I 
114TH CONGRESS 
2D SESSION 
H. R. 5942 
To amend title XVIII of the Social Security Act to establish a demonstration 
program to provide integrated care for Medicare beneficiaries with end- 
stage renal disease, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
SEPTEMBER 7, 2016 
Mr. YOUNG of Indiana (for himself, Mr. BLUMENAUER, Mrs. MCMORRIS ROD-
GERS, and Mr. CA´RDENAS) introduced the following bill; which was re-
ferred to the Committee on Energy and Commerce, and in addition to 
the Committee on Ways and Means, 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 demonstration program to provide integrated care for 
Medicare beneficiaries with end-stage renal disease, 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 ‘‘Dialysis PATIENTS 
Demonstration Act of 2016’’ or the ‘‘Dialysis Patient Ac-
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cess To Integrated-care, Empowerment, Nephrologists, 
Treatment, and Services Demonstration Act of 2016’’. 
SEC. 2. DEMONSTRATION PROGRAM TO PROVIDE INTE-
GRATED 
CARE 
FOR 
MEDICARE 
BENE-
FICIARIES WITH END-STAGE RENAL DISEASE. 
(a) IN GENERAL.—Title XVIII of the Social Security 
Act is amended by inserting after section 1866E the fol-
lowing new section: 
‘‘DEMONSTRATION
PROGRAM
TO
PROVIDE
INTEGRATED 
CARE
FOR
MEDICARE
BENEFICIARIES
WITH
END- 
STAGE RENAL DISEASE 
‘‘SEC. 1866F. (a) ESTABLISHMENT.— 
‘‘(1) IN GENERAL.—The Secretary shall con-
duct under this section the ESRD Integrated Care 
Demonstration Program (in this section referred to 
as the ‘Program’) which is voluntary for patients 
and providers to assess the effects of alternative care 
delivery models on patient care improvements under 
this title for Program-eligible beneficiaries (as de-
fined in paragraph (2)). Under the Program, eligible 
participating providers (as defined in such para-
graph) may form an ESRD Integrated Care Organi-
zation (in this section referred to as an ‘Organiza-
tion’). An Organization shall integrate care and 
serve as the medical home for Program-eligible bene-
ficiaries. 
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‘‘(2) DEFINITIONS.—In this section: 
‘‘(A) 
ELIGIBLE
PARTICIPATING
PRO-
VIDER.—The term ‘eligible participating pro-
vider’ means the following: 
‘‘(i) A facility certified as a renal di-
alysis facility under this title. 
‘‘(ii) A dialysis organization that owns 
one or more of such facilities described in 
clause (i). 
‘‘(iii) A nephrologist or nephrology 
practice. 
‘‘(iv) Any other physician group prac-
tice or a group of affiliated physicians. 
‘‘(B) 
ELIGIBLE
PARTICIPATING
PART-
NER.—The term ‘eligible participating partner’ 
means, with respect to an Organization, the fol-
lowing: 
‘‘(i) A Medicare Advantage plan de-
scribed in section 1851(a)(2) or a Medi-
care Advantage organization offering such 
a plan. 
‘‘(ii) A prescription drug plan (as de-
fined in section 1860D–41(a)(14)). 
‘‘(iii) A medicaid managed care orga-
nization (as defined in section 1903(m)). 
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‘‘(iv) An entity able to bear risk as 
deemed by a State and that chooses to 
bear risk as a condition of partnership in 
such organization. 
‘‘(v) A third party-administrator orga-
nization. 
‘‘(C) PROGRAM-ELIGIBLE BENEFICIARY.— 
The term ‘Program-eligible beneficiary’ means, 
with respect to an Organization offering an 
ESRD Integrated Care Model, an individual en-
titled to benefits under part A and enrolled 
under part B who— 
‘‘(i) is 18 years of age or older; 
‘‘(ii) is identified by the Secretary or 
the Organization as receiving renal dialysis 
services under the original medicare fee- 
for-service program under parts A and B; 
‘‘(iii) resides in the service area of 
such Organization; 
‘‘(iv) receives renal dialysis services 
primarily from a facility that participates 
in such Organization; and 
‘‘(v) has not received a successful kid-
ney transplant. 
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‘‘(b) ESRD INTEGRATED CARE ORGANIZATION ELI-
GIBILITY REQUIREMENTS.— 
‘‘(1) ORGANIZATIONS.— 
‘‘(A) IN GENERAL.—One or more eligible 
participating providers may establish an Orga-
nization or may enter into, subject to subpara-
graph (B), one or more partnership, ownership, 
or co-ownership agreements with one or more 
eligible participating partners to establish an 
Organization. 
‘‘(B) LIMITATION ON NUMBER OF AGREE-
MENTS.—The Secretary may specify a limita-
tion on the number of Organizations in which 
an eligible participating partner may participate 
under agreements described in subparagraph 
(A). 
‘‘(2) ESRD INTEGRATED CARE MODEL.— 
‘‘(A) BENEFITS REQUIREMENTS.— 
‘‘(i) IN GENERAL.—Subject to clause 
(iii), an Organization shall offer at least 
one ESRD Integrated Care Model that is 
an open network model (as described in 
subparagraph (B)(i)) in each of its service 
areas and may offer one or more ESRD 
Integrated Care Models that is a preferred 
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network model (as described in subpara-
graph (B)(ii)) in each of its service areas. 
For purposes of this section an ESRD In-
tegrated Care Model (in this section re-
ferred to as the ‘Model’)— 
‘‘(I) shall cover all benefits under 
parts A and B (other than hospice 
care) and include benefits for transi-
tion (including education) into pallia-
tive care; and 
‘‘(II) may, through a partnership 
or other agreement with an MA–PD 
plan under part C or prescription 
drug plan under part D, cover all pre-
scription drug benefits under such 
part D. 
‘‘(ii) TREATMENT OF SAVINGS.— 
‘‘(I) IN GENERAL.—Any Organi-
zation offering an ESRD Integrated 
Care Model shall provide for the re-
turn under subclause (IV) to a Pro-
gram-eligible beneficiary enrolled in 
the Organization of the amount, if 
any, by which the payment amount 
described in subclause (III) with re-
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such Organization, is the payment 
amount to the Organization under 
subsection (f)(1) made with respect to 
the Program-eligible beneficiary for 
the year. 
‘‘(IV) MEANS
OF
RETURNING 
SAVINGS
TO
PROGRAM-ELIGIBLE 
BENEFICIARIES ENROLLED IN ORGA-
NIZATIONS.—An Organization shall 
return the amount under subclause (I) 
to a Program-eligible beneficiary en-
rolled in the Organization in a man-
ner specified by the Organization, 
which may include cost-sharing lower 
than otherwise applicable, benefits not 
covered under the original medicare 
fee-for-service program, or financial 
incentives (such as reduced cost shar-
ing) for Program-eligible beneficiaries 
enrolled in the Organization to pro-
mote the delivery of high-value and ef-
ficient care and services. 
‘‘(iii) BENEFIT
REQUIREMENTS
FOR 
DUAL ELIGIBLES.—In the case of a Pro-
gram-eligible beneficiary who is eligible for 
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benefits under this title and title XIX, an 
Organization, in accordance with an agree-
ment 
entered 
into 
under 
subsection 
(f)(4)— 
‘‘(I) may be responsible for pro-
viding, or arranging for the provision 
of, all benefits (other than long-term 
services and supports) for which the 
Program-eligible beneficiary is eligible 
for under the State Medicaid program 
under title XIX in which the Pro-
gram-eligible beneficiary is enrolled; 
and 
‘‘(II) may elect to provide, or ar-
range for the provision of, long-term 
services and supports available to the 
Program-eligible beneficiary under the 
State Medicaid program. 
‘‘(B) REQUIREMENTS FOR OPEN NETWORK 
AND PREFERRED NETWORK MODELS.— 
‘‘(i) OPEN NETWORK MODEL.—Under 
an ESRD Integrated Care Model offered 
by an Organization that is an open net-
work model, the Organization shall— 
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‘‘(I) allow Program-eligible bene-
ficiaries to receive such covered bene-
fits from any provider of services or 
supplier regardless of whether such 
provider is within the network assem-
bled under subclause (I); 
‘‘(II) pay any Medicare-certified 
provider or supplier that is not within 
the network assembled under sub-
clause (I) for such covered benefits an 
amount equal to the amount the pro-
vider or supplier would otherwise re-
ceive under this title; and 
‘‘(III) not apply any additional 
premium or cost sharing requirements 
for such covered benefits in addition 
to premium or cost sharing require-
ments, respectively, that would be ap-
plicable under part A or part B for 
such benefits. 
‘‘(ii) 
PREFERRED
NETWORK 
MODEL.—Under 
an 
ESRD 
Integrated 
Care Model offered by an Organization 
that is a preferred network model, the Or-
ganization— 
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‘‘(I) shall assemble a network of 
providers of services and suppliers 
identified by the Organization and 
confirmed by the Secretary as includ-
ing providers of services and suppliers 
with significant expertise in caring for 
individuals with end-stage renal dis-
ease through which Program-eligible 
beneficiaries shall receive covered ben-
efits as described in subparagraph (A) 
that are required to be covered under 
the Model; 
‘‘(II) shall provide for payment 
for items and services furnished by 
providers of services and suppliers 
within such network to Program-eligi-
ble beneficiaries enrolled in such Or-
ganization in accordance with pay-
ment rates determined pursuant to an 
agreement entered into between the 
Organization and such providers of 
services and suppliers and shall pro-
vide for payment for items and serv-
ices furnished by providers of services 
and suppliers not within such network 
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to such beneficiaries so enrolled in ac-
cordance that would be determined 
under section 1853(a)(1)(H); 
‘‘(III) may apply premium and 
cost-sharing requirements, in addition 
to premium or cost-sharing require-
ments, respectively, that would be ap-
plicable under part B, for benefits in 
addition to those required to be cov-
ered under the Model; and 
‘‘(IV) shall apply network stand-
ards as defined by the Secretary. 
‘‘(iii) PROMOTING ACCESS TO HIGH- 
QUALITY
PROVIDERS.—An Organization 
offering an ESRD Integrated Care Model 
may develop and implement performance- 
based incentives for providers of services 
and suppliers to promote delivery of high 
quality and efficient care. Such incentives 
shall be based on clinical measures and 
non-clinical measures, such as with respect 
to notification of patient discharge from a 
hospital, patient education (such as with 
respect to treatment options and nutri-
tion), and the interoperability of electronic 
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health records developed by an Organiza-
tion according to requirements and stand-
ards specified by the Secretary pursuant to 
subparagraph (C). 
‘‘(iv) APPLICATION OF MEDICARE AD-
VANTAGE
REQUIREMENT
WITH
RESPECT 
TO
MEDICARE
SERVICES
FURNISHED
BY 
OUT-OF-NETWORK
PROVIDERS
AND
SUP-
PLIERS.— 
‘‘(I) 
IN
GENERAL.—Section 
1852(k)(1) (relating to limitations on 
balance billing against MA organiza-
tions for noncontract physicians and 
other entities with respect to services 
covered under this title) shall apply to 
Organizations, Program-eligible bene-
ficiaries enrolled in such Organiza-
tions, and physicians and other enti-
ties that do not have a contract or 
other agreement with the Organiza-
tion establishing payment amounts for 
services furnished to such a bene-
ficiary in the same manner as such 
section applies to MA organizations, 
individuals enrolled with such organi-
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