PACE Expanded Act
Bill: H.R.9209 | Sponsor: Rep. Dingell, Debbie (D-MI)
Policy area: Health

Summary:
Program of All-Inclusive Care for the Elderly Expanded Act or the PACE Expanded Act
This bill modifies requirements 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.
The bill also (1) allows the Center for Medicare and Medicaid Innovation to test a model for expanded PACE eligibility that targets high-need and high-cost populations, and (2) requires an evaluation of the effectiveness of PACE in rural and underserved areas.

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 Expanded Act'' or the ``PACE Expanded Act''.

SEC. 2. 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, 2023.
    (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. 3. ANYTIME 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) 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 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, 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 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 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, 2023.

SEC. 5. 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. 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 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.''.

SEC. 7. EVALUATION OF EFFECTIVENESS OF PACE PROGRAM IN RURAL AND 
              UNDERSERVED AREAS.

    (a) In General.--The Assistant Secretary for Planning and 
Evaluation of the Department of Health and Human Services (referred to 
in this section as the ``Assistant Secretary'') shall conduct an 
evaluation of the effectiveness of 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) in rural and underserved areas, including 
with respect to the following factors:
            (1) Reductions in hospitalizations and re-hospitalizations 
        among program beneficiaries.
            (2) Reductions in emergency department use among program 
        beneficiaries.
            (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 program 
        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 evaluation required under subsection (a), an 
analysis of which elements of 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) should be replicated and scaled by 
governmental or non-governmental entities, and such recommendations for 
legislation and administrative action as the Assistant Secretary 
determines appropriate 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 Assistant 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 caregivers, to have an opportunity 
to contribute their expertise to evaluating the strategy and outcomes 
of the program.
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