I 
114TH CONGRESS 
1ST SESSION 
H. R. 837 
To implement a demonstration project under titles XVIII and XIX of the 
Social Security Act to examine the costs and benefits of providing pay-
ments for comprehensive coordinated health care services provided by 
purpose-built, continuing care retirement communities to Medicare bene-
ficiaries. 
IN THE HOUSE OF REPRESENTATIVES 
FEBRUARY 10, 2015 
Mr. FITZPATRICK (for himself, Mr. KELLY of Pennsylvania, Mr. CART-
WRIGHT, Mr. ROTHFUS, Mr. BRENDAN F. BOYLE of Pennsylvania, Mr. 
MICHAEL F. DOYLE of Pennsylvania, Mr. BARTON, Mr. BRADY of Penn-
sylvania, Mr. FATTAH, Mr. BUCHANAN, and Ms. JENKINS of Kansas) in-
troduced the following bill; which was referred to the Committee on En-
ergy and Commerce, and in addition to the Committee on Ways and 
Means, for a period to be subsequently determined by the Speaker, in 
each case for consideration of such provisions as fall within the jurisdic-
tion of the committee concerned 
A BILL 
To implement a demonstration project under titles XVIII 
and XIX of the Social Security Act to examine the 
costs and benefits of providing payments for comprehen-
sive coordinated health care services provided by purpose- 
built, continuing care retirement communities to Medi-
care beneficiaries. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
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SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Medicare Residential 
Care Coordination Act of 2015’’. 
SEC. 2. MEDICARE AND MEDICAID RESIDENTIAL CARE CO-
ORDINATION DEMONSTRATION PROJECT. 
(a) ESTABLISHMENT AND IMPLEMENTATION.— 
(1) IN GENERAL.—The Secretary of Health and 
Human Services (in this section referred to as the 
‘‘Secretary’’) shall establish and implement a dem-
onstration project (in this section referred to as the 
‘‘demonstration project’’) under titles XVIII and 
XIX of the Social Security Act to evaluate the use 
of capitated payments made to eligible continuing 
care retirement communities for residential care co-
ordination programs. 
(2) TIMETABLE
FOR
IMPLEMENTATION.—In 
carrying out this section— 
(A) not later than 1 year after the date of 
the enactment of this Act the Secretary shall 
complete the design for the demonstration 
project and enter into one or more agreements 
with eligible CCRCs for the implementation of 
the project with respect to such CCRCs; and 
(B) not later than 4 years after the date 
of entering into such agreements, first provide 
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for implementation of the project through such 
CCRCs. 
(b) BUDGET NEUTRALITY.—With respect to the pe-
riod of the demonstration project under this section, the 
aggregate expenditures under titles XVIII and XIX of the 
Social Security Act for such period shall not exceed the 
aggregate expenditures that would have been expended 
under such titles if the demonstration project had not been 
implemented. 
(c) STATE ELECTION REQUIRED.— 
(1) IN GENERAL.—The Secretary may only im-
plement the demonstration project in a State that 
elects to participate in the demonstration project. 
(2) BENEFITS AND PAYMENTS.—A State that 
elects to participate in the demonstration project 
shall provide medical assistance through title XIX of 
the Social Security Act for each eligible CCRC resi-
dent who is eligible for medical assistance under the 
State plan under such title (including such residents 
who 
are 
made 
eligible 
under 
subsection 
(d)(3)(B)(iii)) and who is enrolled in a residential 
care coordination program in a manner that is con-
sistent with the requirements of this section, includ-
ing making the payments under subsection (e). 
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(3) LIMITATION.—A State may establish a nu-
merical limit on— 
(A) the number of eligible CCRC residents 
who may be enrolled in residential care coordi-
nation programs in the State; and 
(B) the number of eligible CCRCs that 
may operate residential care coordination pro-
grams in the State. 
(d) RESIDENTIAL CARE COORDINATION PROGRAM 
(RCCP); ELIGIBLE
CONTINUING
CARE
RETIREMENT 
COMMUNITY (CCRC); ELIGIBLE CCRC RESIDENTS; COM-
PREHENSIVE COORDINATED HEALTH CARE SERVICES 
DEFINED.— 
(1) RESIDENTIAL
CARE
COORDINATION
PRO-
GRAM; RCCP.—For purposes of this section, the 
terms ‘‘residential care coordination program’’ and 
‘‘RCCP’’ mean a program that— 
(A) is operated within one or more eligible 
continuing care retirement communities (as de-
fined in paragraph (2)); 
(B) is designed with a capacity of serving 
at least 1,000, but not more than 1,500, eligible 
CCRC residents (as defined in paragraph (3)) 
at any one time; and 
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(C) provides comprehensive coordinated 
health care services (as defined in paragraph 
(4)) to participating CCRC residents enrolled in 
the program in accordance with the program 
agreement under subsection (f) and the require-
ments of this section. 
(2) ELIGIBLE CONTINUING CARE RETIREMENT 
COMMUNITY; ELIGIBLE CCRC.—In this section, the 
terms ‘‘eligible continuing care retirement commu-
nity’’ and ‘‘eligible CCRC’’ mean an entity that is a 
continuing care retirement community (as defined in 
section 1852(l)(4)(B) of the Social Security Act (42 
U.S.C. 1395w–22(l)(4)(B))) that— 
(A) is built for the purposes of partici-
pating in the demonstration project; 
(B) provides onsite— 
(i) housing accommodations for eligi-
ble CCRC residents, including apartments 
for independent living; and 
(ii) additional services to facilitate 
aging in place for such residents, including 
assisted living and skilled nursing facilities 
or alternatives; and 
(C) has entered into a program agreement 
with the Secretary and the State with respect 
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to its operation of the residential care coordina-
tion program and such agreement is consistent 
with the requirements of this section. 
(3) ELIGIBLE CCRC RESIDENT; PARTICIPATING 
CCRC RESIDENT.— 
(A) IN GENERAL.—For purposes of this 
section: 
(i) ELIGIBLE
CCRC
RESIDENT.—The 
term ‘‘eligible CCRC resident’’ means an 
individual who— 
(I) is entitled to, or enrolled for, 
benefits under part A of title XVIII of 
the Social Security Act, and enrolled 
for benefits under part B of such title; 
and 
(II) resides in an eligible CCRC. 
(ii) 
PARTICIPATING
CCRC
RESI-
DENT.—The term ‘‘participating CCRC 
resident’’ means, with respect to a resident 
care coordination program, an eligible 
CCRC resident who is enrolled in that pro-
gram. 
(B) PARTICIPATION BY DUAL-ELIGIBLE IN-
DIVIDUALS; EXPANDED ELIGIBILITY.— 
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(i) IN GENERAL.—An eligible CCRC 
resident may be, but is not required to be, 
a dual-eligible individual. 
(ii) DUAL-ELIGIBLE INDIVIDUAL DE-
FINED.—In this section, the term ‘‘dual-el-
igible individual’’ means any individual 
who is— 
(I) a full-benefit dual eligible in-
dividual 
(as 
defined 
in 
section 
1935(c)(6) of the Social Security 
Act); or 
(II) is described in clause (iii). 
(iii) 
QUALIFICATION
OF
PARTICI-
PATING
CCRC
RESIDENTS
FOR
MEDICAID 
BENEFITS.—An individual who is a partici-
pating CCRC resident, regardless of the 
level of care, who meets income and re-
source eligibility criteria established under 
the State Medicaid plan for an individual 
to obtain coverage for nursing facility serv-
ices on the basis of the individual’s re-
quirement for the level of care for such 
services, shall be treated as a dual-eligible 
individual under this section and under 
title XIX of the Social Security Act so long 
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as the individual remains a participating 
CCRC resident. 
(C) ENROLLMENT
AND
DISENROLLMENT 
RULES.— 
(i) DEEMED
ENROLLMENT
AT
TIME 
OF
INITIAL
RESIDENCY.—An individual 
who is described in subclause (I) of sub-
paragraph (A)(i) is deemed, at the time of 
becoming a resident in an eligible CCRC, 
to have voluntarily consented to enroll in 
the RCCP operated by that CCRC for pur-
poses of subparagraph (A)(ii). 
(ii) DISENROLLMENT PROCESS.—The 
demonstration project shall provide a 
method for the disenrollment from the 
project of participating CCRC residents, 
which method shall take into account the 
unique circumstances of residents who are 
required to leave the CCRC and shall per-
mit disenrollment at least in the same cir-
cumstances as would permit an individual 
to disenroll from a Medicare Advantage 
plan under part C of title XVIII of the So-
cial Security Act for cause. 
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(D) RELATION TO MEDICARE ADVANTAGE 
AND PRESCRIPTION DRUG PROGRAM.— 
(i) SUPERCEDES
ENROLLMENT.—A 
participating CCRC resident is not eligible 
to enroll in an MA plan under part C of 
title XVIII of the Social Security Act or 
under a prescription drug plan under part 
D of such title. 
(ii) 
COORDINATION
IN
CASE
OF 
DISENROLLMENT.—In the case of a par-
ticipating CCRC resident who disenrolls 
from 
the 
demonstration 
project, 
the 
disenrollment shall be treated, for purposes 
of parts C and D of such title, as if the in-
dividual had been previously enrolled in, 
and disenrolled from, an MA–PD plan 
under part C of such title. 
(E) PREMIUM PAYMENTS.—During the pe-
riod in which an individual is a participating 
CCRC resident— 
(i) for purposes of payment of pre-
miums under parts B, C, and D of title 
XVIII of the Social Security Act, the indi-
vidual shall be treated as if the individual 
were enrolled under an MA–PD plan with 
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a premium equal to an amount specified in 
the program agreement; and 
(ii) the individual shall be eligible for 
assistance with respect to such premiums 
under part D and Medicare cost-sharing in 
the same manner and in the equivalent 
amounts as if the individual had not been 
enrolled as a participating CCRC resident. 
(4) COMPREHENSIVE
COORDINATED
HEALTH 
CARE
SERVICES
DEFINED.—For purposes of this 
section, the term ‘‘comprehensive coordinated health 
care services’’, with respect to an eligible CCRC resi-
dent— 
(A) means all items and services that are 
otherwise payable under title XVIII of the So-
cial Security Act, including the minimum pre-
scription drug coverage required under a pre-
scription drug plan under part D of such title; 
(B) includes in the case of a dual eligible 
individual all items and services that are other-
wise payable under the State plan under title 
XIX of such Act of the State in which the resi-
dent resides; and 
(C) also includes— 
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(i) care management services that co-
ordinate acute and specialty services (in-
cluding inpatient hospital services, services 
provided by specialty physicians, and other 
necessary services) provided to eligible 
CCRC residents; 
(ii) wellness services, including assist-
ance and instruction in healthy living (in-
cluding diet and exercise); and 
(iii) other health care items and serv-
ices to manage chronic conditions, treat 
subacute conditions, and provide preventive 
care. 
(e) PAYMENT UNDER MEDICARE AND MEDICAID.— 
(1) IN GENERAL.—In the case of an individual 
who is a participating CCRC resident who is en-
rolled in a residential care coordination program op-
erated by an eligible CCRC— 
(A) the individual shall receive benefits 
under title XVIII of the Social Security Act, 
and, if such individual is a dual-eligible indi-
vidual (as defined in subsection (d)(3)(B)(ii)), 
under the State Medicaid plan or waiver under 
title XIX of such Act, solely through the resi-
dential care coordination program, which shall 
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provide such individual with comprehensive co-
ordinated health care services; and 
(B) the eligible CCRC shall receive 
capitated payments for the provision of such 
services (from the Secretary for benefits under 
title XVIII and from the State for benefits 
under such State plan or waiver), in accordance 
with this section. 
(2) PAYMENT METHODOLOGY.— 
(A) PAYMENT UNDER MEDICARE.— 
(i) PAYMENT ON MONTHLY BASIS.— 
With respect to each eligible CCRC, the 
Secretary shall make prospective monthly 
payments of a capitated amount, based on 
the rate established under clause (ii), for 
each participating CCRC resident enrolled 
in the residential care coordination pro-
gram operated by such CCRC in the same 
manner and from the same sources as pay-
ments are made to a Medicare Advantage 
organization under section 1853 of the So-
cial Security Act (42 U.S.C. 1395w–23). 
Such payments shall be subject to adjust-
ment in the manner described in para-
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graphs (2) and (3) of subsection (a) of 
such section 1853. 
(ii) ESTABLISHMENT
OF
PAYMENT 
RATE.— 
(I) IN GENERAL.—The Secretary 
shall 
establish 
a 
risk-adjusted 
capitated payment rate under title 
XVIII of the Social Security Act for 
comprehensive coordinated health care 
services provided to eligible CCRC 
residents through a residential care 
coordination program operated by an 
eligible CCRC. The payment rate shall 
be 90 percent of the adjusted average 
per capita cost described in section 
1853(c)(1)(D)(i) of such Act (42 
U.S.C. 1395w–23(c)(1)(D)(i)), plus 
an amount equivalent to 90 percent of 
the amount that would have been paid 
to a prescription drug plan the stand-
ardized bid amount of which (as de-
fined in section 1860D–13(a)(5) of 
such 
Act 
(42 
U.S.C. 
1395w– 
113(a)(5))) was equal to the adjusted 
national average monthly bid amount 
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(as 
defined 
in 
section 
1860D– 
13(a)(1)(B)(iii) of such Act (42 
U.S.C. 1395w–113(a)(1)(B)(iii))) and 
taking into account low-income sub-
sidies paid under section 1860D–14 
(42 U.S.C. 1395w–114). 
(II) PROGRAM
AGREEMENT.— 
The mechanism for establishing the 
capitated amount under this subpara-
graph for a specific eligible CCRC 
shall be specified in the program 
agreement. 
(B) PAYMENT UNDER MEDICAID.— 
(i) PAYMENT ON A MONTHLY BASIS.— 
With respect to an eligible CCRC oper-
ating an RCCP, the State shall make pro-
spective monthly payments of the capitated 
amount determined under and specified in 
the program agreement for each eligible 
CCRC resident of such community who is 
a dual-eligible individual. 
(ii) RELATIONSHIP TO MEDICARE PAY-
MENTS.—The payment made under this 
subparagraph shall be in addition to any 
payment made under subparagraph (A) to 
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an eligible CCRC for eligible CCRC resi-
dents who are dual-eligible individuals. 
(iii) 
PROGRAM
AGREEMENT.—The 
capitated amount under this subparagraph 
for a specific eligible CCRC shall be speci-
fied in the program agreement. 
(iv) PAYMENTS TO THE STATE.—The 
Secretary shall treat the payments made 
under clause (i) as medical assistance 
under title XIX of the Social Security Act 
for purposes of making payments to the 
State under section 1903 of such Act (42 
U.S.C. 1396b). 
(v) PAYMENTS
TO
REFLECT
SPEND 
DOWN
AMOUNTS
AND
PERSONAL
NEEDS 
ALLOWANCES.—The payments under this 
subparagraph shall be made in a manner 
that takes into account the financial con-
tributions required of dual-eligible individ-
uals and the personal needs allowance es-
tablished under the State plan. Such per-
sonal needs allowances may vary depending 
upon the level of care required by such an 
individual. 
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(3) TREATMENT OF SERVICES FURNISHED BY 
NONCONTRACT PHYSICIANS AND OTHER ENTITIES.— 
(A) APPLICATION
OF
MEDICARE
ADVAN-
TAGE REQUIREMENTS.—Section 1852(k)(1) of 
the Social Security Act (42 U.S.C. 1395w– 
22(k)(1)) (relating to limitations on balance 
billing against Medicare Advantage organiza-
tions for noncontract physicians and other enti-
ties with respect to services covered under title 
XVIII of such Act) shall apply to eligible 
CCRCs, eligible CCRC residents enrolled in a 
residential care coordination program, and phy-
sicians and other entities that do not have a 
contract or other agreement establishing pay-
ment amounts for services furnished to such a 
resident in the same manner as such section ap-
plies to Medicare Advantage organizations, indi-
viduals enrolled with such organizations, and 
physicians and other entities referred to in such 
section. 
(B) APPLICATION OF BALANCED BILLING 
LIMITATIONS.—Section 1866(a)(1)(O) of the 
Social 
Security 
Act 
(42 
U.S.C. 
1395cc(a)(1)(O)) shall apply to services that 
are covered under title XVIII of the Social Se-
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curity Act and are furnished to any eligible 
CCRC residents enrolled in a residential care 
coordination program in the same manner that 
such section applies to services furnished to an 
individual enrolled with a PACE provider under 
section 1894 or 1934 of such Act (42 U.S.C. 
1395eee). 
(f) PROGRAM AGREEMENT.— 
(1) REQUIREMENT.—The Secretary, in close co-
operation with the single State agency that admin-
isters or supervises the administration of the State 
plan under title XIX of the Social Security Act (42 
U.S.C. 1396 et seq.) (in this section referred to as 
the ‘‘State Medicaid agency’’), shall establish proce-
dures for entering into, extending, and terminating 
program agreements (each in this section referred to 
as a ‘‘program agreement’’) for the operation of resi-
dential care coordination programs by eligible 
CCRCs. 
(2) AGREEMENT REQUIRED FOR PAYMENT.—In 
order to receive payment under subsection (e), each 
eligible CCRC operating a residential care coordina-
tion program shall enter into a program agreement 
with the Secretary and the State, which shall con-
tain such terms and conditions as the parties may 
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agree to, so long as such terms and conditions are 
consistent with this section. 
(3) DURATION.— 
(A) IN GENERAL.—A program agreement 
under this section shall be effective for a con-
tract year, beginning consistent with subsection 
(a)(2)(B) not later than the fourth calendar 
year to begin after the establishment of the 
demonstration project, and shall be extended 
for additional contract years in the absence of 
notice by a party to terminate. 
(B) TERMINATION.— 
(i) 
END
OF
DEMONSTRATION 
PROJECT.—The Secretary and the State 
Medicaid agency shall terminate the pro-
gram agreement at the termination of the 
demonstration project under subsection (i). 
(ii) NOTICE
OF
PROVIDER
TERMI-
NATION.—The eligible CCRC may termi-
nate the agreement after appropriate no-
tice to the Secretary, the State Medicaid 
agency, and eligible CCRC residents. 
(iii) TERMINATION FOR CAUSE.—The 
Secretary and the State Medicaid agency 
may terminate the program agreement at 
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any time for cause (as provided under the 
agreement). Reasons for terminating an 
agreement under this clause include that 
the Secretary or State administering agen-
cy determines that— 
(I) there are significant defi-
ciencies in the quality of care provided 
to eligible CCRC residents enrolled in 
the program or the eligible CCRC has 
failed to comply substantially with the 
requirements of this section; and 
(II) the entity has failed to de-
velop and successfully initiate, within 
30 days of the date of the receipt of 
written notice of such a determina-
tion, a plan to correct the deficiencies, 
or has failed to continue implementa-
tion of such a plan. 
(iv) RIGHT TO REMAIN.—Nothing in 
this paragraph shall be construed, in the 
case that a program agreement is termi-
nated— 
(I) for a previously participating 
CCRC resident continuing, as affect-
ing the individual’s right to continue 
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to reside in the CCRC and to receive 
traditional CCRC care and services in 
accordance with the contract between 
the CCRC resident and the CCRC; 
and 
(II) as relieving the State from 
continuing to provide medical assist-
ance with respect to such services for 
individuals who would qualify as dual- 
eligible individuals if the agreement 
had not been terminated. 
(4) SCOPE OF BENEFITS.— 
(A) IN GENERAL.—Under the agreement 
under paragraph (2), the eligible CCRC shall— 
(i) provide to participating CCRC 
residents of such community, regardless of 
source of payment, directly or under con-
tracts with other entities, at a minimum, 
all comprehensive coordinated health care 
services, without regard to any limitation 
or condition as to amount, duration, or 
scope under title XVIII or title XIX of the 
Social Security Act; 
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(ii) provide such residents with access 
to necessary covered items and services 24 
hours a day, every day of the year; 
(iii) provide services to such residents 
onsite at the eligible CCRC through a mul-
tidisciplinary team that is led by a primary 
care physician and includes care coordina-
tors, case managers, and nurses; 
(iv) has a ratio of accessible physi-
cians to eligible CCRC residents that the 
Secretary determines is adequate; and 
(v) specify the covered items and serv-
ices that will not be provided directly by 
the eligible CCRC and— 
(I) provide for delivery of those 
items and services through contracts 
to ensure compliance with the require-
ments of this section; and 
(II) provides, on an as needed 
basis for those residents who cannot 
transport themselves, for necessary 
transportation services to the pro-
viders of such items and services, if 
such items and services are provided 
outside of the eligible CCRC. 
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(B) APPLICATION
OF
REGULAR
COST- 
SHARING RULES.—Under such agreement the 
eligible CCRC may apply deductibles, copay-
ments, coinsurance, or other cost sharing that 
would otherwise apply under titles XVIII and 
XIX of the Social Security Act in the case of 
an MA–PD plan under part C of title XVIII of 
such Act. 
(5) QUALITY CONTROL.— 
(A) IN
GENERAL.—Under the program 
agreement, the eligible CCRC shall— 
(i) collect data; 
(ii) maintain, and afford the Secretary 
and the State Medicaid agency access to, 
the records relating to the program, in-
cluding pertinent financial, medical, and 
personnel records; and 
(iii) submit to the Secretary and the 
State Medicaid agency such reports as the 
Secretary finds (in consultation with State 
Medicaid agencies) necessary to monitor 
the operation, cost, and effectiveness of the 
demonstration project, including data rel-
evant to the measurements established by 
the Secretary under subparagraph (B), to 
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