engagement, quality measurement developed 
specifically for a chronically ill population, and 
effective use of resources and providers, may 
manage and coordinate care for BCP eligible 
individuals through an integrated care network, 
or Better Care Program (referred to in this sec-
tion as a ‘qualified BCP’). A group of providers 
of services and suppliers described in the pre-
ceding sentence may also be participating in an-
other alternative payment model (as defined in 
subsection (k)). 
‘‘(B) Payments to a qualified BCP shall be 
made in accordance with subsection (g). 
‘‘(C) Implementation of the program shall 
focus on physical, behavioral, and psychosocial 
needs of BCP eligible individuals. 
‘‘(D) Quality and cost containment are 
considered interdependent goals of the program. 
‘‘(E) The calculation of long-term cost sav-
ings is dependent on qualified BCPs delivering 
the full continuum of covered primary, post- 
acute care, and social services using capitated 
financing. 
‘‘(3) TARGETED PARTICIPATION.— 
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‘‘(A) IN GENERAL.—In certifying qualified 
BCPs throughout the country, the Secretary 
shall give priority to areas— 
‘‘(i) that do not have a concentration 
of accountable care organizations under 
section 1899; and 
‘‘(ii) with a high burden of chronic 
conditions. 
‘‘(B) INITIAL REQUIREMENT.—In the first 
5 years of the program, at least 50 percent of 
all new qualified BCPs certified nationwide by 
the Secretary shall be from counties or regions, 
as determined by the Secretary, where the prev-
alence of the most costly chronic conditions is 
at or greater than 125 percent of the national 
average. 
‘‘(C) RESTRICTING THE NUMBER OF PAR-
TICIPATING BCPS.— 
‘‘(i) IN
GENERAL.—The Secretary 
shall take into account geography, urban 
and rural designations, and the population 
case mix that will be served, when selecting 
BCPs for participation. 
‘‘(ii) LIMITATION DURING THE FIRST 
FOUR PROGRAM YEARS.—During the first 
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four years of the program, the total num-
ber of qualified BCPs certified by the Sec-
retary shall not exceed 250. 
‘‘(iii) NO LIMITATION DURING FIFTH 
AND SUBSEQUENT PROGRAM YEARS.—Dur-
ing the fifth year and any subsequent year 
of the program, the Secretary may certify 
any BCP that meets the requirements to 
be certified as a qualified BCP. 
‘‘(4) ALIGNMENT WITH APPROVED STATE PLAN 
WAIVERS.—In certifying qualified BCPs, the Sec-
retary shall ensure alignment with other approved 
waivers of State plans under title XIX. 
‘‘(b) DEFINITION OF BCP ELIGIBLE INDIVIDUALS.— 
‘‘(1) DEFINITION.—For purposes of this sec-
tion, the term ‘BCP eligible individual’ means an in-
dividual who— 
‘‘(A) is entitled to benefits under part A 
and enrolled under parts B and D, including an 
individual who is enrolled in a Medicare Advan-
tage plan under part C, an eligible organization 
under section 1876, or a PACE program under 
section 1894; and 
‘‘(B) is medically complex given the preva-
lence of chronic disease that actively and per-
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sistently affects their health status, and absent 
appropriate care interventions, causes them to 
be at enhanced risk for hospitalization, limita-
tions on activities of daily living, or other sig-
nificant health outcomes. 
‘‘(2) DUAL ELIGIBLE INDIVIDUALS.—An indi-
vidual who is dually eligible for Medicare and Med-
icaid shall not be excluded from enrolling in a quali-
fied BCP. Dually eligible beneficiaries enrolled in a 
qualified BCP will see the full scope of their benefits 
under this title and title XIX (other than long-term 
care) managed by the qualified BCP. 
‘‘(c) NOTIFICATION AND ENROLLMENT.— 
‘‘(1) NOTIFICATION.—Not later than October 1 
of each year, the Secretary shall use all available 
tools, including the notice mailed annually under 
section 1804(a) and State health insurance assist-
ance programs, to notify BCP eligible individuals of 
qualified BCPs in their area for the upcoming plan 
year. Such information shall also be easily accessible 
on the Internet website of the Centers for Medicare 
& Medicaid Services. 
‘‘(2) ENROLLMENT.—The Secretary shall estab-
lish procedures under which BCP eligible individuals 
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may voluntarily enroll in a qualified BCP at the fol-
lowing times: 
‘‘(A) During the annual, coordinated elec-
tion period under section 1851(e)(3)(B). 
‘‘(B) During or following (for a length of 
time determined by the Secretary)— 
‘‘(i) an initial preventive physical ex-
amination 
(as 
defined 
in 
section 
1861(ww)); or 
‘‘(ii) any subsequent visit where a 
chronic condition is identified or a previous 
condition is identified as having escalated 
to the level of a chronic condition. 
‘‘(d) PATIENT ASSESSMENT.— 
‘‘(1) STANDARDIZED FUNCTIONAL AND HEALTH 
RISK ASSESSMENT.— 
‘‘(A) MINIMUM
GUIDELINES.—Not later 
than January 1, 2018, the Secretary shall pub-
lish minimum guidelines for qualified BCPs to 
furnish to enrollees a health information tech-
nology-compatible, standardized, and multi-
dimensional risk assessment that— 
‘‘(i) assesses and quantifies the med-
ical, psychosocial, and functional status of 
an enrollee; and 
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‘‘(ii) includes a mechanism to deter-
mine the level of patient activation and 
ability to engage in self-care of an enrollee. 
‘‘(B) UPDATING.—Not less frequently than 
once every 3 years, the Secretary shall, through 
rulemaking, update such minimum guidelines to 
reflect new clinical standards and practices, as 
appropriate. 
‘‘(2) INDIVIDUAL PATIENT-CENTERED CHRONIC 
CARE PLAN.— 
‘‘(A) MODEL PLAN.—Not later than Janu-
ary 1, 2018, the Secretary shall publish min-
imum guidelines for qualified BCPs to develop 
individual patient-centered chronic care plans 
for enrollees. Such a plan shall— 
‘‘(i) allow health professionals to in-
corporate the medical, psychosocial, and 
functional components identified in the 
risk assessment described in paragraph 
(1)(A)(i); 
‘‘(ii) provide a framework that can be 
easily integrated into electronic health 
records, allowing clinicians to make timely, 
accurate, evidence-based decisions at the 
point of care; and 
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‘‘(iii) allow for the provider to describe 
how services will be provided to the en-
rollee. 
‘‘(B) USE OF TECHNOLOGY FOR PATIENT 
SELF CARE.— 
‘‘(i) IN GENERAL.—Whenever appro-
priate, 
the 
individual 
patient-centered 
chronic care plan of an enrollee shall in-
clude the use of technologies that enhance 
communication 
between 
patients, 
pro-
viders, and communities of care, such as 
telehealth, 
remote 
patient 
monitoring, 
Smartphone applications, and other such 
enabling technologies, that promote patient 
engagement and self care while maintain-
ing patient safety. 
‘‘(ii) COORDINATION
AND
DEVELOP-
MENT OF STREAMLINED PATHWAY.—The 
Secretary shall work with the Office of the 
National Coordinator for Health Informa-
tion Technology and the Department of 
Health and Human Services Chief Tech-
nology Officer to develop a streamlined 
pathway for the use of mobile applications 
and communications devices that effec-
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tively enhance the experience of the patient 
while maintaining patient safety and cost- 
effectiveness. Such pathway shall not du-
plicate existing efforts. 
‘‘(e) QUALIFIED BCP PROVIDERS.— 
‘‘(1) CRITERIA.— 
‘‘(A) IN GENERAL.—Any health plan, pro-
vider of services, or group of providers of serv-
ices and suppliers, who agrees to meet the re-
quirements described in paragraph (2) and is 
specified in subparagraph (C) may form a mul-
tidisciplinary team of health professionals to be 
certified as a qualified BCP. Those providers 
may also choose to partner with a qualified in-
surer to become a qualified BCP. 
‘‘(B) NO PREEMPTION OF STATE LICEN-
SURE LAWS.—Nothing in this section shall pre-
empt State licensure laws. 
‘‘(C) GROUPS
OF
PROVIDERS
AND
SUP-
PLIERS SPECIFIED.— 
‘‘(i) IN GENERAL.—As determined ap-
propriate by the Secretary, the following 
health plans, providers of services, or 
groups of providers of services and sup-
pliers, that meet the criteria described in 
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clause (ii) may be certified as qualified 
BCPs under the program: 
‘‘(I) Health professionals acting 
as part of a multidisciplinary team. 
‘‘(II) 
Networks 
of 
individual 
practices of health professionals that 
may include community health cen-
ters, Federally qualified health cen-
ters, rural health clinics, and partner-
ships or affiliations with hospitals. 
‘‘(III) Health plans that meet ap-
propriate network adequacy stand-
ards, as determined by the Secretary, 
and that include providers with expe-
rience and interest in managing a 
population with chronic conditions. 
‘‘(IV) Independent health profes-
sionals partnering with an inde-
pendent risk manager. 
‘‘(V) Such other groups of pro-
viders of services or suppliers as the 
Secretary determines appropriate. 
‘‘(ii) CRITERIA DESCRIBED.—The fol-
lowing criteria are described in this clause: 
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‘‘(I) Demonstrated capacity to 
manage the full continuum of care 
(other than long-term care) for the 
specialized population of BCP eligible 
individuals. 
‘‘(II) Having a high rate of Medi-
care customer satisfaction, when ap-
plicable, or partnering with providers 
of services or suppliers with such a 
demonstrated high satisfaction rate. 
‘‘(2) REQUIREMENTS.—A qualified BCP shall 
meet the following requirements: 
‘‘(A) The qualified BCP shall be account-
able for the quality, cost, and overall care of en-
rolled BCP eligible individuals and agree to be 
at financial risk for that enrolled population. A 
qualified BCP shall be established with the ob-
jective of serving BCP eligible individuals. 
‘‘(B) The qualified BCP shall be respon-
sible for the full continuum of care (other than 
long-term care) for enrollees. This continuum 
shall include medical care, skilled nursing and 
home health services, behavioral health care, 
and social services. The qualified BCP may not 
actively restrict an enrollee’s access to providers 
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based on a practitioner’s license or medical spe-
cialty based on cost alone. 
‘‘(C) The qualified BCP shall primarily 
consist of a care team tasked with responding 
to, treating, and actively supporting the needs 
of BCP eligible individuals. The care team shall 
also develop a care plan for each eligible BCP 
enrollee and use it as a tool to execute effective 
care management and transitions. 
‘‘(D) The qualified BCP shall include phy-
sicians, nurse practitioners, registered nurses, 
social workers, pharmacists, and behavioral 
health providers who commit to caring for BCP 
eligible individuals. 
‘‘(E) The qualified BCP shall enter into an 
agreement with the Secretary to participate in 
the program under this section for not less than 
a 3-year period. 
‘‘(F) The qualified BCP shall include ade-
quate numbers of primary care and other rel-
evant professionals that can effectively care for 
the number of BCP eligible individuals enrolled 
in the qualified BCP. 
‘‘(G) The qualified BCP shall provide the 
Secretary with such information regarding 
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qualified BCP professionals participating in the 
qualified BCP necessary to support the enroll-
ment of BCP eligible individuals in a qualified 
BCP, including evidence relating to high pa-
tient satisfaction when available, the implemen-
tation of quality reporting and other reporting 
requirements, and evidence to support a deter-
mination of capitated payments in accordance 
with subsection (g). 
‘‘(H) The qualified BCP shall have in 
place a structure that includes clinical and ad-
ministrative systems, including health informa-
tion technology, that supports the integration of 
services and providers across sites of care. 
‘‘(I) The qualified BCP may develop a col-
laborative partnership that supports the mission 
of the BCP with each of the following: 
‘‘(i) A regional or national Chronic 
Care Innovation Center under section 6 of 
the Better Care, Lower Cost Act. 
‘‘(ii) A regional or national Center of 
Innovation (COIN) of the Department of 
Veterans Affairs Health Services Research 
and Development Service to identify and 
implement best practices— 
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‘‘(I) to increase access to, and 
implementation of, prevention and 
wellness tools; 
‘‘(II) to integrate physical and 
behavior health care with social serv-
ices; 
‘‘(III) to promote evidence-based 
medicine and patient engagement; 
‘‘(IV) to coordinate care across 
providers and care settings; 
‘‘(V) to allow more patients to be 
cared for in their homes and commu-
nities; 
‘‘(VI) to reduce hospital readmis-
sions; 
‘‘(VII) to improve health out-
comes for patients with chronic condi-
tions; and 
‘‘(VIII) to report on quality im-
provement and cost measures. 
‘‘(iii) A regional or national Tele-
health Resource Center of the Health Re-
sources 
and 
Services 
Administration 
(HRSA) Office for the Advancement of 
Telehealth to create an interactive, online 
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resource for qualified BCP professionals 
who may need additional training or assist-
ance in managing the needs of a complex 
patient population, including— 
‘‘(I) continuing training and edu-
cation and mentoring for qualified 
BCP professionals at any level of li-
censure; 
‘‘(II) clinician support for com-
plex patients by an expert panel; 
‘‘(III) remote access to regional, 
national, and international experts in 
the field; 
‘‘(IV) forums for best practices 
to be discussed among qualified BCP 
professionals; 
‘‘(V) inter-professional education 
supporting optimal communication be-
tween members of a chronic care 
team; and 
‘‘(VI) continuing training on the 
use of telehealth, remote patient mon-
itoring, and other such enabling tech-
nologies. 
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‘‘(J) The qualified BCP shall demonstrate 
to 
the 
Secretary 
that 
it 
meets 
person- 
centeredness criteria specified by the Secretary 
in collaboration with accreditation organiza-
tions, including the use of patient and caregiver 
assessments and the use of individual patient- 
centered chronic care plans for each enrollee (as 
described in subsection (d)(2)). 
‘‘(K) The qualified BCP may identify and 
respond to unique cultural, social, and economic 
needs of a community that impact access to, 
and quality of, healthcare. 
‘‘(L) The qualified BCP shall provide care 
across settings, including in the home as need-
ed. 
‘‘(M) The qualified BCP shall demonstrate 
financial solvency (as determined by the Sec-
retary). 
‘‘(N) The qualified BCP shall demonstrate 
the ability to partner with providers of social 
and behavioral health services within the com-
munity. 
‘‘(O) The qualified BCP shall engage in 
continuing education on chronic care, on an on-
going basis (as determined necessary by the 
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Chronic Care Innovation Center under the part-
nership under subparagraph (J)(i)), in collabo-
ration with the Agency for Healthcare Research 
and Quality, the Health Resources and Services 
Administration, and the Department of Vet-
erans Affairs. 
‘‘(f) IMPLEMENTING VALUE-BASED INSURANCE DE-
SIGN.— 
‘‘(1) IN GENERAL.— 
‘‘(A) ELECTION.—A qualified BCP may 
elect to provide value-based Medicare coverage 
in accordance with this subsection. 
‘‘(B) INCLUSION OF ORIGINAL MEDICARE 
FEE-FOR-SERVICE
PROGRAM
BENEFITS.—Sub-
ject to subparagraph (C), enrollees in a quali-
fied BCP that elects to provide value-based 
Medicare coverage under this subsection shall 
receive such coverage that includes items and 
services for which benefits are available under 
parts A and B to individuals entitled to benefits 
under part A and enrolled under part B, with 
cost-sharing for those items and services as de-
scribed in subparagraph (C). 
‘‘(C) 
COST-SHARING.—Cost-sharing 
de-
scribed in this subparagraph, with respect to an 
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enrollee in a qualified BCP that makes such an 
election, is varied cost-sharing approved by the 
Secretary to incentivize the use of high-value, 
high-quality services that have been clinically 
proven to benefit BCP eligible individuals. 
‘‘(D) CHANGES IN COVERAGE.—The Sec-
retary, in consultation with experts in the field, 
shall establish a process for qualified BCPs to 
submit value-based Medicare coverage changes 
that encourage and incentivize the use of evi-
dence-based practices that will drive better out-
comes while ensuring patient protections and 
access are maintained. 
‘‘(E) NO REQUIREMENT FOR COVERAGE OF 
LONG-TERM CARE SERVICES.—In no case shall 
a qualified BCP be required to provide to en-
rollees coverage for long-term care services. 
‘‘(2) QUALIFIED BCP PARTICIPATION.— 
‘‘(A) CONTINUED
ACCESS.—Subject to 
subparagraph (B), enrollees in a qualified BCP 
shall continue to have access to all providers of 
services and suppliers under this title. 
‘‘(B) NO APPLICATION OF VARIED COST- 
SHARING
FOR
NONPARTICIPATING
PROVIDERS 
OF SERVICES AND SUPPLIERS.— 
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‘‘(i) IN GENERAL.—The varied cost- 
sharing under paragraph (1)(B) shall only 
apply to items and services furnished by 
qualified BCP professionals of a qualified 
BCP that makes an election under para-
graph (1). In the case where items and 
services are furnished by a provider of 
services or supplier who is not such a 
qualified BCP professional, the cost-shar-
ing applicable for those items and services 
will be the cost-sharing as required under 
parts A and B, or an actuarially equivalent 
level of cost-sharing as determined by the 
Secretary. 
‘‘(ii) NOTIFICATION.—A BCP eligible 
individual shall be notified and counseled 
prior to the time of enrollment on potential 
changes in out-of-pocket costs that may 
occur if care is provided by a provider of 
services or supplier that is not a qualified 
BCP professional. 
‘‘(3) LIMITATIONS
ON
OUT-OF-POCKET
EX-
PENSES OUTSIDE A QUALIFIED BCP.— 
‘‘(A) IN
GENERAL.—Out-of-pocket costs, 
including individual beneficiary copayments, 
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with respect to items and services furnished by 
a provider of services or supplier who is not a 
qualified BCP professional shall not exceed 
what would otherwise have been paid with re-
spect to the item or service under the original 
Medicare fee-for-service program under parts A 
and B for the same services or an actuarially 
equivalent level of cost-sharing as determined 
by the Secretary, or, in the case of a dual eligi-
ble individual, under the Medicaid program 
under title XIX. 
‘‘(B) PROHIBITION
ON
COVERAGE
OF 
COST-SHARING FOR CERTAIN ITEMS AND SERV-
ICES FURNISHED TO AN ENROLLEE OUTSIDE 
OF A QUALIFIED BCP UNDER MEDIGAP POLI-
CIES.—For provisions relating to prohibition on 
coverage of cost-sharing for items and services 
(other than emergent services, as defined by the 
Secretary) furnished to an enrollee outside of a 
qualified BCP under Medigap policies, see sec-
tion 1882(z). 
‘‘(4) PRESCRIPTION DRUG COVERAGE.— 
‘‘(A) DRUG PLAN OPTION.— 
‘‘(i) IN GENERAL.—A health plan cer-
tified as a qualified BCP may provide en-
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rollees with a drug plan option specifically 
designed to reflect the medication needs of 
enrollees. 
‘‘(ii) APPLICATION OF PART D PROVI-
SIONS.— 
‘‘(I) IN
GENERAL.—Except as 
otherwise provided in this section, the 
provisions of part D shall apply to a 
drug plan option offered by a qualified 
BCP under clause (i) in the same 
manner as such provisions apply to a 
prescription drug plan offered by a 
PDP sponsor under such part. 
‘‘(II) LIMITATION
OF
ENROLL-
MENT.—A qualified BCP offering 
such a drug plan option may limit en-
rollment in the drug plan option to 
enrollees in the qualified BCP. 
‘‘(III) WAIVER.—The Secretary 
may waive such provisions of part D 
as are necessary to carry out this sec-
tion. 
‘‘(B) AGREEMENT
WITH
PRESCRIPTION 
DRUG PLANS.—A qualified BCP managed by a 
group of providers of services may enter into an 
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agreement with a PDP sponsor of a prescrip-
tion drug plan under part D to establish and 
encourage individuals enrolled in the qualified 
BCP to enroll in a prescription drug plan under 
such part that is better suited to the needs of 
chronically ill individuals. 
‘‘(C) LIMITATION.—A drug plan option of-
fered by a qualified BCP under subparagraph 
(A)(i) shall not have the authority to increase 
out-of-pocket limits otherwise applicable under 
part D. 
‘‘(g) PAYMENTS AND TREATMENT OF SAVINGS.— 
‘‘(1) PAYMENTS
TO
QUALIFIED
BCPS
ON
A 
CAPITATED BASIS.— 
‘‘(A) IN GENERAL.—In the case of a quali-
fied BCP under this section, the Secretary shall 
make prospective monthly payments of a capita-
tion amount for each BCP eligible individual 
enrolled in the qualified BCP in the same man-
ner and from the same sources as payments are 
made to a Medicare Advantage organization 
under section 1853. Such payments shall be 
subject to adjustment in the manner described 
in section 1853(a)(2) or section 1876(a)(1)(E), 
as the case may be. 
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‘‘(B) CAPITATION
AMOUNT.—The capita-
tion amount to be applied under this paragraph 
for a qualified BCP for each enrollee for a year 
shall be 1⁄12 of the benchmark rate under sub-
paragraph (C)(ii) for the year (or the relevant 
rate under subparagraph (C)(i) for the first 
year of the program under this section) (re-
ferred to in this paragraph as the ‘per member 
per month payment’), as adjusted under clause 
(iii). 
‘‘(C) DETERMINING THE RATE USING RISK 
RELEVANT CONTROL GROUP.— 
‘‘(i) RELEVANT RATE.— 
‘‘(I) IDENTIFICATION OF BENE-
FICIARY
GROUPING.—Using 
claims 
data, the Secretary shall identify a 
group of beneficiaries who have simi-
lar health risk characteristics, and 
have sought care in the same county, 
multi-county, or State level (as deter-
mined appropriate by the Secretary to 
establish a payment area) to the pop-
ulation the qualified BCP is tasked 
with serving. To the extent feasible 
for a statistically valid control group, 
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the health risk of such group shall re-
flect social characteristics, such as in-
come, as well as medical risk. 
‘‘(II) DETERMINATION
OF
REL-
EVANT RATE.—The per capita spend-
ing amounts under this title and, as 
appropriate, title XIX, of the group of 
beneficiaries identified under sub-
clause (I) shall determine the ‘rel-
evant rate’ that will serve as the basis 
of the benchmark for participating 
qualified BCPs. 
‘‘(ii) BENCHMARK
RATE.—The Sec-
retary shall establish the benchmark rate 
for a qualified BCP service area for each 
year of the program by updating the rel-
evant rate determined under clause (i) with 
the projected change in per capita spend-
ing for the group of beneficiaries identified 
under clause (i)(I) for the payment area 
described in such clause, as determined by 
the Chief Actuary of the Centers for Medi-
care & Medicaid Services. 
‘‘(iii) ADJUSTMENT FOR HEALTH STA-
TUS.— 
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‘‘(I) COMPARISON
OF
HEALTH 
STATUS.—The Secretary shall estab-
lish a risk score mechanism to com-
pare the health status of an enrollee 
in a qualified BCP to the average 
health risk of group of beneficiaries 
identified under clause (i)(I). 
‘‘(II) INCLUSION OF NUMBER OF 
CONDITIONS.—The 
Secretary 
shall 
provide that a risk score under the 
mechanism under this clause, with re-
spect to an individual, includes an in-
dicator for the number of chronic con-
ditions with which the individual has 
been diagnosed. 
‘‘(III) USE OF 2 YEARS OF DIAG-
NOSIS DATA.—The Secretary shall en-
sure that such risk score, with respect 
to an individual reflects not less than 
2 years of diagnosis data, to the ex-
tent available. 
‘‘(IV) ADJUSTMENT FOR HEALTH 
STATUS.—The per member per month 
payment to the qualified BCP for 
each enrollee shall be adjusted de-
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pending on how the individual risk 
profile of the enrollee compares to the 
average health status of such group of 
beneficiaries. If an enrollee has a risk 
profile that is not as severe as the av-
erage health status of such group of 
beneficiaries, then the per member per 
month shall be decreased to reflect the 
‘healthier’ status of the enrollee. If an 
enrollee has a risk profile that is more 
severe, then the per member per 
month payment to the qualified BCP 
shall be increased to reflect the more 
acutely ill status of the enrollee. 
‘‘(D) SHARED RISK PAYMENTS FOR CER-
TAIN QUALIFIED BCPS DURING FIRST 3 YEARS 
OF THE PROGRAM.— 
‘‘(i) IN
GENERAL.—This subpara-
graph shall only apply to qualified BCPs 
offered by a group of providers of services 
and suppliers during the first 3 years of 
the program under this section. 
‘‘(ii) SHARING OF RISK TO ALLEVIATE 
OUTLIERS.—The Secretary shall determine 
shared risk payments and recoupments 
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under this subparagraph for a qualified 
BCP described in clause (i) as follows: 
‘‘(I) DETERMINATION
OF
GAIN 
OR
LOSS.—The Secretary shall, for 
each of the first 3 years of the pro-
gram under this section, determine 
the percentage of gain or loss for the 
qualified BCP in providing benefits to 
enrollees under this section. 
‘‘(II) GAIN
OR
LOSS
GREATER 
THAN 5 PERCENT.—If the Secretary 
determines the qualified BCP has a 
gain or loss for the year of greater 
than 5 percent, the qualified BCP 
shall bear 100 percent of the risk or 
reward of such loss or gain. 
‘‘(III) GAIN
OR
LOSS
OF
NOT 
LESS
THAN
AND
NOT
GREATER 
THAN 5 PERCENT.—If the Secretary 
determines the qualified BCP has a 
gain or loss for the year of not less 
than 2 percent but not greater than 5 
percent— 
‘‘(aa) the qualified BCP 
shall bear 80 percent of the risk 
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or reward, as applicable, of such 
loss or gain; and 
‘‘(bb) the Secretary shall 
bear 20 percent of the risk or re-
ward, as applicable, of such loss 
or gain. 
‘‘(IV) GAIN OR LOSS BETWEEN 0 
AND 2 PERCENT.—If the Secretary de-
termines the qualified BCP has a gain 
or loss for the year of greater than 0 
percent but less than 2 percent— 
‘‘(aa) the qualified BCP 
shall bear 50 percent of the risk 
or reward, as applicable, of such 
loss or gain; and 
‘‘(bb) the Secretary shall 
bear 50 percent of the risk or re-
ward, as applicable, of such loss 
or gain. 
‘‘(iii) PROVISION OF INFORMATION.— 
A qualified BCP shall provide to the Sec-
retary such information as the Secretary 
determines is necessary to carry out this 
subparagraph. 
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‘‘(E) BID
SUBMISSION.—Beginning with 
the fourth year of the program, a qualified 
BCP shall submit a bid for participation in the 
program for the year that reflects the experi-
ence of the qualified BCP— 
‘‘(i) in managing the care of the en-
rolled population; and 
‘‘(ii) in managing such care given the 
relevant rate determined under subpara-
graph (C). 
‘‘(F) QUALITY BONUS SYSTEM.— 
‘‘(i) IN
GENERAL.—The Secretary 
shall establish a quality bonus system 
whereby the Secretary distributes bonus 
payments to qualified BCPs that meet the 
requirements described in clause (iii) and 
other standards specified by the Secretary, 
which may include a focus on quality 
measurement and improvement, delivering 
patient-centered care, and practicing in in-
tegrated health systems, including training 
in community-based settings. In developing 
such standards, the Secretary shall collabo-
rate with relevant stakeholders, including 
program 
accrediting 
bodies, 
certifying 
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boards, training programs, health care or-
ganizations, health care purchasers, and 
patient and consumer groups. 
‘‘(ii) DETERMINATION
OF
QUALITY 
BONUSES.—Quality bonuses to the BCP 
shall be based on a comparison of the qual-
ity of care provided by the qualified BCP 
to enrollees to the quality of care provided 
to beneficiaries not enrolled in a qualified 
BCP or a Medicare Advantage plan under 
part C in the same region. For not less 
than the first 5 years of the program 
under this section, quality measures for 
the geographic region shall be based on 
local standards of care, and not on a na-
tional standard. For subsequent years, ap-
propriate national standards shall be con-
sidered for inclusion in the comparison of 
the quality of care under this subpara-
graph. 
‘‘(iii) REQUIREMENTS.—A qualified 
BCP is eligible for quality bonuses under 
this subparagraph if— 
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‘‘(I) the qualified BCP meets 
quality performance standards under 
subsection (h)(3); and 
‘‘(II) the qualified BCP meets 
the requirements under subsection 
(e)(2). 
‘‘(h) QUALITY AND OTHER REPORTING REQUIRE-
MENTS.— 
‘‘(1) IN GENERAL.—The Secretary shall develop 
and implement, with assistance and input of relevant 
experts in the field and the National Strategy for 
Quality Improvement in Health Care, appropriate 
measures for BCP eligible individuals. The Secretary 
shall determine appropriate measures under this title 
and title XIX to assess the quality of care furnished 
by a qualified BCP, as well as those measures that 
are no longer appropriate and shall be removed from 
use. Such measures shall include measures— 
‘‘(A) of clinical processes and outcomes; 
‘‘(B) of patient and, where practicable, 
caregiver experience of care, including measure-
ment that enhances patient activation and en-
gagement; 
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‘‘(C) of utilization (such as rates of hos-
pital admissions for ambulatory care sensitive 
conditions); 
‘‘(D) of care coordination, management, 
and transitions; and 
‘‘(E) that appropriately align with the Na-
tional Strategy for Quality Improvement in 
Health Care. 
The Secretary may use existing measures under this 
title, title XIX, or any other health care program, as 
appropriate, under this paragraph. 
‘‘(2) REPORTING REQUIREMENTS.—A qualified 
BCP shall submit data in a form and manner speci-
fied by the Secretary which is not overly burdensome 
to the qualified BCP, on measures the Secretary de-
termines necessary for the qualified BCP to report 
in order to evaluate the quality of care furnished by 
the qualified BCP. Such data reporting shall empha-
size ‘patient-centered measurement’ and may include 
the functional status of patients, case management 
and care transitions across health care settings, in-
cluding hospital discharge planning and post-hospital 
discharge follow-up by qualified BCP professionals, 
as the Secretary determines appropriate. 
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‘‘(3) QUALITY
PERFORMANCE
STANDARDS.— 
The Secretary shall establish quality performance 
standards to assess the quality of care furnished by 
qualified BCPs. The Secretary shall seek to improve 
the quality of care furnished by qualified BCPs over 
time by specifying higher standards, new measures, 
or both for purposes of assessing such quality of 
care. The Secretary shall also include a process for 
retiring measures that are no longer adequately con-
tributing to improving standards of care at the 
greatest possible value. 
‘‘(4) OTHER REPORTING REQUIREMENTS AND 
CALL FOR ALIGNMENT.—The Secretary shall, as the 
Secretary determines appropriate, incorporate and 
align reporting requirements and incentive payments 
related to the physician quality reporting system 
under section 1848, including those related to re-
porting on quality measures under subsection (m) of 
that section, reporting requirements under sub-
section (o) of that section relating to meaningful use 
of electronic health records, the establishment of a 
value-based payment modifier under subsection (p) 
of that section, and other similar initiatives under 
that section, and may use alternative criteria than 
would otherwise apply under section 1848 for deter-
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mining whether to make such payments to qualified 
BCP professionals. The incentive payments de-
scribed in the preceding sentence shall not be taken 
into consideration when calculating any payments 
otherwise made under subsection (g). 
‘‘(i) BENEFICIARY PROTECTIONS.—The Secretary 
shall ensure that, to the extent consistent with this sec-
tion, a qualified BCP offers beneficiary protections appli-
cable to beneficiaries under this title and, as applicable, 
title XIX. 
‘‘(j) PAYMENT OF MEDICARE COST-SHARING FOR 
DUAL ELIGIBLE INDIVIDUALS.—In the case of a dual eli-
gible individual enrolled in a qualified BCP, the Secretary 
may provide for the payment of medicare cost-sharing (as 
defined in section 1905(p)(3)) that would otherwise be 
available under the State plan under title XIX if the indi-
vidual was not enrolled in the qualified BCP. 
‘‘(k) DEFINITIONS.—In this section: 
‘‘(1) ALTERNATIVE PAYMENT MODEL (APM).— 
The term ‘alternative payment model’ means any of 
the following: 
‘‘(A) A model under section 1115A (other 
than a health care innovation award). 
‘‘(B) An accountable care organization 
under section 1899. 
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‘‘(C) 
A 
demonstration 
under 
section 
1866C. 
‘‘(D) A demonstration required by Federal 
law. 
‘‘(E) A qualified BCP. 
‘‘(2) HOSPITAL.—The term ‘hospital’ means a 
subsection (d) hospital (as defined in section 
1886(d)(1)(B)). 
‘‘(3) QUALIFIED
BCP
PROFESSIONAL.—The 
term ‘qualified BCP professional’ means a certified 
and licensed professional of medical or behavioral 
health services that is participating in a qualified 
BCP.’’. 
(b) FEDERAL ASSUMPTION OF MEDICAID COSTS FOR 
FULL BENEFIT DUAL ELIGIBLE INDIVIDUALS ENROLLED 
IN A QUALIFIED BCP.—Title XIX of the Social Security 
Act is amended by inserting after section 1943 the fol-
lowing new section: 
‘‘FEDERAL ASSUMPTION OF MEDICAID COSTS FOR FULL 
BENEFIT
ELIGIBLE
INDIVIDUALS
ENROLLED
IN
A 
QUALIFIED BCP 
‘‘SEC. 1944. (a) STATE CONTRIBUTION.— 
‘‘(1) IN GENERAL.—The State shall provide for 
payment to the Secretary for each month in an 
amount determined under paragraph (2)(A) for each 
applicable dual eligible BCP enrollee for such State. 
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