I 
114TH CONGRESS 
2D SESSION 
H. R. 5506 
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 
JUNE 16, 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 PATIENT 
Demonstration Act of 2016’’ or the ‘‘Patient Access To 
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Integrated-care, Empowerment, Nephrologists and Treat-
ment Demonstration Act of 2016’’. 
SEC. 2. DEMONSTRATION PROGRAM TO PROVIDE INTE-
GRATED 
CARE 
FOR 
MEDICARE 
BENE-
FICIARIES WITH END-STAGE RENAL DISEASE. 
Title XVIII of the Social Security Act is amended by 
inserting after section 1866E the following 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. 
‘‘(2) DEFINITIONS.—In this section: 
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‘‘(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 the following: 
‘‘(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)). 
‘‘(iv) An entity able to bear risk as 
deemed by a State. 
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‘‘(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. 
‘‘(b) ESRD INTEGRATED CARE ORGANIZATION ELI-
GIBILITY REQUIREMENTS.— 
‘‘(1) ORGANIZATIONS.— 
‘‘(A) IN GENERAL.—One or more eligible 
participating providers may establish an Orga-
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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 
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’)— 
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‘‘(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-
spect to the Program-eligible bene-
ficiary for a year exceeds the revenue 
amount described in subclause (II) 
with respect to the Program-eligible 
beneficiary for the year. 
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‘‘(II) REVENUE
AMOUNT
DE-
SCRIBED.—The revenue amount de-
scribed in this subclause, with respect 
to an Organization offering an ESRD 
Integrated Care Model and a Pro-
gram-eligible beneficiary enrolled in 
such Organization, is the Organiza-
tion’s estimated average revenue re-
quirements, including administrative 
costs and return on investment, for 
the Organization to provide the bene-
fits described in clause (i) under the 
Model for the Program-eligible bene-
ficiary for the year. 
‘‘(III) PAYMENT
AMOUNT
DE-
SCRIBED.—The payment amount de-
scribed in this subclause, with respect 
to an Organization offering an ESRD 
Integrated Care Model and a Pro-
gram-eligible beneficiary enrolled in 
such Organization, is the payment 
amount to the Organization under 
subsection (f)(1) made with respect to 
the Program-eligible beneficiary for 
the year. 
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‘‘(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 
benefits under this title and title XIX, an 
Organization, in accordance with an agree-
ment 
entered 
into 
under 
subsection 
(f)(4)— 
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‘‘(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— 
‘‘(I) allow Program-eligible bene-
ficiaries to receive such covered bene-
fits from any provider of services or 
supplier regardless of whether such 
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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— 
‘‘(I) shall assemble a network of 
providers of services and suppliers 
identified by the Organization and 
confirmed by the Secretary as includ-
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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) 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 
‘‘(III) 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 
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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 
health records developed by an Organiza-
tion according to requirements and stand-
ards specified by the Secretary pursuant to 
subparagraph (C). 
‘‘(C) QUALITY AND REPORTING REQUIRE-
MENTS.— 
‘‘(i) CLINICAL MEASURES.—Under the 
Program, the Secretary shall— 
‘‘(I) require each participating 
Organization to submit to the Sec-
retary data on clinical measures con-
sistent with those measures submitted 
by organizations participating in the 
Comprehensive ESRD Care Initiative 
operated by the Center for Medicare 
and Medicaid Innovation as of Octo-
ber 1, 2016, to assess the quality of 
care provided; 
‘‘(II) establish requirements for 
participating Organizations to report 
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to the Secretary, in a form and man-
ner specified by the Secretary, infor-
mation on such measures; and 
‘‘(III) establish quality perform-
ance standards on such measures to 
assess the quality of care. 
‘‘(ii) 
REQUIREMENT
FOR
STAKE-
HOLDER
INPUT.—In developing require-
ments and standards under subclauses (II) 
and (III) of clause (i), the Secretary shall 
request and consider input from a stake-
holder board, at least one nephrologist, 
other suppliers and providers of services, 
renal dialysis facilities, and beneficiary ad-
vocates, and respond in writing to such 
input. 
‘‘(iii) ADDITIONAL ASSESSMENTS AND 
REPORTING
REQUIREMENTS.—The 
Sec-
retary shall assess the extent to which an 
Organization delivers integrated and pa-
tient-centered care through analysis of in-
formation obtained from Program-eligible 
beneficiaries enrolled in the Organization 
through surveys, such as the In-Center 
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Hemodialysis Consumer Assessment of 
Healthcare Providers and Systems. 
‘‘(D) REQUIREMENTS
FOR
ESRD
INTE-
GRATED CARE STRATEGY.— 
‘‘(i) IN
GENERAL.—An Organization 
seeking a contract under this section to 
offer one or more ESRD Integrated Care 
Models must develop and submit for the 
Secretary’s approval, subject to clause (ii), 
an ESRD Integrated Care Strategy. 
‘‘(ii) 
ESRD 
INTEGRATED
CARE 
STRATEGY.—In assessing an ESRD Inte-
grated Care Strategy under clause (i), the 
Secretary shall consider the extent to 
which the Strategy includes elements, such 
as the following: 
‘‘(I) Interdisciplinary care teams 
led by at least one nephrologist, and 
comprised of registered nurses, social 
workers, renal dialysis facility man-
agers, and other representatives from 
alternative settings described in sub-
clause (VI). 
‘‘(II) Health risk and other as-
sessments to determine the physical, 
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psychosocial, nutrition, language, cul-
tural, and other needs of Program-eli-
gible beneficiaries enrolled in the Or-
ganization involved. 
‘‘(III) Development and at least 
annual updating of individualized care 
plans that incorporate at least the 
medical, social, and functional needs, 
preferences, and care goals of Pro-
gram-eligible beneficiaries enrolled in 
the Organization. 
‘‘(IV) Coordination and delivery 
of non-clinical services, such as trans-
portation, aimed at improving the ad-
herence of Program-eligible bene-
ficiaries enrolled in the Organization 
with care recommendations. 
‘‘(V) Services, such as transplant 
evaluation and vascular access care. 
‘‘(VI) In the case of an individual 
who, while enrolled in the Organiza-
tion, receives confirmation that a kid-
ney transplant is imminent, the provi-
sion by an interdisciplinary care team 
described in subclause (I) of coun-
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seling services to such individual on 
preparation for and potential chal-
lenges surrounding such transplant. 
‘‘(VII) Delivery of benefits and 
services in alternative settings, such 
as the home of the Program-eligible 
beneficiary enrolled in the Organiza-
tion, in coordination with the provider 
or other appropriate stakeholder in-
volved in such delivery serving on an 
interdisciplinary care team described 
in subclause (I). 
‘‘(VIII) Use of patient reminder 
systems. 
‘‘(IX) Education programs for 
patients, families, and caregivers. 
‘‘(X) Use of health care advice 
resources, such as nurse advice lines. 
‘‘(XI) Use of team-based health 
care delivery models that provide com-
prehensive and continuous medical 
care, such as medical homes. 
‘‘(XII) Co-location of providers 
and services. 
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‘‘(XIII) Use of a demonstrated 
capacity to share electronic health 
record information across sites of 
care. 
‘‘(XIV) Use of programs to pro-
mote better adherence to recommend-
ed treatment regimens by individuals, 
including by addressing barriers to ac-
cess to care by such individuals. 
‘‘(XV) Other services, strategies, 
and approaches identified by the Or-
ganization to improve care coordina-
tion and delivery. 
‘‘(3) DIALYSIS FACILITY OWNERSHIP REQUIRE-
MENT.—The Secretary shall enter into contracts 
under this section only with Organizations that have 
at least one eligible participating provider with an 
ownership interest in a renal dialysis facility in the 
Organization’s service area. 
‘‘(4) REQUIREMENT FOR CAPITAL RESERVES.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
enter into contracts under this section only with 
Organizations that demonstrate sufficient cap-
ital reserves, measured as a percentage of 
capitated payments and consistent with require-
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ments established by the State in which the Or-
ganization operates. 
‘‘(B) ALTERNATIVE MECHANISM TO DEM-
ONSTRATE CAPACITY TO BEAR RISK.—An Orga-
nization shall be considered to meet the require-
ment in subparagraph (A) if the Organization 
includes at least one eligible participating pro-
vider or eligible participating partner that is li-
censed as a risk-bearing entity or deemed by a 
State as able to bear risk. 
‘‘(5) NON-APPLICATION
OF
CERTAIN
PROVI-
SIONS OF LAW.—For purposes of sections 162(m)(6) 
and 414(m) of the Internal Revenue Code of 1986 
and section 9010 of the Patient Protection and Af-
fordable Care Act (26 U.S.C. 4001 note prec.), in 
the case of an eligible participating provider that es-
tablishes an Organization or that enters into a part-
nership, ownership, or co-ownership agreement to es-
tablish an Organization, or an Organization with a 
contract under this section, risk-based payments in 
exchange for providing medical care shall not be con-
sidered premiums for health insurance coverage. 
‘‘(6) TREATMENT AS MEDICARE ADVANCED AL-
TERNATIVE PAYMENT MODEL.—Alternative care de-
livery models under the Program shall be treated 
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under this title as an advanced alternative payment 
model. 
‘‘(c) PROGRAM OPERATION AND SCOPE.— 
‘‘(1) IN GENERAL.—Not later than 6 months 
after the date of enactment of this section, the Sec-
retary shall establish a process through which an 
Organization can apply to offer one or more ESRD 
Integrated Care Models. Such application shall in-
clude information on at least the following: 
‘‘(A) 
The 
estimated 
average 
revenue 
amount described in subsection (b)(2)(A)(ii)(II) 
for the Organization to deliver benefits de-
scribed in subsection (b)(2)(A). 
‘‘(B) Any benefits offered by the Organiza-
tion beyond those described in such subsection. 
‘‘(C) A listing of network providers of serv-
ices and supplier. 
‘‘(D) Information on the expertise of net-
work providers of services and suppliers in serv-
ing ESRD patients. 
‘‘(E) A description of the ESRD Inte-
grated Care Strategy of the Organization de-
scribed in subsection (b)(2)(D). 
‘‘(2) PROGRAM
INITIATION.—The Secretary 
shall initiate the Program such that Organizations 
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begin serving Program-eligible beneficiaries not later 
than January 1, 2018. 
‘‘(3) CONTRACT
AWARD
AND
PERIOD.—The 
Secretary shall enter into contracts for an initial pe-
riod of not less than 5 years with all Organizations 
that meet Program requirements. 
‘‘(4) PROGRAM
EXPANSION.—The Secretary 
may expand the duration and scope of the Program 
under this section, to the extent determined appro-
priate by the Secretary, if the Secretary determines 
that such expansion will result in improved quality 
of care under the Medicare program under this title. 
‘‘(5) ALLOWANCE FOR LARGER SERVICE AREAS 
AND EXPANSION OF SERVICE AREAS.—Organizations 
shall demonstrate in their application that the pro-
posed service area has the capacity to serve Pro-
gram-eligible beneficiaries through an adequate pro-
vider network and is reflective of the communities in 
which beneficiaries live, work, and obtain health care 
services. 
‘‘(6) CONTRACT TERMINATION.— 
‘‘(A) IN
GENERAL.—The Secretary may 
terminate a contract with an Organization 
under this section if the Secretary determines 
that an Organization has failed to meet quality 
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requirements described in subsection (b) or vio-
lates other terms of the contract. 
‘‘(B) REMEDY AND APPEALS PROCESS.— 
Prior to the Secretary terminating a contract 
with an Organization under this section, the 
Secretary shall afford such Organization suffi-
cient opportunity to remedy any contract viola-
tions and appeal a contract termination. 
‘‘(C) 
PROGRAM-ELIGIBLE
BENEFICIARY 
NOTICE
AT
TIME
OF
CONTRACT
TERMI-
NATION.—Each contract under this section with 
an Organization shall require the Organization 
to provide (and pay for) written notice in ad-
vance of the contract’s termination, as well as 
a description of alternatives for obtaining bene-
fits under this title, to each Program-eligible 
beneficiary assigned to or who elected to receive 
benefits through the Organization under this 
section. 
‘‘(d) IDENTIFICATION OF PROGRAM-ELIGIBLE BENE-
FICIARIES.—The Secretary shall establish a process for 
the initial and ongoing identification of Program-eligible 
beneficiaries that provides for the identification of Pro-
gram-eligible beneficiaries by Organizations. 
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‘‘(e) PROGRAM-ELIGIBLE BENEFICIARIES ASSIGNED 
INTO AN ESRD INTEGRATED CARE ORGANIZATION OPEN 
NETWORK MODEL.— 
‘‘(1) ASSIGNMENT.— 
‘‘(A) IN GENERAL.—Under the Program, 
subject to the succeeding provisions of this 
paragraph, the Secretary shall, upon the Sec-
retary or an Organization identifying a bene-
ficiary as a Program-eligible beneficiary, assign 
such Program-eligible beneficiary to an open 
network model offered by an Organization that 
includes the dialysis facility at which the Pro-
gram-eligible 
beneficiary 
primarily 
receives 
renal dialysis services. 
‘‘(B) 
PROGRAM-ELIGIBLE
BENEFICIARY 
NOTIFICATION OF ASSIGNMENT.— 
‘‘(i) IN GENERAL.—Upon assignment 
of a Program-eligible beneficiary to an Or-
ganization, the Secretary shall provide to 
the Organization written notification of 
such assignment of such Program-eligible 
beneficiary and not later than 15 business 
days after the date of receipt of such noti-
fication, the Organization shall provide 
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written notice of such assignment to the 
Program-eligible beneficiary. 
‘‘(ii) OPT–OUT PERIOD AND CHANGES 
UPON
INITIAL
ASSIGNMENT.—The Sec-
retary shall provide for a 75-day period be-
ginning on the date on which the assign-
ment of a Program-eligible beneficiary into 
an open network model offered by an Or-
ganization becomes effective during which 
a Program-eligible beneficiary may— 
‘‘(I) opt out of the Program; 
‘‘(II) make a one-time change of 
assignment into an open network 
model offered by a different Organiza-
tion; or 
‘‘(III) elect a preferred network 
model offered by the same or different 
Organization. 
‘‘(C) DEEMED RE-ENROLLMENT.—A Pro-
gram-eligible beneficiary assigned under this 
paragraph to an ESRD Integrated Care Model 
offered by an Organization with respect to a 
year is deemed, unless the individual elects oth-
erwise under this paragraph, to have elected to 
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continue such assignment with respect to the 
subsequent year. 
‘‘(D) ADDITIONAL OPPORTUNITY TO OPT 
OUT OR ELECT DIFFERENT MODEL OR ORGANI-
ZATION.—On the date that is one year after the 
effective date of the initial assignment of a Pro-
gram-eligible beneficiary to an open network 
model offered by an Organization (and annually 
thereafter), a Program-eligible beneficiary shall 
be given the opportunity to— 
‘‘(i) opt out of the Program; 
‘‘(ii) make a one-time change of as-
signment into an open network model of-
fered by a different Organization; or 
‘‘(iii) elect a preferred network model 
offered by the same or different Organiza-
tion. 
‘‘(E) CHANGE
IN
PRINCIPAL
DIAGNOSIS 
OPT OUT.—In addition to any other period dur-
ing which a Program-eligible beneficiary may, 
pursuant to this paragraph, opt out of the Pro-
gram, in the case of a Program-eligible bene-
ficiary who, after assignment under this para-
graph, is diagnosed with a principal diagnosis 
(as defined by the Secretary) other than end- 
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stage renal disease, such individual shall be 
given the opportunity to opt out of the Program 
during such period as specified by the Sec-
retary. 
‘‘(F) SPECIAL
ELECTION
PERIODS.—The 
Secretary shall offer Program-eligible bene-
ficiaries special election periods consistent with 
those described in section 1851(e)(4). 
‘‘(2) PROGRAM-ELIGIBLE BENEFICIARY NOTIFI-
CATION.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
notify Program-eligible beneficiaries about the 
Program under this section and provide them 
with information about receiving benefits under 
this title through an Organization. 
‘‘(B) 
REQUIREMENTS.—Notwithstanding 
any other provision of law, subject to subpara-
graph (C), such notification shall allow for eligi-
ble participating providers that are part of an 
Organization to— 
‘‘(i) inform Program-eligible bene-
ficiaries about the Program; 
‘‘(ii) distribute Program materials to 
Program-eligible beneficiaries; and 
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‘‘(iii) assist Program-eligible bene-
ficiaries in assessing the options of such 
beneficiaries under the Program. 
‘‘(C) LIMITATION ON UNSOLICITED MAR-
KETING.— 
‘‘(i) IN
GENERAL.—Under the Pro-
gram, an eligible participating provider 
may not provide marketing information or 
materials, including information, materials, 
and assistance described in subparagraph 
(B), to a Program-eligible beneficiary un-
less the Program-eligible beneficiary re-
quests such marketing information or ma-
terials. 
‘‘(ii) EXCEPTION
FOR
PROVIDERS 
TREATING
BENEFICIARIES.—An 
eligible 
participating provider that is part of an 
Organization may provide information, ma-
terials, and assistance described in sub-
paragraph (B) to a Program-eligible bene-
ficiary, without prior request of such bene-
ficiary, if such beneficiary is receiving 
renal dialysis services from such provider. 
‘‘(3) PROGRAM-ELIGIBLE
BENEFICIARY
PRO-
TECTIONS.—Program-eligible beneficiaries enrolled 
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in an Organization shall have the same right to ap-
peal any denial of benefits under this title as such 
a Program-eligible beneficiary would have under this 
title if such Program-eligible beneficiary were not so 
enrolled. 
‘‘(f) PAYMENT.— 
‘‘(1) IN GENERAL.—For each Program-eligible 
beneficiary receiving care through an Organization, 
the Secretary shall make a monthly capitated pay-
ment equal to the amount that would be determined 
under section 1853(a)(1)(H). 
‘‘(2) APPLICATION
OF
HEALTH
STATUS
RISK 
ADJUSTMENT METHODOLOGY.—The Secretary shall 
adjust the payment amount to an Organization 
under this subsection in the same manner in which 
the payment amount to a Medicare Advantage plan 
is adjusted under section 1853(a)(1)(C). 
‘‘(3) PAYMENT FOR PART D BENEFITS.—In the 
case where an Organization elects to offer part D 
prescription drug coverage under the Program under 
this section, payments to the Organization for such 
benefits provided to Program-eligible beneficiaries by 
the Organization shall be made in the same manner 
and amount as those payments would be made in 
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the case of an Organization with a contract under 
such part. 
‘‘(4) AGREEMENT
WITH
STATE
MEDICAID 
AGENCY.—In the event of an Organization that 
elects to cover benefits under title XIX for Program- 
eligible beneficiaries eligible for benefits under this 
title and title XIX such Organization shall enter into 
an agreement with the State Medicaid agency to 
provide benefits, or arrange for benefits to be pro-
vided, for which such beneficiaries are entitled to re-
ceive medical assistance under title XIX and to re-
ceive payment from the State for providing or ar-
ranging for the provision of such benefits. 
‘‘(5) AFFIRMATION OF STATE OBLIGATIONS TO 
PAY PREMIUM AND COST-SHARING AMOUNTS.— 
‘‘(A) IN GENERAL.—A State shall continue 
to make medical assistance under the State 
plan under title XIX available in the amount 
described in subparagraph (B) for the duration 
of the Program for cost-sharing (as defined in 
section 1905(p)(3)) under this title for qualified 
medicare beneficiaries described in section 
1905(p)(1) and other individuals who are Pro-
gram-eligible beneficiaries enrolled in an Orga-
nization and entitled to medical assistance for 
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premiums and such cost-sharing under the 
State plan under title XIX. 
‘‘(B) AMOUNTS
MADE
AVAILABLE
FOR 
COST-SHARING.—For purposes of subparagraph 
(A): 
‘‘(i) IN GENERAL.—Subject to clause 
(ii), the amount of medical assistance de-
scribed in this clause to be made available 
for cost-sharing pursuant to subparagraph 
(A) for an individual described in such 
subparagraph entitled to medical assist-
ance for such cost-sharing under a State 
plan under title XIX shall be equal to the 
amount of medical assistance that would 
be made available under such State plan as 
in effect as of January 1, 2016. 
‘‘(ii) AMOUNTS
IN
THE
CASE
OF
A 
STATE
THAT
INCREASES
PAYMENTS
FOR 
COST-SHARING.—If a State increases the 
amount of medical assistance made avail-
able under the State plan under title XIX 
for cost-sharing described in subparagraph 
(A) after such date, such increased 
amounts shall be made available under 
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subparagraph (A) for the remaining dura-
tion of the Program. 
‘‘(g) WAIVER AUTHORITY.— 
‘‘(1) IN GENERAL.—In order to carry out the 
Program under this section, the Secretary shall 
waive those requirements waived under section 1899 
and may waive such additional requirements con-
sistent with those waived under programs adminis-
tered through the Center for Medicare and Medicaid 
Innovation as may be necessary. 
‘‘(2) NOTICE OF WAIVERS.—Not later than 3 
months after the date of enactment of this section, 
the Secretary shall publish a notice of waivers that 
will apply in connection with the Program. The no-
tice shall include the specific conditions that an Or-
ganization must meet to qualify for each waiver, and 
commentary explaining the waiver requirements.’’. 
Æ 
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