments made to such plans under part C of title XVIII of the Social Security Act. (c) Eligible plans To be eligible to participate in the CBI-SNP demonstration program, a Medicare Advantage plan must— (1) have experience in offering special needs plans for nursing home-eligible, non-institutionalized Medicare beneficiaries who live in the community; (2) have experience working with low income seniors groups; (3) be located in a State that the Secretary has determined will participate in the CBI-SNP demonstration program by agreeing to make available data necessary for purposes of conducting the independent evaluation required under subsection (h); and (4) meet such other criteria as the Secretary may require. (d) Eligible Medicare beneficiary defined In this section, the term eligible Medicare beneficiary (1) is enrolled or eligible to enroll in a Medicare Advantage plan that has been selected to participate in the CBI-SNP demonstration program; (2) is a subsidy eligible individual (as defined in section 1860D–14(a)(3)(A) of the Social Security Act ( 42 U.S.C. 1395w114(a)(3)(A) (3) is not eligible to receive benefits under title XIX of the Social Security Act; (4) is unable to perform 2 or more activities of daily living (as defined in section 7702B(c)(2)(B) (5) is age 65 or older. (e) Special election period Notwithstanding sections 1852(e)(2)(C) and 1860D–1(b)(1)(B)(iii) of the Social Security Act ( 42 U.S.C. 1395w–21(e)(2)(C) (1) discontinue enrollment in a Medicare Advantage plan not participating in the CBI-SNP demonstration program and enroll in a Medicare Advantage plan participating in such program; and (2) discontinue enrollment under the original medicare fee-for-service program under parts A and B of such title and the enrollment in a prescription drug plan under part D of such title and enroll in a Medicare Advantage plan participating in the CBI-SNP demonstration program. (f) Beneficiary education The Secretary shall help to educate eligible Medicare beneficiaries on the availability of the CBI-SNP demonstration program through State Health Insurance Assistance Programs and other organizations dedicated to assisting seniors with Medicare benefits and enrollment. (g) Implementation (1) Deadline The CBI-SNP demonstration program shall be implemented not later than January 1, 2017. (2) Duration Subject to paragraph (3), the CBI-SNP demonstration program shall be conducted for a period of 5 years. (3) Extension or expansion Taking into account the report under subsection (h)(2), the Secretary may, through rulemaking, expand (including implementation on a nationwide or permanent basis) the duration or the scope CBI-SNP demonstration program to the extent determined appropriate by the Secretary, unless the Secretary determines that such expansion is expected to— (A) increase expenditures under titles XVIII and XIX of the Social Security Act with respect to eligible Medicare beneficiaries participating in the CBI-SNP demonstration program; or (B) decrease the quality of health care services furnished to eligible Medicare beneficiaries participating in the CBI-SNP demonstration program. (h) Independent evaluation and reports (1) Independent evaluation The Secretary shall provide for the evaluation of the CBI-SNP demonstration program by an independent third party. Such evaluation shall be completed using evaluation criteria that are clearly articulated prior to the implementation of such program. Such criteria shall include specific goals of such program, hypotheses being tested, clear data collection and reporting requirements, recognizing that definitions, benefits and program requirements for long-term care services and supports vary across States. Such evaluation shall determine whether the CBI-SNP demonstration program has— (A) improved patient care; (B) reduced hospitalizations or rehospitalizations; (C) reduced or delayed Medicaid nursing facility admissions and lengths of stay; (D) reduced spend down of income and assets for purposes of becoming eligible for Medicaid; and (E) improved quality of life for the demonstration population and beneficiary and caregiver satisfaction. (2) Reports Not later than 4 years after the implementation of the CBI-SNP demonstration program, the Secretary shall submit to Congress a report containing the results of the evaluation conducted under paragraph (1), together with such recommendations for legislative or administrative action as the Secretary determines appropriate. In preparing such report, the Secretary shall use at least 3 years worth of data under the demonstration program. (i) Budget neutrality By the end of the third year of the CBI-SNP demonstration program, the Secretary shall ensure that the aggregate payments made under titles XVIII and XIX of the Social Security Act, including under the demonstration program, for subsequent periods do not exceed the amount which the Secretary estimates would have been expended under such titles during such a period if the CBI-SNP demonstration program had not been implemented. (j) Paperwork reduction act Chapter 35 1. Short title This Act may be cited as the Community Based Independence for Seniors Act 2. Findings Congress makes the following findings: (1) Community-based services play an essential role in keeping individuals healthy. (2) Without community-based long-term services and supports, which are not typically covered by Medicare, seniors frequently experience negative health outcomes and lose their ability to live independently. (3) Seniors who deplete their resources often have no option but to turn to Medicaid for coverage of long-term care expenses. (4) Targeting community-based services and supports to at-risk seniors can help these individuals avoid depleting their assets and becoming Medicaid dependent. 3. Community-based institutional special needs plan demonstration (a) In general The Secretary of Health and Human Services (referred to in this section as the Secretary CBI-SNP demonstration program (b) Establishment (1) In general The Secretary shall enter into agreements with not more than 5 eligible MA plans to conduct the CBI-SNP demonstration program. Each such eligible MA plan may enroll up to 1,000 eligible low-income Medicare beneficiaries (including new enrollees) in such program. (2) Use of Part C rebate to furnish certain benefits Under the CBI-SNP demonstration program, an eligible MA plan selected to participate in such program shall use the rebate that the plan is required (under section 1854 of the Social Security Act ( 42 U.S.C. 13954–24 42 U.S.C. 1395w–22(a)(3) 42 U.S.C. 1396n(c) (A) homemaker services; (B) home delivered meals; (C) transportation services; (D) respite care; (E) adult day care services; and (F) non-Medicare-covered safety and other equipment. (c) Eligible MA plan In this section, the term eligible MA plan 42 U.S.C. 1395w–28(b)(6) (1) has experience in offering special needs plans for nursing home-eligible, non-institutionalized Medicare beneficiaries who live in the community; (2) has experience working with low income beneficiaries, including low income beneficiaries dually eligible for benefits under titles XVIII and XIX of such Act; (3) has a service area in a State that has agreed to make available to the Secretary Medicaid data necessary for purposes of conducting the independent evaluation required under subsection (j); and (4) meets such other criteria as the Secretary may require. (d) Eligible low-income Medicare beneficiary defined In this section, the term eligible low-income Medicare beneficiary (1) a Medicare Advantage eligible individual (as defined in section 1851(a)(3) of the Social Security Act ( 42 U.S.C. 1395w–21(a)(3) (2) a subsidy eligible individual (as defined in section 1860D–14(a)(3)(A) of such Act ( 42 U.S.C. 1395w-114(a)(3)(A) (3) not eligible to receive benefits under title XIX of the Social Security Act; (4) unable to perform 2 or more activities of daily living (as defined in section 7702B(c)(2)(B) (5) age 65 or older. (e) Special election period Notwithstanding sections 1852(e)(2)(C) and 1860D–1(b)(1)(B)(iii) of the Social Security Act ( 42 U.S.C. 1395w–21(e)(2)(C) (1) discontinue enrollment in a Medicare Advantage plan not participating in the CBI-SNP demonstration program and enroll in an eligible MA plan participating in such program if the beneficiary resides in the participating plan's service area; and (2) discontinue enrollment under the original medicare fee-for-service program under parts A and B of title XVIII of such Act and the enrollment in a prescription drug plan under part D of such title and enroll in an eligible MA plan participating in the CBI-SNP demonstration program if the beneficiary resides in the participating plan's service area. (f) Beneficiary education The Secretary shall help to educate eligible Medicare beneficiaries on the availability of the CBI-SNP demonstration program through State Health Insurance Assistance Programs and other organizations dedicated to assisting seniors with Medicare benefits and enrollment. (g) Duration The CBI-SNP demonstration program shall be implemented not later than January 1, 2018, and shall be conducted for a period of 5 years. (h) Budget neutrality In conducting the CBI-SNP demonstration program, the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed the amount which the Secretary estimates would have been expended under titles XVIII and XIX of the Social Security Act ( 42 U.S.C. 1395 et seq. (i) Expansion of demonstration program Taking into account the evaluation under subsection (j), the Secretary may, through notice and comment rulemaking, expand (including implementation on a nationwide basis) the duration and scope of the CBI-SNP demonstration program under title XVIII of the Social Security Act, other than under the original medicare fee-for-service program under parts A and B of such title, to the extent determined appropriate by the Secretary, if the requirements of paragraphs (1), (2) and (3) of subsection (c) of section 1115A of the Social Security Act ( 42 U.S.C. 1315a (j) Independent evaluation and reports (1) Independent evaluation The Secretary shall provide for the evaluation of the CBI-SNP demonstration program by an independent third party. Such evaluation shall be completed using evaluation criteria that are clearly articulated prior to the implementation of such program. Such criteria shall include specific goals of such program, hypotheses being tested, and clear data collection and reporting requirements, recognizing that definitions, benefits, and program requirements for long-term care services and supports vary across States. Such evaluation shall determine whether the CBI-SNP demonstration program has— (A) improved patient care; (B) reduced hospitalizations or rehospitalizations; (C) reduced or delayed Medicaid nursing facility admissions and lengths of stay; (D) reduced spend down of income and assets for purposes of becoming eligible for Medicaid; and (E) improved quality of life for the demonstration population and beneficiary and caregiver satisfaction. (2) Reports Not later than January 1, 2022, the Secretary shall submit to Congress a report containing the results of the evaluation conducted under paragraph (1), together with such recommendations for legislative or administrative action as the Secretary determines appropriate. In preparing such report, the Secretary shall use at least 3 years worth of data under the CBI-SNP demonstration program. (k) Funding (1) Funding for implementation For purposes of administering the CBI-SNP demonstration program (other than the evaluation and report under subsection (j)), the Secretary shall provide for the transfer from the Federal Hospital Insurance Trust Fund under section 1817 of the Social Security Act ( 42 U.S.C. 1395i 42 U.S.C. 1395t (2) Funding for evaluation and report For purposes of carrying out the evaluation and report under subsection (j), the Secretary shall provide for the transfer from the Federal Hospital Insurance Trust Fund under such section 1817 and the Federal Supplementary Medical Insurance Trust Fund under such section 1841, in such proportion as the Secretary determines appropriate, of $500,000 to the Centers for Medicare & Medicaid Services Program Management Account. (3) Availability Amounts transferred under paragraph (1) or (2) shall remain available until expended. (l) Paperwork reduction act Chapter 35 July 30, 2015 Reported with an amendment

Summary: Community Based Independence for Seniors Act (Sec. 3) This bill directs the Department of Health and Human Services (HHS) to establish a five-year Community-Based Institutional Special Needs Plan demonstration program to prevent and delay institutionalization under title XIX (Medicaid) of the Social Security Act (SSAct) among eligible low-income Medicare beneficiaries age 65 or older. HHS shall enter into agreements with up to five eligible Medicare Advantage (MA) plans under part C (Medicare+Choice) of SSAct title XVIII (Medicare) to conduct the demonstration program. Each eligible MA plan may enroll up to 1,000 eligible low-income Medicare beneficiaries in such program. A participating MA plan shall use the rebate the plan must provide to eligible low-income Medicare enrollees to furnish certain benefits, including homemaker services, home delivered meals, transportation services, respite care, adult day care services, and non-Medicare-covered safety and other equipment. HHS shall help to educate eligible Medicare beneficiaries about the availability of the demonstration program through State Health Insurance Assistance Programs and other organizations dedicated to assisting seniors with Medicare benefits and enrollment. The demonstration program shall be implemented by January 1, 2018. HHS shall arrange for an independent third party evaluation of the demonstration program, on the basis of which its duration and scope may be expanded. Funding for the demonstration program shall come out of the Medicare trust funds.