I 114th CONGRESS 1st Session H. R. 4212 IN THE HOUSE OF REPRESENTATIVES December 10, 2015 Ms. Linda T. Sánchez of California (for herself, Mr. Meehan , Mr. Schrader , and Mr. Lance ) 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 establish a Community-Based Institutional Special Needs Plan demonstration program to target home and community-based care to eligible Medicare beneficiaries, and for other purposes.

1. Short title This Act may be cited as the Community-Based Independence for Seniors Act of 2015 . 2. Findings Congress makes the following findings: (1) Community-based services play an essential role in keeping individuals healthy. (2) Without community-based long-term services and supports, which are not typically covered by Medicare, seniors frequently experience negative health outcomes and lose their ability to live independently. (3) Seniors who deplete their resources often have no option but to turn to Medicaid for coverage of long-term care expenses. (4) Targeting community-based services and supports to at-risk seniors can help these individuals avoid depleting their assets and becoming Medicaid dependent. 3. Community-based institutional special needs plan demonstration Part C of title XVIII of the Social Security Act is amended by inserting after section 1859 ( 42 U.S.C. 1395w–28 ) the following new section: 1859A. Community-based institutional special needs plan demonstration (a) Establishment (1) In general The Secretary shall establish a Community-Based Institutional Special Needs Plan demonstration program (in this section referred to as the CBI–SNP demonstration program ) to provide home and community-based care to eligible Medicare beneficiaries. (2) Agreements The Secretary shall enter into agreements with eligible MA organizations under which such organizations shall offer eligible MA plans under the CBI–SNP demonstration program to eligible Medicare beneficiaries. (3) Limitation on number of plans The CBI–SNP demonstration program shall be carried out with respect to not greater than five MA plans. (4) Eligible MA plans defined For purposes of this section, the term eligible MA plan means a plan that, in addition to items and services for which coverage is otherwise provided under this part (including benefits under section 1852(a)(3) and notwithstanding any waivers under section 1915(c)), provides for coverage of long-term care services and supports that the Secretary determines appropriate for the purposes of the CBI–SNP demonstration program, such as— (A) homemaker services; (B) home delivered meals; (C) transportation services; (D) respite care; (E) adult day care services; and (F) safety and other equipment not otherwise covered under this title. (b) Eligible MA organizations For purposes of this section, the term eligible MA organization means an MA organization that— (1) has experience in offering specialized MA plans for special needs individuals, as defined in section 1859(b)(6)(A), to individuals who live in the community in which the eligible MA plan is offered; (2) has experience working with low-income seniors groups; (3) is located in a State that the Secretary has determined is able to participate in the CBI–SNP demonstration program by agreeing to make available data necessary for purposes of conducting the independent evaluation required under subsection (h); and (4) meets such other criteria as the Secretary may require. (c) Eligible Medicare beneficiary defined In this section, the term eligible Medicare beneficiary means a Medicare beneficiary who— (1) is eligible to enroll in an eligible MA plan under the CBI–SNP demonstration program; (2) is a subsidy eligible individual (as defined in section 1860D–14(a)(3)(A)); (3) is not eligible to receive benefits under title XIX; (4) is unable to perform 2 or more activities of daily living (as defined in section 7702B(c)(2)(B) of the Internal Revenue Code of 1986); and (5) is age 65 or older. (d) Payments The Secretary shall establish payment rates for eligible MA organizations offering eligible MA plans under the CBI–SNP demonstration program for benefits covered under such program (and not otherwise covered under part C) and provided to eligible Medicare beneficiaries under such plans. Such payment rates shall— (1) be based upon payment rates established for purposes of payment under section 1853; (2) be in addition to payments otherwise made to such organization with respect to such plans under part C; (3) be adjusted to reflect the costs of treating eligible Medicare beneficiaries under this section; and (4) not, with respect to a month in which an eligible MA organization provides home and community-based care to eligible Medicare beneficiaries under such demonstration program, exceed an amount for such month that is equal to the amount that would be awarded to such organization if the organization were to receive $400 with respect to each such beneficiary that the organization provides with such care during such month. (e) Special election period Notwithstanding sections 1852(e)(2)(C) and 1860D–1(b)(1)(B)(iii), an eligible Medicare beneficiary may, other than during the annual, coordinated election periods under such sections— (1) discontinue enrollment in an MA plan not participating in the CBI–SNP demonstration program and enroll in an MA plan participating in such program; and (2) discontinue enrollment under the original medicare fee-for-service program under parts A and B and the enrollment in a prescription drug plan under part D and enroll in an MA plan participating in the CBI–SNP demonstration program. (f) Beneficiary education The Secretary shall help to educate, through State Health Insurance Assistance Programs and other organizations that assist seniors with respect to benefits and enrollment under this title, eligible Medicare beneficiaries on the availability of the CBI–SNP demonstration program. (g) Implementation (1) Deadline The CBI–SNP demonstration program shall be implemented not later than January 1 of the second year beginning after the date of the enactment of this section. (2) Duration Subject to paragraph (3), the CBI–SNP demonstration program shall be conducted for a period of five years. (3) Extension or expansion Taking into account the report under subsection (h)(2), the Secretary may, through rulemaking, expand (including implementation on a nationwide or permanent basis) the duration or the scope CBI–SNP demonstration program to the extent determined appropriate by the Secretary, unless the Secretary determines that such expansion is expected to— (A) increase aggregate expenditures under this title and title XIX with respect to eligible Medicare beneficiaries participating in the CBI–SNP demonstration program; or (B) decrease the quality of health care services furnished to eligible Medicare beneficiaries participating in the CBI–SNP demonstration program. (h) Independent evaluation and reports (1) Independent evaluation (A) In general The Secretary shall provide for the evaluation of the CBI–SNP demonstration program by an independent third party. (B) Evaluation objectives Such evaluation shall determine the extent to which the CBI–SNP demonstration program has resulted in— (i) improved patient care; (ii) reduced hospitalizations or rehospitalizations; (iii) reduced or delayed nursing facility admissions and lengths of stay under title XIX; (iv) reduced spend down of income and assets for purposes of becoming eligible for medical assistance under a State plan under title XIX; (v) improved quality of life for the eligible Medicare beneficiaries enrolled in an eligible MA plan participating in the CBI–SNP demonstration program; and (vi) improved caregiver satisfaction. (C) Evaluation process Such evaluation shall be completed in accordance with the following process: (i) The Secretary shall, prior to the implementation of such program, establish goals for such program with respect to the evaluation objectives described in subparagraph (B) and criteria for measuring the extent to which an eligible MA plan participating in the CBI–SNP demonstration program meets such goals. (ii) The Secretary shall implement clear data collection and reporting requirements for such eligible MA plans in order to carry out such evaluation. In carrying out such process, the Secretary shall recognize that definitions, benefits, and program requirements for long-term care services and supports vary across States. (2) Reports Not later than four years after the implementation of the CBI–SNP demonstration program, the Secretary shall submit to Congress a report containing the results of the evaluation conducted under paragraph (1), together with such recommendations for legislative or administrative action as the Secretary determines appropriate. In preparing such report, the Secretary shall use at least three years worth of data under the demonstration program. (i) Budget neutrality For any year after the third year of the CBI–SNP demonstration program, the Secretary shall ensure that the aggregate payments made under this title and title XIX, including under the demonstration program, do not exceed the amount which the Secretary estimates would have been expended under such titles during such year if the CBI–SNP demonstration program had not been implemented. (j) Paperwork reduction act Chapter 35 of title 44, United States Code, shall not apply to the testing and evaluation of the CBI–SNP demonstration program. .