Medicare Residential Care Coordination Act of 2013 - Directs the Secretary of Health and Human Services to establish and implement a demonstration project under titles XVIII (Medicare) and XIX (Medicaid) of the Social Security Act (SSA) to evaluate the use of capitated payments made to eligible continuing care retirement communities for residential care coordination programs.
[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2376 Introduced in House (IH)]
113th CONGRESS
1st Session
H. R. 2376
To implement a demonstration project under titles XVIII and XIX of the
Social Security Act to examine the costs and benefits of providing
payments for comprehensive coordinated health care services provided by
purpose-built, continuing care retirement communities to Medicare
beneficiaries.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
June 14, 2013
Mr. Fitzpatrick introduced the following bill; which was referred to
the Committee on Energy and Commerce, and in addition to the Committee
on Ways and Means, 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 implement a demonstration project under titles XVIII and XIX of the
Social Security Act to examine the costs and benefits of providing
payments for comprehensive coordinated health care services provided by
purpose-built, continuing care retirement communities to Medicare
beneficiaries.
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 ``Medicare Residential Care
Coordination Act of 2013''.
SEC. 2. MEDICARE AND MEDICAID RESIDENTIAL CARE COORDINATION
DEMONSTRATION PROJECT.
(a) Establishment and Implementation.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
establish and implement a demonstration project (in this
section referred to as the ``demonstration project'') under
titles XVIII and XIX of the Social Security Act to evaluate the
use of capitated payments made to eligible continuing care
retirement communities for residential care coordination
programs.
(2) Timetable for implementation.--In carrying out this
section--
(A) not later than 1 year after the date of the
enactment of this Act the Secretary shall complete the
design for the demonstration project and enter into one
or more agreements with eligible CCRCs for the
implementation of the project with respect to such
CCRCs; and
(B) not later than 4 years after the date of
entering into such agreements, first provide for
implementation of the project through such CCRCs.
(b) Budget Neutrality.--With respect to the period of the
demonstration project under this section, the aggregate expenditures
under titles XVIII and XIX of the Social Security Act for such period
shall not exceed the aggregate expenditures that would have been
expended under such titles if the demonstration project had not been
implemented.
(c) State Election Required.--
(1) In general.--The Secretary may only implement the
demonstration project in a State that elects to participate in
the demonstration project.
(2) Benefits and payments.--A State that elects to
participate in the demonstration project shall provide medical
assistance through title XIX of the Social Security Act for
each eligible CCRC resident who is eligible for medical
assistance under the State plan under such title (including
such residents who are made eligible under subsection
(d)(3)(B)(iii)) and who is enrolled in a residential care
coordination program in a manner that is consistent with the
requirements of this section, including making the payments
under subsection (e).
(3) Limitation.--A State may establish a numerical limit
on--
(A) the number of eligible CCRC residents who may
be enrolled in residential care coordination programs
in the State; and
(B) the number of eligible CCRCs that may operate
residential care coordination programs in the State.
(d) Residential Care Coordination Program (RCCP); Eligible Continue
Care Retirement Community (CCRC); Eligible CCRC Residents;
Comprehensive Coordinated Health Care Services Defined.--
(1) Residential care coordination program; rccp.--For
purposes of this section, the terms ``residential care
coordination program'' and ``RCCP'' mean a program that--
(A) is operated within one or more eligible
continuing care retirement communities (as defined in
paragraph (2));
(B) is designed with a capacity of serving at least
1,000, but not more than 1,500, eligible CCRC residents
(as defined in paragraph (3)) at any one time; and
(C) provides comprehensive coordinated health care
services (as defined in paragraph (4)) to participating
CCRC residents enrolled in the program in accordance
with the program agreement under subsection (f) and the
requirements of this section.
(2) Eligible continuing care retirement community; eligible
ccrc.--In this section, the terms ``eligible continuing care
retirement community'' and ``eligible CCRC'' mean an entity
that is a continuing care retirement community (as defined in
section 1852(l)(4)(B) of the Social Security Act (42 U.S.C.
1395w-22(l)(4)(B))) that--
(A) is built for the purposes of participating in
the demonstration project;
(B) provides onsite--
(i) housing accommodations for eligible
CCRC residents, including apartments for
independent living; and
(ii) additional services to facilitate
aging in place for such residents, including
assisted living and skilled nursing facilities
or alternatives; and
(C) has entered into a program agreement with the
Secretary and the State with respect to its operation
of the residential care coordination program and such
agreement is consistent with the requirements of this
section.
(3) Eligible ccrc resident; participating ccrc resident.--
(A) In general.--For purposes of this section:
(i) Eligible ccrc resident.--The term
``eligible CCRC resident'' means an individual
who--
(I) is entitled to, or enrolled
for, benefits under part A of title
XVIII of the Social Security Act, and
enrolled for benefits under part B of
such title; and
(II) resides in an eligible CCRC.
(ii) Participating ccrc resident.--The term
``participating CCRC resident'' means, with
respect to a resident care coordination
program, an eligible CCRC resident who is
enrolled in that program.
(B) Participation by dual-eligible individuals;
expanded eligibility.--
(i) In general.--An eligible CCRC resident
may be, but is not required to be, a dual-
eligible individual.
(ii) Dual-eligible individual defined.--In
this section, the term ``dual-eligible
individual'' means any individual who is--
(I) a full-benefit dual eligible
individual (as defined in section
1935(c)(6) of the Social Security Act);
or
(II) is described in clause (iii).
(iii) Qualification of participating ccrc
residents for medicaid benefits.--An individual
who is a participating CCRC resident,
regardless of the level of care, who meets
income and resource eligibility criteria
established under the State Medicaid plan for
an individual to obtain coverage for nursing
facility services on the basis of the
individual's requirement for the level of care
for such services, shall be treated as a dual-
eligible individual under this section and
under title XIX of the Social Security Act so
long as the individual remains a participating
CCRC resident.
(C) Enrollment and disenrollment rules.--
(i) Deemed enrollment at time of initial
residency.--An individual who is described in
subclause (I) of subparagraph (A)(i) is deemed,
at the time of becoming a resident in an
eligible CCRC, to have voluntarily consented to
enroll in the RCCP operated by that CCRC for
purposes of subparagraph (A)(ii).
(ii) Disenrollment process.--The
demonstration project shall provide a method
for the disenrollment from the project of
participating CCRC residents, which method
shall take into account the unique
circumstances of residents who are required to
leave the CCRC and shall permit disenrollment
at least in the same circumstances as would
permit an individual to disenroll from a
Medicare Advantage plan under part C of title
XVIII of the Social Security Act for cause.
(D) Relation to medicare advantage and prescription
drug program.--
(i) Supercedes enrollment.--A participating
CCRC resident is not eligible to enroll in an
MA plan under part C of title XVIII of the
Social Security Act or under a prescription
drug plan under part D of such title.
(ii) Coordination in case of
disenrollment.--In the case of a participating
CCRC resident who disenrolls from the
demonstration project, the disenrollment shall
be treated, for purposes of parts C and D of
such title, as if the individual had been
previously enrolled in, and disenrolled from,
an MA-PD plan under part C of such title.
(E) Premium payments.--During the period in which
an individual is a participating CCRC resident--
(i) for purposes of payment of premiums
under parts B, C, and D of title XVIII of the
Social Security Act, the individual shall be
treated as if the individual were enrolled
under an MA-PD plan with a premium equal to an
amount specified in the program agreement; and
(ii) the individual shall be eligible for
assistance with respect to such premiums under
part D and Medicare cost-sharing in the same
manner and in the equivalent amounts as if the
individual had not been enrolled as a
participating CCRC resident.
(4) Comprehensive coordinated health care services
defined.--For purposes of this section, the term
``comprehensive coordinated health care services'', with
respect to an eligible CCRC resident--
(A) means all items and services that are otherwise
payable under title XVIII of the Social Security Act,
including the minimum prescription drug coverage
required under a prescription drug plan under part D of
such title;
(B) includes in the case of a dual eligible
individual all items and services that are otherwise
payable under the State plan under title XIX of such
Act of the State in which the resident resides; and
(C) also includes--
(i) care management services that
coordinate acute and specialty services
(including inpatient hospital services,
services provided by specialty physicians, and
other necessary services) provided to eligible
CCRC residents;
(ii) wellness services, including
assistance and instruction in healthy living
(including diet and exercise); and
(iii) other health care items and services
to manage chronic conditions, treat subacute
conditions, and provide preventive care.
(e) Payment Under Medicare and Medicaid.--
(1) In general.--In the case of an individual who is a
participating CCRC resident who is enrolled in a residential
care coordination program operated by an eligible CCRC--
(A) the individual shall receive benefits under
title XVIII of the Social Security Act, and, if such
individual is a dual-eligible individual (as defined in
subsection (d)(3)(B)(ii)), under the State Medicaid
plan or waiver under title XIX of such Act, solely
through the residential care coordination program,
which shall provide such individual with comprehensive
coordinated health care services; and
(B) the eligible CCRC shall receive capitated
payments for the provision of such services (from the
Secretary for benefits under title XVIII and from the
State for benefits under such State plan or waiver), in
accordance with this section.
(2) Payment methodology.--
(A) Payment under medicare.--
(i) Payment on monthly basis.--With respect
to each eligible CCRC, the Secretary shall make
prospective monthly payments of a capitated
amount, based on the rate established under
clause (ii), for each participating CCRC
resident enrolled in the residential care
coordination program operated by such CCRC in
the same manner and from the same sources as
payments are made to a Medicare Advantage
organization under section 1853 of the Social
Security Act. Such payments shall be subject to
adjustment in the manner described in
paragraphs (2) and (3) of section 1853(a).
(ii) Establishment of payment rate.--
(I) In general.--The Secretary
shall establish a risk-adjusted
capitated payment rate under title
XVIII of the Social Security Act for
comprehensive coordinated health care
services provided to eligible CCRC
residents through a residential care
coordination program operated by an
eligible CCRC. The payment rate shall
be 90 percent of the adjusted average
per capita cost described in section
1853(c)(1)(D)(i) of such Act (42 U.S.C.
1395w-23(c)(1)(D)(i)), plus an amount
equivalent to 90 percent of the amount
that would have been paid to a
prescription drug plan the standardized
bid amount of which (as defined in
1860D-13(a)(5) of such Act) was equal
to the adjusted national average
monthly bid amount (as defined in
section 1860D-13(a)(1)(B)(iii) of such
Act) and taking into account low-income
subsidies paid under section 1860D-14.
(II) Program agreement.--The
mechanism for establishing the
capitated amount under this
subparagraph for a specific eligible
CCRC shall be specified in the program
agreement.
(B) Payment under medicaid.--
(i) Payment on a monthly basis.--With
respect to an eligible CCRC operating an RCCP,
the State shall make prospective monthly
payments of the capitated amount determined
under and specified in the program agreement
for each eligible CCRC resident of such
community who is a dual-eligible individual.
(ii) Relationship to medicare payments.--
The payment made under this subparagraph shall
be in addition to any payment made under
subparagraph (A) to an eligible CCRC for
eligible CCRC residents who are dual-eligible
individuals.
(iii) Program agreement.--The capitated
amount under this subparagraph for a specific
eligible CCRC shall be specified in the program
agreement.
(iv) Payments to the state.--The Secretary
shall treat the payments made under clause (i)
as medical assistance under title XIX of the
Social Security Act for purposes of making
payments to the State under section 1903 of
such Act (42 U.S.C. 1396b).
(v) Payments to reflect spend down amounts
and personal needs allowances.--The payments
under this subparagraph shall be made in a
manner that takes into account the financial
contributions required of dual-eligible
individuals and the personal needs allowance
established under the State plan. Such personal
needs allowances may vary depending upon the
level of care required by such an individual.
(3) Treatment of services furnished by noncontract
physicians and other entities.--
(A) Application of medicare advantage
requirements.--Section 1852(k)(1) of the Social
Security Act (42 U.S.C. 1395w-22(k)(1)) (relating to
limitations on balance billing against Medicare
Advantage organizations for noncontract physicians and
other entities with respect to services covered under
title XVIII of such Act) shall apply to eligible CCRCs,
eligible CCRC residents enrolled in a residential care
coordination program, and physicians and other entities
that do not have a contract or other agreement
establishing payment amounts for services furnished to
such a resident in the same manner as such section
applies to Medicare Advantage organizations,
individuals enrolled with such organizations, and
physicians and other entities referred to in such
section.
(B) Application of balanced billing limitations.--
Section 1866(a)(1)(O) shall apply to services that are
covered under title XVIII of the Social Security Act
and are furnished to any eligible CCRC residents
enrolled in a residential care coordination program in
the same manner that such section applies to services
furnished to an individual enrolled with a PACE
provider under section 1894 or 1934 of such Act.
(f) Program Agreement.--
(1) Requirement.--The Secretary, in close cooperation with
the single State agency that administers or supervises the
administration of the State plan under title XIX of the Social
Security Act (42 U.S.C. 1396 et seq.) (in this section referred
to as the ``State Medicaid agency''), shall establish
procedures for entering into, extending, and terminating
program agreements (each in this section referred to as a
``program agreement'') for the operation of residential care
coordination programs by eligible CCRCs.
(2) Agreement required for payment.--In order to receive
payment under subsection (e), each eligible CCRC operating a
residential care coordination program shall enter into a
program agreement with the Secretary and the State, which shall
contain such terms and conditions as the parties may agree to,
so long as such terms and conditions are consistent with this
section.
(3) Duration.--
(A) In general.--A program agreement under this
section shall be effective for a contract year,
beginning consistent with subsection (a)(2)(B) not
later than the fourth calendar year to begin after the
establishment of the demonstration project, and shall
be extended for additional contract years in the
absence of notice by a party to terminate.
(B) Termination.--
(i) End of demonstration project.--The
Secretary and the State Medicaid agency shall
terminate the program agreement at the
termination of the demonstration project under
subsection (i).
(ii) Notice of provider termination.--The
eligible CCRC may terminate the agreement after
appropriate notice to the Secretary, the State
Medicaid agency, and eligible CCRC residents.
(iii) Termination for cause.--The Secretary
and the State Medicaid agency may terminate the
program agreement at any time for cause (as
provided under the agreement). Reasons for
terminating an agreement under this clause
include that the Secretary or State
administering agency determines that--
(I) there are significant
deficiencies in the quality of care
provided to eligible CCRC residents
enrolled in the program or the eligible
CCRC has failed to comply substantially
with the requirements of this section;
and
(II) the entity has failed to
develop and successfully initiate,
within 30 days of the date of the
receipt of written notice of such a
determination, a plan to correct the
deficiencies, or has failed to continue
implementation of such a plan.
(iv) Right to remain.--Nothing in this
paragraph shall be construed, in the case that
a program agreement is terminated--
(I) for a previously participating
CCRC resident continuing, as affecting
the individual's right to continue to
reside in the CCRC and to receive
traditional CCRC care and services in
accordance with the contract between
the CCRC resident and the CCRC; and
(II) as relieving the State from
continuing to provide medical
assistance with respect to such
services for individuals who would
qualify as dual-eligible individuals if
the agreement had not been terminated.
(4) Scope of benefits.--
(A) In general.--Under the agreement under
paragraph (2), the eligible CCRC shall--
(i) provide to participating CCRC residents
of such community, regardless of source of
payment, directly or under contracts with other
entities, at a minimum, all comprehensive
coordinated health care services, without
regard to any limitation or condition as to
amount, duration, or scope under title XVIII or
title XIX of the Social Security Act;
(ii) provide such residents with access to
necessary covered items and services 24 hours a
day, every day of the year;
(iii) provide services to such residents
onsite at the eligible CCRC through a
multidisciplinary team that is led by a primary
care physician and includes care coordinators,
case managers, and nurses;
(iv) has a ratio of accessible physicians
to eligible CCRC residents that the Secretary
determines is adequate; and
(v) specify the covered items and services
that will not be provided directly by the
eligible CCRC and--
(I) provide for delivery of those
items and services through contracts to
ensure compliance with the requirements
of this section; and
(II) provides, on an as needed
basis for those residents who cannot
transport themselves, for necessary
transportation services to the
providers of such items and services,
if such items and services are provided
outside of the eligible CCRC.
(B) Application of regular cost-sharing rules.--
Under such agreement the eligible CCRC may apply
deductibles, copayments, coinsurance, or other cost
sharing that would otherwise apply under titles XVIII
and XIX of the Social Security Act in the case of a MA-
PD plan under part C of title XVIII of such Act.
(5) Quality control.--
(A) In general.--Under the program agreement, the
eligible CCRC shall--
(i) collect data;
(ii) maintain, and afford the Secretary and
the State Medicaid agency access to, the
records relating to the program, including
pertinent financial, medical, and personnel
records; and
(iii) submit to the Secretary and the State
Medicaid agency such reports as the Secretary
finds (in consultation with State Medicaid
agencies) necessary to monitor the operation,
cost, and effectiveness of the demonstration
project, including data relevant to the
measurements established by the Secretary under
subparagraph (B), to permit the Secretary and
the State to evaluate such demonstration
project.
(B) Quality and outcome measures.--The Secretary
shall establish clinical and other outcome measurements
to assess the efficacy of the demonstration project
in--
(i) improving--
(I) the health status and outcomes
of participating CCRC residents
enrolled in residential care
coordination programs under this
demonstration project, compared to
Medicare beneficiaries (including
traditional dual-eligible individuals
described in subsection
(d)(3)(B)(ii)(I)) who are not enrolled
in such programs; and
(II) the quality of health care
provided to such participating CCRC
residents; and
(ii) controlling the overall cost of
providing health care items and services to
such participating CCRC residents, compared to
the cost of providing such items and services
to other Medicare beneficiaries.
(6) Patient safeguards.--The agreement under paragraph (2)
shall provide for written safeguards of the rights of
participating CCRC residents enrolled in a residential care
coordination program (including a patient bill of rights and
procedures for grievances and appeals). Such safeguards shall
be similar to the safeguards required under the section
1894(b)(2)(B) of the Social Security Act (42 U.S.C.
1395eee(b)(2)(B)) with respect to the PACE program.
(7) Transition.--If a participating CCRC resident who is
enrolled in a residential care coordination program is
disenrolled from such program, the eligible CCRC shall provide
assistance to the individual in obtaining necessary care
through appropriate referrals and making the individual's
medical records available to new providers.
(8) Rule of construction.--Nothing is this subsection shall
be construed as preventing the eligible CCRC from assessing
typical and appropriate fees to eligible CCRC residents.
(g) Secretary's Oversight; Enforcement Authority.--
(1) Oversight.--
(A) In general.--During the duration of the
demonstration project, with respect to an eligible CCRC
operating a residential care coordination program under
a program agreement under subsection (f), the Secretary
(acting in cooperation with the State Medicaid agency)
shall conduct a comprehensive annual review of the
operation of the eligible CCRC in order to ensure
compliance with the requirements of this section. Such
review shall include--
(i) an onsite visit to the eligible CCRC;
(ii) a comprehensive assessment of the
community's fiscal soundness;
(iii) a comprehensive assessment of the
eligible CCRC's capacity to provide all
comprehensive coordinated health care services
to participating CCRC residents;
(iv) detailed analysis of the community's
substantial compliance with the requirements of
this section; and
(v) any other elements that the Secretary
or the State Medicaid agency considers
necessary or appropriate.
(B) Disclosure.--The results of reviews under this
paragraph shall be reported promptly to the eligible
CCRC, along with any recommendations for changes to the
community's program, and shall be made available to the
public through a public Web site of the Department of
Health and Human Services.
(2) Sanctions.--
(A) In general.--If the Secretary determines (after
consultation with the State Medicaid agency) that an
eligible CCRC operating a residential care coordination
program under a program agreement under subsection (f)
is failing substantially to comply with the
requirements of this section, the Secretary (and the
State Medicaid agency) may take any or all of the
following actions:
(i) Condition the continuation of the
program agreement upon timely execution of a
corrective action plan.
(ii) Withhold some or all further payments
under the program agreement under this section
with respect to services furnished by such
community until the deficiencies have been
corrected.
(iii) Terminate such agreement under
subsection (f)(3)(B).
(B) Application of intermediate sanctions.--The
Secretary may, by regulation, provide for the
application against an eligible CCRC operating a
residential care coordination program under a program
agreement under this section of remedies described in
section 1857(g)(2) of the Social Security Act (42
U.S.C. 1395w-27(g)(2)) or section 1903(m)(5)(B) of such
Act (42 U.S.C. 1396b(m)(5)(B)) in the case of
violations by the community of the type described in
section 1857(g)(1) or 1903(m)(5)(A) of such Act,
respectively (in relation to agreements, enrollees, and
requirements under this section).
(C) Procedures for termination or imposition of
sanctions.--The provisions of section 1857(h) of the
Social Security Act (42 U.S.C. 1395w-27(h)) shall
apply, by regulation, to termination and sanctions
respecting a program agreement and an eligible CCRC
operating a residential care coordination program under
a program agreement under this subsection in the same
manner as they apply to a termination and sanctions
with respect to a contract and a Medicare Advantage
organization under part C of title XVIII of such Act.
(h) Waiver.--Notwithstanding section 1115(a) of the Social Security
Act (42 U.S.C. 1315(a)), the Secretary may waive such provisions of
titles XI, XVIII, and XIX of that Act as may be necessary to--
(1) accomplish the goals of the demonstration project under
this section; and
(2) maximize the quality of life of eligible CCRC
beneficiaries, as determined using the measures established
under subsection (f)(5)(B).
(i) Duration of 10 Years.--
(1) In general.--Subject to paragraph (2) and subsection
(f)(3)(B), the demonstration project shall terminate 10 years
after the date on which the demonstration project is first
implemented under subsection (a)(2)(B).
(2) Extension.--The Secretary, acting through the Center
for Medicare and Medicaid Innovation, may extend the use of
capitated payments for eligible CCRCs for residential care
coordination programs under this section if, by the termination
date that would otherwise apply under paragraph (1), the
Secretary has demonstrated that the demonstration project has
improved the coordination, quality, and efficiency of health
care services furnished to Medicare beneficiaries.
(j) Study and Report to Congress.--
(1) Interim evaluation and report.--Not later than 3 years
after the date on which the demonstration project is first
implemented under subsection (a)(2)(B), the Secretary shall
submit to Congress a report that contains the following:
(A) An interim evaluation of the costs and benefits
of providing comprehensive coordinated health care
services to Medicare beneficiaries (including dual-
eligible individuals) through residential care
coordination programs, including the costs and benefits
of using payments under title XIX of the Social
Security Act to provide continuity of care by
permitting certain individuals to continue to
participate in such programs after qualifying for
enrollment in the Medicaid program under this section
due to reduced income and assets.
(B) An analysis of the appropriateness of
implementing a new payment methodology under titles
XVIII and XIX of the Social Security Act for such
services in the future.
(2) Final evaluation and report.--Not later than 10 years
after the date on which the demonstration project is first so
implemented, the Secretary shall submit to Congress a report
that contains a final evaluation of the impact of the
demonstration project.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, 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.
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, 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.
Referred to the Subcommittee on Health.
Referred to the Subcommittee on Health.
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