I 
116TH CONGRESS 
2D SESSION 
H. R. 8254 
To establish a demonstration program to provide integrated care for Medicare 
beneficiaries with end-stage renal disease, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
SEPTEMBER 15, 2020 
Mr. BLUMENAUER (for himself, Mr. SMITH of Missouri, Mr. CA´RDENAS, Mrs. 
RODGERS of Washington, Mr. BUTTERFIELD, Mr. WENSTRUP, and Ms. 
SHALALA) introduced the following bill; which was referred to the Com-
mittee on Energy 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 jurisdiction of the committee concerned 
A BILL 
To establish a demonstration program to provide integrated 
care for Medicare beneficiaries with end-stage renal dis-
ease, 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 ‘‘Bringing Enhanced 
Treatments and Therapies to ESRD Recipients Kidney 
Care Act’’ or the ‘‘BETTER Kidney Care Act’’. 
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SEC. 2. FINDINGS. 
Congress finds the following: 
(1) Although the relative rate of end-stage renal 
disease (referred to in this section as ‘‘ESRD’’) 
among the Nation’s minority populations has de-
clined, significant disparities remain. Compared to 
Whites, Black Americans are 2.6 times more likely 
to have kidney failure, while Native Americans and 
Alaska Natives are 1.2 times more likely. Hispanics 
are 1.3 times more likely to have kidney failure com-
pared to non-Hispanics. 
(2) Disparities also exist with respect to treat-
ment modalities. Specifically, although home dialysis 
can offer advantages, Black, Hispanic, and Native 
American and Alaska Native ESRD patients are less 
likely to initiate home treatment than White ESRD 
patients. 
(3) Numerous studies show that individuals 
with low incomes and in low-income communities are 
at greater risk for ESRD. 
(4) In addition to their kidney disease, ESRD 
patients across all races and ethnicities often suffer 
from one or more comorbidities. Eighty-eight per-
cent of ESRD patients have a history of hyper-
tension, 42 percent have diabetes, and nearly 30 
percent have congestive heart failure. 
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(5) Each month, ESRD patients see multiple 
providers and take several medications to manage 
their kidney disease and comorbid conditions. Of all 
patients, those with ESRD stand to benefit greatly 
from better coordinated care. 
(6) The Executive Order on Advancing Amer-
ican Kidney Health recognizes the need to develop 
and implement new ESRD care delivery models to 
improve quality and value for ESRD patients and 
the Medicare program. 
(7) In alignment with that goal, it is imperative 
that Medicare test new models that have at their 
core an interdisciplinary care team, among other 
structural requirements, to— 
(A) help ESRD patients better navigate 
the health care system; 
(B) empower such patients to manage 
their plan of care and medication regimen; 
(C) support such patients in receiving the 
treatment modality, including a kidney trans-
plant, as prescribed by their nephrologist; 
(D) access services to meet the nonclinical 
needs of such patients that can affect care out-
comes; and 
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(E) receive additional services, such as 
transplant evaluation, palliative care, evaluation 
for hospice eligibility, and vascular access care. 
SEC. 3. DEMONSTRATION PROGRAM TO PROVIDE INTE-
GRATED 
CARE 
FOR 
MEDICARE 
BENE-
FICIARIES WITH END-STAGE RENAL DISEASE. 
(a) IN GENERAL.—Title XVIII of the Social Security 
Act is amended by inserting after section 1866F the fol-
lowing new section: 
‘‘DEMONSTRATION
PROGRAM
TO
PROVIDE
INTEGRATED 
CARE
FOR
MEDICARE
BENEFICIARIES
WITH
END- 
STAGE RENAL DISEASE 
‘‘SEC. 1866G. (a) ESTABLISHMENT.— 
‘‘(1) IN GENERAL.—The Secretary shall con-
duct under this section the ESRD Fee-For-Service 
Integrated Care Demonstration Program (in this 
section referred to as the ‘Program’), which is vol-
untary for Program-eligible beneficiaries and eligible 
participating providers, to assess the effects of alter-
native care delivery models and payment methodolo-
gies on patient care improvements under this title 
for such beneficiaries. Under the Program— 
‘‘(A) Program-eligible beneficiaries shall be 
considered original Medicare Fee-For-Service 
beneficiaries (as defined in section 1899(h)(3)) 
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for the duration of the participation of such 
beneficiaries under the Program; 
‘‘(B) eligible participating providers may 
form an ESRD Fee-For-Service Integrated 
Care Organization (in this section referred to as 
an ‘Organization’); and 
‘‘(C) an Organization shall integrate care 
under the original Medicare Fee-For-Service 
program under parts A and B for Program-eli-
gible beneficiaries. 
‘‘(2) DEFINITIONS.—In this section: 
‘‘(A) 
ELIGIBLE
PARTICIPATING
PRO-
VIDER.—The term ‘eligible participating pro-
vider’ means any of the following: 
‘‘(i) A facility certified as a renal di-
alysis facility under this title. 
‘‘(ii) An entity that owns one or more 
of such facilities described in clause (i). 
‘‘(iii) A nephrologist (including a pedi-
atric nephrologist) or nephrology practice. 
‘‘(iv) Any other physician or physician 
group practice. 
‘‘(v) A nurse practitioner, physician 
assistant, or clinical nurse specialist (as 
such 
terms 
are 
defined 
in 
section 
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1861(aa)(5)) or a clinical social worker (as 
defined in section 1861(hh)(1)) working in 
conjunction with such a nurse practitioner, 
physician assistant, or clinical nurse spe-
cialist. 
‘‘(B) 
ELIGIBLE
PARTICIPATING
PART-
NER.—The term ‘eligible participating partner’ 
means, with respect to an Organization, any of 
the following: 
‘‘(i) A Medicare Advantage plan de-
scribed in section 1851(a)(2) or a Medi-
care Advantage organization offering such 
a plan. 
‘‘(ii) A medicaid managed care organi-
zation (as defined in section 1903(m)). 
‘‘(iii) A hospital or an academic med-
ical center experienced in the care of pa-
tients receiving dialysis. 
‘‘(iv) Any other entity determined ap-
propriate by the Secretary. 
‘‘(C) PROGRAM-ELIGIBLE BENEFICIARY.— 
‘‘(i) IN
GENERAL.—The term ‘Pro-
gram-eligible beneficiary’ means, with re-
spect to an Organization offering an 
ESRD Fee-For-Service Integrated Care 
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Model, an individual entitled to benefits 
under part A and enrolled under part B 
(including such an individual entitled to 
medical assistance under a State plan 
under title XIX) who— 
‘‘(I) is identified by the Secretary 
as having end-stage renal disease and 
who is receiving renal dialysis services 
under the original Medicare Fee-For- 
Service program under parts A and B, 
and is not enrolled in a Medicare Ad-
vantage plan under part C or group 
health insurance coverage or indi-
vidual health insurance coverage (as 
defined in section 2791(b) of the Pub-
lic Health Service Act (42 U.S.C. 
300gg–91(b))) that is primary to cov-
erage under this title; 
‘‘(II) receives renal dialysis serv-
ices primarily from an eligible partici-
pating provider of such Organization, 
including such renal dialysis services 
received after being identified as a 
suitable candidate for transplantation; 
and 
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‘‘(III) has attained the age of 18 
years. 
‘‘(ii) AFFIRMATION OF PROGRAM ELI-
GIBILITY
UPON
HOSPICE
ELECTION
OR 
KIDNEY TRANSPLANT.—A Program-eligible 
beneficiary who was assigned to or elected 
an ESRD Fee-For-Service Integrated Care 
Model offered by an Organization and 
who— 
‘‘(I) elects to receive hospice ben-
efits under section 1852(d)(1); or 
‘‘(II) receives a kidney transplant 
as covered under this title and main-
tains entitlement to benefits under 
part A and enrollment in part B on 
the basis of end stage renal disease, 
shall continue to meet the definition of 
Program-eligible 
beneficiary 
established 
under this subparagraph. 
‘‘(b) ESRD FEE-FOR-SERVICE INTEGRATED CARE 
ORGANIZATION ELIGIBILITY REQUIREMENTS.— 
‘‘(1) ORGANIZATIONS.— 
‘‘(A) IN GENERAL.—One or more eligible 
participating providers may establish an Orga-
nization and may enter into, subject to sub-
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Model offered by the Organization and who 
continue their assignment to or election of 
the Organization. 
‘‘(ii) ALLOWING
TRANSITION.—The 
Secretary may waive the requirement 
under clause (i) for an Organization dur-
ing the first agreement year with respect 
to the Organization. 
‘‘(D) 
FISCAL
SOUNDNESS
REQUIRE-
MENTS.— 
‘‘(i) IN
GENERAL.—The Secretary 
shall enter into appropriate agreements 
under this section only with Organizations 
that demonstrate sufficient capital re-
serves, measured as a percentage of 
monthly prospective payments described in 
subsection (e) and consistent with capital 
reserve requirements established by each 
State in which the Organization operates, 
subject to clause (ii). 
‘‘(ii) ALTERNATIVE
MECHANISM
TO 
DEMONSTRATE RISK-BEARING CAPACITY.— 
An Organization shall be considered to 
meet the requirement in clause (i) if the 
Organization includes at least one eligible 
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participating provider or eligible partici-
pating partner that— 
‘‘(I)(aa) is licensed under State 
law as a risk-bearing entity eligible to 
offer health insurance or health bene-
fits coverage in each State in which 
the Organization participates in the 
demonstration under this section; or 
‘‘(bb) is otherwise authorized by 
each state in which the Organization 
participates 
in 
the 
demonstration 
under this section to bear risk for of-
fering health insurance or health ben-
efits; 
‘‘(II) agrees to bear risk under 
the Organization; and 
‘‘(III) has the capacity to bear 
risk commensurate with the Organiza-
tion’s expected expenditures under an 
agreement under this section. 
‘‘(iii) DISCLOSURE.—Each Organiza-
tion with an agreement under this section 
shall, in accordance with current regula-
tions of the Secretary that govern similar 
disclosures, report to the Secretary finan-
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cial information consistent with such infor-
mation required to be reported by a Medi-
care Advantage organization under part C 
to demonstrate that the Organization has 
a fiscally sound operation. 
‘‘(E) 
GOVERNANCE
REQUIREMENTS.— 
Each Organization with an agreement under 
this section shall establish a governing body 
with oversight responsibility for the Organiza-
tion’s compliance with Program requirements 
that includes— 
‘‘(i) representation from each eligible 
participating provider of such Organiza-
tion; 
‘‘(ii) at least two nephrologists, one of 
which may be affiliated with an eligible 
participating provider; and 
‘‘(iii) at least one beneficiary advo-
cate. 
‘‘(2) ESRD 
FEE-FOR-SERVICE
INTEGRATED 
CARE MODEL.— 
‘‘(A) BENEFIT REQUIREMENTS.— 
‘‘(i) IN GENERAL.—Subject to clause 
(iii), an Organization shall offer an ESRD 
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Fee-For-Service Integrated Care Model 
that shall— 
‘‘(I) cover all benefits under 
parts A and B (subject to payment 
rules regarding the treatment of and 
payment for kidney organ acquisitions 
and hospice described in subsections 
(e)(3) and (4)); and 
‘‘(II) include services for transi-
tion (particularly including education) 
into transplantation, palliative care, 
and hospice. 
‘‘(ii) DETERMINATION
AND
TREAT-
MENT OF SAVINGS.— 
‘‘(I) IN
GENERAL.—The Sec-
retary shall require any Organization 
offering an ESRD Fee-For-Service 
Integrated Care Model to provide for 
the return under subclause (VI) to a 
Program-eligible beneficiary assigned 
to or who elects an Organization sav-
ings equal to the amount, if any, by 
which the payment amount described 
in subclause (V) with respect to the 
Program-eligible beneficiary for a year 
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exceeds the average revenue amount 
described in subclause (IV) with re-
spect to the Program-eligible bene-
ficiary for the year. 
‘‘(II) SAVINGS
DETERMINATION 
PROCESS.—The Secretary shall deter-
mine the savings described in sub-
clause (I) in the same manner as the 
rebate calculation for individuals with 
end-stage renal disease enrolled in 
Medicare 
Advantage 
organizations 
under section 1859(b)(6)(B)(iii). 
‘‘(III) APPLICATION OF MEDICAL 
LOSS
RATIO
REQUIREMENTS.—Noth-
ing shall preclude the Secretary from 
applying medical loss ratio require-
ments described in section 1857(e)(4) 
under this section. 
‘‘(IV) 
AVERAGE
REVENUE 
AMOUNT
DESCRIBED.—The revenue 
amount described in this subclause, 
with respect to an Organization offer-
ing an ESRD Fee-For-Service Inte-
grated Care Model and a Program-eli-
gible beneficiary assigned to or who 
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elects such Organization, is the Orga-
nization’s estimated average revenue 
requirements, including administrative 
costs and return on investment, for 
the Organization to provide the bene-
fits described in clause (i) under the 
Model for the Program-eligible bene-
ficiary for the year. 
‘‘(V) PAYMENT
AMOUNT
DE-
SCRIBED.—The payment amount de-
scribed in this subclause, with respect 
to an Organization offering an ESRD 
Fee-For-Service 
Integrated 
Care 
Model and a Program-eligible bene-
ficiary assigned to or who elects such 
Organization, is the payment amount 
to the Organization under subsection 
(e)(1) (adjusted pursuant to sub-
section (e)(2) and subject to the treat-
ment of payments for kidney acquisi-
tions and hospice care described in 
paragraphs (3) and (4) of subsection 
(e), respectively) made with respect to 
the Program-eligible beneficiary for 
the year. 
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