I 113th CONGRESS 1st Session H. R. 3567 IN THE HOUSE OF REPRESENTATIVES November 20, 2013 Mr. Schrader (for himself and Mr. Ribble ) introduced the following bill; which was referred to the Committee on Ways and Means , and in addition to the Committee on Energy and Commerce , for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To amend title XVIII of the Social Security Act to provide for additional coverage options for beneficiaries under the original Medicare fee-for-service program through a Medicare Link program.

1. Short title This Act may be cited as the Medicare Link Act of 2013 . 2. Establishment of Medicare Link program (a) In general Title XVIII of the Social Security Act is amended by adding after section 1899A ( 42 U.S.C. 1395kkk ) the following new section: 1899B. Medicare Link program option (a) In general The Secretary shall establish under this section a program (to be known as the Medicare Link Program and in this section referred to as the Program ) through which individuals who are entitled to enroll in a Medicare Advantage plan under part C but who are not enrolled in such a plan under such part are eligible to enroll with a Medicare Link contractor under this section. (b) Enrollment; disenrollment The Secretary shall establish a process for the enrollment (and disenrollment) of eligible individuals with Medicare Link contractors under the Program which process shall be, to the maximum extent practicable, the same as (and coordinated with) the process for enrollment (and disenrollment) of individuals in Medicare Advantage plans under part C. (c) Qualification of contractors; awarding of contracts (1) In general In this section, the term Medicare Link contractor means a nongovernmental entity, that may be a Medicare Advantage organization, health plan, health insurance issuer, medicare administrative contractor, or other qualified third-party entity, that has entered into a contract with the Secretary with respect to one or more Medicare Link regions (as specified by the Secretary under paragraph (3)) for the offering of Medicare Link services (described in subsection (d)) to individuals residing in the region who enroll with the contractor under the Program. (2) Limitation; requirements For each such Medicare Link region, the Secretary shall select (and contract with) at least 1, and not more than 3, Medicare Link contractors for the offering of plans (in this section referred to as Medicare Link plans ) under this section. The Secretary shall seek to contract with at least 2 Medicare Link contractors within each Medicare Link region. A contract with a Medicare Link contractor may cover a multi-year period. (3) Specification of Medicare Link regions The Secretary shall define and specify Medicare Link regions (each in this section referred to as a Medicare Link region ) that, across all such regions, encompass all 50 States, the District of Columbia, and the territories. (4) Qualification of contractors The Secretary shall establish uniform qualifications for Medicare Link contractors based on their experience and qualifications to offer Medicare Link plans under this section and to provide additional services to individuals enrolled under such plans under this section and to provide for reduced expenditures under parts A and B. Contracts with Medicare Link contractors under this section shall be for periods similar to the contracts with MA organizations under part C and shall contain such terms and conditions as the Secretary shall specify. (5) Contracting authority Nothing in this section shall be construed as preventing a Medicare Link contractor from contracting with other entities in carrying out activities under this section, including the offering of Medicare Link plans under this section. (6) Bidding process In selecting Medicare Link contractors, the Secretary shall establish a bidding process similar to the process of bidding by medicare administrative contractors under section 1874A. (7) Contractor payments Medicare Link contractors with contracts under this section shall be paid, on a monthly basis, a per enrollee monthly service fee for the provision of services under the contract consistent with the provisions of paragraph (8). A portion of such fee (not to exceed 5 percent) may be subject to adjustment based on a contractor’s performance on financial and quality benchmarks based upon pre-established measures specified by the Secretary. (8) Requirement for federal savings under contract (A) In general Before entering into or renewing a contract with a Medicare Link contractor, the Secretary must determine (and the Chief Actuary of the Centers for Medicare & Medicaid Services must certify) that the terms of the contract are expected to yield average, net savings to the Medicare program under this title of not less than 5 percent per program enrollee in the Medicare Link region covered under the contract. (B) Computation Such savings shall be computed taking into account all effects on spending under this title, including any reductions in premiums and cost sharing or other incentives for enrollees under subsection (d), payments to Medicare Link contractors under the contract, and reductions in payments to medicare administrative contractors that would otherwise have been made under section 1874A. (C) Payments based on shared savings, adjusted for quality The contract shall be structured in a manner so that— (i) subject to clause (ii), the payments to the contractor under paragraph (7) are computed to represent a proportion (as specified in the contract) of the net savings in excess of the minimum savings required under subparagraph (A); and (ii) such proportion may be increased under the contract based on a contractor’s performance on quality benchmarks, based upon pre-established measures specified by the Secretary. (D) Guaranteed Federal savings If the Secretary determines that a Medicare Link contractor, after a period of three consecutive years, does not maintain an average net savings to the Medicare program of at least 5 percent per program enrollee as required under subparagraph (A), the Medicare Link contractor shall remit to the Secretary a sum specified by the Secretary and related to the amount of the shortfall. (9) Savings validation audit The Secretary shall provide for the annual auditing of the financial records (including data relating to Medicare utilization and costs) of organizations offering Medicare Link plans under this section (10) GAO audit Every 3 years the Comptroller General of the United States shall conduct an audit of the Medicare Link program costs and program savings. Such report shall be submitted to the committees of the House of Representatives and of the Senate with jurisdiction over Medicare. (d) Services under a Medicare Link plan (1) In general Each Medicare Link plan offered under this section— (A) shall provide for care management services (described in paragraph (2)) and predictive modeling and risk prioritization (described in paragraph (3)) for individuals enrolled under the plan consistent with this subsection; (B) shall carry out the functions of medicare administrative contractors described in paragraph 1874A(a)(4); (C) shall provide a reduction or rebate in the premium otherwise applicable under part B (as determined without regard to section 1839(i)) to individuals so enrolled; and (D) may provide for a reduction in cost-sharing otherwise applicable to such individuals who use providers within a plan network. (2) Care management services (A) Required The required care management services shall include clinical interventions to help coordinate care. (B) Optional Optional care management services may include interventions such as the following: (i) Prevention and wellness. (ii) Transitional and case management and other clinical programs. (iii) Chronic disease management. (iv) Advanced illness care initiatives. (v) Diabetes prevention programs. (vi) Transitional case management, for individuals discharged from a hospital or other health care institution. (vii) Nurse practitioner-led interventions (consistent with restrictions under applicable State law). (viii) Post-acute transition programs. (ix) High-risk case management. (x) Home-based primary care. (xi) Advanced illness transitional care. (xii) Operation of clinical management programs. (xiii) Management and development of provider networks. (xiv) Consumer engagement with decision support. (3) Predictive modeling and risk prioritization The predictive modeling and risk prioritization services described in this paragraph shall include the following: (A) Predictive modeling and high risk identification The use of claims data and trend data to predict which enrollees could benefit from the application of a clinical intervention or which might be high risk and in need of a care plan. (B) Prioritization of interventions Programs to identify, prioritize, and personalize care opportunities through a comprehensive profile of each enrollee. (4) Optional incentives and enrollee empowerment (A) In general A Medicare Link contractor may use appropriate incentives to manage overall care for enrollees. The Secretary shall establish terms and conditions under which a Medicare Link contractor may elect to use optional incentives for its members. (B) Types of incentives The types of incentives that may be used include the following: (i) Healthy rewards Premium rebates and other incentives approved by the Secretary for enrollees to make healthier choices and actively engage in their health care. (ii) Member incentives to use quality network providers Reductions in beneficiary cost-sharing (and other incentives approved by the Secretary) for enrollees who use providers (which may be accountable care organizations) within a plan network in order to reward quality, efficient care. (iii) Cost estimator tools Providing beneficiaries with tools designed to help them simplify the evaluation of health care costs through cost estimates for different treatment options. (5) Application of MA grievance and appeals procedures In accordance with regulations, the provisions of part C insofar as they apply to grievances and appeals, shall apply to Medicare Link plans and enrollees under this section in a manner similar to how such provisions apply to MA plans under such part. (e) Maintenance of current benefits; contractor not at financial risk for original fee-for-Service benefits (1) No change in Medicare covered items and services or limitation on supplemental plans Medicare Link plans shall provide for coverage of the same items and services that are covered under parts A and B. Nothing in this section shall be construed as preventing an individual enrolled under a Medicare Link plan from purchasing a medicare supplemental policy (described in section 1881) or other supplemental coverage outside of a Medicare Link plan. (2) No change in payments to providers (A) In general Subject to subparagraph (B), nothing in this section shall be construed as authorizing a payment level to a provider of services or supplier for Medicare covered services that is other than the payment level otherwise applicable under part A or B for such services. (B) Negotiation of rates permitted A Medicare Link contractor may negotiate with providers of services and suppliers payment rates that are less or greater than the payment rates referred to in subparagraph (A). (3) Contractor not at financial risk A Medicare Link contractor shall not be at financial risk with respect to the coverage or payment for Medicare services covered under parts A and B. But the Secretary may provide financial incentives for contractors that are able to reduce Medicare expenditures for such services below benchmark levels (specified by the Secretary) that reasonably represent the levels of payments that would be made (with respect to individuals enrolled under a Medicare Link plan) if such individuals were not so enrolled. .