I 
117TH CONGRESS 
2D SESSION 
H. R. 9209 
To improve access to the Program of All-Inclusive Care for the Elderly, 
and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
OCTOBER 21, 2022 
Mrs. DINGELL (for herself and Mr. MOOLENAAR) introduced the following bill; 
which was referred to the Committee on Energy and Commerce, and in 
addition to the Committee on Ways and Means, for a period to be subse-
quently determined by the Speaker, in each case for consideration of such 
provisions as fall within the jurisdiction of the committee concerned 
A BILL 
To improve access to the Program of All-Inclusive Care 
for the Elderly, 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 ‘‘Program of All-inclu-
sive Care for the Elderly Expanded Act’’ or the ‘‘PACE 
Expanded Act’’. 
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SEC. 2. IMPROVING ACCESS TO AND AFFORDABILITY OF 
PACE 
PROGRAMS 
FOR 
MEDICARE 
BENE-
FICIARIES WHO ARE NOT DUAL ELIGIBLE 
BENEFICIARIES THROUGH FLEXIBILITY IN 
RATE SETTING FOR SERVICES NOT COVERED 
BY MEDICARE. 
(a) IN GENERAL.—Section 1894 of the Social Secu-
rity Act (42 U.S.C. 1395eee) is amended by adding at the 
end the following new subsection: 
‘‘(j) FLEXIBILITY IN ESTABLISHING PREMIUMS FOR 
MEDICARE PACE PARTICIPANTS WHO ARE NOT ALSO 
ENTITLED
TO BENEFITS UNDER
A STATE MEDICAID 
PROGRAM.— 
‘‘(1) CODIFICATION OF AUTHORITY TO CHARGE 
A MONTHLY CAPITATION AMOUNT FOR NON-MEDI-
CARE SERVICES.—Subject to the succeeding provi-
sions of this subsection, a PACE program operated 
by a PACE provider under a PACE program agree-
ment in any State may charge a Medicare-only 
PACE program eligible individual (as defined in 
paragraph (4)(A)) who is enrolled in such PACE 
program a monthly capitation payment amount for 
the provision of non-Medicare services (as defined in 
paragraph (4)(B)) under the PACE program. 
‘‘(2) DETERMINATION
OF
MONTHLY
CAPITA-
TION PAYMENT AMOUNT.— 
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‘‘(A) IN GENERAL.—Notwithstanding sec-
tion 460.186 of title 42, Code of Federal Regu-
lations (or any successor regulation), the 
monthly capitation payment amount that may 
be charged under paragraph (1) shall be deter-
mined by the PACE provider operating the 
PACE program. Such monthly capitation pay-
ment amount shall be based on assessments 
conducted on the Medicare-only PACE program 
eligible individual who is enrolled in such PACE 
program by the PACE program interdiscipli-
nary team and shall take into account the 
health status of such individual. In determining 
the monthly capitation amount for a Medicare- 
only PACE program eligible individual under 
this paragraph, a PACE provider may take into 
account the services determined necessary for 
the individual by the PACE program inter-
disciplinary team based upon their assessment 
of the individual. A determination described in 
the preceding sentence shall not be construed as 
limiting the responsibility of the PACE provider 
to meet any unforeseen needs or provide for any 
required services for such individual. 
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‘‘(B) AUTHORITY
TO
ADJUST
MONTHLY 
CAPITATION AMOUNT.— 
‘‘(i) IN GENERAL.—Subject to clause 
(ii) and paragraph (3), the monthly capita-
tion payment amount that may be charged 
under paragraph (1) to a Medicare-only 
PACE program eligible individual enrolled 
in a PACE program for non-Medicare 
services may increase or decrease based on 
assessments conducted on such individual. 
Any change in the monthly capitation pay-
ment amount charged to such an indi-
vidual shall take effect beginning with the 
first day of the first month that begins 
after the month during which the plan of 
care is developed for such individual based 
on such an assessment. 
‘‘(ii) LIMITATION ON FREQUENCY OF 
INCREASE.—The monthly capitation pay-
ment amount that may be charged under 
paragraph (1) to such an individual may 
not increase more frequently than once per 
calendar quarter. 
‘‘(3) BENEFICIARY PROTECTIONS.— 
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by the PACE provider (using the assess-
ment instrument developed by the Sec-
retary under clause (i)), accounting for 
health status and corresponding needs. 
‘‘(iii) REQUIREMENT FOR DISCLOSURE 
OF
ASSESSMENT
INSTRUMENT.—The as-
sessment instrument used by the inter-
disciplinary team of the PACE program to 
evaluate the health and social status of 
PACE participants shall be disclosed to 
the individual prior to the assessment. 
‘‘(C) PROCESS TO SEEK REVIEW OF AS-
SESSMENTS.—The Secretary shall establish a 
process for a Medicare-only PACE program eli-
gible individual to seek review of any assess-
ment conducted on the individual under this 
subsection. 
‘‘(4) RULE
OF
CONSTRUCTION.—Nothing in 
this subsection shall be construed to preclude the 
testing under section 1115A of a model to permit a 
PACE provider operating a PACE program to es-
tablish and charge monthly capitation payment 
amounts for the provision of non-Medicare services 
under the PACE program to Medicare-only PACE 
program eligible individuals under a rate structure 
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established by such PACE provider for such pur-
pose, including the use of an assessment instrument 
developed by the PACE program to assign such indi-
viduals to an appropriate rate category under such 
rate structure. 
‘‘(5) DEFINITIONS.—In this subsection— 
‘‘(A) the term ‘Medicare-only PACE pro-
gram eligible individual’ means an individual 
who is described in subsection (a)(1) and who 
is not entitled to medical assistance under title 
XIX, and includes the designated representative 
of the individual as appropriate; and 
‘‘(B) the term ‘non-Medicare services’ 
means items and services covered under title 
XIX that are not covered under this title and 
items and services described in subsection 
(b)(1)(A)(ii).’’. 
(b) EFFECTIVE DATE.—The amendment made by 
subsection (a) shall take effect on the date of the enact-
ment of this Act, and apply with respect to capitation 
amounts that may be charged for months beginning on 
or after January 1, 2023. 
(c) RULE OF CONSTRUCTION.—Nothing in this sec-
tion, or the amendments made by this section, shall be 
construed to modify or otherwise impact the following 
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Medicare capitation rates that may be charged by PACE 
plans for PACE participants who are Medicare bene-
ficiaries who are not both entitled to (or enrolled for) bene-
fits under part A of title XVIII of the Social Security Act 
(42 U.S.C. 1395 et seq.) and enrolled for benefits under 
part B of such title: 
(1) PART A ONLY MEDICARE BENEFICIARY.—In 
the case of a Medicare beneficiary who is a PACE 
participant who is entitled to (or enrolled for) bene-
fits under part A of such title XVIII but who is not 
enrolled for benefits under part B of such title, the 
Medicare Part B capitation rate under paragraph 
(b) of section 460.186 of title 42, Code of Federal 
Regulations (or any successor regulations). 
(2) PART B ONLY MEDICARE BENEFICIARY.—In 
the case of a Medicare beneficiary who is a PACE 
participant who is enrolled for benefits under part B 
of such title XVIII but who is not entitled to (or en-
rolled for) benefits under part A of such title, the 
Medicare Part A capitation rate under paragraph (c) 
of such section 460.186 (or any successor regula-
tions). 
SEC. 3. ANYTIME ENROLLMENT IN PACE. 
(a) IN GENERAL.— 
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(1) ANY TIME ENROLLMENT AND EFFECTIVE 
DATE.—Section 1894(c)(5) of the Social Security 
Act (42 U.S.C. 1395eee(c)(5)) is amended by adding 
at the end the following new subparagraph: 
‘‘(C) ANY TIME ENROLLMENT AND EFFEC-
TIVE DATE OF ENROLLMENT.— 
‘‘(i) ANY
TIME
ENROLLMENT.—A 
PACE program eligible individual may en-
roll in a PACE program at any time dur-
ing a month. 
‘‘(ii) EFFECTIVE
DATE.—Subject to 
clause (iii), the enrollment of a PACE pro-
gram eligible individual in a PACE pro-
gram shall be effective on the date the 
PACE provider operating the PACE pro-
gram receives an enrollment agreement 
signed by such PACE program eligible in-
dividual with respect to such PACE pro-
gram. 
‘‘(iii) SPECIAL RULE IN THE CASE OF 
DUAL
ELIGIBLE
BENEFICIARIES.—In the 
case of a PACE program eligible individual 
who is eligible for benefits under this title 
and title XIX, clause (i) shall only apply if 
the State in which such individual resides 
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has made an election under section 
1934(c)(5)(C) to permit PACE program 
eligible individuals enroll in a PACE pro-
gram at any time during a month in such 
State.’’. 
(2) PRORATED PAYMENTS.—Section 1894(d) of 
the Social Security Act (42 U.S.C. 1395eee(d)) is 
amended by adding at the end the following new 
paragraph: 
‘‘(4) PRORATED PAYMENTS.—In the case of a 
PACE program eligible individual enrolled in a 
PACE program operated by a PACE provider with 
an enrollment effective date that is not the first day 
of a month, the capitation amount that would other-
wise be made under this subsection to the PACE 
provider for such individual for the first month in 
which such individual is so enrolled shall be prorated 
accordingly.’’. 
(b) CONFORMING AMENDMENTS.— 
(1) ANYTIME
ENROLLMENT
AND
EFFECTIVE 
DATE.—Section 1934(c)(5) of the Social Security 
Act (42 U.S.C. 1396u–4(c)(5)) is amended by add-
ing at the end the following new subparagraph: 
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‘‘(C) STATE OPTION TO PERMIT ANY TIME 
ENROLLMENT
AND
EFFECTIVE
DATE
OF
EN-
ROLLMENT.— 
‘‘(i) ANY
TIME
ENROLLMENT.—A 
State may elect to permit a PACE pro-
gram eligible individual to enroll in a 
PACE program at any time during a 
month. 
‘‘(ii) EFFECTIVE DATE.—Pursuant to 
a State election made under clause (i), the 
enrollment of a PACE program eligible in-
dividual in a PACE program shall be effec-
tive on the date the PACE provider oper-
ating the PACE program receives an en-
rollment agreement signed by such PACE 
program eligible individual with respect to 
such PACE program.’’. 
(2) PRORATED PAYMENTS.—Section 1934(d) of 
the Social Security Act (42 U.S.C. 1396u–4(d)) is 
amended by adding at the end the following new 
paragraph: 
‘‘(3) PRORATED PAYMENTS.—If a State elects 
under subsection (c)(5)(C) to permit enrollment at 
any time during a month, in the case of a PACE 
program eligible individual enrolled in a PACE pro-
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gram operated by a PACE provider with an enroll-
ment effective date that is not the first day of a 
month, the State shall prorate the capitation amount 
that would otherwise be made under this subsection 
to the PACE provider for such individual for the 
first month in which such individual is so enrolled.’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall take effect on January 1, 2023. 
SEC. 4. PACE SITE APPROVAL AND EXPANSION. 
(a) IN GENERAL.—Sections 1894(e) and 1934(e) of 
the Social Security Act (42 U.S.C. 1395eee(e), 1396u– 
4(e)) are each amended by striking paragraph (8) and in-
serting the following: 
‘‘(8) AUTHORITY TO SUBMIT APPLICATIONS AT 
ANY
TIME; TIMELY
CONSIDERATION
OF
APPLICA-
TIONS.— 
‘‘(A) AUTHORITY
TO
SUBMIT
APPLICA-
TIONS AT ANY TIME.— 
‘‘(i) NEW PACE PROVIDER STATUS.— 
An entity that seeks to become a PACE 
provider may submit an application for 
PACE provider status at any time. 
‘‘(ii) SERVICE AREA EXPANSION AND 
ADDITION OF PACE CENTER SITE.—To the 
extent the Secretary requires a PACE pro-
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vider to submit an application to expand 
its service area or to add a PACE center 
site, a PACE provider may submit such an 
application at any time, subject to the re-
quirements of section 460.12(d) of title 42, 
Code of Federal Regulations (relating to 
the first trial period audit), or any suc-
cessor regulation. 
‘‘(iii) ASSURANCES.—An application 
for PACE provider status under clause (i) 
or to add a PACE center site under clause 
(ii) shall include the following assurances: 
‘‘(I) An assurance that the re-
quired members of the interdiscipli-
nary team are employees or contrac-
tors of the proposed PACE center or 
will be employees or contractors of the 
proposed PACE center by the time 
the PACE center becomes operational. 
‘‘(II) An assurance that— 
‘‘(aa) the PACE provider’s 
contracts for all contractors and 
contracted personnel will be exe-
cuted by the time the proposed 
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PACE 
center 
becomes 
oper-
ational; and 
‘‘(bb) 
executed 
contracts 
may include provisions for staff-
ing levels commensurate with en-
rollment to full projected census. 
‘‘(B) DEEMED APPROVAL.—An application 
described in subparagraph (A) shall be deemed 
approved unless the Secretary, within 45 days 
after the date of the submission of the applica-
tion to the Secretary, either denies such request 
in writing or informs the applicant in writing 
with respect to any additional information that 
is needed in order to make a final determina-
tion with respect to the application. After the 
date the Secretary receives such additional in-
formation, the application shall be deemed ap-
proved unless the Secretary, within 45 days of 
such date, denies such request.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
subsection (a) shall take effect on January 1, 2023. 
SEC. 5. PACE PILOT. 
Section 1115A(b)(2) of the Social Security Act (42 
U.S.C. 1315a(b)(2)) is amended— 
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(1) in subparagraph (B), by adding at the end 
the following new clause: 
‘‘(xxviii) National testing of a model 
for expanded eligibility for the Program of 
All-Inclusive Care for the Elderly as de-
scribed in subparagraph (D).’’; and 
(2) by adding at the end the following new sub-
paragraph: 
‘‘(D) NATIONAL TESTING OF MODEL FOR 
EXPANDED ELIGIBILITY FOR THE PROGRAM OF 
ALL-INCLUSIVE CARE FOR THE ELDERLY.—In 
the case where the Secretary selects the model 
described in clause (ii) of this subparagraph for 
testing pursuant to clause (xxviii) of subpara-
graph (B), the following shall apply: 
‘‘(i) NATIONAL TESTING.— 
‘‘(I) IN
GENERAL.—Subject to 
subclause (II), the Secretary shall de-
sign a demonstration that allows each 
PACE provider with an executed 
PACE agreement to develop and sub-
mit to the Secretary an application to 
begin testing expanded PACE eligi-
bility for high-need and high-cost pop-
ulations that are not otherwise eligible 
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to participate in a PACE program 
within 1 year of the date on which the 
model is selected. 
‘‘(II) NO
EFFECT
ON
ONGOING 
MODELS
OR
DEMONSTRATION 
PROJECTS.—Nothing in this subpara-
graph shall affect the testing of any 
model under this subsection or any 
demonstration project under this Act 
that is implemented prior to the date 
of the enactment of this subpara-
graph. 
‘‘(ii) MODEL DESCRIBED.—The model 
described in this clause seeks to increase 
access to quality, integrated, care for high- 
need, high-cost individuals who are not 
otherwise eligible to participate in a PACE 
program in order to improve health and re-
duce cost. Under this model, participating 
PACE providers would— 
‘‘(I) be paid fixed, monthly 
capitated rates from both Medicare 
and the applicable State Medicaid 
agency for all services provided to 
each enrollee fitting the criteria of the 
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PACE provider’s designated popu-
lation; 
‘‘(II) partner with non-PACE 
providers, such as Area Agencies on 
Aging, Centers for Independent Liv-
ing, local hospitals, and non-hospital 
providers such as physicians, behav-
ioral health providers and other com-
munity-based organizations to effec-
tively reach the PACE provider’s se-
lected population; 
‘‘(III) adapt the PACE program 
model of care to appropriately serve 
the PACE provider’s selected popu-
lation to integrate care and meet the 
unique needs of said population; and 
‘‘(IV) if the PACE provider is lo-
cated in a State that has not yet 
served the selected population through 
a PACE program under section 1934, 
receive an up-front fixed payment to 
coordinate with the State to develop a 
capitated payment rate, with appro-
priate risk adjustment, for the PACE 
provider’s selected population. 
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under clause (iii)(I) and an expla-
nation of the expanded population the 
PACE organization will serve. 
‘‘(II) The types of services that 
the expanded population will require 
and the PACE provider’s plan to im-
plement these services. 
‘‘(III) How the PACE provider 
will achieve engagement and enroll-
ment of the new population in the 
model, including how it will partner 
with non-PACE providers in the ap-
plicable service area. 
‘‘(IV) How the expanded popu-
lation’s participation in the PACE 
program is intended to improve qual-
ity of care and health outcomes under 
the model. 
‘‘(V) Certification that the appli-
cable State Medicaid agency has ap-
proved the PACE provider’s applica-
tion to participate in the model. 
‘‘(VI) Plans to coordinate with 
the State Medicaid agency to develop 
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an initial capitated rate with appro-
priate risk adjustment. 
‘‘(VII) Plans for the PACE pro-
vider and the State Medicaid agency 
to review and adjust the Medicaid 
capitated rate on a biennial basis, as 
needed. 
‘‘(VIII) Any other information 
required by the Secretary. 
‘‘(v) TECHNICAL
ASSISTANCE.—The 
Secretary shall provide, or designate an en-
tity to provide, technical assistance to par-
ticipating PACE providers as they apply 
for and implement the model. 
‘‘(vi) 
ACCOUNTING
FOR
UNCER-
TAINTY.—In 
order 
for 
implementing 
PACE providers to receive unanticipated 
additional resources needed to implement 
the model, the Secretary shall establish 
procedures for the implementing PACE 
providers to submit to the Secretary a re-
quest for additional resources. 
‘‘(vii) MONITORING OUTCOMES.—The 
Secretary, in conjunction with PACE pro-
viders and in consultation with States that 
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have elected to expand PACE program eli-
gibility under section 1934(l), shall develop 
a plan to— 
‘‘(I) annually monitor outcomes 
under the model, which may include 
financial, quality, access, and utiliza-
tion outcomes; 
‘‘(II) annually monitor the health 
outcomes of the PACE provider’s ex-
panded population; and 
‘‘(III) any other outcomes as de-
termined by the Secretary. 
‘‘(viii) REPORTING REQUIREMENTS.— 
‘‘(I) REPORT
TO
CONGRESS.— 
Not less frequently than every 3 years 
(for the duration of the implementa-
tion of the model under this subpara-
graph), the Secretary shall submit to 
Congress a report on the implementa-
tion of the model under this subpara-
graph. The report shall include demo-
graphic information on the popu-
lations served under the demonstra-
tion, best practices for future imple-
mentation efforts and any other infor-
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mation the Secretary determines ap-
propriate together with recommenda-
tions for such legislation and adminis-
trative action as the Secretary deter-
mines appropriate. 
‘‘(ix) FUNDING.—The Secretary shall 
allocate funds made available under sub-
section (f)(1) to design, implement, evalu-
ate, and report on the model described in 
clause (ii) in accordance with this subpara-
graph.’’. 
SEC. 6. COORDINATION WITH THE FEDERAL COORDINATED 
HEALTH CARE OFFICE. 
Section 1934 of the Social Security Act (42 U.S.C. 
1396u–4), as amended by sections 3 and 8, is amended 
by adding at the end the following new subsection: 
‘‘(m) COORDINATION WITH THE FEDERAL COORDI-
NATED HEALTH CARE OFFICE.— 
‘‘(1) STATE COORDINATION WITH FCHCO.—The 
Director of the Federal Coordinated Health Care Of-
fice established under section 2602 of the Patient 
Protection and Affordable Care Act shall serve as a 
point of contact between State administering agen-
cies and the Federal Government for purposes of im-
plementing and operating a PACE program in a 
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State, and shall coordinate with other relevant of-
fices and staff of the Centers for Medicare & Med-
icaid Services involved in carrying out this section. 
‘‘(2) ANNUAL REPORT.—Not later than Janu-
ary 1, 2023, and annually thereafter, the Director of 
the Federal Coordinated Health Care Office shall 
submit to Congress a report on the demographics of 
the populations served by PACE programs operated 
under this section and section 1894.’’. 
SEC. 7. EVALUATION OF EFFECTIVENESS OF PACE PRO-
GRAM IN RURAL AND UNDERSERVED AREAS. 
(a) IN GENERAL.—The Assistant Secretary for Plan-
ning and Evaluation of the Department of Health and 
Human Services (referred to in this section as the ‘‘Assist-
ant Secretary’’) shall conduct an evaluation of the effec-
tiveness of the program for all-inclusive care for the elder-
ly under sections 1894 and 1934 of the Social Security 
Act (42 U.S.C. 1395eee, 1396u–4) in rural and under-
served areas, including with respect to the following fac-
tors: 
(1) Reductions in hospitalizations and re-hos-
pitalizations among program beneficiaries. 
(2) Reductions in emergency department use 
among program beneficiaries. 
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(3) Reductions in long-term nursing facility use 
among program beneficiaries. 
(4) Reductions in mortality among program 
beneficiaries. 
(5) Achieving lower rates of functional decline, 
and improvements in reported health status and 
quality of life among program beneficiaries. 
(6) Reductions in the total cost of care among 
program beneficiaries. 
(7) The effect of activities supported under the 
program on the local area serviced by the program, 
including on the health and well-being of unpaid and 
family caregivers of program beneficiaries. 
(8) Improvements in quality of life among pro-
gram beneficiaries. 
(b) REPORT.—Not later than 60 months after the 
date of enactment of this Act, the Assistant Secretary 
shall submit a report containing the results of the evalua-
tion required under subsection (a), an analysis of which 
elements of the program for all-inclusive care for the elder-
ly under sections 1894 and 1934 of the Social Security 
Act (42 U.S.C. 1395eee, 1396u–4) should be replicated 
and scaled by governmental or non-governmental entities, 
and such recommendations for legislation and administra-
tive action as the Assistant Secretary determines appro-
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priate to the chairs and ranking members of the following 
committees: 
(1) The Special Committee on Aging of the 
Senate. 
(2) The Committee on Finance of the Senate. 
(3) The Committee on Health, Education, 
Labor, and Pensions of the Senate. 
(4) The Committee on Ways and Means of the 
House of Representatives. 
(5) The Committee on Energy and Commerce 
of the House of Representatives. 
(c) PARTNERS.—In conducting the evaluation and 
completing the report required under this section, the As-
sistant Secretary shall provide an opportunity for partners 
and persons that have participated in the program for all- 
inclusive care for the elderly under sections 1894 and 
1934 of the Social Security Act (42 U.S.C. 1395eee, 
1396u–4) on every level, especially individuals who receive 
care through the program and their unpaid or family care-
givers, to have an opportunity to contribute their expertise 
to evaluating the strategy and outcomes of the program. 
Æ 
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