I 
114TH CONGRESS 
1ST SESSION H. R. 3244 
To amend title XVIII of the Social Security Act to establish a pilot program 
to improve care for the most costly Medicare fee-for-service beneficiaries 
through the use of comprehensive and effective care management while 
reducing costs to the Federal Government for these beneficiaries, and 
for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JULY 28, 2015 
Mrs. MCMORRIS RODGERS (for herself, Mr. LARSON of Connecticut, Mr. 
REED, and Mr. SCHRADER) introduced the following bill; which was re-
ferred to the Committee on Ways and Means, and in addition to the 
Committee on Energy and Commerce, for a period to be subsequently de-
termined by the Speaker, in each case for consideration of such provisions 
as fall within the jurisdiction of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to establish 
a pilot program to improve care for the most costly 
Medicare fee-for-service beneficiaries through the use of 
comprehensive and effective care management while re-
ducing costs to the Federal Government for these bene-
ficiaries, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
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SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Providing Innovative 
Care for Complex Cases Demonstration Act of 2015’’. 
SEC. 2. PROGRAM TO IMPROVE CARE FOR HIGHEST COST 
MEDICARE 
FEE-FOR-SERVICE 
BENE-
FICIARIES. 
Title XVIII of the Social Security Act is amended by 
inserting after section 1866E (42 U.S.C. 1395cc–5) the 
following new section: 
‘‘PROGRAM TO IMPROVE CARE FOR HIGHEST COST 
MEDICARE FEE-FOR-SERVICE BENEFICIARIES 
‘‘SEC. 1866F. (a) ESTABLISHMENT.—The Secretary 
shall conduct under this section a pilot program (in this 
section referred to as the ‘program’) to demonstrate im-
provements in patient care and cost savings for the high-
est cost Medicare fee-for-service beneficiaries through en-
rollment of such beneficiaries with participating organiza-
tions. Under the program, the Secretary shall, through a 
competitive process, enter into a contract with one or two 
selected organizations to offer benefits for items and serv-
ices in service areas identified under subsection (b)(1)(A) 
to the highest cost Medicare fee-for-service beneficiaries 
(identified under subsection (c)(1)) in the service area in-
volved. The program shall be designed in a manner to pro-
vide comprehensive and integrated care management and 
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services through a network of health care providers to 
meet the specialized needs of such identified beneficiaries. 
‘‘(b) CONDUCT OF PROGRAM.— 
‘‘(1) PERIOD OF OPERATION AND SCOPE.— 
‘‘(A) INITIAL
CONDUCT.—The program 
shall initially be conducted over a 3-year period, 
beginning not later than 1 year after the date 
of the enactment of this section, in at least 4 
service areas, each identified by the Secretary 
and each including at least 3 contiguous coun-
ties. 
‘‘(B) EXPANSION
AND
EXTENSION.—The 
Secretary may expand the program to addi-
tional service areas and extend its duration if 
the Secretary determines, in consultation with 
the Chief Actuary of the Centers for Medicare 
& Medicaid Services, that such expansion and 
extension will result in additional savings to the 
Medicare program and will meet the quality 
performance standards established under sub-
section (d)(3)(A)(iii). 
‘‘(C) RELATION TO PART D.— 
‘‘(i) IN
GENERAL.—The Secretary 
shall design and implement the program in 
such manner as to preserve the operation 
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of part D, including payment, noninter-
ference, and beneficiary protections under 
such part. 
‘‘(ii) COORDINATION
MECHANISMS.— 
The Secretary shall identify mechanisms 
that may be used, in the case of a highest 
cost Medicare fee-for-service beneficiary 
who is enrolled with a participating organi-
zation under the program and in a pre-
scription drug plan offered by a PDP 
sponsor under part D or a qualified retiree 
prescription drug plan offered by a sponsor 
under section 1860D–22, in order to en-
hance coordination of the individual’s care 
between the organization and the respec-
tive sponsor. 
‘‘(2) NUMBER
OF
PARTICIPATING
ORGANIZA-
TIONS PER SERVICE AREA.—Under the program the 
Secretary shall enter into a contract with at least 
one selected organization (and no more than 2 se-
lected organizations) in each service area identified 
and covered under the program. 
‘‘(c) IDENTIFICATION AND ENROLLMENT OF HIGH-
EST
COST
MEDICARE
FEE-FOR-SERVICE
BENE-
FICIARIES.— 
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‘‘(1) IDENTIFICATION.— 
‘‘(A) IN GENERAL.—For purposes of the 
program, the Secretary shall develop criteria to 
identify, subject to subparagraph (B), Medicare 
fee-for-service beneficiaries with projected total 
costs under parts A and B in the highest 10th 
percentile of all Medicare fee-for-service bene-
ficiaries on an ongoing basis. Such criteria shall 
be developed in a manner so as to identify such 
beneficiaries using the most recent national 
data available for a 2-year period. 
‘‘(B) REFINEMENT
OF
ELIGIBILITY
CRI-
TERIA.—In identifying highest cost Medicare 
fee-for-service beneficiaries under this para-
graph, the Secretary shall develop such criteria 
in a manner that eliminates, to the extent prac-
ticable, the identification of individuals who oth-
erwise appear to meet such criteria only be-
cause of a single, isolated high-cost incident, 
item, or service. 
‘‘(2) ELIGIBLE
BENEFICIARY
INITIAL
OUT-
REACH.—The Secretary shall inform the highest cost 
Medicare fee-for-service beneficiaries residing in an 
area covered by the program of the program and 
provide them with information about the program 
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and the process for enrollment and disenrollment 
from participation organizations in such area. Such 
information shall include information about such or-
ganizations, about rights and protections under the 
program, a contact telephone number where bene-
ficiaries can obtain additional information about the 
program, and the use of an advance directive (as de-
fined in section 1866(f)(3)) in connection with par-
ticipation in the program. 
‘‘(3) AUTO-ENROLLMENT AND DISENROLLMENT 
PROCEDURES.— 
‘‘(A) IN GENERAL.—Under the program, 
the highest cost Medicare fee-for-service bene-
ficiaries residing in a service area covered under 
the program— 
‘‘(i) shall be enrolled, in a form and 
manner specified by the Secretary, with a 
participating organization offered under 
the program to such a resident in such 
area; and 
‘‘(ii) may change or terminate such 
enrollment in a form and manner so speci-
fied. 
In specifying such form and manner, the Sec-
retary shall take into account the form and 
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manner in which individuals may change or ter-
minate an enrollment under a Medicare Advan-
tage plan under part C, including permitting 
special disenrollment periods described in sec-
tion 1851(e)(4). 
‘‘(B) DEFAULT
ORGANIZATION
SELEC-
TION.—In carrying out subparagraph (A), if 
there are two participating organizations in a 
service area, the Secretary shall identify, to the 
extent possible, and enroll the beneficiary in the 
participating organization which has providers 
in its network from whom the beneficiary has 
received services under the Medicare fee-for- 
service program in the previous year. 
‘‘(C) TIMEFRAMES.—In carrying out sub-
paragraph (A), there shall be an initial enroll-
ment period of 12 months, during which a high-
est cost Medicare fee-for-service beneficiary may 
also opt out of participation in the program. 
‘‘(4) EXTENSION
OF
CERTAIN
GUARANTEED 
ISSUANCE RIGHTS TO MEDIGAP COVERAGE IN CASE 
OF DISENROLLMENT.—Subparagraph (A) of section 
1882(s)(3) shall apply to a Medicare beneficiary en-
rolled with a participating organization under this 
section who had previous coverage under a medicare 
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supplemental insurance policy and who terminates 
enrollment with the participating organization in the 
same manner as such section applies to an individual 
described in subparagraph (B)(v) of such section 
with respect to enrollment with a health plan, re-
gardless of the time period of participation in the 
program and without regard to subparagraph (E)(ii) 
of such section. 
‘‘(5) TREATMENT OF MEDICARE FEE-FOR-SERV-
ICE
BENEFITS
TO
ENROLLEES
THROUGH
PRO-
GRAM.—The provisions of section 1851(i) shall apply 
to individuals enrolled with a participating organiza-
tion under the program in the same manner as they 
apply to an individual enrolled in a Medicare Advan-
tage plan under part C. 
‘‘(6) RELATION TO PART D, EMPLOYER-BASED 
PRESCRIPTION
DRUG
COVERAGE, AND
MEDICARE 
SUPPLEMENTAL COVERAGE.—Except as specifically 
provided, nothing in this section shall be construed 
as intending to impact on benefits or coverage fur-
nished under a prescription drug plan under part D, 
under a group health plan (including under a quali-
fied retiree prescription drug plan as defined in sec-
tion 1860D–22(a)(2)), or under a medicare supple-
mental policy. 
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‘‘(d) 
PARTICIPATING
ORGANIZATION
REQUIRE-
MENTS.— 
‘‘(1) IN
GENERAL.—For purposes of partici-
pating in the program, except as provided in this 
subsection, a participating organization must meet 
the same requirements that apply to a Medicare Ad-
vantage organization and an MA plan that is not an 
MA–PD plan under part C, including requirements 
relating to— 
‘‘(A) coverage of items and services under 
parts A and B; and 
‘‘(B) beneficiary protections under part C. 
‘‘(2) WAIVER
AUTHORITY.—Under the pro-
gram, the Secretary may waive the requirements of 
this title and title XI but only to the extent nec-
essary to permit participating organizations— 
‘‘(A) to provide care management, custo-
dial care, transportation, in-home assistance, 
and other services that are not otherwise cov-
ered under this title; 
‘‘(B) to structure patient incentives, such 
as a reduction or elimination of cost-sharing, 
for services and benefits under parts A and B 
and the use of in-home technology, to improve 
beneficiary adherence to treatment protocols 
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and the effectiveness of treatment for enrolled 
beneficiaries with chronic clinical conditions; 
and 
‘‘(C) to maintain provider and pharmacy 
networks that do not otherwise meet network 
adequacy standards. 
‘‘(3) QUALITY
AND
REPORTING
REQUIRE-
MENTS.— 
‘‘(A) IN GENERAL.—Under the program, 
the Secretary shall— 
‘‘(i) determine appropriate measures 
(including, to the extent feasible, outcome 
measures) to assess the quality of care 
being provided under the program; 
‘‘(ii) establish requirements for par-
ticipating organizations to report, in a 
form and manner specified by the Sec-
retary, information on such measures; 
‘‘(iii) establish quality performance 
standards on such measures to assess the 
quality of care being provided by such or-
ganizations under the program; and 
‘‘(iv) seek the input of stakeholders 
(in a manner similar to that provided for 
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under section 1848(r)) in determining such 
measures, requirements, and standards. 
‘‘(B) TERMINATION
OF
PARTICIPATION 
FOR FAILURE TO MEET QUALITY PERFORMANCE 
STANDARDS.—The Secretary may terminate 
participation of an organization under the pro-
gram for failure to meet the quality perform-
ance standards established under subparagraph 
(A)(iii). 
‘‘(C) 
QUALITY
PERFORMANCE
STAND-
ARDS.—In establishing quality performance 
standards under subparagraph (A)(iii) in the 
case of— 
‘‘(i) a provider-based organization 
(such as an accountable care organization), 
the Secretary may apply the quality meas-
urement system used under the Medicare 
shared savings program under section 
1899(b)(3); and 
‘‘(ii) an MA organization, the Sec-
retary may require that only an organiza-
tion with a rating (under the star quality 
rating system under section 1853(o)(4)) of 
4 stars or higher be permitted to partici-
pate in the program. 
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‘‘(4) USE OF INTEGRATED MODEL OF CARE.— 
The Secretary shall develop care management re-
quirements for participating organizations that pro-
vides an integrated care model and that includes the 
following elements: 
‘‘(A) Provision of person-centered, com-
prehensive, and integrated care management 
and services. 
‘‘(B) Provision of services through— 
‘‘(i) the use of a network of providers 
characterized as best-in-class, such as cen-
ters of excellence; and 
‘‘(ii) the use of an interdisciplinary 
management team that includes a nurse 
coordinator (or other appropriate health 
care professional) assigned to each enrolled 
beneficiary and that shares a common 
health information technology platform. 
‘‘(C) An evidence-based model of care with 
appropriate networks of providers and special-
ists. 
‘‘(D) For each beneficiary enrolled with 
the organization under the program, the organi-
zation— 
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