HR 6590 — PACE Expanded Act

(a) Center for Medicare and Medicaid Innovation established (1) In general There is created within the Centers for Medicare & Medicaid Services a Center for Medicare and Medicaid Innovation (in this section referred to as the “CMI”) to carry out the duties described in this section. The purpose of the CMI is to test innovative payment and service delivery models to reduce program expenditures under the applicable subchapters while preserving or enhancing the quality of care furnished to individuals under such subchapters. In selecting such models, the Secretary shall give preference to models that also improve the coordination, quality, and efficiency of health care services furnished to applicable individuals defined in paragraph (4)(A). (2) Deadline The Secretary shall ensure that the CMI is carrying out the duties described in this section by not later than January 1, 2011. (3) Consultation In carrying out the duties under this section, the CMI shall consult representatives of relevant Federal agencies, and clinical and analytical experts with expertise in medicine and health care management. The CMI shall use open door forums or other mechanisms to seek input from interested parties. (4) Definitions In this section: (A) Applicable individual The term “applicable individual” means— (i) an individual who is entitled to, or enrolled for, benefits under part A of subchapter XVIII or enrolled for benefits under part B of such subchapter; (ii) an individual who is eligible for medical assistance under subchapter XIX, under a State plan or waiver; or (iii) an individual who meets the criteria of both clauses (i) and (ii). (B) Applicable subchapter The term “applicable subchapter” means subchapter XVIII, subchapter XIX, or both. (5) Testing within certain geographic areas For purposes of testing payment and service delivery models under this section, the Secretary may elect to limit testing of a model to certain geographic areas. (b) Testing of models (phase I) (1) In general The CMI shall test payment and service delivery models in accordance with selection criteria under paragraph (2) to determine the effect of applying such models under the applicable subchapter (as defined in subsection (a)(4)(B)) on program expenditures under such subchapters and the quality of care received by individuals receiving benefits under such subchapter. (2) Selection of models to be tested (A) In general The Secretary shall select models to be tested from models where the Secretary determines that there is evidence that the model addresses a defined population for which there are deficits in care leading to poor clinical outcomes or potentially avoidable expenditures. The Secretary shall focus on models expected to reduce program costs under the applicable subchapter while preserving or enhancing the quality of care received by individuals receiving benefits under such subchapter. The models selected under this subparagraph may include, but are not limited to, the models described in subparagraph (B). (B) Opportunities The models described in this subparagraph are the following models: (i) Promoting broad payment and practice reform in primary care, including patient-centered medical home models for high-need applicable individuals, medical homes that address women’s unique health care needs, and models that transition primary care practices away from fee-for-service based reimbursement and toward comprehensive payment or salary-based payment. (ii) Contracting directly with groups of providers of services and suppliers to promote innovative care delivery models, such as through risk-based comprehensive payment or salary-based payment. (iii) Utilizing geriatric assessments and comprehensive care plans to coordinate the care (including through interdisciplinary teams) of applicable individuals with multiple chronic conditions and at least one of the following: (I) An inability to perform 2 or more activities of daily living. (II) Cognitive impairm...

(a) Receipt of benefits through enrollment in PACE program; definitions for PACE program related terms (1) Benefits through enrollment in a PACE program In accordance with this section, in the case of an individual who is entitled to benefits under part A or enrolled under part B and who is a PACE program eligible individual (as defined in paragraph (5)) with respect to a PACE program offered by a PACE provider under a PACE program agreement— (A) the individual may enroll in the program under this section; and (B) so long as the individual is so enrolled and in accordance with regulations— (i) the individual shall receive benefits under this subchapter solely through such program; and (ii) the PACE provider is entitled to payment under and in accordance with this section and such agreement for provision of such benefits. (2) “PACE program” defined For purposes of this section, the term “PACE program” means a program of all-inclusive care for the elderly that meets the following requirements: (A) Operation The entity operating the program is a PACE provider (as defined in paragraph (3)). (B) Comprehensive benefits The program provides comprehensive health care services to PACE program eligible individuals in accordance with the PACE program agreement and regulations under this section. (C) Transition In the case of an individual who is enrolled under the program under this section and whose enrollment ceases for any reason (including that the individual no longer qualifies as a PACE program eligible individual, the termination of a PACE program agreement, or otherwise), the program provides assistance to the individual in obtaining necessary transitional care through appropriate referrals and making the individual’s medical records available to new providers. (3) “PACE provider” defined (A) In general For purposes of this section, the term “PACE provider” means an entity that— (i) subject to subparagraph (B), is (or is a distinct part of) a public entity or a private, nonprofit entity organized for charitable purposes under section 501(c)(3) of the Internal Revenue Code of 1986; and (ii) has entered into a PACE program agreement with respect to its operation of a PACE program. (B) Treatment of private, for-profit providers Clause (i) of subparagraph (A) shall not apply— (i) to entities subject to a demonstration project waiver under subsection (h); and (ii) after the date the report under section 4804(b) of the Balanced Budget Act of 1997 is submitted, unless the Secretary determines that any of the findings described in subparagraph (A), (B), (C), or (D) of paragraph (2) of such section are true. (4) “PACE program agreement” defined For purposes of this section, the term “PACE program agreement” means, with respect to a PACE provider, an agreement, consistent with this section, section 1396u–4 of this title (if applicable), and regulations promulgated to carry out such sections, between the PACE provider and the Secretary, or an agreement between the PACE provider and a State administering agency for the operation of a PACE program by the provider under such sections. (5) “PACE program eligible individual” defined For purposes of this section, the term “PACE program eligible individual” means, with respect to a PACE program, an individual who— (A) is 55 years of age or older; (B) subject to subsection (c)(4), is determined under subsection (c) to require the level of care required under the State medicaid plan for coverage of nursing facility services; (C) resides in the service area of the PACE program; and (D) meets such other eligibility conditions as may be imposed under the PACE program agreement for the program under subsection (e)(2)(A)(ii). (6) “PACE protocol” defined For purposes of this section, the term “PACE protocol” means the Protocol for the Program of All-inclusive Care for the Elderly (PACE), as published by On Lok, Inc., as of April 14, 1995, or any successor protocol that may be agreed upon between the Se...

(a) State option (1) In general A State may elect to provide medical assistance under this section with respect to PACE program services to PACE program eligible individuals who are eligible for medical assistance under the State plan and who are enrolled in a PACE program under a PACE program agreement. Such individuals need not be eligible for benefits under part A, or enrolled under part B, of subchapter XVIII to be eligible to enroll under this section. In the case of an individual enrolled with a PACE program pursuant to such an election— (A) the individual shall receive benefits under the plan solely through such program, and (B) the PACE provider shall receive payment in accordance with the PACE program agreement for provision of such benefits. A State may establish a numerical limit on the number of individuals who may be enrolled in a PACE program under a PACE program agreement. (2) “PACE program” defined For purposes of this section, the term “PACE program” means a program of all-inclusive care for the elderly that meets the following requirements: (A) Operation The entity operating the program is a PACE provider (as defined in paragraph (3)). (B) Comprehensive benefits The program provides comprehensive health care services to PACE program eligible individuals in accordance with the PACE program agreement and regulations under this section. (C) Transition In the case of an individual who is enrolled under the program under this section and whose enrollment ceases for any reason (including that the individual no longer qualifies as a PACE program eligible individual, the termination of a PACE program agreement, or otherwise), the program provides assistance to the individual in obtaining necessary transitional care through appropriate referrals and making the individual’s medical records available to new providers. (3) “PACE provider” defined (A) In general For purposes of this section, the term “PACE provider” means an entity that— (i) subject to subparagraph (B), is (or is a distinct part of) a public entity or a private, nonprofit entity organized for charitable purposes under section 501(c)(3) of the Internal Revenue Code of 1986, and (ii) has entered into a PACE program agreement with respect to its operation of a PACE program. (B) Treatment of private, for-profit providers Clause (i) of subparagraph (A) shall not apply— (i) to entities subject to a demonstration project waiver under subsection (h); and (ii) after the date the report under section 4804(b) of the Balanced Budget Act of 1997 is submitted, unless the Secretary determines that any of the findings described in subparagraph (A), (B), (C), or (D) of paragraph (2) of such section are true. (4) “PACE program agreement” defined For purposes of this section, the term “PACE program agreement” means, with respect to a PACE provider, an agreement, consistent with this section, section 1395eee of this title (if applicable), and regulations promulgated to carry out such sections, among the PACE provider, the Secretary, and a State administering agency for the operation of a PACE program by the provider under such sections. (5) “PACE program eligible individual” defined For purposes of this section, the term “PACE program eligible individual” means, with respect to a PACE program, an individual who— (A) is 55 years of age or older; (B) subject to subsection (c)(4), is determined under subsection (c) to require the level of care required under the State medicaid plan for coverage of nursing facility services; (C) resides in the service area of the PACE program; and (D) meets such other eligibility conditions as may be imposed under the PACE program agreement for the program under subsection (e)(2)(A)(ii). (6) “PACE protocol” defined For purposes of this section, the term “PACE protocol” means the Protocol for the Program of All-inclusive Care for the Elderly (PACE), as published by On Lok, Inc., as of April 14, 1995, or any successor protocol that may be agree...