PACE Plus Act
Bill: H.R.6770 | Sponsor: Rep. Dingell, Debbie (D-MI)
Policy area: Health

Summary:
Program of All-Inclusive Care for the Elderly Plus Act or the PACE Plus Act
This bill modifies requirements and establishes programs regarding Programs of All-Inclusive Care for the Elderly (PACE). PACE is a program under Medicare and Medicaid that provides in-home and community services for certain individuals as an alternative to nursing home care.
The bill allows Medicare beneficiaries to enroll in a PACE program at any time and provides states with the option to allow Medicaid beneficiaries to do the same. Entities may also apply to become PACE providers at any time, upon specified assurances relating to staffing and other requirements. States that provide Medicaid coverage of long-term care may also choose to expand PACE eligibility for Medicaid beneficiaries who are unable to perform at least two activities of daily living and who meet other specified criteria.
Additionally, the bill establishes and provides funds for grant programs for (1) public or nonprofit PACE providers in rural or underserved urban areas for planning, administrative, capital, and other expenses that are necessary for site development; and (2) states that do not have PACE providers for expenses deemed necessary for program establishment. The bill also allows the Center for Medicare and Medicaid Innovation to test a model for expanded PACE eligibility that targets high-need and high-cost populations.

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 Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Program of All-Inclusive Care for 
the Elderly Plus Act'' or the ``PACE Plus Act''.

SEC. 2. PACE EXPANSION GRANT PROGRAM.

    (a) Definitions.--In this section:
            (1) Area agency on aging.--The term ``area agency on 
        aging'' has the meaning given that term in section 102 of the 
        Older Americans Act of 1965 (42 U.S.C. 3002).
            (2) CMS.--The term ``CMS'' means the Centers for Medicare & 
        Medicaid Services.
            (3) For-profit pace provider.--The term ``for-profit PACE 
        provider'' means a PACE provider that is operated by an entity 
        that is not a public entity or a private, nonprofit entity 
        organized for charitable purposes under section 501(c)(3) of 
        the Internal Revenue Code of 1986.
            (4) PACE pilot site.--The term ``PACE pilot site'' means a 
        PACE provider that--
                    (A) has been approved to provide services in a 
                geographic service area that is, in whole or in part, a 
                rural area or an underserved urban area; and
                    (B) has received a grant under subsection (b).
            (5) PACE program.--The term ``PACE program'' has the 
        meaning given that term in sections 1894(a)(2) and 1934(a)(2) 
        of the Social Security Act (42 U.S.C. 1395eee(a)(2); 1396u-
        4(a)(2)).
            (6) PACE provider.--The term ``PACE provider'' has the 
        meaning given that term in section 1894(a)(3) or 1934(a)(3) of 
        the Social Security Act (42 U.S.C. 1395eee(a)(3); 1396u-
        4(a)(3)).
            (7) Rural area.--The term ``rural area'' has the meaning 
        given that term in section 1886(d)(2)(D) of the Social Security 
        Act (42 U.S.C. 1395ww(d)(2)(D)).
            (8) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.
            (9) Underserved urban area.--The term ``underserved urban 
        area'' means an urban health professional shortage area (as 
        such term is defined in section 332 of the Public Health 
        Service Act (42 U.S.C. 254e)).
    (b) Site Development Assistance Program.--
            (1) Site development assistance.--
                    (A) In general.--The Secretary shall establish a 
                process and criteria to award grants to qualified PACE 
                providers that have been approved to serve a rural area 
                or an underserved urban area.
                    (B) Requirements for participating pace 
                providers.--To be eligible for a grant under 
                subparagraph (A), a PACE provider shall demonstrate to 
                the Secretary that the provider has a plan to partner 
                with--
                            (i) each area agency on aging serving the 
                        area that the provider is approved to serve; or
                            (ii) if there is no area agency on aging 
                        serving such area, the applicable State Unit on 
                        Aging.
                    (C) Amount per award.--A grant awarded under 
                subparagraph (A) to any individual PACE pilot site 
                shall not exceed $1,000,000.
                    (D) Number of awards.--Not more than 30 PACE pilot 
                sites shall be awarded a grant under subparagraph (A).
                    (E) Use of funds.--Funds made available under a 
                grant awarded under subparagraph (A) may be used for 
                the following expenses only to the extent such expenses 
                are incurred in relation to establishing or delivering 
                PACE program services in a rural area or underserved 
                urban area:
                            (i) Feasibility analysis and planning.
                            (ii) Interdisciplinary team development.
                            (iii) Development of a provider network, 
                        including contract development.
                            (iv) Development or adaptation of claims 
                        processing systems.
                            (v) Preparation of special education and 
                        outreach efforts required for the PACE program.
                            (vi) Development of any special quality of 
                        care or patient satisfaction data collection 
                        efforts.
                            (vii) Purchase or lease of a building.
                            (viii) Modifications to a building.
                            (ix) To cover the cost of reinsurance 
                        during the grant period.
                            (x) Establishment of a working capital fund 
                        to sustain fixed administrative, facility, or 
                        other fixed costs until the provider reaches 
                        sufficient enrollment size.
                            (xi) Startup and development costs incurred 
                        prior to the approval of the PACE pilot site's 
                        PACE provider application, new center 
                        application, or service area expansion 
                        application by CMS.
                            (xii) Any other efforts determined by the 
                        PACE pilot site to be critical to its 
                        successful startup, as approved by the 
                        Secretary.
                    (F) Site development grant eligibility.--
                            (i) Grant eligibility.--A PACE provider 
                        shall only be eligible to receive a grant under 
                        this subsection if the provider is not a for-
                        profit PACE provider.
                            (ii) Limitation on eligibility to providers 
                        in 3-way pace program agreements.--A PACE 
                        provider shall not be eligible for a grant 
                        under this subsection unless the provider has 
                        entered into an agreement, consistent with 
                        sections 1894 and 1934 of the Social Security 
                        Act (42 U.S.C. 1395eee, 1396u-4), and 
                        regulations promulgated to carry out such 
                        sections, among the PACE provider, the 
                        Secretary, and a State administering agency for 
                        the operation of a PACE program by the provider 
                        under such sections.
            (2) Technical assistance program.--The Secretary shall 
        establish a technical assistance program to provide--
                    (A) outreach and education to State agencies and 
                provider organizations interested in establishing and 
                expanding PACE programs in rural areas or underserved 
                urban areas; and
                    (B) technical assistance necessary to support PACE 
                pilot sites.
            (3) Appropriation.--There is appropriated to the Secretary 
        $30,000,000 to carry out this subsection, to remain available 
        until expended.
    (c) Evaluation of PACE Providers Serving Rural or Underserved Urban 
Service Areas.--Not later than 60 months after the date of enactment of 
this Act, the Secretary shall submit a report to Congress, including 
the Special Committee on Aging of the Senate and the Committee on 
Finance of the Senate, containing an evaluation of the experience of 
PACE pilot sites in rural areas and underserved urban areas.
    (d) State Expansion Grants.--
            (1) In general.--The Secretary shall establish a process 
        and criteria to award State expansion grants to qualified State 
        agencies in States that do not currently have PACE providers.
            (2) Amount per award.--A State expansion grant awarded 
        under subparagraph (A) to any State agency shall not exceed 
        $100,000.
            (3) Use of funds.--Funds made available under a State 
        expansion grant awarded under paragraph (1) may be used for the 
        following expenses only to the extent such expenses are 
        incurred in relation to establishing a PACE program in the 
        State:
                    (A) Expenditures related to the development of a 
                capitated payment rate model, including appropriate 
                risk adjustment, for making payments to PACE providers 
                under a PACE program agreement.
                    (B) Expenditures on any other efforts determined by 
                the State Medicaid agency to be critical to the 
                successful implementation of a PACE program in the 
                State, as approved by the Secretary.
            (4) Appropriation.--There are appropriated to the Secretary 
        $2,000,000 to carry out this subsection, to remain available 
        until expended.
    (e) Amounts in Addition to Payments Under Social Security Act.--Any 
amounts paid under the authority of this section to a PACE provider 
shall be in addition to payments made to the provider under section 
1894 or 1934 of the Social Security Act (42 U.S.C. 1395eee; 1396u-4).

SEC. 3. TWO-WAY PACE PROGRAM AGREEMENTS.

    (a) Medicare.--Section 1894(a)(4) of the Social Security Act (42 
U.S.C. 1395eee(a)(4)) is amended by adding at the end the following new 
sentence: ``Beginning January 1, 2022, with respect to a PACE provider 
operating in a State that has not entered into an agreement described 
in the previous sentence as of such date, such term shall include an 
agreement, consistent with this section and regulations promulgated to 
carry out this section, between such a PACE provider and the Secretary 
for the operation of a PACE program in such State by the provider under 
this section alone.''.
    (b) Medicaid.--Section 1934 of the Social Security Act (42 U.S.C. 
1396u-4) is amended--
            (1) in subsection (a)(4), by adding at the end the 
        following new sentence: ``Beginning January 1, 2022, with 
        respect to a PACE provider operating in a State that has not 
        entered into an agreement described in the previous sentence as 
        of such date, such term shall include an agreement, consistent 
        with section 1894 and regulations promulgated to carry out such 
        section, between such a PACE provider and the Secretary for the 
        operation of a PACE program in such State by the provider under 
        such section 1894 alone.''; and
            (2) by adding at the end the following new subsection:
    ``(k) Application to PACE Providers in 2-Way PACE Program Agreement 
States.--
            ``(1) In general.--In the case of a State described in the 
        second sentence of subsection (a)(4), the Secretary shall 
        administer the preceding provisions of this section with 
        respect to PACE programs offered by PACE providers under PACE 
        program agreements described in such sentence to PACE program 
        eligible individuals who are eligible for benefits under part 
        A, or enrolled under part B, of title XVIII.
            ``(2) Assessment of need of nursing home level of care.--
                    ``(A) In general.--For purposes of the 
                administration of this section pursuant to this 
                subsection, the determination under subsection 
                (a)(5)(B) of whether an individual requires the level 
                of care required under the State plan for coverage of 
                nursing facility services shall be made by an 
                independent entity based on a level of care assessment 
                tool used by the State to determine whether an 
                individual requires such level of care.
                    ``(B) Independent entity defined.--In this 
                subsection, the term `independent entity' means an 
                entity with demonstrated professional knowledge to 
                identify institutional level of care needs that--
                            ``(i) is not the PACE provider operating 
                        the PACE program involved;
                            ``(ii) is not owned or controlled by, or an 
                        employee of, such PACE provider;
                            ``(iii) does not receive any differential 
                        payment (such as a bonus) for identifying 
                        individuals who are PACE program eligible 
                        individuals under the PACE program agreement 
                        involved; and
                            ``(iv) is free of any other conflict of 
                        interest (as defined by the Secretary) between 
                        the entity and the PACE provider operating the 
                        PACE program involved.''.

SEC. 4. ANY TIME ENROLLMENT IN PACE.

    (a) In General.--
            (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 effective date of 
                enrollment.--
                            ``(i) Any time enrollment.--A PACE program 
                        eligible individual may enroll in a PACE 
                        program at any time during a month.
                            ``(ii) Effective date.--Subject to clause 
                        (iii), the enrollment of a PACE program 
                        eligible individual in a PACE program shall be 
                        effective on the date the PACE provider 
                        operating the PACE program receives an 
                        enrollment agreement signed by such PACE 
                        program eligible individual with respect to 
                        such PACE program.
                            ``(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 has made an election under 
                        section 1934(c)(5)(C) to permit PACE program 
                        eligible individuals enroll in a PACE program 
                        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 
        otherwise 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) Any time enrollment and effective date.--Section 
        1934(c)(5) of the Social Security Act (42 U.S.C. 1396u-4(c)(5)) 
        is amended by adding at the end the following new subparagraph:
                    ``(C) State option to permit any time enrollment 
                and effective date of enrollment.--
                            ``(i) Any time enrollment.--A State may 
                        elect to permit a PACE program 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 individual in a PACE 
                        program shall be effective on the date the PACE 
                        provider operating the PACE program receives an 
                        enrollment 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 program operated by a PACE provider with an 
        enrollment 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, 2022.

SEC. 5. IMPROVING ACCESS TO AND AFFORDABILITY OF PACE PROGRAMS FOR 
              MEDICARE BENEFICIARIES 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 Security 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-medicare services.--Subject to the 
        succeeding provisions of this subsection, a PACE program 
        operated by a PACE provider under a PACE program agreement 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 capitation payment amount.--
                    ``(A) In general.--Notwithstanding section 460.186 
                of title 42, Code of Federal Regulations (or any 
                successor regulation), the monthly capitation payment 
                amount that may be charged under paragraph (1) shall be 
                determined by the PACE provider operating the PACE 
                program. Such monthly capitation payment 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 interdisciplinary 
                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 interdisciplinary 
                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.
                    ``(B) Authority to adjust monthly capitation 
                amount.--
                            ``(i) In general.--Subject to clause (ii) 
                        and paragraph (3), the monthly capitation 
                        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 payment amount charged to such an 
                        individual 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 payment 
                        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.--
                    ``(A) Disclosure of premium rate structure.--A PACE 
                provider shall disclose to Medicare-only PACE program 
                eligible individuals the capitation payment amounts 
                that may be charged under this section to such 
                individuals for non-Medicare services under the PACE 
                program operated by such PACE provider under this 
                section--
                            ``(i) prior to enrollment of such 
                        individual in such PACE program, and
                            ``(ii) periodically, and upon request of 
                        such individual, after enrollment.
                    ``(B) Assessment instrument.--
                            ``(i) In general.--The Secretary shall 
                        develop an assessment instrument for use by 
                        PACE programs with respect to Medicare-only 
                        PACE program eligible individuals under this 
                        subsection.
                            ``(ii) Requirement for disclosure of 
                        assessment instrument.--The monthly capitation 
                        payment amount charged under paragraph (1) to a 
                        Medicare-only PACE program eligible individual 
                        for non-Medicare services shall be based on an 
                        assessment of such individual conducted by the 
                        PACE provider (using the assessment instrument 
                        developed by the Secretary under clause (i)), 
                        accounting for health status and corresponding 
                        needs.
                            ``(iii) Requirement for disclosure of 
                        assessment instrument.--The assessment 
                        instrument used by the interdisciplinary 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 assessments.--The 
                Secretary shall establish a process for a Medicare-only 
                PACE program eligible individual to seek review of any 
                assessment 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 establish 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 established by such PACE provider for such purpose, 
        including the use of an assessment instrument developed by the 
        PACE program to assign such individuals to an appropriate rate 
        category under such rate structure.
            ``(5) Definitions.--In this subsection--
                    ``(A) the term `Medicare-only PACE program 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 enactment of this Act, and apply with 
respect to capitation amounts that may be charged for months beginning 
on or after January 1, 2022.
    (c) Rule of Construction.--Nothing in this section, or the 
amendments made by this section, shall be construed to modify or 
otherwise impact the following Medicare capitation rates that may be 
charged by PACE plans for PACE participants who are Medicare 
beneficiaries who are not both entitled to (or enrolled for) benefits 
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) benefits 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 enrolled 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 regulations).

SEC. 6. 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 inserting the following:
            ``(8) Authority to submit applications at any time; timely 
        consideration of applications.--
                    ``(A) Authority to submit applications 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 provider 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 requirements of section 460.12(d) of 
                        title 42, Code of Federal Regulations (relating 
                        to the first trial period audit), or any 
                        successor 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 
                                required members of the 
                                interdisciplinary team are employees or 
                                contractors 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 executed by the time the 
                                        proposed PACE center becomes 
                                        operational; and
                                            ``(bb) executed contracts 
                                        may include provisions for 
                                        staffing levels to commensurate 
                                        with enrollment 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 application 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 determination 
                with respect to the application. After the date the 
                Secretary receives such additional information, the 
                application shall be deemed approved 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, 2022.

SEC. 7. PACE PILOT.

    Section 1115A(b)(2) of the Social Security Act (42 U.S.C. 
1315a(b)(2)) is amended--
            (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 described in 
                        subparagraph (D).''; and
            (2) by adding at the end the following new subparagraph:
                    ``(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 subparagraph 
                (B), the following shall apply:
                            ``(i) National testing.--
                                    ``(I) In general.--Subject to 
                                subclause (II), the Secretary shall 
                                design a demonstration that allows each 
                                PACE provider with an executed PACE 
                                agreement to develop and submit to the 
                                Secretary an application to begin 
                                testing expanded PACE eligibility for 
                                high-need and high-cost populations 
                                that are not otherwise eligible 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 subparagraph 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 subparagraph.
                            ``(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 reduce 
                        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 
                                PACE provider's designated population;
                                    ``(II) partner with non-PACE 
                                providers, such as Area Agencies on 
                                Aging, Centers for Independent Living, 
                                local hospitals, and non-hospital 
                                providers such as physicians, 
                                behavioral health providers and other 
                                community-based organizations to 
                                effectively reach the PACE provider's 
                                selected population;
                                    ``(III) adapt the PACE program 
                                model of care to appropriately serve 
                                the PACE provider's selected population 
                                to integrate care and meet the unique 
                                needs of said population; and
                                    ``(IV) if the PACE provider is 
                                located 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 
                                appropriate risk adjustment, for the 
                                PACE provider's selected population.
                            ``(iii) Requirements for participating pace 
                        organizations.--In order to participate in the 
                        model, a PACE provider must--
                                    ``(I) conduct a survey or needs 
                                assessment of their service area to 
                                determine the most appropriate 
                                population with which to expand their 
                                services;
                                    ``(II) receive prior approval from 
                                the applicable State Medicaid agency to 
                                submit an application to participate in 
                                the model; and
                                    ``(III) following such survey or 
                                needs assessment and approval from the 
                                applicable State Medicaid agency, 
                                submit and receive approval of an 
                                application of expansion from the 
                                Secretary.
                            ``(iv) Application.--A PACE provider's 
                        application to participate in this model shall 
                        include the following information:
                                    ``(I) Results of the survey or 
                                needs assessment of their service area 
                                under clause (iii)(I) and an 
                                explanation 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 
                                implement these services.
                                    ``(III) How the PACE provider will 
                                achieve engagement and enrollment of 
                                the new population in the model, 
                                including how it will partner with non-
                                PACE providers in the applicable 
                                service area.
                                    ``(IV) How the expanded 
                                population's participation in the PACE 
                                program is intended to improve quality 
                                of care and health outcomes under the 
                                model.
                                    ``(V) Certification that the 
                                applicable State Medicaid agency has 
                                approved the PACE provider's 
                                application to participate in the 
                                model.
                                    ``(VI) Plans to coordinate with the 
                                State Medicaid agency to develop an 
                                initial capitated rate with appropriate 
                                risk adjustment.
                                    ``(VII) Plans for the PACE provider 
                                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 entity to 
                        provide, technical assistance to participating 
                        PACE providers as they apply for and implement 
                        the model.
                            ``(vi) Accounting for uncertainty.--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 
                        request for additional resources.
                            ``(vii) Monitoring outcomes.--The 
                        Secretary, in conjunction with PACE providers 
                        and in consultation with States that have 
                        elected to expand PACE program eligibility 
                        under section 1934(l), shall develop a plan 
                        to--
                                    ``(I) annually monitor outcomes 
                                under the model, which may include 
                                financial, quality, access, and 
                                utilization outcomes;
                                    ``(II) annually monitor the health 
                                outcomes of the PACE provider's 
                                expanded population; and
                                    ``(III) any other outcomes as 
                                determined by the Secretary.
                            ``(viii) Reporting requirements.--
                                    ``(I) Report to congress.--Not less 
                                frequently than every 3 years (for the 
                                duration of the implementation of the 
                                model under this subparagraph), the 
                                Secretary shall submit to Congress a 
                                report on the implementation of the 
                                model under this subparagraph. The 
                                report shall include demographic 
                                information on the populations served 
                                under the demonstration, best practices 
                                for future implementation efforts and 
                                any other information the Secretary 
                                determines appropriate together with 
                                recommendations for such legislation 
                                and administrative action as the 
                                Secretary determines appropriate.
                            ``(ix) Funding.--The Secretary shall 
                        allocate funds made available under subsection 
                        (f)(1) to design, implement, evaluate, and 
                        report on the model described in clause (ii) in 
                        accordance with this subparagraph.''.

SEC. 8. STATE OPTION TO EXPAND ELIGIBILITY FOR PACE PROGRAM.

    (a) In General.--Section 1934 of the Social Security Act (42 U.S.C. 
1396u-4), as amended by section 3(b), is amended--
            (1) in subsection (a)(5)(B), by inserting ``, subsection 
        (k), and subsection (l)'' after ``subsection (c)(4)''; and
            (2) by adding at the end the following new subsection:
    ``(l) State Option To Expand Eligibility.--
            ``(1) In general.--A State described in paragraph (3) may, 
        at the option of the State, deem individuals described in 
        paragraph (2) to be PACE program eligible individuals for the 
        purposes of this section without regard to the requirement 
        under subsection (a)(5)(B) that a PACE program eligible 
        individual require the level of care required under the State 
        medicaid plan for coverage of nursing facility services.
            ``(2) Expansion of eligibility.--An individual is described 
        in this paragraph if--
                    ``(A) the individual meets the requirements of 
                subparagraphs (A), (C), and (D) of subsection (a)(5);
                    ``(B) the individual is unable to perform at least 
                2 (or such higher number as the State may establish) 
                activities of daily living, as determined by the State; 
                and
                    ``(C) the individual's income does not exceed 150 
                percent of the poverty line (as defined in section 
                2110(c)(5)) or, if greater, the income level applicable 
                for an individual who has been determined to require an 
                institutional level of care to be eligible for nursing 
                facility services under the State plan and with respect 
                to whom there has been a determination that, but for 
                the provision of such services, the individual would 
                require the level of care provided in a hospital, a 
                nursing facility, an intermediate care facility for the 
                mentally retarded, or an institution for mental 
                diseases, the cost of which could be reimbursed under 
                the State plan.
            ``(3) States eligible for option.--A State shall only be 
        eligible to exercise the option under this subsection if--
                    ``(A) the State administering agency has entered 
                into an agreement for the operation of a PACE program 
                under this section (and section 1894, if applicable) 
                among such agency, the Secretary, and a PACE provider; 
                and
                    ``(B) the State provides coverage under the State 
                plan under this title (or a waiver of such plan) for 
                long-term services and supports.
            ``(4) Enhanced fmap.--Notwithstanding section 1905(b), in 
        the case of a State that exercises the option under this 
        subsection, the Federal medical assistance percentage 
        applicable with respect to expenditures by such State on 
        monthly payments made to PACE providers under a PACE program 
        agreement under this section for individuals who are deemed to 
        be PACE program eligible individuals in accordance with 
        paragraph (2) shall be equal to 90 percent.''.
    (b) Conforming Amendment.--Section 1894(a)(5) of the Social 
Security Act (42 U.S.C. 1395eee(a)(5)) is amended by inserting ``and 
section 1934(l)'' after ``subsection (c)(4)''.

SEC. 9. 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 Coordinated Health Care 
Office.--
            ``(1) State coordination with fchco.--The Director of the 
        Federal Coordinated Health Care Office established under 
        section 2602 of the Patient Protection and Affordable Care Act 
        shall serve as a point of contact between State administering 
        agencies and the Federal Government for purposes of 
        implementing and operating a PACE program in a State, and shall 
        coordinate with other relevant offices and staff of the Centers 
        for Medicare & Medicaid Services involved in carrying out this 
        section.
            ``(2) Annual report.--Not later than January 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.''.
                                 <all>