Community Options for Rural Elders Act of 2005 or the CORE Act of 2005 - Directs the Secretary of Health and Human Services to provide for the Administrator of Health Resources and Services to work with the Administrator of the Centers for Medicare and Medicaid Services to establish Programs for All-Inclusive Care for Elderly (PACE) providers in rural areas.
Directs the Secretary to permit a rural PACE provider applicant to adapt its PACE program to the unique requirements of eligible participants residing in rural areas and the challenges of providing services to them.
Requires the Secretary to waive certain requirements of titles XI, XVIII (Medicare), and XIX (Medicaid) of the Social Security Act as necessary to support the delivery of PACE services in rural areas.
Directs the Secretary to award site development grants to rural PACE providers.
Directs the Secretary, through the Office of Rural Health Policy, to make awards to tax-exempt organizations for the purpose of establishing a technical assistance outreach and education program.
Requires the Secretary to establish a fund to reimburse rural PACE providers awarded a site development grant for outlier costs with respect to eligible enrollees in rural areas.
Directs the Secretary to establish an advisory group.
[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[S. 1067 Introduced in Senate (IS)]
109th CONGRESS
1st Session
S. 1067
To require the Secretary of Health and Human Services to undertake
activities to ensure the provision of services under the PACE program
to frail elders living in rural areas, and for other purposes.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
May 18, 2005
Mrs. Lincoln (for herself, Mr. Brownback, Mr. Jeffords, and Mr.
Dorgan) introduced the following bill; which was read twice and
referred to the Committee on Finance
_______________________________________________________________________
A BILL
To require the Secretary of Health and Human Services to undertake
activities to ensure the provision of services under the PACE program
to frail elders living in rural areas, 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 ``Community Options for Rural Elders
Act of 2005'' or the ``CORE Act of 2005''.
SEC. 2. DEFINITIONS.
In this Act:
(1) CMS.--The term ``CMS'' means the Centers for Medicare &
Medicaid Services.
(2) Eligible participant.--The term ``eligible
participant'' means a PACE program eligible individual (as
defined in sections 1894(a)(5) and 1934(a)(5) of the Social
Security Act (42 U.S.C. 1395eee(a)(5); 1396u-4(a)(5))).
(3) HRSA.--The term ``HRSA'' means the Health Resources and
Services Administration.
(4) ORHP.--The term ``ORHP'' means the Office of Rural
Health Policy of HRSA.
(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 program agreement.--The term ``PACE program
agreement'' has the meaning given that term in section
1894(a)(4) or 1934(a)(4) of the Social Security Act (42 U.S.C.
1395eee(a)(4); 1396u-4(a)(4)).
(7) 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)).
(8) 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)).
(9) Rural pace provider applicant.--The term ``rural PACE
provider applicant'' means a PACE provider or a public entity
or private, nonprofit entity organized under section 501(c)(3)
of the Internal Revenue Code of 1986, that has applied to
provide services in a rural area in a manner consistent with
the objectives of the PACE program and this Act.
(10) Rural pace provider.--The term ``rural PACE provider''
means a rural PACE provider applicant that has been approved to
provide services in whole or in part in a rural area in a
manner consistent with the objectives of the PACE program and
this Act.
(11) Rural provider.--The term ``rural provider'' means a
health care, housing, or community service provider offering
services in whole or in part in a rural area.
(12) Rural service area.--The term ``rural service area''
means a rural area served by a PACE provider.
(13) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
SEC. 3. PURPOSES.
The purposes of this Act are--
(1) to require the Secretary to undertake activities to
fully exercise existing statutory and regulatory authority to
waive certain PACE program elements which may impair the
ability of otherwise qualified entities to provide PACE
services to qualified beneficiaries in rural areas;
(2) to establish a foundation of experience in utilizing
the PACE program model to serve qualified beneficiaries in
rural areas such that the model's transition to those areas
proceeds rationally and in full consideration of the unique
needs of rural, frail elders; and
(3) to regularly evaluate and report on the clinical and
cost-effectiveness of providing PACE services in meeting the
needs of medicare and medicaid beneficiaries living in rural
areas.
SEC. 4. PROGRAM TO SUPPORT PACE DEVELOPMENT IN RURAL AREAS.
(a) In General.--The Secretary shall provide for the Administrator
of HRSA to work with the Administrator of CMS to establish PACE
providers in rural areas.
(b) Adaption of Program for Requirements of Rural Participants.--In
order to support the establishment of PACE providers in rural areas,
the Secretary shall permit a rural PACE provider applicant to modify
the PACE program to be operated by the provider while delivering
services consistent, to the maximum extent feasible, with the general
intent and scope of services of that program, in order to adapt the
PACE program to the unique requirements of eligible participants
residing in rural areas and the challenges of providing services to
such participants.
(c) Deemed Approval of Provision of a PACE Program Agreement of a
Rural PACE Provider Applicant.--In the case of a rural PACE provider
applicant with a PACE program agreement--
(1) the rural PACE provider applicant shall identify the
provisions of such agreement that the applicant proposes to
apply if the applicant is approved to be a rural PACE provider;
and
(2) the Secretary shall review such provisions and, if the
Secretary approves the applicant to be a rural PACE provider,
deem such provisions as the Secretary determines appropriate to
apply to the rural PACE provider's PACE program agreement.
(d) Application of Flexibility in Exercising Waiver Authority.--The
Secretary shall utilize the authority provided under section 903 of the
Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act
of 2000 (114 Stat. 2763A-583), as enacted into law by section 1(a)(6)
of Public Law 106-554, and the regulations issued to carry out that
authority to allow for maximum flexibility in the operations of rural
PACE providers. In exercising such authority, the Secretary shall waive
or modify regulatory requirements applicable under part 460 of title
42, Code of Federal Regulations to the extent necessary for a rural
PACE provider. The waiver or modification of regulatory requirements
shall include requirements relating to--
(1) the PACE Center;
(2) employment;
(3) the use of community-based primary care physicians;
(4) the format, structure, and composition of the
interdisciplinary team and its meetings; and
(5) other requirements as are necessary for purposes of
providing, operating, and integrating PACE services in rural
areas.
(e) Waiver Authority.--
(1) In general.--Subject to paragraph (2), the Secretary
shall waive such requirements of titles XI, XVIII, and XIX of
the Social Security Act (42 U.S.C. 1301 et seq.; 1395 et seq.;
1396 et seq.) as may be necessary for purposes of supporting
the delivery of PACE services in rural areas as set forth by
the rural PACE provider applicants in their applications.
(2) Required waiver of full financial risk requirement for
initial 3-years of operation.--
(A) In general.--The Secretary--
(i) shall waive the requirement that a
rural PACE provider in at least its first 3
years of operation be at full financial risk;
and
(ii) upon request by the rural PACE
provider, may waive such requirement with
respect to years of operation after the first 3
years of operation if the Secretary determines
that the rural PACE provider is operating
properly and has demonstrated a reasonable
basis for not assuming full risk.
(B) Some risk required.--Nothing in subparagraph
(A) shall be construed to imply that a rural PACE
provider shall bear no financial risk for the
population it serves.
SEC. 5. STARTUP AND TECHNICAL ASSISTANCE FOR RURAL PACE PROVIDERS.
(a) Site Development Grants.--
(1) In general.--The Secretary shall award $7,500,000 in
site development grants to rural PACE providers.
(2) Amount per award.--A grant awarded under paragraph (1)
to a rural PACE provider shall not exceed $750,000.
(3) Use of funds.--Funds made available under a grant
awarded under paragraph (1) may be used for the following
expenses only if such expenses are incurred in relation to
establishing or delivering PACE program services in a rural
area:
(A) Feasibility analysis and planning.
(B) Interdisciplinary team development.
(C) Development of a provider network, including
contract development.
(D) Development or adaptation of claims processing
systems.
(E) Preparation of special education and outreach
efforts required for the PACE program.
(F) Development of expense reporting required for
calculation of outlier payments or reconciliation
processes.
(G) Development of any special quality of care or
patient satisfaction data collection efforts.
(H) Establishment of a working capital fund to
sustain fixed administrative, facility, or other fixed
costs until the provider reaches sufficient enrollment
size.
(I) Startup and development costs incurred prior to
the approval of the rural PACE provider applicant's
application by CMS.
(J) Any other efforts determined by the rural PACE
provider to be critical to the provider's successful
startup, as approved by the Secretary.
(4) Administration of site development grants.--The
Secretary shall instruct the ORHP, to develop, in consultation
with the Administrator of CMS, criteria for awarding site
development grants and to establish processes for administering
and overseeing the awarded grant funds. A prerequisite for
receiving a site development grant shall be the approval of the
rural PACE provider applicant's application by CMS. The grant
approval process and the administration of grant funds shall be
the responsibility of ORHP.
(5) Appropriation.--
(A) In general.--Out of any funds in the Treasury
not otherwise appropriated, there are appropriated to
the Secretary to carry out this subsection for the
period of fiscal years 2006 through 2007, $7,500,000.
(B) Availability.--Funds appropriated under
subparagraph (A) shall remain available for expenditure
through fiscal year 2010.
(b) Technical Assistance Program.--
(1) In general.--The Secretary, through ORHP, shall award
up to $250,000 for each of fiscal years 2006 through 2008 to a
public entity or private, nonprofit entity organized under
section 501(c)(3) of the Internal Revenue Code of 1986, for the
purpose of establishing a technical assistance program to
provide--
(A) outreach and education to State agencies and
provider organizations interested in establishing PACE
programs in rural areas; and
(B) technical assistance necessary to support
providers awarded grants under subsection (a).
(2) Preference in choosing a technical assistance
provider.--In selecting an entity for a grant under paragraph
(1), the Secretary shall--
(A) give preference to a technical assistance
program operated by an entity with previous experience
in conducting outreach and support related to PACE
program development and expansion for State agencies
and prospective PACE entities across a nationally
representative number of States and providers; and
(B) consider the entity's familiarity with the
delivery of health services to frail elderly
individuals who reside in rural areas.
(3) Appropriation.--Out of any funds in the Treasury not
otherwise appropriated, there are appropriated to the Secretary
to carry out this subsection for each of fiscal years 2006
through 2008, $250,000.
(c) Fund for Reimbursement of Outlier Costs of Grantees.--
(1) In general.--The Secretary shall establish an outlier
fund to reimburse rural PACE providers awarded a grant under
subsection (a)(1) for outlier costs (as defined in paragraph (2))
incurred with respect to eligible participants enrolled with such
providers who reside in, or receive services in, a rural area in
accordance with the outlier expense payment specified in paragraph (3).
(2) Outlier costs defined.--
(A) In general.--In paragraph (1), the term
``outlier costs'' means the inpatient and related
physician and ancillary costs incurred with respect to
an eligible participant described in paragraph (1) in
excess of $50,000 for the most recent 12-month period.
(B) Inclusion in only 1 period.--Outlier costs may
not be included in more than 1 12-month period for
purposes of calculating an outlier expense payment
under paragraph (3).
(3) Outlier expense payment.--
(A) Payment for outlier costs.--Subject to
subparagraph (B) and the amount appropriated under
paragraph (5), in the case of a rural PACE provider
described in paragraph (1) that has incurred outlier
costs for an eligible participant for the most recent
12-month period, the rural PACE provider shall receive
an outlier expense payment equal to 80 percent of such
costs.
(B) Limitations.--
(i) Costs incurred per eligible
participant.--The total amount of outlier
expense payments made under subparagraph (A) to
a rural PACE provider for outlier costs
incurred with respect to an eligible
participant shall not exceed $100,000 per
participant for the 12-month period used to
calculate the payment.
(ii) Costs incurred per provider.--No rural
PACE program provider may receive more than
$500,000 in total outlier expense payments paid
to the provider in a 12-month period.
(iii) Overall limit.--In no case may the
aggregate amount of outlier expense payments
made under this subsection for a fiscal year
exceed the amount available for expenditure
under paragraph (5).
(4) Requirement to access risk reserves prior to payment.--
A rural PACE provider shall access and exhaust any risk
reserves held or arranged for the provider (other than revenue
or reserves maintained to satisfy the requirements of section 460.80(c)
of title 42, Code of Federal Regulations) and any working capital
established through a grant awarded under subsection (a), prior to
receiving any payment from the outlier fund established under this
subsection.
(5) Appropriation.--
(A) In general.--Out of any funds in the Treasury
not otherwise appropriated, there are appropriated to
the Secretary to carry out this subsection--
(i) $2,000,000 for fiscal year 2006;
(ii) $5,000,000 for fiscal year 2007; and
(iii) $3,000,000 for fiscal year 2008.
(B) Availability.--Funds appropriated under
subparagraph (A) shall remain available for expenditure
through fiscal year 2010.
SEC. 6. EVALUATION OF PACE PROVIDERS SERVING RURAL SERVICE AREAS.
(a) In General.--Beginning with October 1 of the first fiscal year
that begins after the date of enactment of this Act, and for each of
the 2 succeeding fiscal years thereafter, the Secretary shall submit to
Congress annual progress reports on the provision of PACE programs in
rural areas.
(b) Comprehensive Evaluation.--
(1) In general.--In addition to the annual progress reports
to be submitted in accordance with subsection (a), not later
than 60 months after the effective date of final regulations
implementing this Act, the Secretary shall submit a
comprehensive overall evaluation of the clinical and cost-
effectiveness of rural PACE providers. Funds otherwise made
available to the Secretary for the purpose of conducting
research or evaluations shall be used for the costs of
conducting such evaluation.
(2) Requirements.--The evaluation required under paragraph
(1) shall include the following:
(A) An analysis of the quality and cost of
providing PACE program services to eligible
participants in rural areas as compared to such
outcomes and costs for a comparable population of
eligible participants that did not receive such
services from a rural PACE provider.
(B) Such recommendations regarding the extension or
expansion of rural PACE providers as the Secretary
determines appropriate.
(c) Extension of Waivers.--In order to ensure continuity of care
and services, the Secretary is authorized to provide for the continued
participation of a rural PACE provider beyond the otherwise approved
periods under this Act as well as to extend those waivers of PACE
program requirements under the authority of subsections (c) and (d) of
section 4 to rural PACE providers if the Secretary finds that the
providers comply with the objectives of the PACE program and this Act.
(d) Advisory Group.--
(1) In general.--The Secretary shall establish, and
actively consult with, an advisory group that will review and
comment on progress related to providing PACE program services
in rural areas.
(2) Duties.--The advisory group shall review and make
recommendations with respect to--
(A) the consideration of prospective PACE provider
applications to serve rural areas;
(B) the evaluation design, criteria, and results
achieved by rural PACE providers; and
(C) the technical assistance activities provided
under section 5(b) that support those providers and
States.
(3) Membership.--
(A) Number.--Not more than 9 individuals shall be
appointed to the advisory group established under this
subsection.
(B) Expertise.--A member of the advisory group
shall have experience with, and understanding of 1 or
more of the following areas:
(i) The development, organization, and
operation of the PACE program.
(ii) Providing services to frail elderly
individuals who reside in rural areas.
(iii) Federal and State programs and
initiatives that are related to the PACE
program.
<all>
Introduced in Senate
Read twice and referred to the Committee on Finance.
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