I 
114TH CONGRESS 
1ST SESSION H. R. 4212 
To establish a Community-Based Institutional Special Needs Plan demonstra-
tion program to target home and community-based care to eligible Medi-
care beneficiaries, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
DECEMBER 10, 2015 
Ms. LINDA T. SA´NCHEZ of California (for herself, Mr. MEEHAN, Mr. SCHRA-
DER, and Mr. LANCE) introduced the following bill; which was referred 
to the Committee on Ways and Means, and in addition to the Committee 
on Energy and Commerce, for a period to be subsequently determined by 
the Speaker, in each case for consideration of such provisions as fall with-
in the jurisdiction of the committee concerned 
A BILL 
To establish a Community-Based Institutional Special Needs 
Plan demonstration program to target home and commu-
nity-based care to eligible Medicare beneficiaries, and 
for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Community-Based 
Independence for Seniors Act of 2015’’. 
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SEC. 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 serv-
ices and supports, which are not typically covered by 
Medicare, seniors frequently experience negative 
health outcomes and lose their ability to live inde-
pendently. 
(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. 
SEC. 
3. 
COMMUNITY-BASED 
INSTITUTIONAL 
SPECIAL 
NEEDS PLAN DEMONSTRATION. 
Part C of title XVIII of the Social Security Act is 
amended by inserting after section 1859 (42 U.S.C. 
1395w–28) the following new section: 
‘‘SEC. 1859A. COMMUNITY-BASED INSTITUTIONAL SPECIAL 
NEEDS PLAN DEMONSTRATION. 
‘‘(a) ESTABLISHMENT.— 
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish a Community-Based Institutional Special Needs 
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Plan demonstration program (in this section referred 
to as the ‘CBI–SNP demonstration program’) to 
provide home and community-based care to eligible 
Medicare beneficiaries. 
‘‘(2) AGREEMENTS.—The Secretary shall enter 
into agreements with eligible MA organizations 
under which such organizations shall offer eligible 
MA plans under the CBI–SNP demonstration pro-
gram to eligible Medicare beneficiaries. 
‘‘(3) LIMITATION ON NUMBER OF PLANS.—The 
CBI–SNP demonstration program shall be carried 
out with respect to not greater than five MA plans. 
‘‘(4) ELIGIBLE MA PLANS DEFINED.—For pur-
poses of this section, the term ‘eligible MA plan’ 
means a plan that, in addition to items and services 
for which coverage is otherwise provided under this 
part (including benefits under section 1852(a)(3) 
and notwithstanding any waivers under section 
1915(c)), provides for coverage of long-term care 
services and supports that the Secretary determines 
appropriate for the purposes of the CBI–SNP dem-
onstration program, such as— 
‘‘(A) homemaker services; 
‘‘(B) home delivered meals; 
‘‘(C) transportation services; 
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‘‘(D) respite care; 
‘‘(E) adult day care services; and 
‘‘(F) safety and other equipment not other-
wise covered under this title. 
‘‘(b) ELIGIBLE MA ORGANIZATIONS.—For purposes 
of this section, the term ‘eligible MA organization’ means 
an MA organization that— 
‘‘(1) has experience in offering specialized MA 
plans for special needs individuals, as defined in sec-
tion 1859(b)(6)(A), to individuals who live in the 
community in which the eligible MA plan is offered; 
‘‘(2) has experience working with low-income 
seniors groups; 
‘‘(3) is located in a State that the Secretary has 
determined is able to participate in the CBI–SNP 
demonstration program by agreeing to make avail-
able data necessary for purposes of conducting the 
independent evaluation required under subsection 
(h); and 
‘‘(4) meets such other criteria as the Secretary 
may require. 
‘‘(c) 
ELIGIBLE
MEDICARE
BENEFICIARY
DE-
FINED.—In this section, the term ‘eligible Medicare bene-
ficiary’ means a Medicare beneficiary who— 
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‘‘(1) is eligible to enroll in an eligible MA plan 
under the CBI–SNP demonstration program; 
‘‘(2) is a subsidy eligible individual (as defined 
in section 1860D–14(a)(3)(A)); 
‘‘(3) is not eligible to receive benefits under title 
XIX; 
‘‘(4) is unable to perform 2 or more activities 
of daily living (as defined in section 7702B(c)(2)(B) 
of the Internal Revenue Code of 1986); and 
‘‘(5) is age 65 or older. 
‘‘(d) PAYMENTS.—The Secretary shall establish pay-
ment rates for eligible MA organizations offering eligible 
MA plans under the CBI–SNP demonstration program for 
benefits covered under such program (and not otherwise 
covered under part C) and provided to eligible Medicare 
beneficiaries under such plans. Such payment rates 
shall— 
‘‘(1) be based upon payment rates established 
for purposes of payment under section 1853; 
‘‘(2) be in addition to payments otherwise made 
to such organization with respect to such plans 
under part C; 
‘‘(3) be adjusted to reflect the costs of treating 
eligible Medicare beneficiaries under this section; 
and 
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‘‘(4) not, with respect to a month in which an 
eligible MA organization provides home and commu-
nity-based care to eligible Medicare beneficiaries 
under such demonstration program, exceed an 
amount for such month that is equal to the amount 
that would be awarded to such organization if the 
organization were to receive $400 with respect to 
each such beneficiary that the organization provides 
with such care during such month. 
‘‘(e) SPECIAL ELECTION PERIOD.—Notwithstanding 
sections 1852(e)(2)(C) and 1860D–1(b)(1)(B)(iii), an eli-
gible Medicare beneficiary may, other than during the an-
nual, coordinated election periods under such sections— 
‘‘(1) discontinue enrollment in an MA plan not 
participating in the CBI–SNP demonstration pro-
gram and enroll in an MA plan participating in such 
program; and 
‘‘(2) discontinue enrollment under the original 
medicare fee-for-service program under parts A and 
B and the enrollment in a prescription drug plan 
under part D and enroll in an MA plan participating 
in the CBI–SNP demonstration program. 
‘‘(f) BENEFICIARY EDUCATION.—The Secretary shall 
help to educate, through State Health Insurance Assist-
ance Programs and other organizations that assist seniors 
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with respect to benefits and enrollment under this title, 
eligible Medicare beneficiaries on the availability of the 
CBI–SNP demonstration program. 
‘‘(g) IMPLEMENTATION.— 
‘‘(1) DEADLINE.—The CBI–SNP demonstra-
tion program shall be implemented not later than 
January 1 of the second year beginning after the 
date of the enactment of this section. 
‘‘(2) DURATION.—Subject to paragraph (3), the 
CBI–SNP demonstration program shall be con-
ducted for a period of five years. 
‘‘(3) EXTENSION OR EXPANSION.—Taking into 
account the report under subsection (h)(2), the Sec-
retary 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 
aggregate 
expenditures 
under this title and title XIX with respect to el-
igible Medicare beneficiaries participating in the 
CBI–SNP demonstration program; or 
‘‘(B) decrease the quality of health care 
services furnished to eligible Medicare bene-
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ficiaries participating in the CBI–SNP dem-
onstration program. 
‘‘(h) INDEPENDENT EVALUATION AND REPORTS.— 
‘‘(1) INDEPENDENT EVALUATION.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
provide for the evaluation of the CBI–SNP 
demonstration program by an independent third 
party. 
‘‘(B) 
EVALUATION
OBJECTIVES.—Such 
evaluation shall determine the extent to which 
the CBI–SNP demonstration program has re-
sulted in— 
‘‘(i) improved patient care; 
‘‘(ii) reduced hospitalizations or rehos-
pitalizations; 
‘‘(iii) reduced or delayed nursing facil-
ity admissions and lengths of stay under 
title XIX; 
‘‘(iv) reduced spend down of income 
and assets for purposes of becoming eligi-
ble for medical assistance under a State 
plan under title XIX; 
‘‘(v) improved quality of life for the 
eligible Medicare beneficiaries enrolled in 
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an eligible MA plan participating in the 
CBI–SNP demonstration program; and 
‘‘(vi) improved caregiver satisfaction. 
‘‘(C) EVALUATION
PROCESS.—Such eval-
uation shall be completed in accordance with 
the following process: 
‘‘(i) The Secretary shall, prior to the 
implementation of such program, establish 
goals for such program with respect to the 
evaluation objectives described in subpara-
graph (B) and criteria for measuring the 
extent to which an eligible MA plan par-
ticipating in the CBI–SNP demonstration 
program meets such goals. 
‘‘(ii) The Secretary shall implement 
clear data collection and reporting require-
ments for such eligible MA plans in order 
to carry out such evaluation. 
In carrying out such process, the Secretary 
shall recognize that definitions, benefits, and 
program requirements for long-term care serv-
ices and supports vary across States. 
‘‘(2) REPORTS.—Not later than four years after 
the implementation of the CBI–SNP demonstration 
program, the Secretary shall submit to Congress a 
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report containing the results of the evaluation con-
ducted under paragraph (1), together with such rec-
ommendations for legislative or administrative action 
as the Secretary determines appropriate. In pre-
paring such report, the Secretary shall use at least 
three years worth of data under the demonstration 
program. 
‘‘(i) BUDGET NEUTRALITY.—For any year after the 
third year of the CBI–SNP demonstration program, the 
Secretary shall ensure that the aggregate payments made 
under this title and title XIX, including under the dem-
onstration program, do not exceed the amount which the 
Secretary estimates would have been expended under such 
titles during such year if the CBI–SNP demonstration 
program had not been implemented. 
‘‘(j) PAPERWORK REDUCTION ACT.—Chapter 35 of 
title 44, United States Code, shall not apply to the testing 
and evaluation of the CBI–SNP demonstration program.’’. 
Æ 
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