[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[S. 870 Introduced in Senate (IS)]
<DOC>
115th CONGRESS
1st Session
S. 870
To amend title XVIII of the Social Security Act to implement Medicare
payment policies designed to improve management of chronic disease,
streamline care coordination, and improve quality outcomes without
adding to the deficit.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
April 6 (legislative day, April 4), 2017
Mr. Hatch (for himself, Mr. Wyden, Mr. Isakson, Mr. Warner, Mr. Bennet,
Mr. Cardin, Mr. Thune, Mr. Casey, Mr. Cornyn, Mr. Crapo, Mr. Grassley,
Mr. Carper, Ms. Stabenow, and Mrs. McCaskill) introduced the following
bill; which was read twice and referred to the Committee on Finance
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to implement Medicare
payment policies designed to improve management of chronic disease,
streamline care coordination, and improve quality outcomes without
adding to the deficit.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Creating High-
Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC)
Care Act of 2017''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--RECEIVING HIGH QUALITY CARE IN THE HOME
Sec. 101. Extending the Independence at Home Demonstration Program.
Sec. 102. Expanding access to home dialysis therapy.
TITLE II--ADVANCING TEAM-BASED CARE
Sec. 201. Providing continued access to Medicare Advantage special
needs plans for vulnerable populations.
TITLE III--EXPANDING INNOVATION AND TECHNOLOGY
Sec. 301. Adapting benefits to meet the needs of chronically ill
Medicare Advantage enrollees.
Sec. 302. Expanding supplemental benefits to meet the needs of
chronically ill Medicare Advantage
enrollees.
Sec. 303. Increasing convenience for Medicare Advantage enrollees
through telehealth.
Sec. 304. Providing accountable care organizations the ability to
expand the use of telehealth.
Sec. 305. Expanding the use of telehealth for individuals with stroke.
TITLE IV--IDENTIFYING THE CHRONICALLY ILL POPULATION
Sec. 401. Providing flexibility for beneficiaries to be part of an
accountable care organization.
TITLE V--EMPOWERING INDIVIDUALS AND CAREGIVERS IN CARE DELIVERY
Sec. 501. Eliminating barriers to care coordination under accountable
care organizations.
Sec. 502. GAO study and report on longitudinal comprehensive care
planning services under Medicare part B.
TITLE VI--OTHER POLICIES TO IMPROVE CARE FOR THE CHRONICALLY ILL
Sec. 601. GAO study and report on improving medication synchronization.
Sec. 602. GAO study and report on impact of obesity drugs on patient
health and spending.
TITLE I--RECEIVING HIGH QUALITY CARE IN THE HOME
SEC. 101. EXTENDING THE INDEPENDENCE AT HOME DEMONSTRATION PROGRAM.
Section 1866E of the Social Security Act (42 U.S.C. 1395cc-5) is
amended--
(1) in subsection (e)--
(A) in paragraph (1), by striking ``5-year period''
and inserting ``7-year period''; and
(B) in paragraph (5), by striking ``10,000'' and
inserting ``15,000''; and
(2) in subsection (i), by striking ``second of 2'' and
inserting ``third of 3''.
SEC. 102. EXPANDING ACCESS TO HOME DIALYSIS THERAPY.
(a) In General.--Section 1881(b)(3) of the Social Security Act (42
U.S.C. 1395rr(b)(3)) is amended--
(1) by redesignating subparagraphs (A) and (B) as clauses
(i) and (ii), respectively;
(2) in clause (ii), as redesignated by subparagraph (A),
strike ``on a comprehensive'' and insert ``subject to
subparagraph (B), on a comprehensive'';
(3) by striking ``With respect to'' and inserting ``(A)
With respect to''; and
(4) by adding at the end the following new subparagraph:
``(B) For purposes of subparagraph (A)(ii), an individual
determined to have end stage renal disease receiving home dialysis may
choose to receive the monthly end stage renal disease-related visits
furnished on or after January 1, 2019, via telehealth if the individual
receives a face-to-face visit, without the use of telehealth, at least
once every three consecutive months.''.
(b) Originating Site Requirements.--
(1) In general.--Section 1834(m) of the Social Security Act
(42 U.S.C. 1395m(m)) is amended--
(A) in paragraph (4)(C)(ii), by adding at the end
the following new subclauses:
``(IX) A renal dialysis facility,
but only for purposes of section
1881(b)(3)(B).
``(X) The home of an individual,
but only for purposes of section
1881(b)(3)(B).''; and
(B) by adding at the end the following new
paragraph:
``(5) Treatment of home dialysis monthly esrd-related
visit.--The geographic requirements described in paragraph
(4)(C)(i) shall not apply with respect to telehealth services
furnished on or after January 1, 2019, for purposes of section
1881(b)(3)(B), at an originating site described in subclause
(VI), (IX), or (X) of paragraph (4)(C)(ii).''.
(2) No facility fee if originating site for home dialysis
therapy is the home.--Section 1834(m)(2)(B) of the Social
Security (42 U.S.C. 1395m(m)(2)(B)) is amended--
(A) by redesignating clauses (i) and (ii) as
subclauses (I) and (II), and indenting appropriately;
(B) in subclause (II), as redesignated by
subparagraph (A), by striking ``clause (i) or this
clause'' and inserting ``subclause (I) or this
subclause'';
(C) by striking ``site.--With respect to'' and
inserting ``site.--
``(i) In general.--Subject to clause (ii),
with respect to''; and
(D) by adding at the end the following new clause:
``(ii) No facility fee if originating site
for home dialysis therapy is the home.--No
facility fee shall be paid under this
subparagraph to an originating site described
in paragraph (4)(C)(ii)(X).''.
(c) Conforming Amendment.--Section 1881(b)(1) of the Social
Security Act (42 U.S.C. 1395rr(b)(1)) is amended by striking
``paragraph (3)(A)'' and inserting ``paragraph (3)(A)(i)''.
TITLE II--ADVANCING TEAM-BASED CARE
SEC. 201. PROVIDING CONTINUED ACCESS TO MEDICARE ADVANTAGE SPECIAL
NEEDS PLANS FOR VULNERABLE POPULATIONS.
(a) Extension.--Section 1859(f)(1) of the Social Security Act (42
U.S.C. 1395w-28(f)(1)) is amended by striking ``and for periods before
January 1, 2019''.
(b) Increased Integration of Dual SNPs.--
(1) In general.--Section 1859(f) of the Social Security Act
(42 U.S.C. 1395w-28(f)) is amended--
(A) in paragraph (3), by adding at the end the
following new subparagraph:
``(F) The plan meets the requirements applicable
under paragraph (8).''; and
(B) by adding at the end the following new
paragraph:
``(8) Increased integration of dual snps.--
``(A) Designated contact.--The Secretary, acting
through the Federal Coordinated Health Care Office
established under section 2602 of the Patient
Protection and Affordable Care Act, shall serve as a
dedicated point of contact for States to address
misalignments that arise with the integration of
specialized MA plans for special needs individuals
described in subsection (b)(6)(B)(ii) under this
paragraph and, consistent with such role, shall--
``(i) establish a uniform process for
disseminating to State Medicaid agencies
information under this title impacting
contracts between such agencies and such plans
under this subsection; and
``(ii) establish basic resources for States
interested in exploring such plans as a
platform for integration, such as a model
contract or other tools to achieve those goals.
``(B) Unified grievances and appeals process.--
``(i) In general.--Not later than April 1,
2020, the Secretary shall establish procedures,
to the extent feasible, unifying grievances and
appeals procedures under sections 1852(f),
1852(g), 1902(a)(3), 1902(a)(5), and 1932(b)(4)
for items and services provided by specialized
MA plans for special needs individuals
described in subsection (b)(6)(B)(ii) under
this title and title XIX. The Secretary shall
solicit comment in developing such procedures
from States, plans, beneficiaries and their
representatives, and other relevant
stakeholders.
``(ii) Procedures.--The procedures
established under clause (i) shall be included
in the plan contract under paragraph (3)(D) and
shall--
``(I) adopt the provisions for the
enrollee that are most protective for
the enrollee and, to the extent
feasible as determined by the
Secretary, are compatible with unified
timeframes and consolidated access to
external review under an integrated
process;
``(II) take into account
differences in State plans under title
XIX to the extent necessary;
``(III) be easily navigable by an
enrollee; and
``(IV) include the elements
described in clause (iii), as
applicable.
``(iii) Elements described.--Both unified
appeals and unified grievance procedures shall
include, as applicable, the following elements
described in this clause:
``(I) Single written notification
of all applicable grievances and appeal
rights under this title and title XIX.
For purposes of this subparagraph, the
Secretary may waive the requirements
under section 1852(g)(1)(B) when the
specialized MA plan covers items or
services under this part or under title
XIX.
``(II) Single pathways for
resolution of any grievance or appeal
related to a particular item or service
provided by specialized MA plans for
special needs individuals described in
subsection (b)(6)(B)(ii) under this
title and title XIX.
``(III) Notices written in plain
language and available in a language
and format that is accessible to the
enrollee, including in non-English
languages that are prevalent in the
service area of the specialized MA
plan.
``(IV) Unified timeframes for
grievances and appeals processes, such
as an individual's filing of a
grievance or appeal, a plan's
acknowledgment and resolution of a
grievance or appeal, and notification
of decisions with respect to a
grievance or appeal.
``(V) Requirements for how the plan
must process, track, and resolve
grievances and appeals, to ensure
beneficiaries are notified on a timely
basis of decisions that are made
throughout the grievance or appeals
process and are able to easily
determine the status of a grievance or
appeal.
``(iv) Continuation of benefits pending
appeal.--The unified procedures under clause
(i) shall, with respect to all benefits under
parts A and B and title XIX subject to appeal
under such procedures, incorporate provisions
under current law and implementing regulations
that provide continuation of benefits pending
appeal under this title and title XIX.
``(C) Requirement for unified grievances and
appeals.--For 2021 and subsequent years, the contract
of a specialized MA plan for special needs individuals
described in subsection (b)(6)(B)(ii) with a State
Medicaid agency under paragraph (3)(D) shall require
the use of unified grievances and appeals procedures as
described in subparagraph (B).
``(D) Requirements for integration.--For 2022 and
subsequent years, a specialized MA plan for special
needs individuals described in subsection (b)(6)(B)(ii)
shall meet one or more of the following requirements,
to the extent permitted under State law, for
integration of benefits under this title and title XIX:
``(i) The specialized MA plan must meet the
requirements of contracting with the State
Medicaid agency described in paragraph (3)(D)
in addition to coordinating long-term services
and supports or behavioral health services, or
both, by meeting an additional minimum set of
requirements determined by the Secretary
through the Federal Coordinated Health Care
Office established under section 2018 of the
Patient Protection and Affordable Care Act
based on input from stakeholders, such as
notifying the State in a timely manner of
hospitalizations, emergency room visits, and
hospital or nursing home discharges of
enrollees, assigning one primary care provider
for each enrollee, or sharing data that would
benefit the coordination of items and services
under this title and the State plan under title
XIX. Such minimum set of requirements must be
included in the contract of the specialized MA
plan with the State Medicaid agency under such
paragraph.
``(ii) The specialized MA plan must meet
the requirements of a fully integrated plan
described in section 1853(a)(1)(B)(iv)(II)
(other than the requirement that the plan have
similar average levels of frailty, as
determined by the Secretary, as the PACE
program), or enter into a capitated contract
with the State Medicaid agency to provide long-
term services and supports or behavioral health
services, or both.
``(iii) In the case where an individual is
enrolled in the specialized MA plan and a
Medicaid managed care organization (as defined
in section 1903(m)(1)(A)) that provides long
term services and supports or behavioral health
services with the same parent organization, the
parent organization offering both the
specialized MA plan and the Medicaid managed
care plan must assume clinical and financial
responsibility for benefits provided under this
title and title XIX.''.
(2) Conforming amendment to responsibilities of federal
coordinated health care office.--Section 2602(d) of the Patient
Protection and Affordable Care Act (42 U.S.C. 1315b(d)) is
amended by adding at the end the following new paragraphs:
``(6) To act as a designated contact for States under
subsection (f)(8)(A) of section 1859 of the Social Security Act
(42 U.S.C. 1395w-28) with respect to the integration of
specialized MA plans for special needs individuals described in
subsection (b)(6)(B)(ii) of such section.
``(7) To be responsible for developing regulations and
guidance related to the implementation of a unified grievance
and appeals process as described in subparagraphs (B) and (C)
of section 1859(f)(8) of the Social Security Act (42 U.S.C.
1395w-28(f)(8)).''.
(c) Improvements to Severe or Disabling Chronic Condition SNPs.--
(1) Care management requirements.--Section 1859(f)(5) of
the Social Security Act (42 U.S.C. 1395w-28(f)(5)) is amended--
(A) by striking ``all snps.--The requirements'' and
inserting ``all snps.--
``(A) In general.--Subject to subparagraph (B), the
requirements'';
(B) by redesignating subparagraphs (A) and (B) as
clauses (i) and (ii), respectively, and indenting
appropriately;
(C) in clause (ii), as redesignated by subparagraph
(B), by redesignating clauses (i) through (iii) as
subclauses (I) through (III), respectively, and
indenting appropriately; and
(D) by adding at the end the following new
subparagraph:
``(B) Improvements to care management requirements
for severe or disabling chronic condition snps.--For
2020 and subsequent years, in the case of a specialized
MA plan for special needs individuals described in
subsection (b)(6)(B)(iii), the requirements described
in this paragraph include the following:
``(i) The interdisciplinary team under
subparagraph (A)(ii)(III) includes a team of
providers with demonstrated expertise,
including training in an applicable specialty,
in treating individuals similar to the targeted
population of the plan.
``(ii) Requirements developed by the
Secretary to provide face-to-face encounters
with individuals enrolled in the plan not less
frequently than on an annual basis.
``(iii) As part of the model of care under
clause (i) of subparagraph (A), the results of
the initial assessment and annual reassessment
under clause (ii)(I) of such subparagraph of
each individual enrolled in the plan are
addressed in the individual's individualized
care plan under clause (ii)(II) of such
subparagraph.
``(iv) As part of the annual evaluation and
approval of such model of care, the Secretary
shall take into account whether the plan
fulfilled the previous year's goals (as
required under the model of care).
``(v) The Secretary shall establish a
minimum benchmark for each element of the model
of care of a plan. The Secretary shall only
approve a plan's model of care under this
paragraph if each element of the model of care
meets the minimum benchmark applicable under
the preceding sentence.''.
(2) Revisions to the definition of a severe or disabling
chronic conditions specialized needs individual.--
(A) In general.--Section 1859(b)(6)(B)(iii) of the
Social Security Act (42 U.S.C. 1395w-28(b)(6)(B)(iii))
is amended--
(i) by striking ``who have'' and inserting
``who--
``(I) before January 1, 2022,
have'';
(ii) in subclause (I), as added by clause
(i), by striking the period at the end and
inserting ``; and''; and
(iii) by adding at the end the following
new subclause:
``(II) on or after January 1, 2022,
have one or more comorbid and medically
complex chronic conditions that is life
threatening or significantly limits
overall health or function, have a high
risk of hospitalization or other
adverse health outcomes, and require
intensive care coordination and that is
listed under subsection (f)(9)(A).''.
(B) Panel of clinical advisors.--Section 1859(f) of
the Social Security Act (42 U.S.C. 1395w-28(f)), as
amended by subsection (b), is amended by adding at the
end the following new paragraph:
``(9) List of conditions for clarification of the
definition of a severe or disabling chronic conditions
specialized needs individual.--
``(A) In general.--Not later than December 31,
2020, and every 5 years thereafter, the Secretary shall
convene a panel of clinical advisors to establish and
update a list of conditions that meet each of the
following criteria:
``(i) Conditions that meet the definition
of a severe or disabling chronic condition
under subsection (b)(6)(B)(iii) on or after
January 1, 2022.
``(ii) Conditions that--
``(I) require prescription drugs,
providers, and models of care that are
unique to the specific population of
enrollees in a specialized MA plan for
special needs individuals described in
such subsection on or after such date
and would not be needed by the general
population of beneficiaries under this
title; and
``(II) have a low prevalence in the
general population of beneficiaries
under this title or a disproportionally
high per-beneficiary cost under this
title.
``(B) Requirement.--In establishing and updating
the list under subparagraph (A), the panel shall take
into account the availability of varied benefits, cost-
sharing, and supplemental benefits under the model
described in paragraph (2) of section 1859(h),
including the expansion under paragraph (1) of such
section.''.
(d) Quality Measurement at the Plan Level for SNPs and
Determination of Feasability of Quality Measurement at the Plan Level
for All MA Plans.--Section 1853(o) of the Social Security Act (42
U.S.C. 1395w-23(o)) is amended by adding at the end the following new
paragraphs:
``(6) Quality measurement at the plan level for snps.--
``(A) In general.--Subject to subparagraph (B), the
Secretary may require reporting of data under section
1852(e) for, and apply under this subsection, quality
measures at the plan level for specialized MA plans for
special needs individuals instead of at the contract
level.
``(B) Considerations.--Prior to applying quality
measurement at the plan level under this paragraph, the
Secretary shall--
``(i) take into consideration the minimum
number of enrollees in a specialized MA plan
for special needs individuals in order to
determine if a statistically significant or
valid measurement of quality at the plan level
is possible under this paragraph;
``(ii) if quality measures are reported at
the plan level, ensure that MA plans are not
required to provide duplicative information;
and
``(iii) ensure that such reporting does not
interfere with the collection of encounter data
submitted by MA organizations or the
administration of any changes to the program
under this part as a result of the collection
of such data.
``(C) Application.--If the Secretary applies
quality measurement at the plan level under this
paragraph, such quality measurement may include
Medicare Health Outcomes Survey (HOS), Healthcare
Effectiveness Data and Information Set (HEDIS),
Consumer Assessment of Healthcare Providers and Systems
(CAHPS) measures and quality measures under part D.
``(7) Determination of feasibility of quality measurement
at the plan level for all ma plans.--
``(A) Determination of feasibility.--The Secretary
shall determine the feasibility of requiring reporting
of data under section 1852(e) for, and applying under
this subsection, quality measures at the plan level for
all MA plans under this part.
``(B) Consideration of change.--After making a
determination under subparagraph (A), the Secretary
shall consider requiring such reporting and applying
such quality measures at the plan level as described in
such subparagraph.''.
(e) GAO Study and Report on State-Level Integration Between Dual
SNPs and Medicaid.--
(1) Study.--The Comptroller General of the United States
(in this paragraph referred to as the ``Comptroller General'')
shall conduct a study on State-level integration between
specialized MA plans for special needs individuals described in
subsection (b)(6)(B)(ii) of section 1859 of the Social Security
Act (42 U.S.C. 1395w-28) and the Medicaid program under title
XIX of such Act (42 U.S.C. 1396 et seq.). Such study shall
include an analysis of the following:
(A) The characteristics of States in which the
State agency responsible for administering the State
plan under such title XIX has a contract with such a
specialized MA plan and that delivers long term
services and supports under the State plan under such
title XIX through a managed care program, including the
requirements under such State plan with respect to long
term services and supports.
(B) The types of such specialized MA plans, which
may include the following:
(i) A plan described in section
1853(a)(1)(B)(iv)(II) of such Act (42 U.S.C.
1395w-23(a)(1)(B)(iv)(II)).
(ii) A plan that meets the requirements
described in subsection (f)(3)(D) of such
section 1859.
(iii) A plan described in clause (ii) that
also meets additional requirements established
by the State.
(C) The characteristics of individuals enrolled in
such specialized MA plans.
(D) As practicable, the following with respect to
State programs for the delivery of long term services
and supports under such title XIX through a managed
care program:
(i) Which populations of individuals are
eligible to receive such services and supports.
(ii) Whether all such services and supports
are provided on a capitated basis or if any of
such services and supports are carved out and
provided through fee-for-service.
(E) How the availability and variation of
integration arrangements of such specialized MA plans
offered in States affects spending, service delivery
options, access to community-based care, and
utilization of care.
(2) Report.--Not later than 2 years after the date of the
enactment of this Act, the Comptroller General shall submit to
Congress a report containing the results of the study conducted
under paragraph (1), together with recommendations for such
legislation and administrative action as the Comptroller
General determines appropriate.
TITLE III--EXPANDING INNOVATION AND TECHNOLOGY
SEC. 301. ADAPTING BENEFITS TO MEET THE NEEDS OF CHRONICALLY ILL
MEDICARE ADVANTAGE ENROLLEES.
Section 1859 of the Social Security Act (42 U.S.C. 1395w-28) is
amended by adding at the end the following new subsection:
``(h) National Testing of Model for Medicare Advantage Value-Based
Insurance Design.--
``(1) In general.--In implementing the model described in
paragraph (2) proposed to be tested under section 1115A(b), the
Secretary shall revise the testing of the model under such
section to cover, effective not later than January 1, 2020, all
States.
``(2) Model described.--The model described in this
paragraph is the testing of a model of Medicare Advantage
value-based insurance design that would allow Medicare
Advantage plans the option to propose and design benefit
structures that vary benefits, cost-sharing, and supplemental
benefits offered to enrollees with specific chronic diseases
proposed to be carried out in Oregon, Arizona, Texas, Iowa,
Michigan, Indiana, Tennessee, Alabama, Pennsylvania, and
Massachusetts.
``(3) Termination and modification provision not applicable
until january 1, 2022.--The provisions of section
1115A(b)(3)(B) shall apply to the model described in paragraph
(2), including such model as expanded under paragraph (1),
beginning January 1, 2022, but shall not apply to such model,
as so expanded, prior to such date.
``(4) Funding.--The Secretary shall allocate funds made
available under section 1115A(f)(1) to design, implement, and
evaluate the model described in paragraph (2), as expanded
under paragraph (1).''.
SEC. 302. EXPANDING SUPPLEMENTAL BENEFITS TO MEET THE NEEDS OF
CHRONICALLY ILL MEDICARE ADVANTAGE ENROLLEES.
(a) In General.--Section 1852(a)(3) of the Social Security Act (42
U.S.C. 1395w-22(a)(3)) is amended--
(1) in subparagraph (A), by striking ``Each'' and inserting
``Subject to subparagraph (D), each''; and
(2) by adding at the end the following new subparagraph:
``(D) Expanding supplemental benefits to meet the
needs of chronically ill enrollees.--
``(i) In general.--For plan year 2020 and
subsequent plan years, in addition to any
supplemental health care benefits otherwise
provided under this paragraph, an MA plan may
provide supplemental benefits described in
clause (ii) to a chronically ill enrollee (as
defined in clause (iii)).
``(ii) Supplemental benefits described.--
``(I) In general.--Supplemental
benefits described in this clause are
supplemental benefits that, with
respect to a chronically ill enrollee,
have a reasonable expectation of
improving or maintaining the health or
overall function of the chronically ill
enrollee and may not be limited to
being primarily health related
benefits.
``(II) Authority to waive
uniformity requirements.--The Secretary
may, only with respect to supplemental
benefits provided to a chronically ill
enrollee under this subparagraph, waive
the uniformity requirement under
subsection (d)(1)(A), as determined
appropriate by the Secretary.
``(iii) Chronically ill enrollee defined.--
In this subparagraph, the term `chronically ill
enrollee' means an enrollee in an MA plan that
the Secretary determines--
``(I) has one or more comorbid and
medically complex chronic conditions
that is life threatening or
significantly limits the overall health
or function of the enrollee;
``(II) has a high risk of
hospitalization or other adverse health
outcomes; and
``(III) requires intensive care
coordination.''.
(b) GAO Study and Report.--
(1) Study.--The Comptroller General of the United States
(in this subsection referred to as the ``Comptroller General'')
shall conduct a study on supplemental benefits provided to
enrollees in Medicare Advantage plans under part C of title
XVIII of the Social Security Act. Such study shall include an
analysis of the following:
(A) The type of supplemental benefits provided to
such enrollees, the total number of enrollees receiving
each supplemental benefit, and whether the supplemental
benefit is covered by the standard benchmark cost of
the benefit or with an additional premium.
(B) The frequency in which supplemental benefits
are utilized by such enrollees.
(C) The impact supplemental benefits have on--
(i) indicators of the quality of care
received by such enrollees, including overall
health and function of the enrollees;
(ii) the utilization of items and services
for which benefits are available under the
original Medicare fee-for-service program
option under parts A and B of such title XVIII
by such enrollees; and
(iii) the amount of the bids submitted by
Medicare Advantage Organizations for Medicare
Advantage plans under such part C.
(2) Report.--Not later than 5 years after the date of the
enactment of this Act, the Comptroller General shall submit to
Congress a report containing the results of the study conducted
under paragraph (1), together with recommendations for such
legislation and administrative action as the Comptroller
General determines appropriate.
SEC. 303. INCREASING CONVENIENCE FOR MEDICARE ADVANTAGE ENROLLEES
THROUGH TELEHEALTH.
(a) In General.--Section 1852 of the Social Security Act (42 U.S.C.
1395w-22) is amended--
(1) in subsection (a)(1)(B)(i), by inserting ``, subject to
subsection (m),'' after ``means''; and
(2) by adding at the end the following new subsection:
``(m) Provision of Additional Telehealth Benefits.--
``(1) MA plan option.--For plan year 2020 and subsequent
plan years, subject to the requirements of paragraph (3), an MA
plan may provide additional telehealth benefits (as defined in
paragraph (2)) to individuals enrolled under this part.
``(2) Additional telehealth benefits defined.--
``(A) In general.--For purposes of this subsection
and section 1854:
``(i) Definition.--The term `additional
telehealth benefits' means services--
``(I) for which benefits are
available under part B, including
services for which payment is not made
under section 1834(m) due to the
conditions for payment under such
section; and
``(II) that are identified as
clinically appropriate to furnish using
electronic information and
telecommunications technology when a
physician (as defined in section
1861(r)) or practitioner (described in
section 1842(b)(18)(C)) providing the
service is not at the same location as
the plan enrollee.
``(ii) Exclusion of capital and
infrastructure costs and investments.--The term
`additional telehealth benefits' does not
include capital and infrastructure costs and
investments relating to such benefits.
``(B) Public comment.--Not later than November 30,
2018, the Secretary shall solicit comments on what
types of telehealth services currently offered to
enrollees under this part through supplemental health
care benefits should be considered to meet the
definition of additional telehealth benefits under this
paragraph.
``(3) Requirements for additional telehealth benefits.--The
Secretary shall specify requirements for the provision or
furnishing of additional telehealth benefits, including with
respect to the following:
``(A) Physician or practitioner licensure and other
requirements such as specific training.
``(B) Factors necessary to ensure the coordination
of such benefits with items and services furnished in-
person.
``(C) Such other areas as determined by the
Secretary.
``(4) Enrollee choice.--If an MA plan provides a service as
an additional telehealth benefit (as defined in paragraph (2)),
an individual enrollee shall have discretion as to whether to
receive such service as an additional telehealth benefit.
``(5) Construction regarding network access adequacy.--
Provision of additional telehealth benefits under this
subsection shall not be construed as making such benefits
available and accessible for purposes of compliance with
subsection (d).
``(6) Treatment under ma.--For purposes of this subsection
and section 1854, additional telehealth benefits shall be
treated as if they were benefits under the original Medicare
fee-for-service program option.
``(7) Construction.--Nothing in this subsection shall be
construed as affecting the requirement under subsection (a)(1)
that MA plans provide enrollees with items and services (other
than hospice care) for which benefits are available under parts
A and B, including benefits available under section 1834(m).''.
(b) Clarification Regarding Inclusion in Bid Amount.--Section
1854(a)(6)(A)(ii)(I) of the Social Security Act (42 U.S.C. 1395w-
24(a)(6)(A)(ii)(I)) is amended by inserting ``, including, for plan
year 2020 and subsequent plan years, the provision of additional
telehealth benefits as described in section 1852(m)'' before the
semicolon at the end.
SEC. 304. PROVIDING ACCOUNTABLE CARE ORGANIZATIONS THE ABILITY TO
EXPAND THE USE OF TELEHEALTH.
(a) In General.--Section 1899 of the Social Security Act (42 U.S.C.
1395jjj) is amended by adding at the end the following new subsection:
``(l) Providing ACOs the Ability To Expand the Use of Telehealth
Services.--
``(1) In general.--In the case of telehealth services for
which payment would otherwise be made under this title
furnished on or after January 1, 2020, for purposes of this
subsection only, the following shall apply with respect to such
services furnished by a physician or practitioner participating
in an applicable ACO (as defined in paragraph (2)) to a
Medicare fee-for-service beneficiary assigned to the applicable
ACO:
``(A) Inclusion of home as originating site.--
Subject to paragraph (3), the home of a beneficiary
shall be treated as an originating site described in
section 1834(m)(4)(C)(ii).
``(B) No application of geographic limitation.--The
geographic limitation under section 1834(m)(4)(C)(i)
shall not apply with respect to an originating site
described in section 1834(m)(4)(C)(ii) (including the
home of a beneficiary under subparagraph (A)), subject
to State licensing requirements.
``(2) Definitions.--In this subsection:
``(A) Applicable aco.--The term `applicable ACO'
means an ACO participating in a model tested or
expanded under section 1115A or under this section--
``(i) that operates under a two-sided
model--
``(I) described in section
425.600(a) of title 42, Code of Federal
Regulations; or
``(II) tested or expanded under
section 1115A; and
``(ii) for which Medicare fee-for-service
beneficiaries are assigned to the ACO using a
prospective assignment method, as determined
appropriate by the Secretary.
``(B) Home.--The term `home' means, with respect to
a Medicare fee-for-service beneficiary, the place of
residence used as the home of the beneficiary.
``(3) Telehealth services received in the home.--In the
case of telehealth services described in paragraph (1) where
the home of a Medicare fee-for-service beneficiary is the
originating site, the following shall apply:
``(A) No facility fee.--There shall be no facility
fee paid to the originating site under section
1834(m)(2)(B).
``(B) Exclusion of certain services.--No payment
may be made for such services that are inappropriate to
furnish in the home setting such as services that are
typically furnished in inpatient settings such as a
hospital.''.
(b) Study and Report.--
(1) Study.--
(A) In general.--The Secretary of Health and Human
Services (in this subsection referred to as the
``Secretary'') shall conduct a study on the
implementation of section 1899(l) of the Social
Security Act, as added by subsection (a). Such study
shall include an analysis of the utilization of, and
expenditures for, telehealth services under such
section.
(B) Collection of data.--The Secretary may collect
such data as the Secretary determines necessary to
carry out the study under this paragraph.
(2) Report.--Not later than January 1, 2026, the Secretary
shall submit to Congress a report containing the results of the
study conducted under paragraph (1), together with
recommendations for such legislation and administrative action
as the Secretary determines appropriate.
SEC. 305. EXPANDING THE USE OF TELEHEALTH FOR INDIVIDUALS WITH STROKE.
Section 1834(m) of the Social Security Act (42 U.S.C. 1395m(m)), as
amended by section 102(b)(2), is amended by adding at the end the
following new paragraph:
``(6) Treatment of stroke telehealth services.--
``(A) Non-application of originating site
requirements.--The requirements described in paragraph
(4)(C) shall not apply with respect to telehealth
services furnished on or after January 1, 2019, for
purposes of evaluation of an acute stroke, as
determined by the Secretary.
``(B) No originating site facility fee.--The
Secretary shall not pay an originating site facility
fee (as described in paragraph (2)(B)) with respect to
such telehealth services.''.
TITLE IV--IDENTIFYING THE CHRONICALLY ILL POPULATION
SEC. 401. PROVIDING FLEXIBILITY FOR BENEFICIARIES TO BE PART OF AN
ACCOUNTABLE CARE ORGANIZATION.
Section 1899(c) of the Social Security Act (42 U.S.C. 1395jjj(c))
is amended--
(1) by redesignating paragraphs (1) and (2) as
subparagraphs (A) and (B), respectively, and indenting
appropriately;
(2) by striking ``ACOs.--The Secretary'' and inserting
``ACOs.--
``(1) In general.--Subject to paragraph (2), the
Secretary''; and
(3) by adding at the end the following new paragraph:
``(2) Providing flexibility.--
``(A) Choice of prospective assignment.--For each
agreement period (effective for agreements entered into
or renewed on or after January 1, 2020), in the case
where an ACO established under the program is in a
Track that provides for the retrospective assignment of
Medicare fee-for-service beneficiaries to the ACO, the
Secretary shall permit the ACO to choose to have
Medicare fee-for-service beneficiaries assigned
prospectively, rather than retrospectively, to the ACO
for an agreement period.
``(B) Assignment based on voluntary identification
by medicare fee-for-service beneficiaries.--
``(i) In general.--For performance year
2019 and each subsequent performance year, if a
system is available for electronic designation,
the Secretary shall permit a Medicare fee-for-
service beneficiary to voluntarily identify an
ACO professional as the primary care provider
of the beneficiary for purposes of assigning
such beneficiary to an ACO, as determined by
the Secretary.
``(ii) Notification process.--The Secretary
shall establish a process under which a
Medicare fee-for-service beneficiary is--
``(I) notified of their ability to
make an identification described in
clause (i); and
``(II) informed of the process by
which they may make and change such
identification.
``(iii) Superseding claims-based
assignment.--A voluntary identification by a
Medicare fee-for-service beneficiary under this
subparagraph shall supersede any claims-based
assignment otherwise determined by the
Secretary.''.
TITLE V--EMPOWERING INDIVIDUALS AND CAREGIVERS IN CARE DELIVERY
SEC. 501. ELIMINATING BARRIERS TO CARE COORDINATION UNDER ACCOUNTABLE
CARE ORGANIZATIONS.
(a) In General.--Section 1899 of the Social Security Act (42 U.S.C.
1395jjj), as amended by section 304(a), is amended--
(1) in subsection (b)(2), by adding at the end the
following new subparagraph:
``(I) An ACO that seeks to operate an ACO
Beneficiary Incentive Program pursuant to subsection
(m) shall apply to the Secretary at such time, in such
manner, and with such information as the Secretary may
require.'';
(2) by adding at the end the following new subsection:
``(m) Authority To Provide Incentive Payments to Beneficiaries With
Respect to Qualifying Primary Care Services.--
``(1) Program.--
``(A) In general.--In order to encourage Medicare
fee-for-service beneficiaries to obtain medically
necessary primary care services, an ACO participating
under this section under a payment model described in
clause (i) or (ii) of paragraph (2)(B) may apply to
establish an ACO Beneficiary Incentive Program to
provide incentive payments to such beneficiaries who
are furnished qualifying services in accordance with
this subsection. The Secretary shall permit such an ACO
to establish such a program at the Secretary's
discretion and subject to such requirements, including
program integrity requirements, as the Secretary
determines necessary.
``(B) Implementation.--The Secretary shall
implement this subsection on a date determined
appropriate by the Secretary. Such date shall be no
earlier than January 1, 2019, and no later than January
1, 2020.
``(2) Conduct of program.--
``(A) Duration.--Subject to subparagraph (H), an
ACO Beneficiary Incentive Program established under
this subsection shall be conducted for such period (of
not less than 1 year) as the Secretary may approve.
``(B) Scope.--An ACO Beneficiary Incentive Program
established under this subsection shall provide
incentive payments to all of the following Medicare
fee-for-service beneficiaries who are furnished
qualifying services by the ACO:
``(i) With respect to the Track 2 and Track
3 payment models described in section
425.600(a) of title 42, Code of Federal
Regulations (or in any successor regulation),
Medicare fee-for-service beneficiaries who are
preliminarily prospectively or prospectively
assigned (or otherwise assigned, as determined
by the Secretary) to the ACO.
``(ii) With respect to any future payment
models involving two-sided risk, Medicare fee-
for-service beneficiaries who are assigned to
the ACO, as determined by the Secretary.
``(C) Qualifying service.--For purposes of this
subsection, a qualifying service is a primary care
service, as defined in section 425.20 of title 42, Code
of Federal Regulations (or in any successor
regulation), with respect to which coinsurance applies
under part B, furnished through an ACO by--
``(i) an ACO professional described in
subsection (h)(1)(A) who has a primary care
specialty designation included in the
definition of primary care physician under
section 425.20 of title 42, Code of Federal
Regulations (or any successor regulation);
``(ii) an ACO professional described in
subsection (h)(1)(B); or
``(iii) a Federally qualified health center
or rural health clinic (as such terms are
defined in section 1861(aa)).
``(D) Incentive payments.--An incentive payment
made by an ACO pursuant to an ACO Beneficiary Incentive
Program established under this subsection shall be--
``(i) in an amount up to $20, with such
maximum amount updated annually by the
percentage increase in the consumer price index
for all urban consumers (United States city
average) for the 12-month period ending with
June of the previous year;
``(ii) in the same amount for each Medicare
fee-for-service beneficiary described in clause
(i) or (ii) of subparagraph (B) without regard
to enrollment of such a beneficiary in a
medicare supplemental policy (described in
section 1882(g)(1)), in a State Medicaid plan
under title XIX or a waiver of such a plan, or
in any other health insurance policy or health
benefit plan;
``(iii) made for each qualifying service
furnished to such a beneficiary described in
clause (i) or (ii) of subparagraph (B) during a
period specified by the Secretary; and
``(iv) made no later than 30 days after a
qualifying service is furnished to such a
beneficiary described in clause (i) or (ii) of
subparagraph (B).
``(E) No separate payments from the secretary.--The
Secretary shall not make any separate payment to an ACO
for the costs, including incentive payments, of
carrying out an ACO Beneficiary Incentive Program
established under this subsection. Nothing in this
subparagraph shall be construed as prohibiting an ACO
from using shared savings received under this section
to carry out an ACO Beneficiary Incentive Program.
``(F) No application to shared savings
calculation.--Incentive payments made by an ACO under
this subsection shall be disregarded for purposes of
calculating benchmarks, estimated average per capita
Medicare expenditures, and shared savings under this
section.
``(G) Reporting requirements.--An ACO conducting an
ACO Beneficiary Incentive Program under this subsection
shall, at such times and in such format as the
Secretary may require, report to the Secretary such
information and retain such documentation as the
Secretary may require, including the amount and
frequency of incentive payments made and the number of
Medicare fee-for-service beneficiaries receiving such
payments.
``(H) Termination.--The Secretary may terminate an
ACO Beneficiary Incentive Program established under
this subsection at any time for reasons determined
appropriate by the Secretary.
``(3) Exclusion of incentive payments.--Any payment made
under an ACO Beneficiary Incentive Program established under
this subsection shall not be considered income or resources or
otherwise taken into account for purposes of--
``(A) determining eligibility for benefits or
assistance (or the amount or extent of benefits or
assistance) under any Federal program or under any
State or local program financed in whole or in part
with Federal funds; or
``(B) any Federal or State laws relating to
taxation.'';
(3) in subsection (e), by inserting ``, including an ACO
Beneficiary Incentive Program under subsections (b)(2)(I) and
(m)'' after ``the program''; and
(4) in subsection (g)(6), by inserting ``or of an ACO
Beneficiary Incentive Program under subsections (b)(2)(I) and
(m)'' after ``under subsection (d)(4)''.
(b) Amendment to Section 1128B.--Section 1128B(b)(3) of the Social
Security Act (42 U.S.C. 1320a-7b(b)(3)) is amended--
(1) by striking ``and'' at the end of subparagraph (I);
(2) by striking the period at the end of subparagraph (J)
and inserting ``; and''; and
(3) by adding at the end the following new subparagraph:
``(K) an incentive payment made to a Medicare fee-
for-service beneficiary by an ACO under an ACO
Beneficiary Incentive Program established under
subsection (m) of section 1899, if the payment is made
in accordance with the requirements of such subsection
and meets such other conditions as the Secretary may
establish.''.
(c) Evaluation and Report.--
(1) Evaluation.--The Secretary of Health and Human Services
(in this subsection referred to as the ``Secretary'') shall
conduct an evaluation of the ACO Beneficiary Incentive Program
established under subsections (b)(2)(I) and (m) of section 1899
of the Social Security Act (42 U.S.C. 1395jjj), as added by
subsection (a). The evaluation shall include an analysis of the
impact of the implementation of the Program on expenditures and
beneficiary health outcomes under title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.).
(2) Report.--Not later than October 1, 2023, the Secretary
shall submit to Congress a report containing the results of the
evaluation under paragraph (1), together with recommendations
for such legislation and administrative action as the Secretary
determines appropriate.
SEC. 502. GAO STUDY AND REPORT ON LONGITUDINAL COMPREHENSIVE CARE
PLANNING SERVICES UNDER MEDICARE PART B.
(a) Study.--The Comptroller General shall conduct a study on the
establishment under part B of the Medicare program under title XVIII of
the Social Security Act of a payment code for a visit for longitudinal
comprehensive care planning services. Such study shall include an
analysis of the following to the extent such information is available:
(1) The frequency with which services similar to
longitudinal comprehensive care planning services are furnished
to Medicare beneficiaries, which providers of services and
suppliers are furnishing those services, whether Medicare
reimbursement is being received for those services, and, if so,
through which codes those services are being reimbursed.
(2) Whether, and the extent to which, longitudinal
comprehensive care planning services would overlap, and could
therefore result in duplicative payment, with services covered
under the hospice benefit as well as the chronic care
management code, evaluation and management codes, or other
codes that already exist under part B of the Medicare program.
(3) Any barriers to hospitals, skilled nursing facilities,
hospice programs, home health agencies, and other applicable
providers working with a Medicare beneficiary to engage in the
care planning process and complete the necessary documentation
to support the treatment and care plan of the beneficiary and
provide such documentation to other providers and the
beneficiary or his representative.
(4) Any barriers to providers, other than the provider
furnishing longitudinal comprehensive care planning services,
accessing the care plan and associated documentation for use
related to the care of the Medicare beneficiary.
(5) Potential options for ensuring that applicable
providers are notified of a patient's existing longitudinal
care plan and that applicable providers consider that plan in
making their treatment decisions, and what the challenges might
be in implementing such options.
(6) Stakeholder's views on the need for the development of
quality metrics with respect to longitudinal comprehensive care
planning services, such as measures related to--
(A) the process of eliciting input from the
Medicare beneficiary or from a legally authorized
representative and documenting in the medical record
the patient-directed care plan;
(B) the effectiveness and patient-centeredness of
the care plan in organizing delivery of services
consistent with the plan;
(C) the availability of the care plan and
associated documentation to other providers that care
for the beneficiary; and
(D) the extent to which the beneficiary received
services and support that is free from discrimination
based on advanced age, disability status, or advanced
illness.
(7) Stakeholder's views on how such quality metrics would
provide information on--
(A) the goals, values, and preferences of the
beneficiary;
(B) the documentation of the care plan;
(C) services furnished to the beneficiary; and
(D) outcomes of treatment.
(8) Stakeholder's views on--
(A) the type of training and education needed for
applicable providers, individuals, and caregivers in
order to facilitate longitudinal comprehensive care
planning services;
(B) the types of providers of services and
suppliers that should be included in the
interdisciplinary team of an applicable provider; and
(C) the characteristics of Medicare beneficiaries
that would be most appropriate to receive longitudinal
comprehensive care planning services, such as
individuals with advanced disease and individuals who
need assistance with multiple activities of daily
living.
(9) Stakeholder's views on the frequency with which
longitudinal comprehensive care planning services should be
furnished.
(b) Report.--Not later than 18 months after the date of the
enactment of this Act, the Comptroller General shall submit to Congress
a report containing the results of the study conducted under subsection
(a), together with recommendations for such legislation and
administrative action as the Comptroller General determines
appropriate.
(c) Definitions.--In this section:
(1) Applicable provider.--The term ``applicable provider''
means a hospice program (as defined in subsection (dd)(2) of
section 1861 of the Social Security Act (42 U.S.C. 1395ww)) or
other provider of services (as defined in subsection (u) of
such section) or supplier (as defined in subsection (d) of such
section) that--
(A) furnishes longitudinal comprehensive care
planning services through an interdisciplinary team;
and
(B) meets such other requirements as the Secretary
may determine to be appropriate.
(2) Comptroller general.--The term ``Comptroller General''
means the Comptroller General of the United States.
(3) Interdisciplinary team.--The term ``interdisciplinary
team'' means a group that--
(A) includes the personnel described in subsection
(dd)(2)(B)(i) of such section 1861;
(B) may include a chaplain, minister, or other
clergy; and
(C) may include other direct care personnel.
(4) Longitudinal comprehensive care planning services.--The
term ``longitudinal comprehensive care planning services''
means a voluntary shared decisionmaking process that is
furnished by an applicable provider through an
interdisciplinary team and includes a conversation with
Medicare beneficiaries who have received a diagnosis of a
serious or life-threatening illness. The purpose of such
services is to discuss a longitudinal care plan that addresses
the progression of the disease, treatment options, the goals,
values, and preferences of the beneficiary, and the
availability of other resources and social supports that may
reduce the beneficiary's health risks and promote self-
management and shared decisionmaking.
(5) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
TITLE VI--OTHER POLICIES TO IMPROVE CARE FOR THE CHRONICALLY ILL
SEC. 601. GAO STUDY AND REPORT ON IMPROVING MEDICATION SYNCHRONIZATION.
(a) Study.--The Comptroller General of the United States (in this
section referred to as the ``Comptroller General'') shall conduct a
study on the extent to which Medicare prescription drug plans (MA-PD
plans and standalone prescription drug plans) under part D of title
XVIII of the Social Security Act and private payors use programs that
synchronize pharmacy dispensing so that individuals may receive
multiple prescriptions on the same day to facilitate comprehensive
counseling and promote medication adherence. The study shall include a
review of the following:
(1) The extent to which pharmacies have adopted such
programs.
(2) The common characteristics of such programs, including
how pharmacies structure counseling sessions under such
programs and the types of payment and other arrangements that
Medicare prescription drug plans and private payors employ
under such programs to support the efforts of pharmacies.
(3) How such programs compare for Medicare prescription
drug plans and private payors.
(4) What is known about how such programs affect patient
medication adherence and overall patient health outcomes and
health outcomes, including if adherence and outcomes vary by
patient subpopulations, such as disease state and socioeconomic
status.
(5) What is known about overall patient satisfaction with
such programs and satisfaction with such programs, including
within patient subpopulations, such as disease state and
socioeconomic status.
(6) The extent to which laws and regulations of the
Medicare program support such programs.
(7) Barriers to the use of medication synchronization
programs by Medicare prescription drug plans.
(b) Report.--Not later than 18 months after the date of the
enactment of this Act, the Comptroller General shall submit to Congress
a report containing the results of the study under subsection (a),
together with recommendations for such legislation and administrative
action as the Comptroller General determines appropriate.
SEC. 602. GAO STUDY AND REPORT ON IMPACT OF OBESITY DRUGS ON PATIENT
HEALTH AND SPENDING.
(a) Study.--The Comptroller General of the United States (in this
section referred to as the ``Comptroller General'') shall conduct a
study on the use of prescription drugs to manage the weight of obese
patients and the impact of coverage of such drugs on patient health and
on health care spending. Such study shall examine the use and impact of
these obesity drugs in the non-Medicare population and for Medicare
beneficiaries who have such drugs covered through an MA-PD plan (as
defined in section 1860D-1(a)(3)(C) of the Social Security Act (42
U.S.C. 1395w-101(a)(3)(C))) as a supplemental health care benefit. The
study shall include an analysis of the following:
(1) The prevalence of obesity in the Medicare and non-
Medicare population.
(2) The utilization of obesity drugs.
(3) The distribution of Body Mass Index by individuals
taking obesity drugs, to the extent practicable.
(4) What is known about the use of obesity drugs in
conjunction with the receipt of other items or services, such
as behavioral counseling, and how these compare to items and
services received by obese individuals who do not take obesity
drugs.
(5) Physician considerations and attitudes related to
prescribing obesity drugs.
(6) The extent to which coverage policies cease or limit
coverage for individuals who fail to receive clinical benefit.
(7) What is known about the extent to which individuals who
take obesity drugs adhere to the prescribed regimen.
(8) What is known about the extent to which individuals who
take obesity drugs maintain weight loss over time.
(9) What is known about the subsequent impact such drugs
have on medical services that are directly related to obesity,
including with respect to subpopulations determined based on
the extent of obesity.
(10) What is known about the spending associated with the
care of individuals who take obesity drugs, compared to the
spending associated with the care of individuals who do not
take such drugs.
(b) Report.--Not later than 18 months after the date of the
enactment of this Act, the Comptroller General shall submit to Congress
a report containing the results of the study under subsection (a),
together with recommendations for such legislation and administrative
action as the Comptroller General determines appropriate.
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