[Congressional Bills 117th Congress]
[From the U.S. Government Publishing Office]
[S. 3626 Introduced in Senate (IS)]
<DOC>
117th CONGRESS
2d Session
S. 3626
To improve access to the Program of All-Inclusive Care for the Elderly,
and for other purposes.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
February 10, 2022
Mr. Casey (for himself and Mr. Scott of South Carolina) introduced the
following bill; which was read twice and referred to the Committee on
Finance
_______________________________________________________________________
A BILL
To improve access to the Program of All-Inclusive Care for the Elderly,
and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Program of All-inclusive Care for
the Elderly Expanded Act'' or the ``PACE Expanded Act''.
SEC. 2. IMPROVING ACCESS TO AND AFFORDABILITY OF PACE PROGRAMS FOR
MEDICARE BENEFICIARIES WHO ARE NOT DUAL ELIGIBLE
BENEFICIARIES THROUGH FLEXIBILITY IN RATE SETTING FOR
SERVICES NOT COVERED BY MEDICARE.
(a) In General.--Section 1894 of the Social Security Act (42 U.S.C.
1395eee) is amended by adding at the end the following new subsection:
``(j) Flexibility in Establishing Premiums for Medicare PACE
Participants Who Are Not Also Entitled to Benefits Under a State
Medicaid Program.--
``(1) Codification of authority to charge a monthly
capitation amount for non-medicare services.--Subject to the
succeeding provisions of this subsection, a PACE program
operated by a PACE provider under a PACE program agreement in
any State may charge a Medicare-only PACE program eligible
individual (as defined in paragraph (4)(A)) who is enrolled in
such PACE program a monthly capitation payment amount for the
provision of non-Medicare services (as defined in paragraph
(4)(B)) under the PACE program.
``(2) Determination of monthly capitation payment amount.--
``(A) In general.--Notwithstanding section 460.186
of title 42, Code of Federal Regulations (or any
successor regulation), the monthly capitation payment
amount that may be charged under paragraph (1) shall be
determined by the PACE provider operating the PACE
program. Such monthly capitation payment amount shall
be based on assessments conducted on the Medicare-only
PACE program eligible individual who is enrolled in
such PACE program by the PACE program interdisciplinary
team and shall take into account the health status of
such individual. In determining the monthly capitation
amount for a Medicare-only PACE program eligible
individual under this paragraph, a PACE provider may
take into account the services determined necessary for
the individual by the PACE program interdisciplinary
team based upon their assessment of the individual. A
determination described in the preceding sentence shall
not be construed as limiting the responsibility of the
PACE provider to meet any unforeseen needs or provide
for any required services for such individual.
``(B) Authority to adjust monthly capitation
amount.--
``(i) In general.--Subject to clause (ii)
and paragraph (3), the monthly capitation
payment amount that may be charged under
paragraph (1) to a Medicare-only PACE program
eligible individual enrolled in a PACE program
for non-Medicare services may increase or
decrease based on assessments conducted on such
individual. Any change in the monthly
capitation payment amount charged to such an
individual shall take effect beginning with the
first day of the first month that begins after
the month during which the plan of care is
developed for such individual based on such an
assessment.
``(ii) Limitation on frequency of
increase.--The monthly capitation payment
amount that may be charged under paragraph (1)
to such an individual may not increase more
frequently than once per calendar quarter.
``(3) Beneficiary protections.--
``(A) Disclosure of premium rate structure.--A PACE
provider shall disclose to Medicare-only PACE program
eligible individuals the capitation payment amounts
that may be charged under this section to such
individuals for non-Medicare services under the PACE
program operated by such PACE provider under this
section--
``(i) prior to enrollment of such
individual in such PACE program, and
``(ii) periodically, and upon request of
such individual, after enrollment.
``(B) Assessment instrument.--
``(i) In general.--The Secretary shall
develop an assessment instrument for use by
PACE programs with respect to Medicare-only
PACE program eligible individuals under this
subsection.
``(ii) Requirement for disclosure of
assessment instrument.--The monthly capitation
payment amount charged under paragraph (1) to a
Medicare-only PACE program eligible individual
for non-Medicare services shall be based on an
assessment of such individual conducted by the
PACE provider (using the assessment instrument
developed by the Secretary under clause (i)),
accounting for health status and corresponding
needs.
``(iii) Requirement for disclosure of
assessment instrument.--The assessment
instrument used by the interdisciplinary team
of the PACE program to evaluate the health and
social status of PACE participants shall be
disclosed to the individual prior to the
assessment.
``(C) Process to seek review of assessments.--The
Secretary shall establish a process for a Medicare-only
PACE program eligible individual to seek review of any
assessment conducted on the individual under this
subsection.
``(4) Rule of construction.--Nothing in this subsection
shall be construed to preclude the testing under section 1115A
of a model to permit a PACE provider operating a PACE program
to establish and charge monthly capitation payment amounts for
the provision of non-Medicare services under the PACE program
to Medicare-only PACE program eligible individuals under a rate
structure established by such PACE provider for such purpose,
including the use of an assessment instrument developed by the
PACE program to assign such individuals to an appropriate rate
category under such rate structure.
``(5) Definitions.--In this subsection--
``(A) the term `Medicare-only PACE program eligible
individual' means an individual who is described in
subsection (a)(1) and who is not entitled to medical
assistance under title XIX, and includes the designated
representative of the individual as appropriate; and
``(B) the term `non-Medicare services' means items
and services covered under title XIX that are not
covered under this title and items and services
described in subsection (b)(1)(A)(ii).''.
(b) Effective Date.--The amendment made by subsection (a) shall
take effect on the date of the enactment of this Act, and apply with
respect to capitation amounts that may be charged for months beginning
on or after January 1, 2023.
(c) Rule of Construction.--Nothing in this section, or the
amendments made by this section, shall be construed to modify or
otherwise impact the following Medicare capitation rates that may be
charged by PACE plans for PACE participants who are Medicare
beneficiaries who are not both entitled to (or enrolled for) benefits
under part A of title XVIII of the Social Security Act (42 U.S.C. 1395
et seq.) and enrolled for benefits under part B of such title:
(1) Part a only medicare beneficiary.--In the case of a
Medicare beneficiary who is a PACE participant who is entitled
to (or enrolled for) benefits under part A of such title XVIII
but who is not enrolled for benefits under part B of such
title, the Medicare Part B capitation rate under paragraph (b)
of section 460.186 of title 42, Code of Federal Regulations (or
any successor regulations).
(2) Part b only medicare beneficiary.--In the case of a
Medicare beneficiary who is a PACE participant who is enrolled
for benefits under part B of such title XVIII but who is not
entitled to (or enrolled for) benefits under part A of such
title, the Medicare Part A capitation rate under paragraph (c)
of such section 460.186 (or any successor regulations).
SEC. 3. ANYTIME ENROLLMENT IN PACE.
(a) In General.--
(1) Any time enrollment and effective date.--Section
1894(c)(5) of the Social Security Act (42 U.S.C. 1395eee(c)(5))
is amended by adding at the end the following new subparagraph:
``(C) Any time enrollment and effective date of
enrollment.--
``(i) Any time enrollment.--A PACE program
eligible individual may enroll in a PACE
program at any time during a month.
``(ii) Effective date.--Subject to clause
(iii), the enrollment of a PACE program
eligible individual in a PACE program shall be
effective on the date the PACE provider
operating the PACE program receives an
enrollment agreement signed by such PACE
program eligible individual with respect to
such PACE program.
``(iii) Special rule in the case of dual
eligible beneficiaries.--In the case of a PACE
program eligible individual who is eligible for
benefits under this title and title XIX, clause
(i) shall only apply if the State in which such
individual resides has made an election under
section 1934(c)(5)(C) to permit PACE program
eligible individuals enroll in a PACE program
at any time during a month in such State.''.
(2) Prorated payments.--Section 1894(d) of the Social
Security Act (42 U.S.C. 1395eee(d)) is amended by adding at the
end the following new paragraph:
``(4) Prorated payments.--In the case of a PACE program
eligible individual enrolled in a PACE program operated by a
PACE provider with an enrollment effective date that is not the
first day of a month, the capitation amount that would
otherwise be made under this subsection to the PACE provider
for such individual for the first month in which such
individual is so enrolled shall be prorated accordingly.''.
(b) Conforming Amendments.--
(1) Anytime enrollment and effective date.--Section
1934(c)(5) of the Social Security Act (42 U.S.C. 1396u-4(c)(5))
is amended by adding at the end the following new subparagraph:
``(C) State option to permit any time enrollment
and effective date of enrollment.--
``(i) Any time enrollment.--A State may
elect to permit a PACE program eligible
individual to enroll in a PACE program at any
time during a month.
``(ii) Effective date.--Pursuant to a State
election made under clause (i), the enrollment
of a PACE program eligible individual in a PACE
program shall be effective on the date the PACE
provider operating the PACE program receives an
enrollment agreement signed by such PACE
program eligible individual with respect to
such PACE program.''.
(2) Prorated payments.--Section 1934(d) of the Social
Security Act (42 U.S.C. 1396u-4(d)) is amended by adding at the
end the following new paragraph:
``(3) Prorated payments.--If a State elects under
subsection (c)(5)(C) to permit enrollment at any time during a
month, in the case of a PACE program eligible individual
enrolled in a PACE program operated by a PACE provider with an
enrollment effective date that is not the first day of a month,
the State shall prorate the capitation amount that would
otherwise be made under this subsection to the PACE provider
for such individual for the first month in which such
individual is so enrolled.''.
(c) Effective Date.--The amendments made by this section shall take
effect on January 1, 2023.
SEC. 4. PACE SITE APPROVAL AND EXPANSION.
(a) In General.--Sections 1894(e) and 1934(e) of the Social
Security Act (42 U.S.C. 1395eee(e), 1396u-4(e)) are each amended by
striking paragraph (8) and inserting the following:
``(8) Authority to submit applications at any time; timely
consideration of applications.--
``(A) Authority to submit applications at any
time.--
``(i) New pace provider status.--An entity
that seeks to become a PACE provider may submit
an application for PACE provider status at any
time.
``(ii) Service area expansion and addition
of pace center site.--To the extent the
Secretary requires a PACE provider to submit an
application to expand its service area or to
add a PACE center site, a PACE provider may
submit such an application at any time, subject
to the requirements of section 460.12(d) of
title 42, Code of Federal Regulations (relating
to the first trial period audit), or any
successor regulation.
``(iii) Assurances.--An application for
PACE provider status under clause (i) or to add
a PACE center site under clause (ii) shall
include the following assurances:
``(I) An assurance that the
required members of the
interdisciplinary team are employees or
contractors of the proposed PACE center
or will be employees or contractors of
the proposed PACE center by the time
the PACE center becomes operational.
``(II) An assurance that--
``(aa) the PACE provider's
contracts for all contractors
and contracted personnel will
be executed by the time the
proposed PACE center becomes
operational; and
``(bb) executed contracts
may include provisions for
staffing levels commensurate
with enrollment to full
projected census.
``(B) Deemed approval.--An application described in
subparagraph (A) shall be deemed approved unless the
Secretary, within 45 days after the date of the
submission of the application to the Secretary, either
denies such request in writing or informs the applicant
in writing with respect to any additional information
that is needed in order to make a final determination
with respect to the application. After the date the
Secretary receives such additional information, the
application shall be deemed approved unless the
Secretary, within 45 days of such date, denies such
request.''.
(b) Effective Date.--The amendments made by subsection (a) shall
take effect on January 1, 2023.
SEC. 5. PACE PILOT.
Section 1115A(b)(2) of the Social Security Act (42 U.S.C.
1315a(b)(2)) is amended--
(1) in subparagraph (B), by adding at the end the following
new clause:
``(xxviii) National testing of a model for
expanded eligibility for the Program of All-
Inclusive Care for the Elderly as described in
subparagraph (D).''; and
(2) by adding at the end the following new subparagraph:
``(D) National testing of model for expanded
eligibility for the program of all-inclusive care for
the elderly.--In the case where the Secretary selects
the model described in clause (ii) of this subparagraph
for testing pursuant to clause (xxviii) of subparagraph
(B), the following shall apply:
``(i) National testing.--
``(I) In general.--Subject to
subclause (II), the Secretary shall
design a demonstration that allows each
PACE provider with an executed PACE
agreement to develop and submit to the
Secretary an application to begin
testing expanded PACE eligibility for
high-need and high-cost populations
that are not otherwise eligible to
participate in a PACE program within 1
year of the date on which the model is
selected.
``(II) No effect on ongoing models
or demonstration projects.--Nothing in
this subparagraph shall affect the
testing of any model under this
subsection or any demonstration project
under this Act that is implemented
prior to the date of the enactment of
this subparagraph.
``(ii) Model described.--The model
described in this clause seeks to increase
access to quality, integrated, care for high-
need, high-cost individuals who are not
otherwise eligible to participate in a PACE
program in order to improve health and reduce
cost. Under this model, participating PACE
providers would--
``(I) be paid fixed, monthly
capitated rates from both Medicare and
the applicable State Medicaid agency
for all services provided to each
enrollee fitting the criteria of the
PACE provider's designated population;
``(II) partner with non-PACE
providers, such as Area Agencies on
Aging, Centers for Independent Living,
local hospitals, and non-hospital
providers such as physicians,
behavioral health providers and other
community-based organizations to
effectively reach the PACE provider's
selected population;
``(III) adapt the PACE program
model of care to appropriately serve
the PACE provider's selected population
to integrate care and meet the unique
needs of said population; and
``(IV) if the PACE provider is
located in a State that has not yet
served the selected population through
a PACE program under section 1934,
receive an up-front fixed payment to
coordinate with the State to develop a
capitated payment rate, with
appropriate risk adjustment, for the
PACE provider's selected population.
``(iii) Requirements for participating pace
organizations.--In order to participate in the
model, a PACE provider must--
``(I) conduct a survey or needs
assessment of their service area to
determine the most appropriate
population with which to expand their
services;
``(II) receive prior approval from
the applicable State Medicaid agency to
submit an application to participate in
the model; and
``(III) following such survey or
needs assessment and approval from the
applicable State Medicaid agency,
submit and receive approval of an
application of expansion from the
Secretary.
``(iv) Application.--A PACE provider's
application to participate in this model shall
include the following information:
``(I) Results of the survey or
needs assessment of their service area
under clause (iii)(I) and an
explanation of the expanded population
the PACE organization will serve.
``(II) The types of services that
the expanded population will require
and the PACE provider's plan to
implement these services.
``(III) How the PACE provider will
achieve engagement and enrollment of
the new population in the model,
including how it will partner with non-
PACE providers in the applicable
service area.
``(IV) How the expanded
population's participation in the PACE
program is intended to improve quality
of care and health outcomes under the
model.
``(V) Certification that the
applicable State Medicaid agency has
approved the PACE provider's
application to participate in the
model.
``(VI) Plans to coordinate with the
State Medicaid agency to develop an
initial capitated rate with appropriate
risk adjustment.
``(VII) Plans for the PACE provider
and the State Medicaid agency to review
and adjust the Medicaid capitated rate
on a biennial basis, as needed.
``(VIII) Any other information
required by the Secretary.
``(v) Technical assistance.--The Secretary
shall provide, or designate an entity to
provide, technical assistance to participating
PACE providers as they apply for and implement
the model.
``(vi) Accounting for uncertainty.--In
order for implementing PACE providers to
receive unanticipated additional resources
needed to implement the model, the Secretary
shall establish procedures for the implementing
PACE providers to submit to the Secretary a
request for additional resources.
``(vii) Monitoring outcomes.--The
Secretary, in conjunction with PACE providers
and in consultation with States that have
elected to expand PACE program eligibility
under section 1934(l), shall develop a plan
to--
``(I) annually monitor outcomes
under the model, which may include
financial, quality, access, and
utilization outcomes;
``(II) annually monitor the health
outcomes of the PACE provider's
expanded population; and
``(III) any other outcomes as
determined by the Secretary.
``(viii) Reporting requirements.--
``(I) Report to congress.--Not less
frequently than every 3 years (for the
duration of the implementation of the
model under this subparagraph), the
Secretary shall submit to Congress a
report on the implementation of the
model under this subparagraph. The
report shall include demographic
information on the populations served
under the demonstration, best practices
for future implementation efforts and
any other information the Secretary
determines appropriate together with
recommendations for such legislation
and administrative action as the
Secretary determines appropriate.
``(ix) Funding.--The Secretary shall
allocate funds made available under subsection
(f)(1) to design, implement, evaluate, and
report on the model described in clause (ii) in
accordance with this subparagraph.''.
SEC. 6. COORDINATION WITH THE FEDERAL COORDINATED HEALTH CARE OFFICE.
Section 1934 of the Social Security Act (42 U.S.C. 1396u-4), as
amended by sections 3 and 8, is amended by adding at the end the
following new subsection:
``(m) Coordination With the Federal Coordinated Health Care
Office.--
``(1) State coordination with fchco.--The Director of the
Federal Coordinated Health Care Office established under
section 2602 of the Patient Protection and Affordable Care Act
shall serve as a point of contact between State administering
agencies and the Federal Government for purposes of
implementing and operating a PACE program in a State, and shall
coordinate with other relevant offices and staff of the Centers
for Medicare & Medicaid Services involved in carrying out this
section.
``(2) Annual report.--Not later than January 1, 2023, and
annually thereafter, the Director of the Federal Coordinated
Health Care Office shall submit to Congress a report on the
demographics of the populations served by PACE programs
operated under this section and section 1894.''.
SEC. 7. EVALUATION OF EFFECTIVENESS OF PACE PROGRAM IN RURAL AND
UNDERSERVED AREAS.
(a) In General.--The Assistant Secretary for Planning and
Evaluation of the Department of Health and Human Services (referred to
in this section as the ``Assistant Secretary'') shall conduct an
evaluation of the effectiveness of the program for all-inclusive care
for the elderly under sections 1894 and 1934 of the Social Security Act
(42 U.S.C. 1395eee, 1396u-4) in rural and underserved areas, including
with respect to the following factors:
(1) Reductions in hospitalizations and re-hospitalizations
among program beneficiaries.
(2) Reductions in emergency department use among program
beneficiaries.
(3) Reductions in long-term nursing facility use among
program beneficiaries.
(4) Reductions in mortality among program beneficiaries.
(5) Achieving lower rates of functional decline, and
improvements in reported health status and quality of life
among program beneficiaries.
(6) Reductions in the total cost of care among program
beneficiaries.
(7) The effect of activities supported under the program on
the local area serviced by the program, including on the health
and well-being of unpaid and family caregivers of program
beneficiaries.
(8) Improvements in quality of life among program
beneficiaries.
(b) Report.--Not later than 60 months after the date of enactment
of this Act, the Assistant Secretary shall submit a report containing
the results of the evaluation required under subsection (a), an
analysis of which elements of the program for all-inclusive care for
the elderly under sections 1894 and 1934 of the Social Security Act (42
U.S.C. 1395eee, 1396u-4) should be replicated and scaled by
governmental or non-governmental entities, and such recommendations for
legislation and administrative action as the Assistant Secretary
determines appropriate to the chairs and ranking members of the
following committees:
(1) The Special Committee on Aging of the Senate.
(2) The Committee on Finance of the Senate.
(3) The Committee on Health, Education, Labor, and Pensions
of the Senate.
(4) The Committee on Ways and Means of the House of
Representatives.
(5) The Committee on Energy and Commerce of the House of
Representatives.
(c) Partners.--In conducting the evaluation and completing the
report required under this section, the Assistant Secretary shall
provide an opportunity for partners and persons that have participated
in the program for all-inclusive care for the elderly under sections
1894 and 1934 of the Social Security Act (42 U.S.C. 1395eee, 1396u-4)
on every level, especially individuals who receive care through the
program and their unpaid or family caregivers, to have an opportunity
to contribute their expertise to evaluating the strategy and outcomes
of the program.
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