Comprehensive Care for Alzheimer’s Act
Bill: H.R.2517 | Sponsor: Rep. Higgins, Brian (D-NY)
Policy area: Health

Summary:
Comprehensive Care for Alzheimer's Act
This bill allows the Center for Medicare and Medicaid Innovation (CMMI) to test a Dementia Care Management Model that provides comprehensive care to Medicare beneficiaries with Alzheimer's disease or a related dementia.
Under the model, participating health care providers receive payment under Medicare for comprehensive care management services that are provided to individuals with diagnosed dementia, excluding Medicare Advantage enrollees, hospice care recipients, and nursing home residents. Required services include medication management, care coordination, and health, financial, and environmental monitoring, as well as trainings and other support services for unpaid caregivers. Providers must furnish services through interdisciplinary teams and must ensure access to a team member or primary care provider 24-7. The CMMI must set payments and determine quality measures for the model in accordance with specified requirements.
The bill also allows the CMMI to design a similar model under Medicaid.

To recommend that the Center for Medicare and Medicaid Innovation test 
the effect of a dementia care management model, 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 ``Comprehensive Care for Alzheimer's 
Act''.

SEC. 2. CMI TESTING OF DEMENTIA CARE MANAGEMENT.

    Section 1115A of the Social Security Act (42 U.S.C. 1315a) is 
amended--
            (1) in subsection (b)(2)(B), by adding at the end the 
        following new clause:
                            ``(xxviii) Furnishing comprehensive care 
                        management services to eligible individuals 
                        with Alzheimer's disease or a related dementia 
                        through a Dementia Care Management Model, as 
                        described in subsection (h).''; and
            (2) by adding at the end the following new subsection:
    ``(h) Dementia Care Management Model.--
            ``(1) Description of model and requirements.--
                    ``(A) In general.--The Dementia Care Management 
                Model described in this subsection is a model under 
                which payments are made under title XVIII to eligible 
                entities that furnish comprehensive care management 
                services to eligible individuals with Alzheimer's 
                disease or a related dementia, in order to test the 
                effectiveness of comprehensive care management services 
                on patient health, care quality, and care experience, 
                as well as on unpaid caregivers, and on reducing 
                spending under title XVIII without reducing the quality 
                of care.
                    ``(B) Voluntary participation.--Participation under 
                the Dementia Care Management Model shall be voluntary 
                with respect to both eligible individuals and eligible 
                entities.
                    ``(C) Implementation of dementia care management 
                model.--
                            ``(i) In general.--The Secretary shall--
                                    ``(I) implement the Dementia Care 
                                Management Model as a stand-alone 
                                model;
                                    ``(II) incorporate the Dementia 
                                Care Management Model into the Primary 
                                Care First Model; or
                                    ``(III) incorporate the Dementia 
                                Care Management Model into--
                                            ``(aa) the Primary Care 
                                        First Model; and
                                            ``(bb) the Direct 
                                        Contracting Model.
                            ``(ii) Additional authority.--In addition 
                        to the models described in subclauses (I) 
                        through (III) of clause (i), the Secretary may 
                        incorporate the Dementia Care Management Model 
                        into other existing coordinated care models 
                        established under title XVIII or under this 
                        section, including accountable care 
                        organizations, value-based purchasing 
                        arrangements, and such other coordinated care 
                        models as the Secretary determines to be 
                        appropriate.
            ``(2) Comprehensive care management services defined.--In 
        this subsection, the term `comprehensive care management 
        services' means the following services furnished by an eligible 
        entity with respect to an eligible individual:
                    ``(A) Continuous monitoring and assessment.--An 
                eligible entity shall regularly assess and continuously 
                monitor the following:
                            ``(i) Neuropsychiatric symptoms, including 
                        behavior, physical safety, and function of an 
                        eligible individual.
                            ``(ii) Comorbidities.
                            ``(iii) Financial resources and needs.
                            ``(iv) Caregiver supports and resources, 
                        including caregiver education, training, and 
                        support.
                            ``(v) The well-being of unpaid caregivers 
                        of the eligible individual.
                            ``(vi) Potential risks and harms of the 
                        eligible individual's home and environment and 
                        the need for support for activities of daily 
                        living.
                    ``(B) Ongoing dementia care plan.--An eligible 
                entity shall develop and implement an Alzheimer's 
                disease or related dementia care plan, including 
                advance care planning as appropriate, for an eligible 
                individual. The care plan shall include patient-
                centered goals for the eligible individual as well as 
                goals for unpaid caregivers of the eligible individual. 
                Such care plan shall be continuously evaluated and 
                modified as appropriate.
                    ``(C) Psychosocial interventions.--An eligible 
                entity may implement psychosocial interventions 
                designed to prevent or reduce the burden of cognitive, 
                functional, behavioral, and psychological challenges as 
                well as the associated stress on unpaid caregivers of 
                the eligible individual.
                    ``(D) Self-management tools.--An eligible entity 
                shall provide self-management tools to enhance the 
                skills of the unpaid caregiver of the eligible 
                individual to manage the Alzheimer's disease or related 
                dementia of the eligible individual and to navigate the 
                health care system. Such tools shall include training 
                and support for unpaid caregivers in managing the 
                limitations of eligible individuals, including 
                education, problem solving strategies, care navigation 
                support, support after discharge from a hospital or 
                nursing home, and decision-making support.
                    ``(E) Medication management.--An eligible entity 
                shall furnish evidence-based medication review and 
                management services to an eligible individual, 
                including polypharmacy management, using a planned 
                process to reduce or stop medications that may no 
                longer be of benefit or may be having adverse cognitive 
                effects, prescribing approved medications, and 
                enhancing adherence to appropriate medications.
                    ``(F) Treatment of related conditions.--An eligible 
                entity shall provide interventions to prevent or treat 
                conditions related to the Alzheimer's disease or 
                related dementia of the eligible individual, such as 
                depression and delirium.
                    ``(G) Care coordination.--An eligible entity shall 
                provide ongoing care management services and shall 
                coordinate services and supports among providers of 
                services and suppliers, as well as social and community 
                resources. Such services shall include necessary 
                assistance for referrals to social and community-based 
                organizations, collaboration with primary care 
                providers and the interdisciplinary team of the 
                eligible individual, and support for care transitions 
                and continuity of care.
                    ``(H) Exclusion of palliative care and hospice 
                care.--Comprehensive care management services shall not 
                include palliative care or hospice care.
                    ``(I) Other services.--The Secretary may require or 
                permit other services, as appropriate.
            ``(3) Eligible entity defined.--In this subsection, the 
        term `eligible entity' means an entity, such as a health 
        system, hospital, physician or nonphysician group practice, 
        multiple physician practices, a Federally qualified health 
        center, a rural health clinic, or an accountable care 
        organization, that--
                    ``(A) is qualified to furnish comprehensive care 
                management services to an eligible individual, and any 
                unpaid caregiver of such eligible individual, under the 
                Dementia Care Management Model either directly or 
                through arrangements with Medicare participating 
                providers of services and suppliers as well as social 
                and community-based organizations;
                    ``(B) is accountable for the quality of 
                comprehensive care management services furnished to an 
                eligible individual under the model;
                    ``(C) furnishes comprehensive care management 
                services through an interdisciplinary team that has at 
                least 1 physician, physician assistant, nurse 
                practitioner, or advanced practice nurse who devotes 25 
                percent or more of patient contact time to the 
                evaluation and care of patients with acquired cognitive 
                impairment;
                    ``(D) furnishes comprehensive care management 
                services in a culturally appropriate manner;
                    ``(E) utilizes a comprehensive, person-centered 
                care management approach;
                    ``(F) furnishes wellness and healthcare planning, 
                including medication review and management;
                    ``(G) supports family and caregiver engagement;
                    ``(H) provides access to a primary care provider or 
                a member of the interdisciplinary team 24 hours a day 7 
                days a week;
                    ``(I) has relationships with medical and nonmedical 
                community-based organizations that support patients 
                with Alzheimer's disease or a related dementia and 
                their caregivers; and
                    ``(J) meets such other requirements as the 
                Secretary may determine to be appropriate.
            ``(4) Eligible individual defined.--In this subsection, the 
        term `eligible individual' means an individual--
                    ``(A) who--
                            ``(i) is entitled to, or enrolled for, 
                        benefits under part A of title XVIII and 
                        enrolled under part B of such title (including 
                        such an individual who is a dual eligible 
                        individual described in subsection 
                        (a)(4)(A)(iii)); and
                            ``(ii) is not enrolled under part C of such 
                        title or under a PACE program under section 
                        1894;
                    ``(B) who has been diagnosed with a form of 
                dementia;
                    ``(C) who has not made an election to receive 
                hospice care; and
                    ``(D) who is not a resident of a nursing home.
            ``(5) Patient pathways.--
                    ``(A) Initial placement.--
                            ``(i) Placement of patients into care 
                        pathways.--An eligible entity shall assign an 
                        eligible individual to an appropriate pathway 
                        (as described in clauses (ii), (iii), and (iv)) 
                        based on an assessment of the clinical and 
                        financial status of the eligible individual 
                        that is conducted not later than 60 days after 
                        the eligible individual is enrolled in the 
                        model.
                            ``(ii) Pathway for uncomplicated dementia 
                        diagnosis.--During the preceding 12-month 
                        period, the eligible individual has not more 
                        than 1 unplanned inpatient hospitalization or 
                        visit to a hospital emergency department.
                            ``(iii) Pathway for dementia diagnosis with 
                        enhanced care coordination needs.--During the 
                        preceding 12-month period, the eligible 
                        individual--
                                    ``(I)(aa) has 2 or more unplanned 
                                inpatient hospitalizations or visits to 
                                a hospital emergency department; or
                                    ``(bb) has a psychiatric 
                                hospitalization; and
                                    ``(II) has sufficient financial or 
                                caregiver resources (as determined by 
                                the Secretary).
                            ``(iv) Pathway for dementia diagnosis with 
                        complex care needs.--During the preceding 12-
                        month period, the eligible individual--
                                    ``(I)(aa) has 2 or more unplanned 
                                inpatient hospitalizations or visits to 
                                a hospital emergency department; or
                                    ``(bb) has a psychiatric 
                                hospitalization; and
                                    ``(II) has insufficient financial 
                                or caregiver resources (as determined 
                                by the Secretary).
                    ``(B) Regular patient assessments for appropriate 
                pathway.--
                            ``(i) In general.--After determination of 
                        the initial pathway, at a frequency to be 
                        determined by the Secretary, but not less than 
                        once per year, an eligible entity shall 
                        reassess the pathway determination of each 
                        eligible individual enrolled under the model.
                            ``(ii) Increased adl limitations.--Each 
                        eligible individual enrolled in the pathway for 
                        uncomplicated dementia diagnosis (as described 
                        in subparagraph (A)(ii)) who has had increased 
                        limitations in performing activities of daily 
                        living since the prior assessment shall be 
                        assigned to the pathway for dementia diagnosis 
                        with enhanced care coordination needs (as 
                        described in subparagraph (A)(iii)) or the 
                        pathway for dementia diagnosis with complex 
                        care needs (as described in subparagraph 
                        (A)(iv)), depending on the eligible 
                        individual's financial and caregiver resources 
                        applicable to each pathway.
                            ``(iii) Enhanced or complex care needs.--
                        Each eligible individual enrolled in the 
                        pathway for dementia diagnosis with enhanced 
                        care coordination needs (as described in 
                        subparagraph (A)(iii)) or the pathway for 
                        dementia diagnosis with complex care needs (as 
                        described in subparagraph (A)(iv)) shall be 
                        assigned to 1 of the 2 pathways based on the 
                        eligible individual's financial and caregiver 
                        resources applicable to each pathway.
            ``(6) Quality assessment.--
                    ``(A) In general.--The Secretary shall specify 
                appropriate measures to assess the quality of care 
                furnished by an eligible entity under the Dementia Care 
                Management Model. Such measures shall include, as 
                appropriate, measures for clinical processes and 
                outcomes, patient and caregiver experience of care, and 
                utilization of services for which payment is made under 
                the original medicare fee-for-service program under 
                title XVIII, including measures for--
                            ``(i) emergency department utilization;
                            ``(ii) inpatient hospital utilization;
                            ``(iii) documented advanced care plan;
                            ``(iv) medication review;
                            ``(v) screening for future fall risk;
                            ``(vi) depression screening for caregivers;
                            ``(vii) caregiver stress assessment; and
                            ``(viii) caregiver assessment of outcomes.
                    ``(B) Reporting.--An eligible entity shall submit 
                data in a form and manner determined by the Secretary 
                on measures specified by the Secretary.
                    ``(C) Performance assessment.--In order to assess 
                the quality of care furnished by an eligible entity 
                under the model, the Secretary shall establish--
                            ``(i) quality performance standards; and
                            ``(ii) methodologies for quality 
                        performance scoring and related payment 
                        adjustments.
                    ``(D) Stakeholder input.--The Secretary shall seek 
                input from eligible entities on final measure 
                specifications, including appropriate adjustment for 
                patient preferences.
            ``(7) Payments.--
                    ``(A) In general.--Under the Dementia Care 
                Management Model, the Secretary shall establish payment 
                amounts for care management services furnished to 
                eligible individuals, including initial investment 
                costs. Such amounts shall reflect start-up costs and 
                initial investments incurred by an eligible entity in 
                establishing the Dementia Care Management Model.
                    ``(B) Capitated basis.--Payments under the Dementia 
                Care Management Model shall be made on a capitated 
                basis, such as a per-member, per-month payment, or such 
                other similar payment mechanisms that the Secretary 
                determines to be appropriate. Payments shall vary based 
                on the assigned pathway of each patient as described in 
                paragraph (5).
                    ``(C) Quality bonus.--Under the Dementia Care 
                Management Model, additional payments shall be made to 
                any eligible entity for quality bonuses based on the 
                performance of the eligible entity in providing quality 
                care (as determined under paragraph (6)).
                    ``(D) Zero cost-sharing.--An eligible individual 
                shall not be liable for any cost-sharing, including 
                deductibles, coinsurance, or copayments, for care 
                management services for dementia care furnished to such 
                eligible individual under the model.
                    ``(E) Supplemental to payments for covered 
                services.--Payments made under the model shall be in 
                addition to any payments for items or services not 
                provided under the model for which payment may be made 
                under title XVIII for services furnished to such 
                eligible individuals.
                    ``(F) Nonduplication.--Payments for care management 
                services furnished to eligible individuals under the 
                Dementia Care Management Model may not duplicate 
                payments for services furnished to such eligible 
                individuals for which payments are made under the 
                original medicare fee-for-service program under title 
                XVIII.
            ``(8) Waivers.--The Secretary shall waive provisions of 
        this title, and title XVIII, to permit an eligible entity 
        operating a Dementia Care Management Model to provide the 
        following:
                    ``(A) Beneficiary rewards.--Gift cards or other 
                rewards for patients who successfully participate in 
                the program (as determined by the Secretary).
                    ``(B) Caregivers.--Supports for caregivers.
                    ``(C) Telehealth.--Telehealth services without 
                regard to geographic or other originating site 
                limitations under section 1834(m).
                    ``(D) Services from community organizations.--
                Payments, cost-sharing support, or both, for nonmedical 
                services furnished by community-based organizations, 
                such as limited caregiving services, respite care, 
                adult day care counseling services, and such other 
                services as the Secretary determines to be appropriate.
            ``(9) Modifications for application in the primary care 
        first and direct contracting models.--
                    ``(A) In general.--Except as provided under 
                subparagraph (B), if the Secretary elects to 
                incorporate the Dementia Care Management Model into the 
                Primary Care First Model, the Direct Contracting Model, 
                or both, as provided for under paragraph (1)(C)(i), the 
                Secretary shall maintain the requirements of this 
                subsection.
                    ``(B) Permissible modifications.--The Secretary may 
                adjust the requirements of this subsection to the 
                extent necessary to ensure consistency of the Dementia 
                Care Management Model with the Primary Care First 
                Model, the Direct Contracting Model, or both, with 
                respect to--
                            ``(i) any eligible entity, including 
                        beneficiary alignment thresholds;
                            ``(ii) any eligible individual;
                            ``(iii) capitated payments; and
                            ``(iv) quality-bonus payments.
                    ``(C) Consultation with stakeholders.--Prior to 
                making any adjustment under subparagraph (B), the 
                Secretary shall consult with appropriate stakeholders 
                and patient advocacy organizations.
            ``(10) Outreach to underrepresented minority populations.--
        An eligible entity shall carry out public outreach and 
        education efforts, including the dissemination of information, 
        for members of underrepresented minority populations regarding 
        participation in the Dementia Care Management Model to ensure 
        diversity in the patient population of such model.
            ``(11) Option to expand to medicaid.--The Secretary may 
        design a model under which payments are made under title XIX, 
        in a similar manner to the manner in which payments are made 
        under title XVIII under the Dementia Care Management Model 
        described in this subsection, to eligible entities that furnish 
        comprehensive care management services to individuals who are 
        eligible for medical assistance under a State plan under title 
        XIX (or a waiver of such a plan) with Alzheimer's disease or a 
        related dementia, in order to test the effectiveness of 
        comprehensive care management services on patient health, care 
        quality, and care experience, as well as on unpaid caregivers, 
        and on reducing spending under title XIX without reducing the 
        quality of care.''.
                                 <all>