‘‘(i) conducts an initial assessment 
and an annual reassessment of the bene-
ficiary’s physical, psychosocial, and func-
tional needs, including an evaluation and 
plan with respect to the beneficiary’s 
chronic conditions; 
‘‘(ii) provides for regular in-person 
visits to the beneficiary by a care provider 
and provides the beneficiary with access to 
a specialized team, including a hospitalist 
physician; and 
‘‘(iii) develops a plan, in consultation 
with the beneficiary as feasible, that identi-
fies goals and objectives with respect to the 
beneficiary, including measurable outcomes 
as well as specific services and benefits to 
be provided. 
‘‘(e) PAYMENTS.— 
‘‘(1) IN
GENERAL.—For each individual en-
rolled with a participating organization under the 
program, the Secretary shall make a monthly 
capitated payment to the organization in the same 
manner as such a payment would be made under 
part C for an individual enrolled in an MA-plan 
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(that was not an MA–PD plan) offered by a Medi-
care Advantage organization, except that— 
‘‘(A) notwithstanding section 1853, the 
amount of the payment shall be determined, 
subject to subparagraph (B), in an amount 
equivalent to 98 percent of the projected cost, 
under the Medicare fee-for-service program 
under parts A and B for the highest cost Medi-
care fee-for-service beneficiaries; and 
‘‘(B) the amount of such payment shall be 
adjusted, in a manner specified by the Sec-
retary, to take into account differences in costs 
among different geographic areas and among 
high cost Medicare fee-for-service beneficiaries 
(including outlier costs for the most costly such 
beneficiaries). 
‘‘(2) PROJECTION
BASED
UPON
HISTORICAL 
DATA.—In applying paragraph (1)(A), the Secretary 
shall use historical fee-for-service spending and en-
rollment data for the highest cost Medicare fee-for- 
service beneficiaries, trended forward to the first 
year of the program, and, for subsequent years of 
the program, increased by projected growth in such 
spending for such beneficiaries. 
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‘‘(3) RELATIONSHIP
TO
PAYMENT
FOR
COV-
ERED PART D DRUGS.—In the case of an individual 
who is enrolled with a participating organization 
under the program— 
‘‘(A) if the individual is enrolled with a 
prescription drug plan under part D, payment 
for covered part D drugs for such individual is 
made under such prescription drug plan under 
such part and not under the program; and 
‘‘(B) if the individual is covered under a 
qualified retiree prescription drug plan under 
section 1860D–22, payment for covered part D 
drugs for such individual is made under such 
plan and not under the program. 
‘‘(f) EVALUATION AND REPORT TO CONGRESS.— 
‘‘(1) EVALUATION.—The Secretary shall con-
duct an independent evaluation of the program. 
Such evaluation shall include an analysis of the im-
pact of the program on coordination of care, expend-
itures by participating organizations and plans, the 
program’s impact on reducing expenditures under 
this title, beneficiary access to services and pro-
viders, the quality of health care services furnished 
to beneficiaries, and beneficiary experiences with 
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auto-enrollment and disenrollment under the pro-
gram. 
‘‘(2) REPORT.—Not later than 2 years after the 
date that Medicare beneficiaries are first enrolled 
under the program, the Secretary shall submit to 
Congress a report on the performance of the pro-
gram. Such report shall include the results of the 
evaluation conducted under paragraph (1) and the 
program’s impact on reducing expenditures under 
this title and on improving the quality of care for 
the highest cost Medicare fee-for-service beneficiaries 
enrolled under the program. 
‘‘(g) DEFINITIONS.—In this section: 
‘‘(1) HIGHEST COST MEDICARE FEE-FOR-SERV-
ICE BENEFICIARY.—The term ‘highest cost Medicare 
fee-for-service beneficiary’ means a Medicare fee-for- 
service beneficiary who has been identified under 
subsection (c). 
‘‘(2) 
MEDICARE
FEE-FOR-SERVICE
BENE-
FICIARY
DEFINED.—The term ‘Medicare fee-for- 
service beneficiary’ means an individual who— 
‘‘(A) is entitled to benefits under part A, 
and enrolled under part B, regardless of the 
basis for entitlement or eligibility to benefits 
under any such part; and 
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‘‘(B) is not enrolled in a Medicare Advan-
tage plan under part C. 
‘‘(3) PROGRAM.—Unless the context indicates 
otherwise, the term ‘program’ means the program 
under this section. 
‘‘(4) 
PARTICIPATING
ORGANIZATION.—The 
term ‘participating organization’ means a selected 
organization that has entered into a contract to par-
ticipate in the program. 
‘‘(5) SELECTED ORGANIZATION.—The term ‘se-
lected organization’ means a provider-based organi-
zation (such as an accountable care organization) or 
MA organization (as defined for purposes of part C) 
that the Secretary determines— 
‘‘(A) meets the requirements to provide 
services to the highest cost Medicare fee-for- 
services beneficiaries under the program; and 
‘‘(B) is accredited by the National Com-
mittee for Quality Assurance or otherwise is 
certified as meeting quality standards.’’. 
Æ 
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