SEC. 2. QUALIFIED DIRECT PRIMARY CARE MEDICAL HOME 
PILOT 
FOR 
MEDICARE 
PART 
B 
BENE-
FICIARIES. 
(a) IN GENERAL.—The Secretary of Health and 
Human Services (in this section referred to as the ‘‘Sec-
retary’’) shall establish a program of pilot projects (each 
in this section referred to as the ‘‘pilot project’’) under 
part B of title XVIII of the Social Security Act under 
which the Secretary reimburses a qualified direct primary 
care medical home practice, as described in section 
1301(a)(3) of the Patient Protection and Affordable Care 
Act (as amended by section 10104(a) of such Act), using 
a monthly fee-based payment methodology. 
(b) AFFORDABLE PRIMARY CARE.—No pilot project 
may be established under this section with respect to a 
medical home if the monthly fee under this section for an 
enrolled individual exceeds $100 (or $125 in the case of 
a dual eligible individual (as defined in subsection (i)). The 
Secretary shall adjust from time to time the dollar 
amounts specified in the previous sentence for inflation. 
(c) SCOPE OF SERVICES.—Each pilot project shall 
employ the following activities and functions associated 
with direct primary care medical homes: 
(1) Provision of preventive care. 
(2) Wellness counseling. 
(3) Primary care. 
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(4) Coordination of primary care with specialty 
and hospital care. 
(5) Urgent care services. 
(6) Availability of office appointments 7 days 
per week. 
(7) E-mail and telephone consultation. 
(8) Availability of telephone access for urgent 
care consultation on a 7-day per week, 24-hour per 
day basis. 
(9) Use of a primary care provider panel size 
that promotes the ability of participating providers 
to appropriately provide the scope of services de-
scribed in this subparagraph. 
(d) PRIORITIES.— 
(1) QUALIFIED STATE.—At least one such pilot 
project shall be conducted in a State that— 
(A) has enacted legislation to enable direct 
primary care practices to deliver monthly fee- 
based primary care without being regulated as 
an insurer or health maintenance organization; 
and 
(B) has direct primary care practices 
which enroll, in the aggregate as of September 
1, 2011, at least 3,000 individuals using the 
monthly fee-based primary care model. 
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(2) PROJECTS INCLUDING DUAL ELIGIBLES.— 
Subject to paragraph (1), the Secretary shall provide 
priority to pilot projects that seek to enroll individ-
uals who are dual eligible individuals. 
(e) NO INSURANCE.—Care provided under a pilot 
project shall not be considered an insurance product and 
shall not be subject to regulation as insurance product or 
health maintenance organization by State insurance com-
missioners. 
(f) APPLICATION OF PROVISIONS.—The provisions of 
subsections (b)(3) and (d) of section 1115A of the Social 
Security Act (42 U.S.C. 1315a) shall apply in carrying 
out the program of pilot projects under this section in the 
same manner as such provisions apply to testing models 
under subsection (b)(1) of such section and, notwith-
standing any other provision of law, funds appropriated 
under subsection (f)(1)(B) of such section for activities 
under such section shall be available to carry out pilot 
projects under this section. 
(g) REPORTING TO SECRETARY.—An entity that es-
tablishes a pilot project shall submit to the Secretary an 
annual report that measures the progress, of patients en-
rolled in the project with one or more chronic conditions, 
on the following: 
(1) Emergency room visits. 
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(2) Hospitalizations. 
(3) Surgeries (including type of surgery). 
(4) Specialist visits. 
(5) Use of advanced radiology (other than 
mammograms and DEXA scans). 
(h) PROVISION OF DATA.—The Secretary shall pro-
vide the entities operating pilot projects with all necessary 
and relevant patient data, including any prior claims data, 
needed for clinical purposes and for the purpose of pro-
viding an evaluation of such projects. 
(i) DUAL ELIGIBLE INDIVIDUAL DEFINED.—In this 
section, the term ‘‘dual eligible individual’’ means a Medi-
care beneficiary who is described in subparagraph (A)(ii) 
of section 1935(c)(6) of the Social Security Act (42 U.S.C. 
1396u–5(c)(6)), taking into account the application of 
subparagraph (B) of such section. 
Æ 
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